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Pediatrics, Hand-Foot-and-Mouth Disease

Author: Pamela L Dyne, MD, Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center
Coauthor(s): Stacy Sawtelle, MD, Staff Physician, Department of Emergency Medicine, University of California at Los Angeles/Olive View; Heather Kesler DeVore, MD, Clinical Attending Physician, Assistant Professor Physician, Department of Emergency Medicine, Washington Hospital Center/Georgetown University Hospital
Contributor Information and Disclosures

Updated: Aug 13, 2009

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

Hand-foot-and-mouth disease is caused by a group of RNA viruses called enteroviruses. The most commonly implicated enterovirus is coxsackievirus A16.¹ However, coxsackieviruses A5, A9, A10, A16, B1, and B3; human enterovirus 71 (HEV71); as well as herpes simplex viruses (HSV) 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.²

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, Hand-foot-and-mouth disease is not usually associated with meningitis.

Sex

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

Age

Hand-foot-and-mouth disease, as well as severe disease complications, are more common among infants and children younger than 5 years.

Clinical

History

• The usual incubation period of hand-foot-and-mouth (HFM) disease is 4-6 days.
• The prodrome is associated with the following:
  • 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

Hand-foot-and-mouth disease is the most common cause of mouth sores in pediatric patients.

• Yellow ulcers surrounded by red halos characterize the oral lesions.
  • These primarily occur on the labial and buccal mucosal surfaces but 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 may also 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.

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