Hand foot and mouth disease

Hand foot and mouth disease ( HFMD ) is an acute communicable disease , caused by enteroviruses. It usually affects infants and children but can also affect adults

Caused by Enteroviruses -number of viruses can cause it -commonly from Enterovirus genus of the Picornaviridae family Enteroviruses -familiar viruses also include polioviruses ( PV ) , Coxsackievirus ( CV-A & B ) and ECHO viruses EV are non-enveloped , positive-sense , single stranded RNA viruses Atleast 23 EV serotypes -belonging to two different EV species are known to cause HFMD Of the 23 EV serotypes EV71 and CV-A16 are the most virulent Infection with EV71 can lead to severe disease and sometimes result in death ( main strain of severe and fatal HFMD across the globe )

primarily affects infants and children ( age quoted varies from 5-10 yrs ) but is seen and diagnosed more frequently in children under 5 global disease -several small and large outbreaks have been reported through out the world since the early 1970’s recent surge has been seen in Asia-Pacific region with large outbreaks in China ( 2008-2009 ) causing serious public health concerns outbreaks common in daycares , summer camps or within family it is estimated that about 350-900 children die annually in China due to severe HFMD

Transmission-transmission occurs through direct contact with saliva , faeces , vesicular fluid or respiratory droplets from the infected individual mother to fetus transmission is possible during epidemics incubation period is 3-7 days virus initially replicates in the oral cavity particularly in the tonsils and the bowel infectious period starts from several days before the start of symptoms and peaks within 1 week of the disease onset ( most infectious in the 1st 7 days )

Children can return to school or nursery as soon as they are feeling better No need to stay off until the blisters have all healed Keeping the child for longer periods off school is unlikely to stop the illness from spreading Exclusion of a well pupil is not necessary

starts with low grade fever , reduced appetite , general malaise , irritability mouth or throat pain can happen flat , red or discolured bumps appear on the hands , feet
( including soles ie on palmar and plantar aspects ) and mouth
( can also involve the buttocks and genitals ) appear 3-5 days after exposure to the virus -these can often blister and become vesicular sores vesicles can also be seen in the oral cavity particularly on the tongue and soft palate , surface of the cheeks , gums and tongue fever can persist for 4-5 days rash is generally not itchy in children

erythema multiforme herpangina herpes simplex herpes zoster Kawasaki disease Toxic epidermal necrolyses viral pharyngitis

diagnosis is clinical virus is shed in stools for several weeks hence the advice to promote good hand washing laboratory testing is usually not necessary in mild cases in severe cases / complications -testing can include
○ nasopharyngeal or throat swab ( within 1st few days of illness )
○ faeces
○ others as from vesical fluid ,CSF and tissue Serological tests of limited value but IgG can be used to monitor recovery

usually self limiting and resolves in 10-14 days after disease onset no specific anti-viral treatment is available against any of the viruses that cause HFMD treatment is supportive and for mild cases involve rehydration , analgesics for painful blisters and anti-inflammatories to reduce swelling advise on adequate hydration ( sore throat/ vesicles – reduced oral intake ) recurrence or persistence of infection is rarely seen prognosis is usually excellent for majority of patients

persistent severe headache or high fever age < 3 yrs ( higher risk possibly as the immune function of these children is not fully matured ) myoclonus with sleep disturbances confusion , weakness , lethargy , drowsiness , irritability , generalised seizures , coma abdominal distension , repeated vomiting , photophobia , hallucinations SOB , cold sweats , poor peripheral circulation , tachycardia.

No current vaccine in UK – although 2 vaccines have
 been approved for use in China.

aseptic meningitis ( more common 
with EV71 ) brainstem encephalitis encephalomyelitis acute cerebral ataxia polio like syndrome acute transverse myelitis Guillain-Barre syndrome Benign intracranial hypertension
 dehydration ( common due to stomatitis ) secondary bacterial infection of lesions HFMD during pregnancy / delivery- seek specialist advice occasional pulmonary oedema / haemorrhaged tachycardia and immediate death due to cardiopulmonary failure have been also reported

PATIENT INFORMATION

Printable leaflet from NHS Highlands https://www.nhshighland.scot.nhs.uk/publications/documents/leaflets/hand%20foot%20and%20mouth%20disease%20leaflet.pdf

A comprehensive review by BUPA ( Dr Adrian Raby ) https://www.bupa.co.uk/health-information/childrens-health/hand-foot-and-mouth

Good overview by CDC https://www.cdc.gov/hand-foot-mouth/about/signs-symptoms.html

Learn further -with excellent image collection by DermNet NZ https://dermnetnz.org/topics/hand-foot-and-mouth-disease

REFERENCES

1. Li K, Li X, Si W, et al
   Identifying risk factors for neurological complications and monitoring long-term neurological sequelae: protocol for the Guangzhou prospective cohort study on hand-foot-and-mouth disease  BMJ Open 2019;9:e027224. doi: 10.1136/bmjopen-2018-027224
2. Aswathyraj, S., Arunkumar, G., Alidjinou, E.K. et al. Hand, foot and mouth disease (HFMD): emerging epidemiology and the need for a vaccine strategy. Med Microbiol Immunol 205, 397–407 (2016). https://doi.org/10.1007/s00430-016-0465-y
3. Wang, Xiao-Fang et al. “Epidemiological Features of Hand, Foot and Mouth Disease Outbreaks among Chinese Preschool Children: A Meta-analysis.” Iranian journal of public health vol. 47,9 (2018): 1234-1243.
4. Guerra AM, Orille E, Waseem M. Hand Foot And Mouth Disease. [Updated 2021 Sep 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK431082/
5. Scenario: Management of hand, foot, and mouth disease | Management | Hand foot and mouth disease | CKS | NICE
6. Koh, Wee Ming MSc; Bogich, Tiffany PhD; Siegel, Karen MPH; Jin, Jing MSc; Chong, Elizabeth Y. PhD; Tan, Chong Yew BSc; Chen, Mark IC MBBS, PhD; Horby, Peter MBBS, PhD; Cook, Alex R. PhD The Epidemiology of Hand, Foot and Mouth Disease in Asia, The Pediatric Infectious Disease Journal: October 2016 – Volume 35 – Issue 10 – p e285-e300 doi: 10.1097/INF.0000000000001242
7. Frontiers | Immunopathogenesis and Virus–Host Interactions of Enterovirus 71 in Patients with Hand, Foot and Mouth Disease | Microbiology (frontiersin.org)
8. Hand foot and mouth disease: Enteroviral load and disease severity – EBioMedicine (thelancet.com) Abstract
9. *Management of Hand Foot Mouth Disease (HFMD) in Health Care Settings (chp.gov.hk)
10. CDC image source Symptoms and Diagnosis of Hand, Foot, and Mouth Disease | CDC
11. Chapter 9: managing specific infectious diseases – GOV.UK (www.gov.uk)