History

Fact Explanation
Vesicular erruptions on hands, feet, buttocks, genitalia and mouth This is a viral illness with vesicular eruptions in mouth, hands, foot, buttocks and genitalia. Infection is caused by coxsackievirus A5, A7, A9, A10, B2, B5 strains, polio virus, echovirus and enterovirus 71 (EV-71). Commonly seen in infants and in children less than 5 years but some adults can also get affected. [1,3]
Fever Usually fever is the first clinical manifestation. Fever is accompanied by malaise and poor appetite. [1,2]
Sore throat and oral ulcers Soreness in the throat or mouth is common. Later blisters appear in the oral mucosa and they rupture making ulcers. [1,2]
Skin rash Flat or raised red spots and blisters usually involves the palms and soles. Skin over the knees, elbows and genitalia can also get affected. [1,2]
Vomiting Vomiting is common in EV-71 infection. EV 71 can cause disease outbreaks. [1]
Symptoms of dehydration Affected children can get dehydrated due to vomiting, and poor oral intake because of the sore throat and oral ulcers.[1]
Symptoms of meningitis Aseptic meningitis is a rare complication of the disease. Headache, neck pain and stiffness and photophobia are the usual symptoms. [1,5]
Symptoms of encephalitis This is an even rare complication of the disease. Affected children have fever, headache, altered consciousness or drowsiness and seizures. [1,3,5]
Symptoms of myocarditis Myocarditis is also another rare but life threatening complication of the disease. [3] Although most of the patients are asymptomatic, some have chest pain, palpitations due to arrhythmia and even sudden death. [4]
Involvement of the central nervous system Except from meningitis and encephalitis, hand- foot and mouth disease can result in Guillain-Barré syndrome, acute cerebellar ataxia and acute transverse myelitis. [5]
References
  1. Hand, Foot, and Mouth Disease (HFMD). Centers for Disease Control and Prevention. [online] [viewed 19 May 2014] Available from: http://www.cdc.gov/hand-foot-mouth/about/index.html
  2. MEADOW SR. Hand, foot, and mouth diseases. Arch Dis Child [online] 1965 Oct, 40(213):560-564 [viewed 19 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2019444
  3. CHAN KP, GOH KT, CHONG CY, TEO ES, LAU G, LING AE. Epidemic Hand, Foot and Mouth Disease Caused by Human Enterovirus 71, Singapore Emerg Infect Dis [online] 2003 Jan, 9(1):78-85 [viewed 19 May 2014] Available from: doi:10.3201/eid1301.020112
  4. SCHULTZ JC, HILLIARD AA, COOPER LT JR, RIHAL CS. Diagnosis and Treatment of Viral Myocarditis Mayo Clin Proc [online] 2009 Nov, 84(11):1001-1009 [viewed 19 May 2014] Available from: doi:10.1016/S0025-6196(11)60670-8
  5. CHONG CY, CHAN KP, SHAH VA, NG WY, LAU G, TEO TE, LAI SH, LING AE. Hand, foot and mouth disease in Singapore: a comparison of fatal and non-fatal cases. Acta Paediatr [online] 2003 Oct, 92(10):1163-9 [viewed 19 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/14632332

Examination

Fact Explanation
Fever Affected children are usually febrile, in response to the viremia. [1,2]
Mucosal ulcers Oral vesicles and ulcers are seen. The surrounding skin is erythemic. [2]
Skin lesions First macules appear and they become small flaccid blisters which rupture easily. Lesions can involve palms, soles, buttocks and genital skin. [1,2]
Signs suggestive of myocarditis and heart failure Arrhythmia or tachycardia, low blood pressure and pulmonary edema are suggestive of myocarditis and heart failure. [3]
References
  1. Hand, Foot, and Mouth Disease (HFMD). Centers for Disease Control and Prevention. [online] [viewed 19 May 2014] Available from: http://www.cdc.gov/hand-foot-mouth/about/index.html
  2. MEADOW SR. Hand, foot, and mouth diseases. Arch Dis Child [online] 1965 Oct, 40(213):560-564 [viewed 19 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2019444
  3. CHAN L. G., et al. Deaths of Children during an Outbreak of Hand, Foot, and Mouth Disease in Sarawak, Malaysia: Clinical and Pathological Characteristics of the Disease. Clinical Infectious Diseases [online] 2000 September, 31(3):678-683 [viewed 19 May 2014] Available from: doi:10.1086/314032

Differential Diagnoses

Fact Explanation
Enteroviral infection Some strains of enterovirus can cause lower respiratory tract infections. [1]
Kawasaki disease Kawasaki disease is an acute febrile illness with skin and mucous membrane lesions. [2]
Pharyngitis Pharyngitis is caused by either bacteria or viruses. Patients present with sore throat and pain during swallowing. [3]
Toxic epidermal necrolysis (TEN) TEN is an acute hypersensitivity reaction with formation of bulla. Cutaneous manifestations are associated with fever, malaise, headache cough and conjunctivitis. TEN and Stevens-Johnson Syndrome are severe forms of erythema multiforme. [4]
Herpes Zoster Headache, photophobia, malaise and skin rash are common symptoms. Few patients can have fever. Characteristically the rash involves only one dermatome. [5]
Herpes Simplex Herpes simplex type 1 virus is contagious and affects children and cause gingivostomatitis. This typically affects the oral mucosa. [6]
References
  1. ANDRéOLETTI LAURENT, RENOIS FANNY, JACQUES JéRôME, LéVêQUE NICOLAS. Entérovirus non poliomyélitiques et pathologies respiratoires. Med Sci (Paris) [online] December, 25(11):921-930 [viewed 19 May 2014] Available from: doi:10.1051/medsci/20092511921
  2. KUO HO-CHANG, YANG KUENDER D., CHANG WEI-CHIAO, GER LUO-PING, HSIEH KAI-SHENG. Kawasaki Disease: An Update on Diagnosis and Treatment. Pediatrics & Neonatology [online] 2012 February, 53(1):4-11 [viewed 19 May 2014] Available from: doi:10.1016/j.pedneo.2011.11.003
  3. VINCENT MT, CELESTIN N, HUSSAIN AN. Pharyngitis. Am Fam Physician [online] 2004 Mar 15, 69(6):1465-70 [viewed 19 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15053411
  4. USATINE RP, SANDY N. Dermatologic emergencies. Am Fam Physician [online] 2010 Oct 1, 82(7):773-80 [viewed 19 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20879700
  5. GNANN JW JR, WHITLEY RJ. Clinical practice. Herpes zoster. N Engl J Med [online] 2002 Aug 1, 347(5):340-6 [viewed 19 May 2014] Available from: doi:10.1056/NEJMcp013211
  6. ARDUINO PG, PORTER SR. Herpes Simplex Virus Type 1 infection: overview on relevant clinico-pathological features. J Oral Pathol Med [online] 2008 Feb, 37(2):107-21 [viewed 19 May 2014] Available from: doi:10.1111/j.1600-0714.2007.00586.x

Investigations - for Diagnosis

Fact Explanation
Detection of the virus Respiratory tract secretions and stool samples can be collected for viral studies and demonstration of the presence of the virus. [1] Polymerase chain reaction can be used to isolate the virus. [2] However investigations are not necessary as this is a clinical diagnosis.
References
  1. Hand, Foot, and Mouth Disease (HFMD). Centers for Disease Control and Prevention. [online] [viewed 19 May 2014] Available from: http://www.cdc.gov/hand-foot-mouth/about/index.html
  2. HUANG WEN-CHAN, HUANG LI-MIN, LU CHUN-YI, CHENG AI-LING, CHANG LUAN-YIN. Atypical hand-foot-mouth disease in children: a hospital-based prospective cohort study. Array [online] 2013 December [viewed 19 May 2014] Available from: doi:10.1186/1743-422X-10-209

Investigations - Followup

Fact Explanation
ECG Detects arrhythmia. [1]
Echocardiogram Aids in the diagnosis of ventricular dilatation and heart failure secondary to myocarditis. [1]
Chest X-ray Signs of heart failure like cardiomegaly, pulmonary edema, Kerley B lines and upper lobe diversion can be detected. [1]
References
  1. CHAN L. G., et al. Deaths of Children during an Outbreak of Hand, Foot, and Mouth Disease in Sarawak, Malaysia: Clinical and Pathological Characteristics of the Disease. Clinical Infectious Diseases [online] 2000 September, 31(3):678-683 [viewed 19 May 2014] Available from: doi:10.1086/314032

Management - General Measures

Fact Explanation
Health education The disease is transmitted through infected person's respiratory secretions, blister fluid and feces. Maintenance of good personal hygiene (hand washing, use of handkerchief ) will prevent the disease transmission. Parents are advised to clean their children's toys with disinfectants. [1]
Maintain adequate hydration Children with dehydration should be given fluids either orally or intravenously. [1]
Antipyeritics Fever should be treated with antipyretics other than non-steroidal anti inflammatory drugs. [1]
Analgesics Pain in the mouth can be relieved by analgesics. [1]
References
  1. Hand, Foot, and Mouth Disease (HFMD). Centers for Disease Control and Prevention. [online] [viewed 19 May 2014] Available from: http://www.cdc.gov/hand-foot-mouth/about/index.html

Management - Specific Treatments

Fact Explanation
Conservative management Hand, foot and mouth disease is often self-limiting and does not require any treatment. Antipyretics and analgesics can be prescribed for the comfort of the patient. [1,2]
References
  1. CHAN KP, GOH KT, CHONG CY, TEO ES, LAU G, LING AE. Epidemic Hand, Foot and Mouth Disease Caused by Human Enterovirus 71, Singapore Emerg Infect Dis [online] 2003 Jan, 9(1):78-85 [viewed 19 May 2014] Available from: doi:10.3201/eid1301.020112
  2. MUPPA RADHIKA, DUDDU MAHESH, BHUPATIRAJU PRAMEELA, DANDEMPALLY ARTHI. Hand, foot and mouth disease. J Indian Soc Pedod Prev Dent [online] 2011 December [viewed 19 May 2014] Available from: doi:10.4103/0970-4388.84692