Paeds · infectious-diseases
Hand-foot-and-mouth disease and enterovirus infection
Also known as Hand-foot-and-mouth disease (HFMD) · Enterovirus 71 infection · EV71 brainstem encephalitis · Coxsackievirus A6 atypical HFMD · Eczema coxsackium · Enteroviral vesicular stomatitis with exanthem
Fellowship topic on hand-foot-and-mouth disease (HFMD) and enterovirus infection in children: the causative enteroviruses (coxsackievirus A16, enterovirus 71 and the atypical coxsackievirus A6) and their faecal-oral, droplet and vesicle-fluid transmission; the classic vesicular oral-and-acral picture; the atypical CVA6 phenotype with onychomadesis; and the feared EV71 neurological spectrum from aseptic meningitis through brainstem encephalitis to neurogenic pulmonary oedema and death; the differential of oral ulcers and vesicular rashes; PCR and serology interpreted by sample type and duration; stepwise management from outpatient analgesia and hydration through PICU care with fluid restriction and milrinone for EV71 cardiopulmonary failure, the weak-evidence role of IVIG, and the absence of any proven antiviral; childcare exclusion, outbreak notification and household hygiene; the inactivated EV71 vaccines licensed in China and the WHO SAGE 2016 position; special populations (infants, immunocompromised, Asia-Pacific and migrant communities, rural and remote children); and ANZ/UK/US/Canada guidance.
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Target exams
Red flags
- A febrile child with HFMD who develops myoclonus, ataxia, tremor or limb weakness — enterovirus 71 brainstem encephalitis or myelitis until proven otherwise; admit and escalate
- Tachycardia, hypertension, poor perfusion or cold extremities in EV71 disease — autonomic dysregulation preceding cardiopulmonary collapse; this is a PICU emergency
- Tachypnoea, desaturation, frothy sputum or pulmonary oedema in a child with EV71 neurological signs — neurogenic pulmonary oedema; mortality is high
- An infant under one with poor feeding, drowsiness, irritability or reduced urine output — dehydration from painful oral ulcers or early encephalopathy; admit for fluids and observation
- Widespread vesiculobullous rash with skin, nail and mucosal involvement beyond palms and soles — coxsackievirus A6 atypical HFMD; distinguish from Stevens-Johnson syndrome
Life stages
Care settings
Clinical exam formats
Board mappings
- General Paediatrics and Infectious Diseases: hand-foot-and-mouth disease — causative enteroviruses, classic and atypical clinical picture, complications and management
- Community child health: childcare exclusion, outbreak notification and household hygiene in HFMD
- Renewed curriculum — Infectious diseases: enterovirus 71 neurological spectrum, brainstem encephalitis and neurogenic pulmonary oedema recognition and PICU management
- Neurology and critical care: EV71 grading, fluid restriction, milrinone and prognostic markers
- General Paediatrics: the febrile child with a vesicular rash and oral ulcers — diagnosis, red flags and disposition
- Emergency presentation: recognition of EV71 brainstem encephalitis and autonomic dysregulation
- Long Case / Structured discussion: a child recovering from uncomplicated HFMD complicated by EV71 encephalitis — pathophysiology, critical care, prognosis and prevention
- Communication station: explaining HFMD, infectivity, childcare return and absence of a routine vaccine to a family
- Level 2 / 3 — Infection: enterovirus infection and HFMD as a common exanthem; clinical features, complications and when to escalate
- Public health: childcare exclusion, outbreak management and infection control
- Foundation of Practice (FOP): HFMD clinical picture, differential of oral ulcers and vesicular rashes
- Applied Knowledge in Practice (AKP): EV71 neurological complications and stepwise management
- History-taking and management: the febrile child with a rash and poor feeding
- Communication: explaining HFMD, infectivity and prevention to a family
- General Pediatrics Content Outline — HFMD and enterovirus infection: causative agents, clinical features, differential, complications and management
- Infectious Diseases and Critical Care: EV71 brainstem encephalitis and neurogenic pulmonary oedema
- Prevention: hygiene, childcare exclusion and the EV71 vaccine landscape
- Patient Care: diagnosis and stepwise management of HFMD from outpatient support to PICU care of EV71 disease
- Systems-Based Practice and Population Health: childcare exclusion, outbreak notification and the WHO EV71 vaccine position
- Medical Knowledge: enterovirus pathophysiology, the EV71 neurological spectrum and prognostic markers
- Medical Expert: HFMD diagnosis, differential, complications and EV71 critical-care management
- Health Advocate and Collaborator: childcare exclusion, outbreak response and equity of access to care
- Communicator: explaining HFMD, infectivity and prevention to families
The same rash, two different threats
Coxsackievirus A16 — the common face
Enterovirus 71 — the dangerous face
Overview & Definition
Picture a two-year-old brought to the general practice with two days of fever, drooling and refusing to eat. On examination there are shallow grey ulcers on the tongue and buccal mucosa, and a handful of oval vesicles on the palms, the soles and around the buttocks. The child is miserable but alert and well hydrated. This is textbook hand-foot-and-mouth disease, and the task is to recognise it, manage the discomfort, advise the family on infectivity — and stay alert for the small minority in whom the same rash heralds a life-threatening neurological illness. [2] [8]
Hand-foot-and-mouth disease is an acute, self-limiting enterovirus infection whose hallmark is a vesicular enanthem in the mouth paired with a vesicular exanthem on the hands, feet and around the buttocks. It is caused by non-polio enteroviruses, most often coxsackievirus A16 and enterovirus 71, and increasingly by coxsackievirus A6. The illness spreads readily among young children in childcare through saliva, vesicle fluid and the faecal-oral route, which is why it sweeps through kindergartens each season. [1] [2]
The clinician's job has two halves that rarely overlap. The common half is reassurance and symptomatic care for the child with the classic rash. The dangerous half is recognising enterovirus 71 disease, in which the identical rash is the portal to a brainstem encephalitis that can progress to autonomic dysregulation, neurogenic pulmonary oedema and death within hours. Holding both halves in mind at once — ordinary and lethal — is the core skill this topic asks of you. [2] [9]
References10ShowHide
- [1]Solomon T; Lewthwaite P; Perera D; Cardosa MJ; Ooi MH; et al Virology, epidemiology, pathogenesis, and control of enterovirus 71. Lancet Infect Dis, 2010.PMID 20961813
- [2]Ooi MH; Wong SC; Lewthwaite P; Cardosa MJ; Solomon T Clinical features, diagnosis, and management of enterovirus 71. Lancet Neurol, 2010.PMID 20965438
- [3]Zhu F; Xu W; Xia J; Liang Z; et al Efficacy, safety, and immunogenicity of an enterovirus 71 vaccine in China. N Engl J Med, 2014.PMID 24571754
- [4]Li R; Liu L; Mo Z; Wang X; Xia J; et al An inactivated enterovirus 71 vaccine in healthy children. N Engl J Med, 2014.PMID 24571755
- [5]Ooi MH; Wong SC; Mohan A; Podin Y; et al Identification and validation of clinical predictors for the risk of neurological involvement in children with hand, foot, and mouth disease in Sarawak. BMC Infect Dis, 2009.PMID 19152683
- [6]Ooi MH; Solomon T; Podin Y; Mohan A; et al Evaluation of different clinical sample types in diagnosis of human enterovirus 71-associated hand-foot-and-mouth disease. J Clin Microbiol, 2007.PMID 17446325
- [7]Griffiths MJ; Ooi MH; Wong SC; Mohan A; et al In enterovirus 71 encephalitis with cardio-respiratory compromise, elevated interleukin 1β, interleukin 1 receptor antagonist, and granulocyte colony-stimulating factor levels are markers of poor prognosis. J Infect Dis, 2012.PMID 22829643
- [8]Cox JA; Hiscox JA; Solomon T; Ooi MH; et al Immunopathogenesis and Virus-Host Interactions of Enterovirus 71 in Patients with Hand, Foot and Mouth Disease. Front Microbiol, 2017.PMID 29238324
- [9]Weng KF; Chen LL; Huang PN; Shih SR Neural pathogenesis of enterovirus 71 infection. Microbes Infect, 2010.PMID 20348010
- [10]Qiu J; Lu X; Liu P; Zhang X; et al N-terminal pro-B-type natriuretic peptide for the prognostic prediction of severe enterovirus 71-associated hand, foot, and mouth disease. Int J Infect Dis, 2017.PMID 27818360