Hand-foot-and-mouth disease and enterovirus infection

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]