Basics
Description
Hand, foot, and mouth disease is a viral illness with the characteristic clinical features of the following:
- Vesiculoulcerative stomatitis
- Papular or vesicular exanthem on the hands and/or the feet
- Mild constitutional symptoms such as fever and malaise
General Prevention
- Frequent hand washing, especially after changing diapers, and good personal hygiene are the most useful means to prevent spread of enteroviral illnesses.
- Contact precautions should be maintained with all hospitalized patients.
- The prodromal and enanthem periods appear to be the most contagious; however, some may shed virus in the stool 3 months after infection.
Epidemiology
- In temperate climates, hand, foot, and mouth disease is most common in the summer and fall (a pattern common to many of the enterovirus infections).
- In tropical climates, disease is present year-round.
- Transmitted by oral-fecal route. Respiratory secretions may also transmit the virus.
- Incubation period is 3-6 days.
- Highly contagious, afflicting up to 50% of those exposed
- Close household contacts are particularly susceptible.
- Most common in children younger than 5 years but may affect adults
- May occur as an isolated case or in an epidemic distribution
Pathophysiology
- Enteroviruses are acquired primarily from oral-fecal contamination.
- Lymphatic invasion leads to viremia and spread to secondary sites.
- Viremia ceases with antibody production.
- Direct inoculation of the extremities from oral lesions has been hypothesized with regard to hand, foot, and mouth disease.
Etiology
Coxsackie A16 virus is the most common causative agent. Other serotypes include the following:
- Coxsackieviruses A5, A7, A9, A10, A16, B1, and B3
- Enterovirus 71
- Echoviruses
- Other enteroviruses
Diagnosis
History
- History of ill contacts
- Family members or close contacts are often similarly affected.
- Incubation period 3-6 days
- Any fever, pain, or other symptoms
- A mild prodrome occasionally precedes the characteristic enanthem and exanthem by 1 or 2 days
- Low-grade fever (usually near 101 °F [38.3 °C])
- Malaise, sore mouth, anorexia, coryza, diarrhea, abdominal pain
- Lesions in mouth
- Oral lesions typically occur shortly before the hand and foot manifestations.
- Hydration status
- Determine quality and amount of oral intake, quality and amount of urine output, recent weight loss, duration of symptoms.
Physical Exam
- Enanthem
- Oral lesions begin as small, red papules.
- Papules quickly evolve to small vesicles on an erythematous base.
- Lesions progress to ulcerations.
- Tongue, buccal mucosa, palate, gingiva, uvula, and/or tonsillar pillars may be involved.
- Typically 2-10 lesions that may persist up to 1 week
- Exanthem
- Less consistently present than oral lesions occurring in 1/4-2/3 of patients
- Maculopapular eruptions progress to vesicles.
- Rarely tender or pruritic
- Most frequent on the dorsal aspects of fingers and toes
- May also occur on the palms, soles, arms, legs, buttocks, and face
- Adenopathy
- Enlarged anterior cervical or submandibular nodes are present in 1/4 of cases.
- Other
- Attention should be given to the patient's vital signs; general appearance; and respiratory, cardiac, and neurologic functioning to help identify the rare patient with a threatening complication of hand, foot, and mouth disease.
Diagnostic Tests & Interpretation
Lab
- Hand, foot, and mouth disease has unique clinical features and a relatively benign course. Laboratory confirmation of the diagnosis is seldom needed or indicated.
- Culture
- Causative viruses may be cultured from many sites:
- Oral ulcers
- Cutaneous vesicles
- Nasopharyngeal swabs
- Stool (Isolation of an enterovirus from the stool does not confirm it to be the cause of disease because the virus can be shed for many weeks after infection.)
- Cerebrospinal fluid (CSF) (in cases where meningoencephalitis is suspected). Reverse transcription-polymerase chain reaction (RT-PCR) can be used and is more sensitive than culture in the CSF.
Differential Diagnosis
Few infectious diseases have such characteristic clinical findings. Oral ulcerations followed by lesions on the distal extremities are virtually pathognomonic. The most difficult diagnostic dilemmas may occur early in the disease course when isolated oral lesions predominate:
- Herpangina
- Also caused by coxsackie A viruses
- Associated with higher fever
- Usually limited to the posterior oropharynx
- Herpetic gingivostomatitis
- Most common cause of stomatitis in children
- Associated with higher fever
- More frequently associated with lymphadenopathy
- Gingival involvement severe
- Aphthous ulcers
- Can occur without fever or upper respiratory symptoms
- Does not occur in outbreaks
- No seasonal predilection
- Stevens-Johnson syndrome
- Ulcerations frequently coalesce.
- Usually affects other mucous membranes
- Often appears with separate cutaneous manifestations
- The Boston exanthem
- Caused by echovirus 16
- Mild febrile illness with a macular rash on the palms and soles occurring at time of or after defervescence
- Oral lesions absent
Treatment
Supportive Care
No specific therapy is indicated or usually necessary. Most cases are mild and self-limiting and only require parental reassurance.
Special Therapy
- Symptomatic relief from particularly painful oral ulcers may be accomplished by application of a topical antihistamine or anesthetic directly to the sores.
- Dehydration should be treated when present. IV fluids may be required in the more severe cases, especially in infants and young children.
- Good supportive care is generally sufficient to treat most complications.
Medication
Acetaminophen may relieve malaise and minor discomfort associated with the oral ulcers. It also may be used as an antipyretic in those children with fever.
Inpatient Considerations
Admission Criteria
Dehydration and inability to maintain adequate oral hydration
Discharge Criteria
Rehydration and good oral intake
Ongoing Care
Follow-up Recommendations
Small children must be followed closely for signs of dehydration.
Diet
Dietary adjustments often improve oral intake from painful oral lesions and prevent or relieve dehydration:
- Avoid spicy or acidic foods.
- Provide cool or iced liquids in small quantities frequently.
Prognosis
- In nearly all instances, hand, foot, and mouth disease will resolve quickly, usually within 1 week after diagnosis, requiring only supportive care.
- Careful history and examination should distinguish those patients with the rare aforementioned complications.
- Rare cases may recur at intervals for up to 1 year.
Complications
- Hand, foot, and mouth disease is usually self-limited and uncomplicated, resolving within 7-10 days.
- Dehydration is the most frequent morbid complication:
- Oral ulcerations are painful and interfere with feeding.
- Infants and children are at highest risk.
- Rare complications include the following:
- Neurologic complications such as aseptic meningitis, encephalitis, and acute flaccid paralysis
- Pneumonia
- Myocarditis
- A possible association with 1st-trimester spontaneous abortions in previously infected women
Additional Reading
- American Academy of Pediatrics. Herpes simplex. In: Pickering LK, Baker CJ, Kimberlin DW, et al, eds. Red Book: 2012 Report of the Committee on Infectious Diseases. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012.
- Robinson CR, Doane FW, Rhodes AJ. Report of an outbreak of febrile illness with pharyngeal lesions and exanthem: Toronto, summer 1957; isolation of group A coxsackie virus. Can Med Assoc J. 1958;79(8):615-621. [View Abstract]
- Ruan F, Yang T, Ma H, et al. Risk factors for hand, foot, and mouth disease and herpangina and the preventive effect of hand-washing. Pediatrics. 2011;127(4):e898-e904. [View Abstract]
- Scott LA, Stone MS. Viral exanthems. Dermatol Online J. 2003;9(3):4. [View Abstract]
- Slavin KA, Frieden IJ. Picture of the month: hand-foot-and-mouth disease. Arch Pediatr Adolesc Med. 1998;152(5):505-506. [View Abstract]
Codes
ICD09
- 074.3 Hand, foot, and mouth disease
- 079.2 Coxsackie virus infection in conditions classified elsewhere and of unspecified site
ICD10
- B08.4 Enteroviral vesicular stomatitis with exanthem
- B34.1 Enterovirus infection, unspecified
SNOMED
- 266108008 hand foot and mouth disease (disorder)
- 186658007 Coxsackie virus disease (disorder)
FAQ
- Q: What is in the "magic mouthwash" often used to relieve the pain of stomatitis?
- A: Many health care providers will prescribe a magic mouthwash for symptomatic relief of oral ulcers, pharyngitis, and teething pain. The most common such treatment consists of an aluminum hydroxide/magnesium hydroxide gel suspension and diphenhydramine elixir (12.5 mg/5 mL) in a 1:1 formulation. It can be applied directly to the sores with a cotton swab or a small syringe before meals. Note: Some people will have a reaction to topical diphenhydramine.
- Q: Should lidocaine be used topically or in suspension with magic mouthwash for symptomatic relief of oral ulcers?
- A: The routine use of lidocaine in this situation is not recommended. Lidocaine is an effective topical anesthetic and comes in a 2% viscous suspension. In practice, the pain relief is short lived, which encourages frequent administration. Lidocaine is absorbed from the mucous membranes (bypassing 1st-pass liver metabolism) and has been frequently reported to cause poisoning of the cardiovascular and central nervous systems. Both pediatric and adult fatalities have occurred. Topical viscous lidocaine should be reserved for use by physicians knowledgeable about its proper dosage and potential side effects and by educated, compliant parents or caregivers.
- Q: When may children with hand, foot, and mouth disease return to school?
- A: Good hygiene will greatly reduce viral transmission. Isolation from school or day care contacts should occur while fever remains and/or while the enanthem persists. As mentioned, some patients may shed the virus in their stool for weeks after symptoms have resolved (again stressing the need for good personal hygiene).