Hand, foot, and mouth disease explained

Hand, foot, and mouth disease
Synonyms:Enteroviral vesicular stomatitis with exanthem
Field:Infectious disease
Symptoms:Fever, flat discolored spots or bumps that may blister
Complications:Temporary loss of nails, viral meningitis
Onset:3–6 days post exposure
Duration:1 week
Causes:Coxsackievirus A16, Enterovirus 71
Diagnosis:Based on symptoms, viral culture
Prevention:Handwashing
Treatment:Supportive care
Medication:Pain medication such as ibuprofen
Frequency:As outbreaks

Hand, foot, and mouth disease (HFMD) is a common infection caused by a group of enteroviruses. It typically begins with a fever and feeling generally unwell. This is followed a day or two later by flat discolored spots or bumps that may blister, on the hands, feet and mouth and occasionally buttocks and groin.[1] [2] [3] Signs and symptoms normally appear 3–6 days after exposure to the virus.[4] The rash generally resolves on its own in about a week. Fingernail and toenail loss may occur a few weeks later, but they will regrow with time.[5]

The viruses that cause HFMD are spread through close personal contact, through the air from coughing and the feces of an infected person. Contaminated objects can also spread the disease.[6] Coxsackievirus A16 is the most common cause, and enterovirus 71 is the second-most common cause. Other strains of coxsackievirus and enterovirus can also be responsible.[7] [8] Some people may carry and pass on the virus despite having no symptoms of disease. Other animals are not involved.[6] Diagnosis can often be made based on symptoms. Occasionally, a throat or stool sample may be tested for the virus.[9]

Most people with hand, foot, and mouth disease get better on their own in 7 to 10 days.[6] Most cases require no specific treatment.[10] No antiviral medication or vaccine is available, but development efforts are underway.[11] [12] For fever and for painful mouth sores, over-the-counter pain medications such as ibuprofen may be used, though aspirin should be avoided in children.[13] The illness is usually not serious. Occasionally, intravenous fluids are given to children who are dehydrated.[14] Very rarely, viral meningitis or encephalitis may complicate the disease.[5] Because HFMD is normally mild, some jurisdictions allow children to continue to go to child care and schools as long as they have no fever or uncontrolled drooling with mouth sores, and as long as they feel well enough to participate in classroom activities.

HFMD occurs in all areas of the world. It often occurs in small outbreaks in nursery schools or kindergartens.[1] Large outbreaks have been occurring in Asia since 1997. It usually occurs during the spring, summer and fall months.[15] Typically it occurs in children less than five years old but can occasionally occur in adults.[1] [16] HFMD should not be confused with foot-and-mouth disease (also known as hoof-and-mouth disease), which mostly affects livestock.[17]

Signs and symptoms

Common constitutional signs and symptoms of the HFMD include fever, nausea, vomiting, feeling tired, generalized discomfort, loss of appetite, and irritability in infants and toddlers. Skin lesions frequently develop in the form of a rash of flat discolored spots and bumps which may be followed by vesicular sores with blisters on palms of the hands, soles of the feet, buttocks, and sometimes on the lips.[18] The rash is rarely itchy for children,[4] but can be extremely itchy for adults. Painful facial ulcers, blisters, or lesions may also develop in or around the nose or mouth.[1] [19] HFMD usually resolves on its own after 7–10 days. Most cases of the disease are relatively harmless, but complications including encephalitis, meningitis, and paralysis that mimics the neurological symptoms of polio can occur.[20]

Cause

The viruses that cause the disease are of the Picornaviridae family. Coxsackievirus A16 is the most common cause of HFMD.[7] Enterovirus 71 (EV-71) is the second-most common cause.[7] Many other strains of coxsackievirus and enterovirus can also be responsible.[7] [8]

Transmission

HFMD is highly contagious and is transmitted by nasopharyngeal secretions such as saliva or nasal mucus, by direct contact, or by fecal–oral transmission. It is possible to be infectious for days to weeks after the symptoms have resolved.[6]

Child care settings are the most common places for HFMD to be contracted because of toilet training, diaper changes, and the fact that children often put their hands into their mouths. HFMD is contracted through nose and throat secretions such as saliva, sputum, nasal mucus and as well as fluid in blisters, and stool.

Diagnosis

A diagnosis usually can be made by the presenting signs and symptoms alone. If the diagnosis is unclear, a throat swab or stool specimen may be taken to identify the virus by culture. The common incubation period (the time between infection and onset of symptoms) ranges from three to six days.[4] Early detection of HFMD is important in preventing an outbreak in the pediatric population.[21]

Prevention

Preventive measures include avoiding direct contact with infected individuals (including keeping infected children home from school), proper cleaning of shared utensils, disinfecting contaminated surfaces, and proper hand hygiene. These measures have been shown to be effective in decreasing the transmission of the viruses responsible for HFMD.[22]

Protective habits include hand washing and disinfecting surfaces in play areas. Breast-feeding has also shown to decrease rates of severe HFMD, though does not reduce the risk for the infection of the disease.

Vaccine

A vaccine known as the EV71 vaccine is available to prevent HFMD in China .[23] No vaccine is currently available in the United States.[22]

Treatment

Medications are usually not needed as hand, foot, and mouth disease is a viral disease that typically resolves on its own. Currently, there is no specific curative treatment for hand, foot and mouth disease. Disease management typically focuses on achieving symptomatic relief. Pain from the sores may be eased with the use of analgesic medications. Infection in older children, adolescents, and adults is typically mild and lasts approximately 1 week, but may occasionally run a longer course. Fever reducers can help decrease body temperature.

A minority of individuals with hand, foot and mouth disease may require hospital admission due to complications such as inflammation of the brain, inflammation of the meninges, or acute flaccid paralysis. Non-neurologic complications such as inflammation of the heart, fluid in the lungs, or bleeding into the lungs may also occur.

Complications

Complications from the viral infections that cause HFMD are rare, but require immediate medical treatment if present. HFMD infections caused by Enterovirus 71 tend to be more severe and are more likely to have neurologic or cardiac complications including death than infections caused by Coxsackievirus A16. Viral or aseptic meningitis can occur with HFMD in rare cases and is characterized by fever, headache, stiff neck, or back pain.[8] The condition is usually mild and clears without treatment; however, hospitalization for a short time may be needed. Other serious complications of HFMD include encephalitis (inflammation of the brain), or flaccid paralysis in rare circumstances.[18]

Fingernail and toenail loss have been reported in children 4–8 weeks after having HFMD.[4] The relationship between HFMD and the reported nail loss is unclear; however, it is temporary and nail growth resumes without treatment.[4] [24]

Minor complications due to symptoms can occur such as dehydration, due to mouth sores causing discomfort with intake of foods and fluid.[25]

Epidemiology

Hand, foot and mouth disease most commonly occurs in children under the age of 10[4] and more often under the age of 5, but it can also affect adults with varying symptoms. It tends to occur in outbreaks during the spring, summer, and autumn seasons.[7] This is believed to be due to heat and humidity improving spread.[26] HFMD is more common in rural areas than urban areas; however, socioeconomic status and hygiene levels need to be considered.[27] Poor hygiene is a risk factor for HFMD.[28]

Outbreaks

India 2022

An outbreak of an illness referred to as tomato fever or tomato flu was identified in the Kollam district on May 6, 2022.[52] The illness is endemic to Kerala, India and gets its name because of the red and round blisters it causes, which look like tomatoes.[52] The disease may be a new variant of the viral HFMD or an effect of chikungunya or dengue fever.[52] [53] [54] Flu may be a misnomer.[53] [55]

The condition mainly affects children under the age of five.[52] [56] An article in The Lancet states that the appearance of the blisters is similar to that seen in monkey pox, and the illness is not thought to be related to SARS-CoV-2.[52] Symptoms, treatment and prevention are similar to HFMD.[52]

History

HFMD cases were first described clinically in Canada and New Zealand in 1957.[57] The disease was termed "Hand Foot and Mouth Disease", by Thomas Henry Flewett, after a similar outbreak in 1960.[58] [59]

Research

Novel antiviral agents to prevent and treat infection with the viruses responsible for HFMD are currently under development. Preliminary studies have shown inhibitors of the EV-71 viral capsid to have potent antiviral activity.[11]

Notes and References

  1. Kaminska . K . Martinetti. G . Lucchini . R. Kaya. G. Mainetti. C. Coxsackievirus A6 and Hand, Foot, and Mouth Disease: Three Case Reports of Familial Child-to-Immunocompetent Adult Transmission and a Literature Review. Case Reports in Dermatology. 5 . 2 . 203–209 . 2013. 24019771. 10.1159/000354533 . 3764954.
  2. Ooi . MH . Wong . SC . Lewthwaite . P. Cardosa. MJ. Solomon. T. Clinical features, diagnosis, and management of enterovirus 71. Lancet Neurology. 9 . 11 . 1097–1105 . 2010. 20965438. 10.1016/S1474-4422(10)70209-X. 17505751 .
  3. Frydenberg. A. Starr. M. Hand, foot and mouth disease.. Australian Family Physician. August 2003. 32. 8. 594–5. 12973865.
  4. Hoy . NY . Leung . AK . Metelitsa . AI. Adams. S. New concepts in median nail dystrophy, onychomycosis, and hand, foot and mouth disease nail pathology. ISRN Dermatology. 2012 . 680163 . 680163. 2012. 22462009. 10.5402/2012/680163 . 3302018 . free .
  5. Web site: May 7, 2024 . HFMD Symptoms and Complications . live . July 7, 2024 . CDC.
  6. Web site: Causes & Transmission. CDC. May 15, 2016. August 18, 2015. live. https://web.archive.org/web/20160514150205/http://www.cdc.gov/hand-foot-mouth/about/transmission.html. May 14, 2016.
  7. Repass GL, Palmer WC, Stancampiano FF . Hand, foot, and mouth disease: Identifying and managing an acute viral syndrome . Cleve Clin J Med . 81 . 9 . 537–43. September 2014. 25183845. 10.3949/ccjm.81a.13132. free .
  8. Li . Y . Zhu . R . Qian . Y. Deng. J. The characteristics of blood glucose and WBC counts in peripheral blood of cases of hand foot and mouth disease in China: a systematic review. PLOS ONE. 7 . 1 . e29003 . 2012. 22235257. 10.1371/journal.pone.0029003 . 3250408. 2012PLoSO...729003L . free .
  9. Web site: Diagnosis. CDC. May 15, 2016. August 18, 2015. live. https://web.archive.org/web/20160514142722/http://www.cdc.gov/hand-foot-mouth/about/diagnosis.html. May 14, 2016.
  10. Book: Longo. Dan L.. Harrison's Principles of Internal Medicine.. 2012. McGraw-Hill. New York. 978-0-07174889-6. 18th.
  11. Pourianfar HR, Grollo L . Development of antiviral agents toward enterovirus 71 infection. J Microbiol Immunol Infect. 48 . 1. 1–8. February 2014. 24560700. 10.1016/j.jmii.2013.11.011.
  12. Fang. Chih-Yeu. Liu. Chia-Chyi. 2018. Recent development of enterovirus A vaccine candidates for the prevention of hand, foot, and mouth disease. Expert Review of Vaccines. 17. 9. 819–831. 10.1080/14760584.2018.1510326. 1744-8395. 30095317. 51952220.
  13. Web site: February 2, 2021. Treat Hand, Foot, and Mouth Disease. October 9, 2021. CDC.
  14. Web site: Hand-foot-and-mouth disease – Symptoms and causes. October 9, 2021. Mayo Clinic. en.
  15. Web site: Outbreaks. CDC. May 15, 2016. August 18, 2015. live. https://web.archive.org/web/20160517180547/http://www.cdc.gov/hand-foot-mouth/outbreaks.html. May 17, 2016.
  16. Web site: Hand Foot and Mouth Disease. CDC. May 14, 2016. August 18, 2015. live. https://web.archive.org/web/20160516032600/http://www.cdc.gov/hand-foot-mouth/about/signs-symptoms.html. May 16, 2016.
  17. Web site: Foot and Mouth Disease update: further temporary control zone established in Surrey . Defra. August 14, 2007. August 14, 2007 . https://web.archive.org/web/20070927000836/http://www.defra.gov.uk/news/2007/070814c.htm. September 27, 2007.
  18. Huang. CC. Liu. CC. Chang. YC. Chen. CY. Wang. ST. Yeh. TF. Neurologic complications in children with enterovirus 71 infection.. The New England Journal of Medicine. September 23, 1999. 341. 13. 936–42. 10498488. 10.1056/nejm199909233411302. free.
  19. Web site: Hand, Foot and Mouth Disease: Signs & Symptoms . May 5, 2008 . mayoclinic.com . The Mayo Clinic . live . https://web.archive.org/web/20080501111320/http://www.mayoclinic.com/health/hand-foot-and-mouth-disease/DS00599/DSECTION%3D2 . May 1, 2008 .
  20. Web site: Hand, Foot and Mouth Disease (HFMD). https://web.archive.org/web/20120423165020/http://www.wpro.who.int/topics/hand_foot_mouth/en/. dead. April 23, 2012. WHO Western Pacific Region. en-GB. November 6, 2017.
  21. Omaña-Cepeda. Carlos. Martínez-Valverde. Andrea. del Mar Sabater- Recolons. María. Jané-Salas. Enric. Marí-Roig. Antonio. López-López. José. March 15, 2016. A literature review and case report of hand, foot and mouth disease in an immunocompetent adult. BMC Research Notes. 9. 165. 10.1186/s13104-016-1973-y. 26975350. 4791924. 1756-0500 . free .
  22. Web site: Hand, Foot and Mouth Disease . 2013 . Prevention and Treatment . Centers for Disease Control and Prevention . October 18, 2013 . live . https://web.archive.org/web/20131017175928/http://www.cdc.gov/hand-foot-mouth/about/prevention-treatment.html . October 17, 2013 .
  23. Mao. QY. Wang. Y. Bian. L. Xu. M. Liang. Z. EV71 vaccine, a new tool to control outbreaks of hand, foot and mouth disease (HFMD).. Expert Review of Vaccines. May 2016. 15. 5. 599–606. 26732723. 10.1586/14760584.2016.1138862. 45722352.
  24. Web site: Hand, Foot and Mouth Disease . 2011 . Complications . Centers for Disease Control and Prevention . October 14, 2013 . live . https://web.archive.org/web/20131017093341/http://www.cdc.gov/hand-foot-mouth/about/complications.html . October 17, 2013 .
  25. Web site: Hand, Foot and Mouth Disease. https://web.archive.org/web/20140424065042/http://www.wpro.who.int/mediacentre/factsheets/fs_10072012_HFMD/en/. dead. April 24, 2014. WHO Western Pacific Region. en-GB. November 6, 2017.
  26. Koh. Wee Ming. Bogich. Tiffany. Siegel. Karen. Jin. Jing. Chong. Elizabeth Y.. Tan. Chong Yew. Chen. Mark Ic. Horby. Peter. Cook. Alex R.. October 2016. The Epidemiology of Hand, Foot and Mouth Disease in Asia: A Systematic Review and Analysis. The Pediatric Infectious Disease Journal. 35. 10. e285–300. 10.1097/INF.0000000000001242. 1532-0987. 5130063. 27273688.
  27. Koh. Wee Ming. Bogich. Tiffany. Siegel. Karen. Jin. Jing. Chong. Elizabeth Y.. Tan. Chong Yew. Chen. Mark IC. Horby. Peter. Cook. Alex R.. October 2016. The Epidemiology of Hand, Foot and Mouth Disease in Asia: A Systematic Review and Analysis. The Pediatric Infectious Disease Journal. 35. 10. e285–e300. 10.1097/INF.0000000000001242. 27273688. 0891-3668. 5130063.
  28. News: Hand-Foot-and-Mouth Disease. WebMD. November 28, 2017. en-US.
  29. Deaths of Children during an Outbreak of Hand, Foot, and Mouth Disease in Sarawak, Malaysia: Clinical and Pathological Characteristics of the Disease. L. G. Chan. Umesh D. Parashar. M. S. Lye. F. G. L. Ong. Sherif R. Zaki. James P. Alexander. K. K. Ho. Linda L. Han. Mark A. Pallansch. Abu Bakar Suleiman. M. Jegathesan. Larry J. Anderson. Clinical Infectious Diseases. 31. 3. 678–683. Oxford Academic. 2000. 10.1086/314032. 11017815. free.
  30. Book: Academy of Medicine (Singapore). Annals of the Academy of Medicine, Singapore. 2003. Academy of Medicine.. 385. In April 1997, in Sarawak, Malaysia, 600 cases of HFMD were admitted and over 30 children died..
  31. Enterovirus 71 in Malaysia: A decade later. Yoke Fun-Chan. I-Ching Sam. Kai-Li Wee. Sazaly Abu Bakar. Neurology Asia. University of Malaya. 2011. August 29, 2019. 16. 1. https://web.archive.org/web/20190829040819/http://eprints.um.edu.my/7327/1/Enterovirus_71_in_Malaysia-_A_decade_later.pdf. August 29, 2019. live.
  32. Assessing the Prevalence of Hand, Foot and Mouth Disease (HFMD) Using Geospatial Density and Distribution Techniques. Nur Najihah Hasan. Faculty of Geoinformation and Real Estate. Universiti Teknologi Malaysia. 2017. August 29, 2019. 2–3 [18–35]. https://web.archive.org/web/20190829025807/http://eprints.utm.my/id/eprint/78873/1/NurNajihahHasanMFGHT2017.pdf. August 29, 2019. live.
  33. Centers for Disease Control and Prevention (CDC) . Deaths among children during an outbreak of hand, foot, and mouth disease—Taiwan, Republic of China, April–July 1998 . MMWR Morb. Mortal. Wkly. Rep. . 47 . 30 . 629–32 . 1998 . 9704628 . live . https://web.archive.org/web/20080726222228/http://www.cdc.gov/mmwr/preview/mmwrhtml/00054640.htm . July 26, 2008 .
  34. Ho M, Chen ER, Hsu KH, etal . An epidemic of enterovirus 71 infection in Taiwan. Taiwan Enterovirus Epidemic Working Group . N. Engl. J. Med. . 341 . 13. 929–35 . 1999 . 10498487 . 10.1056/NEJM199909233411301. free .
  35. News: Suhaimi. Nur Dianah. HFMD: 1,000 cases a week is unusual, says doc. Singapore. The Sunday Times (Straits Times). April 20, 2008. 1–2.
  36. http://vietnamnews.vnagency.com.vn/showarticle.php?num=01HEA150508 Viet Nam News: HFMD cases prompt tighter health screening at airport
  37. http://ubpost.mongolnews.mn/index.php?option=com_content&task=view&id=1847&Itemid=1 EV-71 Virus Continues Dramatic Rise
  38. News: 1,053 HFD cases recorded . Bandar Seri Begawan . November 7, 2008 . The Birmingham News . May 11, 2012 . dead . https://web.archive.org/web/20120722220853/http://www.bt.com.bn/home_news/2008/11/07/1_053_hfmd_cases_recorded . July 22, 2012 .
  39. News: Hand-foot-mouth disease death toll rises to 17 in East China's Shandong Province . April 9, 2009 . China View . September 29, 2009 . dead . https://web.archive.org/web/20090413063806/http://news.xinhuanet.com/english/2009-04/09/content_11159556.htm . April 13, 2009 . mdy-all .
  40. News: Health Ministry: Hand-foot-mouth disease claims 50 lives this year . April 10, 2009 . China View . September 29, 2009 . dead . https://web.archive.org/web/20090415093929/http://news.xinhuanet.com/english/2009-04/10/content_11165126.htm . April 15, 2009 . mdy-all .
  41. Web site: China reports 537 deaths from hand-foot-mouth disease this year . December 2, 2011 . dead . https://web.archive.org/web/20110501194633/http://news.xinhuanet.com/english2010/china/2010-06/24/c_13367598.htm . May 1, 2011 .
  42. Web site: China reports 537 deaths from hand-foot-mouth disease this year . 2010 . People's Daily Online . October 16, 2013 . live . https://web.archive.org/web/20131017081837/http://english.peopledaily.com.cn/90001/90782/90880/7039439.html . October 17, 2013 .
  43. Web site: Coxsackievirus A6 (CVA6). 2013. California Department of Public Health. October 16, 2013. dead. https://web.archive.org/web/20131017090918/http://www.cdph.ca.gov/programs/cder/Pages/CVA6.aspx. October 17, 2013.
  44. News: Outbreak of hand, foot and mouth disease severe in Alabama. Hannah Wolfson. February 13, 2012. The Birmingham News. May 11, 2012. live. https://web.archive.org/web/20120304001524/http://blog.al.com/spotnews/2012/02/outbreak_of_hand_foot_and_mout.html. March 4, 2012.
  45. Web site: Joint Press Release Between The Ministry of Health Kingdom of Cambodia and the World Health Organization. CBS News Staff. 2012. CBS News. October 16, 2013. live. https://web.archive.org/web/20131017073643/http://www.wpro.who.int/cambodiaPRdisease.pdf. October 17, 2013.
  46. Web site: Mysterious deadly illness in Cambodian children tied to hand, foot and mouth disease. 2012. Hand, Foot and Mouth Disease. World Health Organization. June 7, 2022. live. https://web.archive.org/web/20130603011518/http://www.cbsnews.com/8301-504763_162-57468483-10391704/mysterious-deadly-illness-in-cambodian-children-tied-to-hand-foot-and-mouth-disease/. June 3, 2013.
  47. Web site: Global Alert and Response (GAR). 2012. Undiagnosed illness in Cambodia-update. World Health Organization. October 16, 2013. dead. https://web.archive.org/web/20131017073810/http://www.who.int/csr/don/2012_07_09/en/index.html. October 17, 2013.
  48. Web site: Emerging disease surveillance and response . 2013 . Hand, Foot and Mouth Disease . World Health Organization . October 16, 2013 . dead . https://web.archive.org/web/20131017073800/http://www.wpro.who.int/emerging_diseases/HFMD/en/index.html . October 17, 2013 .
  49. Web site: Over 50,000 cases of HFMD recorded, virus strain relatively benign. Martin Carvalho. Hemananthani Sivanandam. Rahimy Rahim. Loshana K Shagar. The Star. August 16, 2018. August 29, 2019. Over 50,000 cases of hand, foot and mouth disease (HFMD) stemming from the Coxsackie virus have been reported since the outbreak of the disease..
  50. Web site: A 2-Year-Old Boy In Sarawak Suffering From HFMD Has Died. Katrina Khairul Azman. Says.com. July 29, 2018. August 29, 2019. https://web.archive.org/web/20190829030802/https://says.com/my/news/hfmd-claimed-its-first-victim-as-two-year-old-died-from-the-virus. August 29, 2019. live.
  51. Web site: 17-month-old boy's death in Penang due to HFMD. The Star. July 30, 2018. August 29, 2019.
  52. Chavda VP, Patel K, Apostolopoulos V . Tomato flu outbreak in India . Lancet Respir Med . August 2022 . 11 . 1 . e1–e2 . 35987204 . 10.1016/S2213-2600(22)00300-9 . 9385198 .
  53. Web site: It's not tomato flu, fever caused by HFMD virus variant: Health Secy Radhakrishnan . June 16, 2022 . The New Indian Express. May 14, 2022.
  54. Web site: May 11, 2022 . Tomato flu in Kerala: No need to panic, authorities instructed to be vigilant . June 30, 2022 . livemint.com.
  55. Web site: Tomato fever or HFMD virus in Kerala? Know causes, and symptoms of HFMD . June 16, 2022 . Zee News . May 15, 2022.
  56. Thiagarajan K . Reports of "tomato flu" outbreak in India are not due to new virus, say doctors . BMJ . 378 . o2101 . August 2022 . 36028244 . 10.1136/bmj.o2101 . 251814659 .
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  58. Alsop J, Flewett TH, Foster JR . "Hand-foot-and-mouth disease" in Birmingham in 1959 . British Medical Journal . 2 . 5214 . 1708–11 . December 1960 . 13682692 . 2098292 . 10.1136/bmj.2.5214.1708.
  59. Flewett TH, Warin RP, Clarke SK . 'Hand, foot, and mouth disease' associated with Coxsackie A5 virus . Journal of Clinical Pathology . 16 . 53–5 . January 1963 . 1 . 13945538 . 480485 . 10.1136/jcp.16.1.53.

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