|Year : 2015 | Volume
| Issue : 4 | Page : 616-619
Hand, foot, and mouth disease in adults: An enigma among diagnosticians - A case series
Benila Mathew, Sunila Thomas, Vivek Velayudhan, Ranimol Prasanna
Department of Oral Medicine and Radiology, PMS College of Dental Science and Research, Trivandrum, Kerala, India
|Date of Submission||10-Jun-2015|
|Date of Acceptance||26-Feb-2016|
|Date of Web Publication||19-Aug-2016|
Dr. Sunila Thomas
Department of Oral Medicine and Radiology, PMS College of Dental Science and Research, Golden Hills, Vattappara, Venkode PO, Trivandrum - 695 028, Kerala
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Hand, foot, and mouth disease (HFMD) is a highly contagious enterovirus infection mainly affecting children less than 5 years of age. In a majority of cases, it is caused by coxsackievirus A16 (CVA16), although instances have been described in which A5, A6, A7, A9, A10, B2, B5, or human enterovirus 71 (HEV-71) has been isolated. The disease occurs rarely in adults, and has been reported in immunocompromised patients. It usually has a benign and self-limiting course with an incubation period of 3-10 days. The prodromal symptoms include fever, malaise, and sore throat. This initial phase is usually followed by erythematous macules, papules, and vesicles on palm and soles, lateral and dorsal surfaces of hands and feet, and also the oral cavity. The purpose of this article is to highlight to the general practitioner about the atypical presentation in healthy adults as well. In the present paper, we describe three cases of HFMD in otherwise healthy adults, with complete recovery.
Keywords: Coxsackievirus A16, HFMD, immunocompetent adults, maculopapular
|How to cite this article:|
Mathew B, Thomas S, Velayudhan V, Prasanna R. Hand, foot, and mouth disease in adults: An enigma among diagnosticians - A case series. J Indian Acad Oral Med Radiol 2015;27:616-9
|How to cite this URL:|
Mathew B, Thomas S, Velayudhan V, Prasanna R. Hand, foot, and mouth disease in adults: An enigma among diagnosticians - A case series. J Indian Acad Oral Med Radiol [serial online] 2015 [cited 2020 Jan 24];27:616-9. Available from: http://www.jiaomr.in/text.asp?2015/27/4/616/188776
| Introduction|| |
Hand, foot, and mouth disease (HFMD) is a well-known enterovirus infection affecting children less than 5 years of age.  It is mainly caused by coxsackievirus A16 (CVA16), but A5, A6, A7, A9, A10, B2, B5, and human enterovirus 71 have also been isolated.  The incubation period is 3-10 days. Prodromal symptoms include fever, malaise, and sore throat, followed by erythematous macules, papules, and vesicles on palm, soles, hands, and feet. It occurs rarely in adults and immunocompromised patients. , CVA6 has also been identified in adult patients. ,, Reports have shown that 25% adults were affected in several outbreaks in western countries between 2011 and 2012.  The present paper describes three cases of HFMD in otherwise healthy adults, with complete recovery.
| Case Reports|| |
A 22-year-old female dental student reported to the Medical OP department of our dental institution with papulovesicular eruptions on hand and foot associated with itching since 2 days. She reported having fever, malaise, body pain, and throat pain the day before the onset of eruptions and was prescribed Levocetirizin e 10 mg and Paracetamol 650 mg. History revealed treating a patient with similar eruptions a few days prior to her symptoms appeared. She had vesicular eruptions with peeling of skin from feet following wearing of new plastic footwear 2 months previously and showed allergic reaction during contrast-enhanced CT radiography for diagnosis of appendicitis 1 year back. She was not under any medication before the onset of lesions. After 3 days, she reported to the Medical OP as the symptoms persisted and was prescribed Betamethasone (0.1%) ointment and oral steroid. She developed severe itching, and the maculopapular rashes aggravated immediately after she started taking oral steroids. She was then referred to the Department of Oral Medicine and Radiology. Examination revealed multiple erythematous papulovesicular eruptions of 4 × 3 mm on the palm, soles, and dorsal surfaces of hands and feet. Some macules of 3 × 2 mm were also seen. Intraorally, diffuse erythematous areas were seen on the soft palate and buccal sulcus corresponding to 38 [Figure 1]a-c. Routine blood examination showed elevated erythrocyte sedimentation rate (ESR; 40 mm/h).
|Figure 1: Case 1-(a) Multiple papules on fingers. (b) Papular lesions and scaly areas on foot. (c) Erythema in relation to 38 region|
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Based on history and clinical examination, a provisional diagnosis of a viral infection, possibly HFMD, was made. Contact dermatitis was also considered due to history of allergy. The patient was then referred to a dermatologist, where HFMD was confirmed and managed with Paracetamol 500 mg, Cetirizine 10 mg, and Lactocalamine lotion. The eruptions resolved within 2 weeks, but skin peeling lasted for a month.
A 22-year-old female student (colleague of case 1) reported with papulovesicular eruptions on hands and feet, 2 weeks after case 1 reported. She had history of fever and sore throat 1 day before the onset of lesions, which was managed with Paracetamol 500 mg. Subsequently, tender erythematous papules appeared on the heel of left foot and sole of right foot. Examination revealed multiple painful erythematous papulovesicular lesions on the sole and lateral surface of right foot and the heel of left foot and measured about 4 × 5 mm. By the third day, similar lesions appeared on the ventral surface of fingers of both hands. Intraorally, diffuse erythematous areas were observed on the left side of soft palate [Figure 2]a-c. Routine blood examinations were normal. Since the lesions were similar to those of case 1, provisional diagnosis of HFMD was made. The student was then referred to a dermatologist and was prescribed Azithromycin 250 mg, Hydroxyzine 10 mg, Orovit, and Paracetamol 650 mg. Lesions resolved completely in 2 weeks without scarring.
|Figure 2: Case 2-(a) Multiple vesiculopapular lesions on heel. (b) Multiple papular lesions on sole. (c) Diffuse erythema on the left side of soft palate|
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A 24-year-old female intern in our institution presented with fever and sore throat at the same time as case 2 and was prescribed Novaclox 500 mg. Next day, she developed erythema of hand, feet, and oral cavity. Some macular erythema was identified on trunk. Physical examination revealed a papule of size 7 × 4 mm with a central clear area surrounded by erythema on the lateral surface of left toe. Multiple erythematous papules of 2 × 2 mm were observed on the sole of left foot, ventral surface of both hands, and trunk. Intraorally, lower lip showed on the right side a yellowish white papule of 1 × 1 mm surrounded by erythema [Figure 3]a-c. Routine blood investigation showed reduced hemoglobin (10 g/dl) and elevated ESR (43 mm/h). Based on similarity with the above two cases, HFMD was considered first. Allergic dermatitis was also considered as she was under antibiotic treatment prior to onset of erythema. Lesions resolved after 2 weeks with symptomatic management.
|Figure 3: Case 3-(a) Multiple papular lesions on fingers. (b) Multiple papulovesicular lesions on foot. (c) Erythematous vesicle on lower lip|
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| Discussion|| |
HFMD was first described by Robinson and Rhodes (1957) in Toronto, Canada, where 60 patients were affected. But the name HFMD was first used in 1960 during a similar outbreak in Birmingham, England. ,, The term is derived from typical maculopapular or vesicular lesions involving the skin of hands, feet, and oral mucosa. Patients do not need to have manifestations in all three areas to be classified as having HFMD. 
The first major outbreak was reported in Malaysia (Sarawak) in 1997.  The first case reported in India was from Kerala (Calicut) in 2003.  Several outbreaks in adults have been reported from many Asian countries. ,,,
In case 1, allergic dermatitis was considered because of history of allergy to plastic footwear, but was ruled out due to presence of lesions on hand. A viral infection was considered as the patient reported prodromal symptoms, and also, the lesions aggravated after using topical Betamethasone (0.1%) ointment and oral steroid. HFMD was confirmed based on the presence of typical lesions on hand, foot, and oral cavity and history of treating a patient with eruptions on hand. The second case was diagnosed based on clinical presentation and history of contact with case 1. Allergic dermatitis was considered for case 3 due to history of taking antibiotics during prodromal symptoms, which could have precipitated the lesions. HFMD with lesions on trunk in addition to hand, foot, and mouth has been reported.  Hence, based on clinical presentation and history, diagnosis of HFMD was made. Another contributing history was all the three students were posted in the same department at the time of presentation of lesions.
As laboratory diagnosis for HFMD is not commonly available in most centers in India, diagnosis is usually made with clinical characteristics alone.  Laboratory tests include microneutralization test, Reverse Transcriptase - Polymerase Chain Reaction, culture method, neutralizing antibody detection, and enzyme-linked immunosorbent assay. , In all three cases, laboratory diagnosis could not be performed due to unwillingness of patients and as most symptoms responded to symptomatic management.
Treatment is usually symptomatic and spontaneous resolution occurs in 2 weeks. Topical anesthetics like viscous lidocaine or diphenhydramine can be used for painful oral ulcers; antipyretics like acetaminophen for fever, analgesics like ibuprofen for arthralgias, local application of bland lotions like Calamine lotion on skin lesions, soothening agents like magnesium hydroxide and sucralfate, and low-level laser therapy to reduce the duration of painful oral ulcers are used for symptomatic management. No effective antiviral therapy or vaccine is available for treatment. The use of oral polio vaccine and acyclovir has been reported, but no beneficial results have been published.  All three cases responded to basic symptomatic treatment effectively.
Since HFMD is a contagious disease, it has the potential to spread very fast over a large population in the community. HFMD often spreads through contact with saliva, respiratory secretions, fecal-oral routes, and fluids in vesicles. Strict implementation of basic protocols like monitoring cleanliness of hands, disinfecting common areas with household bleach (5.25% hypochlorite solution), wearing a surgical mask, isolating contagious people, avoiding close contact with infected persons, and restricting children from attending schools or other outdoor activities can help to reduce the chances of infection with HFMD. Interns and students should have a profound knowledge of the various viral infections, and awareness should be created among them of the different modes of transmission and subsequent clinical implications.
| Conclusion|| |
Even though HFMD is a self-limiting contagious viral disease usually occurring in small children and rarely in adults, the current scenario points out that coxsackie and human enteroviruses can affect healthy individuals too. Clinicians should be aware of this possibility and try to confine and avoid the infection spreading to more vulnerable persons. Thus, it is important for doctors to recognize the atypical presentation of HFMD in adults and treat accordingly.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]