Atypical hand-foot-and-mouth disease associated with coxsackievirus A6 infection

Abstract

Background: Hand-foot-and-mouth disease (HFMD) is an acute viral illness commonly caused by coxsackievirus (CV)-A16 and enterovirus 71 infections. Recently, atypical HFMD has been reported in association with CV-A6, an uncommon enterovirus strain.

Objective: We sought to describe the clinical features of atypical HFMD associated with CV-A6 infection and its diagnostic laboratory evaluation.

Methods: Patients presenting to our institution with history and examination suggestive of atypical HFMD from January 2012 to July 2012 were identified. Morphology and distribution of mucocutaneous lesions were recorded. Enterovirus infection was assessed by reverse transcriptase polymerase chain reaction of biologic specimens. Enterovirus type was determined by viral capsid protein 1 gene sequencing.

Results: Two adults and 3 children with atypical HFMD were identified. Four of 5 patients exhibited widespread cutaneous lesions. In 2 patients with a history of atopic dermatitis, accentuation in areas of dermatitis was noted. Associated systemic symptoms prompted 4 of 5 patients to seek emergency care, and both adults were hospitalized for diagnostic evaluation. Infection with CV-A6 was confirmed in all patients.

Limitations: This study is a case series from a single institution.

Conclusion: Consideration of the expanded range of cutaneous findings in atypical HFMD caused by CV-A6 infection may assist clinicians in diagnosis and management.

Keywords: AD; CDC; CV; Centers for Disease Control and Prevention; ED; HFMD; PCR; RT; atopic dermatitis; atypical; coxsackievirus; coxsackievirus A6; diagnosis; emergency department; enterovirus; evaluation; exanthem; hand-foot-and-mouth disease; polymerase chain reaction; reverse transcriptase.

Figures 1

Cutaneous lesions of atypical HFMD. Erythematous papulovesicles involving the fingers of Patient 1 (A). Erythematous papules involving the ear and antecubital fossa of Patient 2 (B, C). Significant involvement of the antecubital fossa, a common site of involvement of AD in Patient 3, in addition to scattered papules on the forearm and thigh (D). Papulovesicles involving the perioral area and lips (E), sole (F), and palm (G) in Patient 4.