eMedicine Specialties > Emergency Medicine > Pediatric

Pediatrics, Hand-Foot-and-Mouth Disease

Author: Pamela L Dyne, MD, Associate Professor, Program Director, Department of Medicine, Division of Emergency Medicine, University of California at Los Angeles School of Medicine
Coauthor(s): Stacy Sawtelle, MD, Staff Physician, Department of Emergency Medicine, University of California at Los Angeles/Olive View; Heather Kesler DeVore, MD, Staff Physician, Department of Emergency Medicine, University of California at Los Angeles Olive View Medical Center
Contributor Information and Disclosures

Updated: Dec 20, 2007

Introduction

Background

Hand-foot-and-mouth (HFM) disease is a viral syndrome with a distinct exanthem-enanthem.

This clearly recognizable syndrome is characterized by vesicular lesions on the mouth and an exanthem on the hands and feet (and buttocks) in association with fever.

Pathophysiology

HFM disease is caused by a group of RNA viruses called enteroviruses. The most commonly implicated enterovirus is coxsackievirus A16. However, coxsackieviruses A5, A9, A10, A16, B1, and B3; human enterovirus 71 (HEV71); as well as herpes simplex viruses can cause the illness.

Cases are commonly spread via the fecal-oral or oral-oral route. Respiratory droplet transmission also may occur but is less likely. Typically, the virus seeds the GI tract via the buccal mucosa or the ileum. Over the next 72 hours (accounting for the incubation period), a viremia is established via spread through nearby lymph nodes.1

Frequency

International

Distribution of this disease is worldwide, with a peak incidence in the summer and fall in temperate climates and with no seasonal pattern in the tropics.

Mortality/Morbidity

This illness has, essentially, a full recovery rate. However, HEV71 has been recently implicated in several large outbreaks with severe complications and deaths.

  • Complications are rare, but as with any pruritic rash, a secondary skin infection may occur.
  • Severe complications may occur when CNS or cardiopulmonary involvement is present. These sequelae include dysphagia, limb weakness, cardiopulmonary failure, and even death. Although death is very rare, it is most often due to pulmonary hemorrhage or edema. 
  • Enteroviruses as a group are a cause of aseptic meningitis and encephalitis; however, HFM disease is usually not associated with meningitis.

Sex

Males and females are affected with equal frequency. Males are more likely to become symptomatically ill.

Age

HFM disease as well as severe disease complications are more common among infants and children younger than 5 years.

Clinical

History

  • The usual incubation period is 4-6 days.
  • Prodrome
    • Low-grade fever
    • Malaise
    • Anorexia
    • Abdominal pain 
    • Sore mouth
  • The prodrome precedes the development of oral lesions, followed shortly by skin lesions, primarily on the hands and feet and occasionally on the buttocks.

Physical

HFM disease is the most common cause of mouth sores in pediatric patients.

  • Yellow ulcers surrounded by red halos characterize the oral lesions.
    • These occur primarily on the labial and buccal mucosal surfaces, but they may be observed on the tongue, palate, uvula, anterior tonsillar pillars, or gums. Unlike herpetic gingivostomatitis, perioral lesions are uncommon. Coxsackie A virus also causes herpangina, mostly described as palatal and posterior oropharyngeal lesions without any associated exanthem.
    • The oral ulcers are painful. Children younger than 5 years are predominately more symptomatic than older patients.
  • The exanthem typically involves the dorsal surfaces but frequently may include the palmar, plantar, and interdigital surfaces of the hands and feet.
    • These lesions may be asymptomatic or pruritic.
    • They usually begin as erythematous macules that rapidly progress to thick-walled grey vesicles with an erythematous base.
    • In young infants, these lesions also may be observed on the trunk, thighs, and buttocks.
    • The rash is usually self-limited, lasting approximately 3-6 days.
    • Case reports have documented subacute, chronic, and recurring skin lesions.

Causes

The enteroviruses, specifically coxsackievirus A16, predominate.

More on Pediatrics, Hand-Foot-and-Mouth Disease

Overview: Pediatrics, Hand-Foot-and-Mouth Disease
Differential Diagnoses & Workup: Pediatrics, Hand-Foot-and-Mouth Disease
Treatment & Medication: Pediatrics, Hand-Foot-and-Mouth Disease
Follow-up: Pediatrics, Hand-Foot-and-Mouth Disease
References
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References

  1. Wolff K, Johnson RA, Suurmond D. Viral infections of skin and mucosa. In: Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology. 5th ed. New York, NY: McGraw-Hill; 2005:790-92.

  2. Chang LY, Tsao KC, Hsia SH, et al. Transmission and clinical features of enterovirus 71 infections in household contacts in Taiwan. JAMA. Jan 14 2004;291(2):222-7. [Medline].

  3. Chen KT, Chang HL, Wang ST, Cheng YT, Yang JY. Epidemiologic features of hand-foot-mouth disease and herpangina caused by enterovirus 71 in Taiwan, 1998-2005. Pediatrics. Aug 2007;120(2):e244-52. [Medline].

  4. Cherry JD. Enteroviruses: polioviruses, coxsackieviruses, echoviruses and enteroviruses. In: Textbook of Pediatric Infectious Diseases. 5th ed. 2005:2007.

  5. Cherry JD. Viral exanthems. Curr Probl Pediatr. Apr 1983;13(6):1-44. [Medline].

  6. Davis H, Karasic R. Pediatric infectious disease. In: Atlas of Pediatric Physical Diagnosis. 3rd ed. 1997:347-8.

  7. Marks M. Viral and presumably viral syndromes. In: Pediatric Infectious Diseases for the Practitioner. 1985:494-6.

  8. Sasidharan CK, Sugathan P, Agarwal R, et al. Hand-foot-and-mouth disease in Calicut. Indian J Pediatr. Jan 2005;72(1):17-21. [Medline].

  9. Wang CY, Li Lu F, Wu MH, et al. Fatal coxsackievirus A16 infection. Pediatr Infect Dis J. Mar 2004;23(3):275-6. [Medline].

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Further Reading

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Keywords

HFM, enteroviruses, coxsackievirus A16, coxsackievirus A5, coxsackievirus A9, coxsackievirus A10, coxsackievirus A16, coxsackievirus B1, coxsackievirus B3, herpes simplex virus, yellow ulcers surrounded by red halos, hand-foot-mouth disease, hand-foot and mouth disease

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Contributor Information and Disclosures

Author

Pamela L Dyne, MD, Associate Professor, Program Director, Department of Medicine, Division of Emergency Medicine, University of California at Los Angeles School of Medicine
Pamela L Dyne, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Stacy Sawtelle, MD, Staff Physician, Department of Emergency Medicine, University of California at Los Angeles/Olive View
Disclosure: Nothing to disclose.

Heather Kesler DeVore, MD, Staff Physician, Department of Emergency Medicine, University of California at Los Angeles Olive View Medical Center
Heather Kesler DeVore, MD is a member of the following medical societies: Emergency Medicine Residents Association and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

William G Gossman, MD, Associate Clinical Professor of Emergency Medicine, Creighton University School of Medicine; Consulting Staff, Department of Emergency Medicine, Creighton University Medical Center
William G Gossman, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Wayne Wolfram, MD, MPH, Clinical Associate Professor, Departments of Pediatrics, Children's Hospital and University of Cincinnati
Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School
John Halamka, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD, Assistant Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston
Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
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