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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

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fifth 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 Medicine.

Figure 2.

  • Figure 1.
  • Figure 3.

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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 of the exanthem, but they are not frequently vesicular in nature. Lesions involving the perineum seem to be more common in children who wear diapers, suggesting that friction or minor trauma may play a role in the development of lesions. Occasionally, children present with a diaper rash, the oral and extremity lesions being evident only on careful examination.

Figure 2. Multiple erythematous papules and a few scattered vesicles are present over the perineum.

Figure 3. Superficially eroded papules are present on the lips.

n outbreak of the vesicular exanthem known as hand-foot-and-mouth disease was first de-

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scribed in 1958.1 The anatomically descriptive

DIFFERENTIAL DIAGNOSIS

name was applied following an epidemic in Birmingham, England, in 1959.2 Although the infectious exanthem was originally ascribed to Coxsackievirus type A16, the clinical picture has also been described with Coxsackievirus types A5, A9, A10, B1, B3, and enterovirus 71.3
The differential diagnosis of hand-foot-and-mouth disease includes other viral exanthems, including herpes simplex virus and varicella infections. The hands and feet of infants and children suspected of having herpes gingivostomatitis, herpangina, or aphthous stomatitis should be examined carefully for the vesicles consistent with hand-foot-and-mouth disease. Insect bites and allergic contact dermatitis may also cause similar appearing lesions.
The clinical features of hand-foot-and-mouth disease occur in almost 100% of the affected preschoolaged children, but only 11% of infected adults have the cutaneous findings.4 The disease tends to be more severe in children younger than 5 years. The skin lesions are frequently preceded by a prodrome of fever (temperature, 38.3° to 40°C), anorexia, malaise, and a sore mouth. The exanthem usually appears 1 to 2 days after the onset of fever but may vary depending on the serotype of the Coxsackievirus involved. The exanthem follows the exanthem by one to several days.

Accepted for publication August 15, 1997.
Reprints: Kevin A. Slavin, MD, University of Califor- nia, San Francisco, Division of Pediatric Infectious Dis- eases, San Francisco General Hospital, 1001 Potrero Ave, 6E6, San Francisco, CA 94110.

The exanthem typically begins as small red macules on the soft and hard palate, buccal mucosa, gingivae, and tongue. The macules rapidly progress to vesicles that can range in size from 1 to 3 mm up to 2 cm. The vesicles rapidly ulcerate. Oral lesions may persist for 1 to 6 days. Young children with extensive involvement around the mouth may become dehydrated from poor fluid intake.
The exanthem is primarily found on the extremities, particularly on the dorsal and palmar and plantar surfaces of the hands and feet. The buttocks are the most commonly involved site beside the hand and foot lesions. The lesions are less commonly found on the arms, legs, and face. The exanthem initially contains macular and papular characteristics but quickly progresses to superficial 3- to 7-mm gray vesicles on an erythematous base. The vesicles are often elliptical or arcuate. The lesions persist for 2 to 7 days. They may rupture, leaving a superficial scab.
Involvement of the buttocks and perineum with the exanthem is common (31% of the reported cases of hand-

REFERENCES

1. Robinson CR, Doane FW, Rhoades AJ. Report of an outbreak of febrile illness with pharyngeal lesions and exanthem: Toronto, summer 1957—isolation of group A coxsackie virus. Can Med Assoc J. 1958;79:615-21.
2. Alsop J, Flewett TH, Foster JR. “Hand-foot-mouth disease” in Birmingham in 1959. BMJ. 1960;2:1708-1711.
3. Cherry JD. Cutaneous manifestations of systemic infections. In: Feigen RD, Cherry JD, eds. Textbook of Pediatric Infectious Diseases. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1992:755-782.
4. Cherry JD. Viral exanthems. Curr Probl Pediatr 1983;13:5-44. 5. Cherry JD. Enteroviruses. In: Feigin RD, Cherry JD, eds. Textbook of Pediatric Infectious Diseases. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1992:1705- 1753.
6. Froeschle JE, Nahmias AJ, Feornio PM, McCord G, Naib Z. Hand, foot, and mouth disease (Coxsackievirus A16) in Atlanta. AJDC. 1967;114:278-283.
7. Magoffin RL, Jackson W, Lennette H. Vesicular stomatitis and exanthem: a syndrome associated with Coxsackie virus, type A16. JAMA. 1961;175:441- 445.
8. Meadow SR. Hand, foot, and mouth diseases. Arch Dis Child. 1965;40:560-564. 9. Richardson HB Jr, Leibovitz A. Hand, foot, and mouth disease in children. J Pediatr. 1965;67:6-12.

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