Diagnostic Considerations

A review by Nassef et al reported that atypical manifestations of hand-foot-and-mouth disease in children with atopic dermatitis may mimic herpetic superinfection. The authors further add that in a child presenting with nail changes, physicians should consider antecedent hand-foot-and-mouth disease in the differential diagnosis.^{[6, 7]}

Differential Diagnoses

Emergent Management of Pediatric Patients with Fever
Herpes Simplex Virus (HSV) in Emergency Medicine
Kawasaki Disease
Measles
Pediatric Chickenpox
Pediatric Dehydration
Pediatrics, Henoch-Schönlein Purpura
Pharyngitis
Stevens-Johnson Syndrome

Workup

Suzuki Y, Taya K, Nakashima K, et al. Study on Risk Factors for Severe Hand-foot-and-mouth Disease. Pediatr Int. 2009 Aug 3. [QxMD MEDLINE Link].
Wolff K, Johnson RA, Suurmond D. Viral infections of skin and mucosa. Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology. 5th ed. New York, NY: McGraw-Hill; 2005. 790-92.
Xing W, Liao Q, Viboud C, Zhang J, Sun J, Wu JT, et al. Hand, foot, and mouth disease in China, 2008-12: an epidemiological study. Lancet Infect Dis. 2014 Apr. 14(4):308-18. [QxMD MEDLINE Link]. [Full Text].
Wang SM, Lei HY, Liu CC. Cytokine immunopathogenesis of enterovirus 71 brain stem encephalitis. Clin Dev Immunol. 2012. 2012:876241. [QxMD MEDLINE Link]. [Full Text].
Lott JP, Liu K, Landry ML, Nix WA, Oberste MS, Bolognia J, et al. Atypical hand-foot-and-mouth disease associated with coxsackievirus A6 infection. J Am Acad Dermatol. 2013 Nov. 69(5):736-41. [QxMD MEDLINE Link].
Nassef C, Ziemer C, Morrell DS. Hand-foot-and-mouth disease: a new look at a classic viral rash. Curr Opin Pediatr. 2015 Aug. 27 (4):486-91. [QxMD MEDLINE Link].
Kuehnel NA, Thach S, Thomas DG. Onychomadesis as a Late Complication of Hand-Foot-Mouth Disease: A Case Series Shedding Light on Nail Shedding. Pediatr Emerg Care. 2017 Nov. 33 (11):e122-e123. [QxMD MEDLINE Link].
Hopper SM, McCarthy M, Tancharoen C, Lee KJ, Davidson A, Babl FE. Topical Lidocaine to Improve Oral Intake in Children With Painful Infectious Mouth Ulcers: A Blinded, Randomized, Placebo-Controlled Trial. Ann Emerg Med. 2013 Nov 7. [QxMD MEDLINE Link].
Chang LY, Tsao KC, Hsia SH, et al. Transmission and clinical features of enterovirus 71 infections in household contacts in Taiwan. JAMA. 2004 Jan 14. 291(2):222-7. [QxMD MEDLINE Link].
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. 2007 Aug. 120(2):e244-52. [QxMD MEDLINE Link].
Cherry JD. Enteroviruses: polioviruses, coxsackieviruses, echoviruses and enteroviruses. Textbook of Pediatric Infectious Diseases. 5th ed. 2005. 2007.
Cherry JD. Viral exanthems. Curr Probl Pediatr. 1983 Apr. 13(6):1-44. [QxMD MEDLINE Link].
Davis H, Karasic R. Pediatric infectious disease. Atlas of Pediatric Physical Diagnosis. 3rd ed. 1997. 347-8.
Marks M. Viral and presumably viral syndromes. Pediatric Infectious Diseases for the Practitioner. 1985. 494-6.
Sasidharan CK, Sugathan P, Agarwal R, et al. Hand-foot-and-mouth disease in Calicut. Indian J Pediatr. 2005 Jan. 72(1):17-21. [QxMD MEDLINE Link].
Wang CY, Li Lu F, Wu MH, et al. Fatal coxsackievirus A16 infection. Pediatr Infect Dis J. 2004 Mar. 23(3):275-6. [QxMD MEDLINE Link].
Jones E, Pillay TD, Liu F, Luo L, Bazo-Alvarez JC, Yuan C, et al. Outcomes following severe hand foot and mouth disease: A systematic review and meta-analysis. Eur J Paediatr Neurol. 2018 Sep. 22 (5):763-773. [QxMD MEDLINE Link].
Zhao Y, Zhang H, Liu H, Zhang J, He L, Sun H, et al. Molecular characteristics of hand, foot, and mouth disease for hospitalized pediatric patients in Yunnan, China. Medicine (Baltimore). 2018 Aug. 97 (31):e11610. [QxMD MEDLINE Link].

Media Gallery

The lower lip has an ulcer with an erythematous halo.
The tongue has an ulcer with an erythematous halo.
A typical cutaneous lesion has an elliptical vesicle surrounded by an erythematous halo. The long axis of the lesion is oriented along the skin lines.

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Author

Pamela L Dyne, MD Professor of Clinical Medicine/Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center

Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Stacy Sawtelle, MD Clinical Instructor, Department of Emergency Medicine, University of California, San Francisco, School of Medicine

Disclosure: Nothing to disclose.

Heather Kesler DeVore, MD Assistant Professor, Clinical Attending Physician, Department of Emergency Medicine, Georgetown University Hospital and Washington Hospital Center

Heather Kesler DeVore, MD is a member of the following medical societies: Society for Academic Emergency Medicine, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Wayne Wolfram, MD, MPH Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center; Chairman, Pediatric Institutional Review Board, Mercy St Vincent Medical Center, Toledo, Ohio

Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, Southern Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

William G Gossman, MD, FAAEM Associate Clinical Professor of Emergency Medicine, Creighton University School of Medicine; Chairman, Department of Emergency Medicine, Creighton University Medical Center

William G Gossman, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.