Picture of the Month

SPECIAL FEATURE

SECTION EDITOR: WALTER W. TUNNESSEN, JR, MD Picture of the Month

Kevin A. Slavin, MD; Ilona J. Frieden, MD

15-MONTH-OLD child had a 4-day history of fever and a 1-day history of a rash. On physical examination she was irritable and had a temperature of 38.3°C. Scattered vesicles were present on her thumb and Afifth toe (Figure 1), erythematous papules and a few vesicles were present over her perineum (Figure 2), and a few superficially eroded papules were evident on her lips (Figure 3). The lesions were gone 3 days later, but a playmate presented with early findings of a similar exanthem.

From the Department of Pediatrics, Division of Infectious Diseases (Dr Slavin) and the Department of Pediatrics and Dermatology (Dr Frieden), University of California, San Francisco School of Figure 2. Medicine.

Figure 1. Figure 3.

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©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 Denouement and Discussion Hand-Foot-and-Mouth Disease Figure 1. Vesicles are present on the thumb and fifth toe. foot-and-mouth disease).1,2,5-9 The lesions on the buttocks are of the same size and typical of the early forms Figure 2. Multiple erythematous papules and a few scattered vesicles are of the exanthem, but they are not frequently vesicular present over the perineum. in nature. Lesions involving the perineum seem to be more Figure 3. Superficially eroded papules are present on the lips. common in children who wear diapers, suggesting that friction or minor trauma may play a role in the develop- ment of lesions. Occasionally, children present with a dia- n outbreak of the vesicular exanthem known as per rash, the oral and extremity lesions being evident only hand-foot-and-mouth disease was first de- on careful examination. scribed in 1958.1 The anatomically descriptive A DIFFERENTIAL DIAGNOSIS name was applied following an epidemic in Birming- ham, England, in 1959.2 Although the infectious exanthem was originally ascribed to Coxsackievirus type A16, The differential diagnosis of hand-foot-and-mouth dis- the clinical picture has also been described with ease includes other viral exanthems, including herpes sim- Coxsackievirus types A5, A9, A10, B1, B3, and entero- plex virus and varicella infections. The hands and feet virus 71.3 of infants and children suspected of having herpes gin- The clinical features of hand-foot-and-mouth dis- givostomatitis, herpangina, or aphthous stomatitis should ease occur in almost 100% of the affected preschool- be examined carefully for the vesicles consistent with aged children, but only 11% of infected adults have the hand-foot-and-mouth disease. Insect bites and allergic cutaneous findings.4 The disease tends to be more se- contact dermatitis may also cause similar appearing vere in children younger than 5 years. The skin lesions lesions. are frequently preceded by a prodrome of fever (temperature, 38.3° to 40°C), anorexia, malaise, and a sore Accepted for publication August 15, 1997. mouth. The exanthem usually appears 1 to 2 days after Reprints: Kevin A. Slavin, MD, University of Califor- the onset of fever but may vary depending on the sero- nia, San Francisco, Division of Pediatric Infectious Dis- type of the Coxsackievirus involved. The exanthem fol- eases, San Francisco General Hospital, 1001 Potrero Ave, lows the exanthem by one to several days. 6E6, San Francisco, CA 94110. The exanthem typically begins as small red macules on the soft and hard palate, buccal mucosa, gingi- REFERENCES vae, and tongue. The macules rapidly progress to vesicles that can range in size from 1 to 3 mm up to 2 cm. The 1. Robinson CR, Doane FW, Rhoades AJ. Report of an outbreak of febrile illness vesicles rapidly ulcerate. Oral lesions may persist for 1 with pharyngeal lesions and exanthem: Toronto, summer 1957—isolation of group to 6 days. Young children with extensive involvement A coxsackie virus. Can Med Assoc J. 1958;79:615-21. around the mouth may become dehydrated from poor 2. Alsop J, Flewett TH, Foster JR. “Hand-foot-mouth disease” in Birmingham in 1959. fluid intake. BMJ. 1960;2:1708-1711. 3. Cherry JD. Cutaneous manifestations of systemic infections. In: Feigen RD, Cherry The exanthem is primarily found on the extremi- JD, eds. Textbook of Pediatric Infectious Diseases. 3rd ed. Philadelphia, Pa: WB ties, particularly on the dorsal and palmar and plantar sur- Saunders Co; 1992:755-782. faces of the hands and feet. The buttocks are the most com- 4. Cherry JD. Viral exanthems. Curr Probl Pediatr 1983;13:5-44. monly involved site beside the hand and foot lesions. The 5. Cherry JD. Enteroviruses. In: Feigin RD, Cherry JD, eds. Textbook of Pediatric Infectious Diseases. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1992:1705- lesions are less commonly found on the arms, legs, and 1753. face. The exanthem initially contains macular and papu- 6. Froeschle JE, Nahmias AJ, Feornio PM, McCord G, Naib Z. Hand, foot, and mouth lar characteristics but quickly progresses to superficial 3- disease (Coxsackievirus A16) in Atlanta. AJDC. 1967;114:278-283. to 7-mm gray vesicles on an erythematous base. The vesicles 7. Magoffin RL, Jackson W, Lennette H. Vesicular stomatitis and exanthem: a are often elliptical or arcuate. The lesions persist for 2 to syndrome associated with Coxsackie virus, type A16. JAMA. 1961;175:441- 445. 7 days. They may rupture, leaving a superficial scab. 8. Meadow SR. Hand, foot, and mouth diseases. Arch Dis Child. 1965;40:560-564. Involvement of the buttocks and perineum with the 9. Richardson HB Jr, Leibovitz A. Hand, foot, and mouth disease in children. J Pe- exanthem is common (31% of the reported cases of hand- diatr. 1965;67:6-12.

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