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Atypical hand, foot, and mouth disease: a vesiculobullous eruption caused by Coxsackie virus A6

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Summary

A previously well infant aged 9 months presented with an acute, self-limiting illness characterised by high fever and a papular eruption that started on the face. Although fever subsided within 3 days, the rash worsened and extended over the whole body, with some papules evolving into vesiculobullous lesions. The infant had been exposed to children with a similar illness 1 week before onset. PCR of vesicular swabs and stool samples taken on day 6 of illness showed Coxsackie virus A6. The illness resolved within 10 days of onset, although onychomadesis was seen on both big toes at follow-up 5 weeks later. Our case exemplifies the severe, atypical cases of hand, foot, and mouth disease that have been reported worldwide since 2008, and in the USA since the 2011. Atypical hand, foot, and mouth disease is caused by a new lineage of Coxsackie virus A6 and is characterised by high fever and vesiculobullous eruptions on the calves and backs of the hands. Infants with eczema might be predisposed to severe disease.

Section snippets

Case report

A boy aged 9 months presented to his primary care paediatrician with a 1 day history of fever and papular exanthem. The skin lesions had appeared first around the mouth and progressed to involve other areas of the face, trunk, buttocks, and extremities with evolution of some papules to larger vesicular lesions. The infant was febrile with a rectal temperature of 39·4°C but seemed to be comfortable. The skin lesions were distributed most prominently on the calves and the backs of the hands, with

Enteroviruses

The human enteroviruses cause a spectrum of acute illnesses, including self-limited syndromes characterised by fever and diffuse lesions involving the skin, oral mucous membranes, or both. Among these is hand, foot, and mouth disease, a common, highly contagious disease that mainly affects young children. Multiple outbreaks of hand, foot, and mouth disease are reported worldwide every year. The principal cause is Coxsackie virus A enteroviruses, especially Coxsackie virus A16, and the closely

Conclusions

Atypical hand, foot, and mouth disease caused by a new strain of Coxsackie virus A6 affects children worldwide. This syndrome is characterised by high fever, generalised vesiculobullous lesions that ulcerate and scab, and onychomadesis and is seen mostly in young children. Skin involvement might be more extensive in patients with eczema than in those without. Differential diagnosis must include a varicella zoster virus infection, eczema herpeticum, and bullous impetigo. Almost all cases of

Search strategy and selection criteria

We searched PubMed for articles published from Jan 1, 1960, to July 31, 2013, with the search terms “coxsackievirus”, “hand, foot, and mouth disease”, “atypical hand, foot, and mouth disease”, and “onychomadesis”. Additionally, each author searched their personal files and the reference lists of retrieved articles were searched manually.

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