eMedicine Specialties > Dermatology > Viral Infections

Hand-Foot-and-Mouth Disease

Author: Brad S Graham, MD, Consulting Staff, Dermatology Associates of Tyler
Contributor Information and Disclosures

Updated: Aug 3, 2009

Introduction

Background

Hand-foot-and-mouth disease (HFMD) is a viral illness with a distinct clinical presentation of oral and characteristic distal extremity lesions. Most commonly, the etiologic agents are coxsackieviruses, members of the Picornaviridae family.

Pathophysiology

Epidemic hand-foot-and-mouth disease (HFMD) viral infections are usually caused by members of the Enterovirus genus, namely, coxsackievirus A16 or enterovirus 71. In addition, sporadic cases with coxsackievirus types A4-A7, A9, A10, B1-B3, and B5 have been reported. Infections usually occur as isolated events, but epidemics occur regularly. An outbreak of HFMD in China during 2003 was caused by echovirus 19.¹

The incubation period averages 3-6 days. Coxsackievirus infection is highly contagious. During epidemics, the virus is spread by horizontal transmission from child to child and from mother to fetus. Transmission occurs by means of direct contact with nasal and/or oral secretions, fecal material, or aerosolized droplets in a fecal-oral or oral-oral route. Initial viral implantation in the buccal and ileal mucosa is followed by spread to lymph nodes within 24 hours. Viremia rapidly ensues, with spread to the oral mucosa and skin. By day 7, neutralizing antibody levels increase and the virus is eliminated.

Frequency

United States

HFMD epidemics tend to occur every 3 years in the United States.

International

Worldwide HFMD occurrences are reported. A seasonal pattern is present in temperate climates, with a peak incidence in late summer and early fall.

Mortality/Morbidity

• Hand-foot-and-mouth disease (HFMD) is more severe in infants and children than adults, but generally, the disease has a mild course.
• Enteroviral infections may also cause myocarditis, pneumonia, meningoencephalitis, and even death.
• Rarely, disease recurs.
• Infection in the first trimester may lead to spontaneous abortion or intrauterine growth retardation.
• A large outbreak of HFMD in Taiwan caused by enterovirus 71 had a high mortality rate of 19.3% in the severe cases; the deaths resulted from pulmonary hemorrhage. During this outbreak, mortality rates were highest in children younger than 3 years.²
• In a large epidermic (138 cases) of HFMD related to enterovirus 71 in Singapore, 7 fatalities occurred, most from interstitial pneumonitis or brainstem encephalitis. The report's conclusions were that in general, HFMD is a benign disease but the presence of unusual physical findings, elevated total white blood cell count, and vomiting and the absence of oral ulcers may signify a patient with higher risk of a fatal outcome.³
• A later study of an HFMD epidermic (14 children) in Australia, again with enterovirus 71, reported that 9 (64%) developed severe neurologic disease in which the host immune response seemed to cause most of the neurologic manifestations.⁴
• In one study of an outbreak HFMD in Sarawak, Malaysia caused by human enterovirus 71, the authors identified 3 clinical risk factors to help detect children at risk for neurologic complications. Total duration of fever for 3 or more days, peak temperature elevation greater or equal to 38.5°C, and a history of lethargy all were independently associated with cerebrospinal fluid pleocytosis and neurologic disease.⁵

Race

No racial predilection is recognized for hand-foot-and-mouth disease.

Sex

The male-to-female ratio for hand-foot-and-mouth disease is 1:1.

Age

Most cases of hand-foot-and-mouth disease affect children younger than 10 years, although cases in adults are reported.

Clinical

History

• A brief prodrome of 12-36 hours duration is part of the usual presentation of hand-foot-and-mouth disease (HFMD), which consists of the following:
  • Low-grade fever with an average temperature of 38.3°C and duration of 2-3 days
  • Anorexia
  • Malaise
  • Abdominal pain
  • Sore mouth
  • Cough
• In one study, 80% of the children presented with anorexia and mouth soreness.
• The enanthem usually precedes the exanthem that is asymptomatic, but both may occur simultaneously.
• The lesions on the hands and feet are present for 5-10 days.
• The mucosal and cutaneous lesions heal spontaneously in 5-7 days.

Physical

• Hand-foot-and-mouth disease (HFMD) is more severe in infants and children than adults, but generally, the disease has a mild course.
  • Symptoms such as malaise, low-grade fever, and anorexia are often present.
  • Occasionally, patients have high fever, marked malaise, diarrhea, and arthralgias.
  • Enteroviral infections may also cause myocarditis, pneumonia, meningoencephalitis, and even death.
  • Rarely, disease recurs. One report describes a 15-year-old white boy with recurrent episodes of HFMD at 3 weeks and 7 months following the initial viral illness.⁶ The lesions in the recurrent episodes were located in the same distribution as the initial presentation. His workup after the last case revealed an absence of immunodeficiency and a greater than 4-fold increase in coxsackievirus B titers. No serologic evidence of acute infection was identified, and titers of immunoglobulin G remained elevated for 1 year following this third episode.
  • Infection in the first trimester may lead to spontaneous abortion or intrauterine growth retardation.
• Oral lesions begin as erythematous macules that evolve into 2-3 mm vesicles on an erythematous base.
• The vesicles are rarely observed because they rapidly become ulcerated.
  • They are painful and may interfere with eating.
  • The total number of ulcers averages 5-10.
• The vesicles may involve the palate, buccal mucosa, gingiva, and tongue. The tongue is involved in 44% of the cases, and, in addition to the ulcers, the tongue may be edematous and tender.

• Cutaneous lesions are characteristic and are present in two-thirds of patients.
  • Typically, the hands, feet, and buttocks are involved.
  • The hands are involved more often than the feet, and the dorsal aspect of the hands and sides of the fingers are more commonly involved than the palmar surfaces.
  • Each lesion begins as a 2-10 mm erythematous macule on which a central, gray, oval vesicle develops.
  • The lesions are characteristically elliptical; their long axis parallels the skin lines.
  • These lesions are asymptomatic and resolve in 3-7 days as a result of fluid resorption.

• Erythematous maculopapular eruptions may also occur on the buttocks and arms.
• In one report, 22% of the patients also had marked cervical or submandibular lymphadenopathy.

Causes

• Epidemic hand-foot-and-mouth disease (HFMD) infections are usually caused by coxsackievirus A16 or enterovirus 71.
• In addition, sporadic cases with coxsackievirus types A4-A7, A9, A10, B1-B3, and B5 are reported.
• An outbreak of hand-foot-and-mouth disease in China during 2003 was caused by echovirus 19.¹

• Search for CME/CE on This Topic »

• Hand-Foot-and-Mouth Disease (Infectious Diseases)
• Pediatrics, Hand-Foot-and-Mouth Disease (Emergency Medicine)
• Enteroviral Infections (Dermatology)
• Coxsackieviruses (Infectious Diseases)

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