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ORIGINAL ARTICLE
Year : 2016  |  Volume : 17  |  Issue : 1  |  Page : 7-12

Hand, foot and mouth disease in children: A clinico epidemiological study


Department of Dermatology, Venereology and Leprosy, Gandhi Medical College, Hyderabad, Telangana, India

Date of Web Publication4-Jan-2016

Correspondence Address:
K Bhumesh Kumar
Department of Dermatology, Venereology and Leprosy, Gandhi Medical College, Hyderabad - 500 003, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2319-7250.173150

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  Abstract 

Background: Epidemics of hand, foot, and mouth disease (HFMD) are increasing every year globally. The disease now presents an increasing threat to public health worldwide. HFMD is a highly contagious viral infection characterized by a typical maculopapular or vesicular eruptions on the hands and feet and in the oral cavity. It affects predominantly children and/or immunocompromised adults and follows a benign self-limiting course. However, HFMD cases with severe or lethal complications such as encephalitis, meningitis, pulmonary edema, and myocarditis have been reported mostly in children, and also in immunocompromised adults. The common pathogens are coxsackievirus A16, enterovirus 71, and recently coxsackieviruses A6 and A10 have been included. Differences in the course of HFMD have been observed depending on the virus type, age, and immune status.
Aim: This study is to review the clinico epidemiological data for HFMD for early diagnosis and treatment, to prevent the complications and to implement the precautionary measures during outbreaks.
Materials and Methods: A prospective observational study is conducted from August 2013 to January 2014. Consecutive cases clinically diagnosed as HFMD, in the pediatric age group were taken up.
Results: We report the clinico epidemiological study of 50 cases of HFMD, their benign course and recovery among immunocompetent children.
Conclusion: Early accurate diagnosis and treatment of HFMD along with monitoring is crucial to prevent severe complications. Hence, a high index of suspicion is required to diagnose HFMD.

Keywords: Coxsackievirus, hand, foot and mouth disease, immunocompetent children


How to cite this article:
Kumar K B, Kiran A G, Kumar B U. Hand, foot and mouth disease in children: A clinico epidemiological study. Indian J Paediatr Dermatol 2016;17:7-12

How to cite this URL:
Kumar K B, Kiran A G, Kumar B U. Hand, foot and mouth disease in children: A clinico epidemiological study. Indian J Paediatr Dermatol [serial online] 2016 [cited 2020 Feb 21];17:7-12. Available from: http://www.ijpd.in/text.asp?2016/17/1/7/173150


  Introduction Top


Hand, foot, and mouth disease (HFMD), a viral infection which predominantly affects the children is characterized by a brief prodrome and erythematous papulovesicles mostly localized to palms and soles with or without oral ulcerations. Involvement of buttocks, knees, elbows, and perioral skin is found less commonly.[1],[2] HFMD is usually been associated with coxsackie A16, not uncommonly by coxsackie A5, A10, and by human enterovirus 71.[3] The most cases occur during summer and early autumn.[1],[2] In most instances, this is a mild self-limiting illness. The skin lesions heal spontaneously without scarring. The analysis of the recent epidemics has shown a spectrum of central nervous system complications.[4] Mortality is due to cardio-respiratory failure in severely affected children.[5]


  Materials and Methods Top


A prospective observational study is conducted from August 2013 to January 2014 in Hyderabad city. Consecutive cases clinically diagnosed as HFMD, in pediatric age group, attending DVL outpatient department (OPD) were taken up.

Inclusion Criteria

All clinically diagnosed cases of HFMD children were taken up for the study.

Exclusion Criteria

All above 18 years of age were excluded from the study.

Objectives

This study is to review the clinico epidemiological data for HFMD for early diagnosis, to prevent the complications and to implement the precautionary measures during outbreaks.


  Results Top


A total of 50 cases were observed during an outbreak of HFMD. The youngest child among the cases studied was 7-month-old and the oldest being 16 years [Chart 1]. The infection predominantly affected the children younger than 5 years (80%). Male to female ratio was 1:1. History of contact with similar cases was found in 84% (42) of cases [Chart 2]. All 50 cases presented with both enanthemas and exanthemas either serially or simultaneously, of which 44% (22) cases were associated with prodromal symptoms such as fever, irritability, etc. [Chart 3] and [Chart 4]. All the cases were mild in the form. There were no symptoms and signs of the primary immunodeficiency disorders such as recurrent or atypical microbial infections, and they were not on immunosuppressive medication.



Enathemas

Oral involvement [Figure 1] and [Figure 2] was found among 48% (24) of 50 cases as a presenting complaint, of which 70% (17) cases gave history of either drooling of saliva or refusal of feeds probably due to painful erosions in infants. In seven cases (30%), painful oral erosions were seen on the soft palate, buccal mucosa, lateral side of the tongue, or on the dorsum of the tongue in children [Chart 5]. Oral erosions were either single or multiple in number.
Figure 1: Erosion on soft palate

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Figure 2: Erosion on tongue

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Exanthemas

52% (26) cases presented with cutaneous manifestations [Figure 3],[Figure 4],[Figure 5] as a presenting complaint with itching and pain over the skin lesions in 6 and 2 cases, respectively. Remaining 70% (18) cases were asymptomatic [Chart 6]. Exanthemas were usually present in clusters of 3–10 maculopapules on erythematous skin involving the extremities either on the hand or palm then spreading to other parts of the body such as buttocks, legs, arms, and trunk. The dorsal aspect of the hands and sides of the fingers were involved more often than the palmar aspect and feet.
Figure 3: Football shaped vesicle on erythmatous base on palm and sole

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Figure 4: On buttocks

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Figure 5: Extensive involvement on trunk

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The diagnosis of HFMD was made based on detailed clinical history and examination. Routine investigations of complete blood profile, erythrocyte sedimentation rate, C-reactive protein, complete urine examination and chest X-ray were normal. Tzanck smears were negative ruling out other viral infections such as herpes simplex virus, varicella, and measles.

All the children were treated with supportive and symptomatic therapy such as cold sponging, antipyretics, plenty of oral fluids along with reassurance and counseling their parents. The lesions subsided in 7–10 days without any significant complications such as dehydration, encephalitis, meningitis, myocarditis, and pulmonary edema. All cases were treated on OPD basis, and none of the patients required hospitalization.


  Discussion Top


HFMD is also known as vesicular stomatitis with exanthema caused by coxsackievirus which is highly contagious.[6] During epidemics, the virus spread by horizontal transmission with an incubation period of 3–6 days. Initially, viral implantation occurs in the buccal and ileal mucosa followed by spread to the lymph nodes within 24 h. Oral lesions begin as erythematous macules that evolve into 2–3 mm vesicles on an erythematous base. The vesicles may involve the palate, buccal mucosa, gingival, lips and tongue. The vesicles are rarely observed because they rapidly become eroded. They are painful with drooling of saliva and may interfere with the mastication and feeding as it observed in our study, especially in infants. In 44% of cases, tongue involvement is reported.[7] Viremia rapidly ensues, with spread to the oral mucosa and skin. All lesions will be cleared over a period of 1–2 weeks because after 7–10 days, neutralizing antibody levels increase and the virus is eliminated.[8]

The same was noted in our study in the form of clinical clearance of lesions in 1 to 2 weeks.

Normally there is no enteric virus flora in a human being. In an individual, only one type of enterovirus multiplies within the intestine at any given point of time. Polio vaccination has been eliminated polioviruses from the gut, thereby increasing the chances of other enteroviruses like coxsackievirus and echo viral infections. It is possible that the emergence of HFMD in India may be related to the mass polio vaccination.[9] The largest outbreak of HFMD occurred in an eastern part of India in 2007, where about 38 cases of HFMD in and around Kolkata was reported.[10]

Complications such as dehydration, meningoenchephalitis, myocarditis, pulmonary edema and death occasionally occur in children with HFMD.[11] Complications mainly depend on the strain of the organism, age and immune status of the child. Out of all complications, dehydration was the most common. It may be due to hyperpyrexia and refusal of feeding due to painful erosions, it may be easily prevented by plenty of oral fluids, cold sponging, and antipyretics. In our study of HFMD, we could not find any major complications since this outbreak may be caused by coxsackievirus A16. It is a benign and most common strain whereas enterovirus 71 is a rare strain commonly associated with severe complications. Hence, early diagnosis and treatment along with monitoring for severe complication is mandatory because clinically we may not know the strain of the virus.

Oral lesions of HFMD can be easily misdiagnosed as aphthous ulcers, varicella or herpangina. However, aphthous ulcers are multiple, more painful and recurrent not associated with prodromal symptoms. Varicella rarely presents with oral lesions and the skin lesions are more concentrated on the trunk, rarely affecting the palms and soles. Herpangina is a viral infection of the children caused by a Type A coxsackievirus which presents with similar types of oral ulcers extensively involving the tonsils, pharyngeal mucosa, soft palate and the posterior part of buccal mucosa.[12] Most of the parents come to us with the suspicion of either measles or varicella infection.

Treatment

Medications are usually not needed as HFMD is a viral disease that typically gets better on its own. Currently, there is no specific treatment for HFMD.[13] Disease management typically focuses on achieving symptomatic relief. Pain from the sores may be eased with the use of analgesic medications like the topical application of anesthetics and viscous lidocaine or dyphenhydramine. Infection in older children, adolescents, and adults is typically mild and lasts approximately 1-week, but may occasionally run a longer course. Prodromal symptoms like fever can be treated with plenty of oral fluids, cold sponging, and antipyretics. A minority of individuals with HFMD may require hospital admission due to uncommon neurologic complications such as encephalitis, meningitis, or acute flaccid paralysis.[14] Nonneurologic complications such as myocarditis, pleural effusion, or bleeding into the lungs may also occur.[14]

Complications from the viral infections that cause HFMD are rare but require immediate medical treatment if present. HFMD infections caused by enterovirus 71 tend to be more severe and are more likely to have neurologic or cardiac complications, including death than infections caused by coxsackievirus A16.[13] Viral or aseptic meningitis can occur with HFMD in rare cases and is characterized by fever, headache, stiff neck, or back pain.[13] The condition is usually mild and clears without treatment. However, hospitalization for a short time may be needed. Other serious complications of HFMD include encephalitis or flaccid paralysis in rare circumstances.[13]

Fingernail and toenail loss have been reported in children 4–8 weeks after having HFMD.[15] The relationship between HFMD and the reported nail loss is unclear; however, it is temporary, and nail growth resumes without treatment.[15]

Prevention

Currently, there is no specific vaccine or antiviral therapy against HFMD but such vaccines are being developed.[13] HFMD is highly contagious and is transmitted by nasopharyngeal secretions such as saliva or nasal mucus, by direct contact, or by fecal-oral transmission. Preventive measures include avoiding direct contact with infected individuals, including keeping infected children home from school, proper cleaning of shared utensils, disinfecting contaminated surfaces, and proper hand hygiene. These measures have been shown to be effective in decreasing the transmission of the viruses responsible for HFMD.[13]


  Conclusion Top


Normally there is no enteric viral flora in human beings. Usually, only one type of enterovirus multiplies in an individual at any given point of time. Polio vaccination has eliminated polio viruses from the gut thereby increasing the chances of the coxsackievirus and enteroviral infections. It is possible that the emergence of HFMD in India may be related to the mass polio vaccination. Coxsackievirus A16 is more common and has a benign course, whereas enerovirus 71 is rare and has a lethal outcome. Early accurate diagnosis and treatment of HFMD along with monitoring is crucial to prevent severe complications. Hence, a high index of suspicion is required to diagnose HFMD.

Declaration of Patient Consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.

 
  References Top

1.
Miller GD, Tindall JP. Hand-foot-and-mouth disease. JAMA 1968;203:827-30.  Back to cited text no. 1
    
2.
Ang LW, Koh BK, Chan KP, Chua LT, James L, Goh KT. Epidemiology and control of hand, foot and mouth disease in Singapore, 2001-2007. Ann Acad Med Singapore 2009;38:106-12.  Back to cited text no. 2
    
3.
Chen KT, Chang HL, Wang ST, Cheng YT, Yang JY. Epidemiologic features of hand-foot-mouth disease and herpangina caused by enterovirus 71 in Taiwan, 1998-2005. Pediatrics 2007;120:e244-52.  Back to cited text no. 3
    
4.
Ho M, Chen ER, Hsu KH, Twu SJ, Chen KT, Tsai SF, et al. An epidemic of enterovirus 71 infection in Taiwan. Taiwan Enterovirus Epidemic Working Group. N Engl J Med 1999;341:929-35.  Back to cited text no. 4
    
5.
Huang CC, Liu CC, Chang YC, Chen CY, Wang ST, Yeh TF. Neurologic complications in children with enterovirus 71 infection. N Engl J Med 1999;341:936-42.  Back to cited text no. 5
    
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Buchner A, Mlinek A. Hand-foot-and-mouth disease in children in Israel. Harefuah 1973;84:321-2.  Back to cited text no. 6
    
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8.
Chang LY, King CC, Hsu KH, Ning HC, Tsao KC, Li CC, et al. Risk factors of enterovirus 71 infection and associated hand, foot, and mouth disease/herpangina in children during an epidemic in Taiwan. Pediatrics 2002;109:e88.  Back to cited text no. 8
    
9.
Martin LA. Enteric viruses. In: Petersdorf RG, Adams RD, Braunwald E, Isselbacker KJ, Wilson JD, editors. Harrison Principles of Internal Medicine. 10th ed. McGraw-Hill International Book Company; 1983. p. 1125-32.  Back to cited text no. 9
    
10.
Sarma N, Sarkar A, Mukherjee A, Ghosh A, Dhar S, Malakar R. Epidemic of hand, foot and mouth disease in West Bengal, India in August, 2007: A multicentric study. Indian J Dermatol 2009;54:26-30.  Back to cited text no. 10
[PUBMED]  Medknow Journal  
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Thomas J. Hand foot and mouth disease – An overview. EJ Indian Soc Teledermatol 2009;3:1-5.  Back to cited text no. 11
    
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Sterling JC. Viral infections. In: Burns T, Breathnach S, Cox N, Griffiths C, editors. Rooks Text Book of Dermatology. 7th ed., Vol. 25. Oxford: Blackwell Science; 2004. p. 1-83.  Back to cited text no. 12
    
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Sarma N. Hand, foot, and mouth disease: Current scenario and Indian perspective. Indian J Dermatol Venereol Leprol 2013;79:165-75.  Back to cited text no. 13
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Li Y, Zhu R, Qian Y, Deng J. The characteristics of blood glucose and WBC counts in peripheral blood of cases of hand foot and mouth disease in China: A systematic review. PLoS One 2012;7:e29003.  Back to cited text no. 14
    
15.
Hoy NY, Leung AK, Metelitsa AI, Adams S. New concepts in median nail dystrophy, onychomycosis, and hand, foot, and mouth disease nail pathology. ISRN Dermatol 2012;2012:680163.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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