Dermatologic Manifestations of Enteroviral Infections Clinical Presentation

  • Author: Susanna Nogués-Siuraneta, MD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Jul 12, 2010
 

History

Coxsackieviruses and echoviruses cause many nonspecific exanthems and enanthems. An exanthem (ie, nonspecific morbilliform eruption) normally occurs 3-4 days before the characteristic enanthem (ie, oral vesicles) appears. Note the images below.

Erosions on the base of the tongue. Erosions on the base of the tongue. A red halo surrounds several vesicles on the fingeA red halo surrounds several vesicles on the finger flexures and palms. Small linear vesicle on the thumb. Small linear vesicle on the thumb. Vesicle on the dorsal hand of a young adult. Vesicle on the dorsal hand of a young adult.

Seasonal distribution is a characteristic feature. In temperate climates, enteroviral infections are most common in the summer and autumn, whereas in tropical areas, they tend to occur year round. Some of the more specific clinical syndromes are described below.

  • Herpangina
    • The principle cause is coxsackie A viruses (serotypes 2-6, 8, and 10). Other viral etiologies include coxsackie B viruses (serotypes 1-4), echoviruses, adenoviruses, and other enteroviruses.
    • After an incubation period of approximately 4 days, the disease begins with acute onset of fever (temperature range, 38.5-40°C) accompanied by headache, sore throat, dysphagia, anorexia, and, occasionally, vomiting and abdominal pain.
  • Hand-foot-and-mouth disease
    • HFMD is most commonly associated with coxsackie A virus 16. HFMD is also associated with infection by coxsackie A virus serotypes 4-7, 9, and 10; coxsackie B virus serotypes 2 and 5; and enterovirus 71. The incubation time is 1-7 days.
    • A brief prodromal period is characterized by low-grade fever, malaise, abdominal pain, and/or respiratory symptoms.
    • Prominent historical features include oral pain and odynophagia, painless vesicles on the hands and feet, and a morbilliform eruption on the buttocks.
  • Boston exanthem disease
    • BED is caused by echovirus 16.
    • Similar to HFMD, BED begins with a brief febrile prodrome.
  • Eruptive pseudoangiomatosis[11]
    • EP is associated with echovirus 25 and echovirus 32.
    • An initial viral prodrome is characteristic.
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Physical

  • Herpangina
    • The enanthem is characterized by the presence of gray-white minute papulovesicles approximately 1-2 mm in diameter.
    • The lesions are surrounded by an erythematous halo, which progresses to a shallow ulcer covered by fibrin.
    • The lesions are self-limiting, resolving over 5-10 days.
    • Lesions are most frequently found on tonsils, uvula, soft palate, and anterior pillars of the tonsillar fauces.
    • The most important differential diagnosis to be considered is acute herpetic gingivostomatitis. However, acute gingivitis is not present in herpangina. Furthermore, herpetic gingivostomatitis is characterized by longer duration and more severe pain.
  • Hand-foot-and-mouth disease
    • Oral lesions begin as erythematous macules and papules that are 2-8 mm in diameter; these progress to form thin-walled vesicles. The vesicles rapidly ulcerate, remaining as shallow painful ulcers surrounded by an erythematous halo. Lesions heal without treatment over 5-10 days. The lesions may be found anywhere in the oral cavity, but they most frequently appear on the hard palate, tongue, buccal mucosa, and gums. The tongue may be erythematous and edematous, and pain may interfere with adequate oral intake.
    • Skin lesions are variably present, but they are characteristic when they occur. The lesions appear along with or shortly after the oral lesions appear, and they may vary in number from a few to more than 100. They begin as erythematous macules or papules, which quickly become small (as large as 5 mm in diameter), gray, oval or linear vesicles surrounded by a red halo. The hands are more commonly involved than the feet. Lesions usually occur on the lateral aspects of the fingers and toes, especially around the nails, but they may be seen in the digital flexures and on the palms and soles. The lesions gradually disappear over 7-10 days, without scarring.
    • In some patients, especially infants, a more widespread papular or vesicular exanthem appears principally on the buttocks, although it may occasionally generalize.
    • In Asia, some epidemics of HFMD have been associated with severe refractory left ventricular failure, cardiogenic shock, CNS disorders, and death. These cases have generally been linked to enterovirus 71.
  • Boston exanthem disease
    • After a brief febrile illness, pink macules and papules abruptly erupt on the face, trunk, and, less commonly, on the extremities.
    • Small ulcerations may be seen on the soft palate and tonsils.
  • Eruptive pseudoangiomatosis
    • After the prodromal period, 2- to 4-mm blanchable, red papules resembling cherry angiomas appear.
    • The lesions usually number no more than 10, and they resolve spontaneously within 10 days.
    • They are distributed on the face, trunk, and extremities.
  • Other associations
    • Acute hemorrhagic conjunctivitis[12, 13, 4] is linked to enterovirus 70 and coxsackie A virus 24.
    • Pustular stomatitis associated with erythema multiforme is linked to coxsackie B virus 5.[14]
    • Widespread vesicular eruption is linked to coxsackie A virus 4.
    • Gianotti-Crosti–like eruption is linked to coxsackie A virus 16.
    • Rubelliform eruption is linked to echovirus 2.
    • Morbilliform eruption is linked to echoviruses 6, 11, and 25.
    • Rubelliform or morbilliform eruption is linked to echovirus 9.
    • Petechiae are linked to echoviruses 11 and 19.
    • Punctate macular eruption is linked to echovirus 19.
    • Vesicular eruption is linked to echovirus 11.
    • Some epidemiological studies strongly suggest that coxsackievirus infections, in particular type B coxsackieviruses, are related to the induction or exacerbation of type 1 diabetes.[15, 16]
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Causes

See Pathophysiology.

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Contributor Information and Disclosures
Author

Susanna Nogués-Siuraneta, MD  Resident, Department of Dermatology, Hospital Clinic de Barcelona

Disclosure: Nothing to disclose.

Coauthor(s)

Mercè Alsina-Gibert, MD  Consultant, Department of Dermatology, Hospital Clinic, Spain

Disclosure: Nothing to disclose.

Steven Brett Sloan, MD  Assistant Professor, Department of Dermatology, University of Connecticut School of Medicine; Director of Nail Disease Clinic and Chief of Dermatology, Newington Veterans Affairs Medical Center

Steven Brett Sloan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Connecticut State Medical Society, New England Dermatological Society, and Texas Dermatological Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Michelle Pelle, MD  Clinical Assistant Professor, Division of Dermatology, Department of Medicine, University of California at San Diego

Michelle Pelle, MD is a member of the following medical societies: American Academy of Dermatology, California Medical Association, Medical Dermatology Society, and Pennsylvania Medical Society

Disclosure: Nothing to disclose.

David F Butler, MD  Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Lester F Libow, MD  Dermatopathologist, South Texas Dermatopathology Laboratory

Lester F Libow, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Texas Medical Association

Disclosure: Nothing to disclose.

Catherine M Quirk, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania

Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD  Director, Department of Dermatology, Geisinger Medical Center

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

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Erosions on the base of the tongue.
A red halo surrounds several vesicles on the finger flexures and palms.
Small linear vesicle on the thumb.
Vesicle on the dorsal hand of a young adult.
 
 
 
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