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Handfootandmouthdisease:AcasereportfromIndia

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75Journal of Cranio-Maxillary Diseases / Vol 2 / Issue 1 / January 2013

Hand foot and mouth disease: A case report from India

Reema Rao, Shruthi Hegde, Reshma Suvarna, Subhas BabuDepartment of Oral Medicine and Radiology, A.B. Shetty Memorial Institute of Dental Sciences, Mangalore, India

ABSTRACT

Hand, foot, and mouth disease (HFMD) is a highly infectious viral disease caused by human enteroviruses. It usually occurs in summer affecting children below ten years of age. The clinical symptoms manifest as low‑grade fever, cough, malaise, and a sore mouth and throat. The exanthemas are first in maculopapular form and changes to vesicles. They are found in mouth, hand, and foot. The treatment of this disease is symptomatic. Although seen worldwide, it is not common in India. It is very important to establish the right diagnosis to avoid epidemics. This report describes a case of HFMD from Mangalore, India.Keywords: Coxsackie virus, hand foot and mouth disease, mouth ulcers

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DOI:

10.4103/2278-9588.113579

Correspondence to:Dr. Shruthi Hegde, Department of Oral Medicine and Radiology, A.B. Shetty Memorial Institute of Dental Sciences, Mangalore, India. E‑mail: drshruthihegde@yahoo.co.in

is not commonly seen in India, only a few reports are available in literature. This report describes a case of HFMD seen in a 10‑year‑old boy.

CASE REPORTA 10‑year‑old male patient reported to the

department with the complaint of stains on his teeth since 1 month. The patient also complained of ulcers in the mouth since 1 week. History revealed the presence of fever and erythematous lesions on hands, legs, and in the mouth since 1 week. The patient had consulted a physician and was prescribed on medication for the same. Fever had subsided within few days. Vesicles ruptured, which contained a clear fluid leaving behind the healing scars on the hands and the legs. On examination the patient was moderately built and nourished. Healing lesions were noticed on the legs and hands [Figures 1 and 2]. Intraoral examination revealed multiple ulcers on the gingiva, retromolar area of the left side, and on the soft palate [Figures 3 and 4]. Vesicles and ulcers were observed in the lower labial mucosa. Ulcers had regular borders and were surrounded by a erythematous halo [Figure 5]. Extrinsic stains were observed on the teeth surface [Figure 3]. Based on the history and clinical features diagnosis of HFMD was

INTRODUCTIONHand, foot, and mouth disease (HFMD) is a highly

infectious viral disease caused by human enteroviruses. HFMD is mainly caused by Coxsackievirus A16, other causative viruses include Coxsackievirus A5, A7, A9, A10, B2, B5. and enterovirus 71.[1,2] It usually occurs in summer affecting children below ten years of age.[3] The usual incubation period is 3‑7 days. The clinical feature is characteristic and classically consists of a combination of exanthema and enanthem. The clinical symptoms manifest themselves with low‑grade fever, cough, malaise, and a sore mouth and throat.[4‑6] Within 1 and 2 days after the onset off fever, painful sores may appear in the mouth or throat. A rash may become evident on the hands, feet, mouth, tongue, inside of the cheeks, buttocks, knees, and elbows. Oral lesions appear as vesicles, which rapidly ulcerate producing multiple small superficial ulcers with erythematous halos.[7] It

Case Report

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Rao, et al.: Hand foot and mouth disease

Journal of Cranio-Maxillary Diseases / Vol 2 / Issue 1 / January 201376

arrived upon. Application of local anesthetic agent was advised to provide relief from the discomfort. The patient was placed on soft diet. The patient was followed up and healing of all lesions were noticed

within 1 week. Thorough oral prophylaxis was done. Informed consent was obtained from the patient for reporting the case.

DISCUSSIONHFMD was first described by Robinson and Rhodes

in 1957 from an outbreak in an housing estate in Toronto, affecting 60 patients from 27 families.[4] The first major outbreak of HFMD occurred in Sarawak, Malaysia in 1997 in the Asia Pacific region.[8] The largest outbreak of HFMD occurred in eastern part of India in 2007, where about 38 cases of HFMD in and around Kolkata were reported.[3]

HFMD is a human syndrome caused by viruses of the Picornaviridae family. Humans are thought to be the only natural host of the Coxsackie virus.

Figure 1: Clinical image of the right and left hands showing multiple healing lesions

Figure 3: Intraoral photograph showing stains on the teeth and ulcer in the gingiva with respect to maxillary right central incisor

Figure 5: Intraoral photograph showing vesicle and ulcer in the lower labial mucosa

Figure 2: Clinical image showing healing lesions in the leg

Figure 4: Intraoral photograph showing ulcer in the soft palate

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77Journal of Cranio-Maxillary Diseases / Vol 2 / Issue 1 / January 2013

During epidemics, the virus is spread by horizontal transmission. Initial viral implantation in the buccal and ileal mucosa is followed by spread to lymph nodes within 24 h. The spread occurs through a direct contact with mucous, oral or nasal secretions, or feces of an infected persons.[9] These pathogens spread in a near homogenous population.[10]

The age distribution of the reported cases is between 6 months and 3 years. There are reports where HFMD affects neonatal patients or those above 25 years of age.[11] In the present report a 10‑year‑old boy is affected. HFMD may also be seen in immunocompromised patients.[12] But it is very uncommon in adults.

The exanthem begins as macules and rapidly changes into papules and vesicles. The lesions usually disappear within 10‑14 days. The lesions can usually be noticed on buccal mucosa, hard palate and tongue.[4,9,11] In the form of maculo‑papular exanthems 2‑10 mm in diameter, changing later into ulcerating vesicles. Similar features were noticed in the present case. These ulcers have an oval shape, are grayish in color, surrounded by a hyperemic border.[11] These lesions are widely distributed along and at the tip of the tongue and on the gingiva and are quite painful.[11] They heal within 5‑10 days. They are painful and may interfere with mastication and feeding. In 44% of the cases, tongue involvement is reported.[13] Oral lesions of HFMD can be easily misdiagnosed as aphthous ulcers, varicella or Herpangina.

The lesions on the hand and feet appear 1‑2 days following the lesions in the mouth. They appear as a macule developing into vesicle measuring around 3‑10 mm.[11] In infants and young children a maculopapular rash may be seen on the buttocks, the spots tend to form tiny vesicles which dry within an hour or two.[13] Viremia rapidly ensues, with spread to the oral mucosa and skin. After a week, neutralizing antibody levels increase and the virus is eliminated.[14]

There is no normal enteric virus flora. Usually only a single type of enterovirus multiplies within the intestine of an individual at any given time. Polio vaccination has eliminated polio viruses from the gut, thereby increasing the chances of Coxsackie

viral and echoviral infections. It is possible that the emergence of HFMD in India may be related to the mass polio vaccination.[13]

For the much commoner type of HFMD caused by Coxsackie viruses, complications are rare and most patients recover completely. The first monoclonal antibody described is 7C7, which can differentiate Coxsackievirus 16 from Enterovirus 71.[15] Treatment is mainly symptomatic with antipyretics, local application of bland lotions (e.g., calamine lotion) to the skin lesions. The mouth washes including a local anesthetic provides short‑term comfort. Patients are placed on soft and liquid diet. Similar treatment protocol was followed for the present case. Secondary infections are very rare. Hospitalization is very rarely necessary except for[1] the child who develops neurological complications,[2] the child who becomes dehydrated because of feed refusal. Low‑level laser therapy has also shortened the duration of painful oral ulcers.[16]

This report highlights the features of HFMD. Dentists need to be aware of such disease for timely diagnosis and prompt treatment.

REFERENCES1. Ji H, Li L, Wu B, Xu K, Huo Xue, Chen J, et al. Epidemiology

and etiology of hand‑foot‑and‑mouth disease seen in Jiangsu province from 2008 to 2010. Chinese Journal of Pediatric 2012;50:261‑6.

2. Shin JU, Oh SH, Lee JH. A case of hand‑foot‑mouth disease in an immunocompetent adult. Ann Dermatol 2010;22:216‑8.

3. Saoji VA. Hand, foot and mouth disease in Nagpur. Indian J Dermatol Venereol Leprol 2008;74:133‑5.

4. Sarma N, Sarkar A, Mukherjee A, Ghosh A, Dhar S, Malakar R. Epidemic of hand, foot and mouth disease in West Bengal, India in August, 2007: A multicentric study. Indian J Dermatol 2009;54:26‑30.

5. Alsop J, Flewett TH, Foster JR. “Hand‑foot‑and‑mouth disease” in Birmingham in 1959. Br Med J 1960;10:1708‑11.

6. Stewart RE, Barber TK, Troutman KC, Wei SH. Hand foot and mouth disease. In: Pediatric Dentistry, Scientific Foundations and Clinical Practice. USA: CV Mosby Comp; 1987. p. 247.

7. Sterling JC. Virus infections. In: Burns T, Breathnach S, Cox N, Griffiths C, editors. Rook’s Textbook of Dermatology. 7th ed. Oxford: Blackwell Science; 2004. p. 25:1‑83.

8. Podin Y, Gias EL, Ong F, Leong YW, Yee SF, Yusof MA, et al. Sentinel surveillance for human enterovirus 71 in Sarawak, Malaysia: Lessons from the first 7 years. BMC Public Health 2006;6:180.

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Journal of Cranio-Maxillary Diseases / Vol 2 / Issue 1 / January 201378

9. Thomas J. Hand foot and mouth disease. An overview. E J Indian Soc Teledermatol 2009;3:1‑5.

10. Yoshikura H. A new method for monitoring and forecasting the case‑fatality rate in ongoing epidemics and its evaluation using published data of SARS in 2003, H1N1 pandemic in 2009/2010, hand‑foot‑mouth disease in China in 2009/2010, and cholera in Haiti in 2010. Jpn J Infect Dis 2011;64:92‑4.

11. Batirbaygil Y, Altay N. Hand foot and mouth disease. J Islamic Acad Sci 1988;1:17‑9.

12. Faulkner CF, Godbolt AM, DeAmbrosis B, Triscott J. Hand, foot and mouth disease in an immunocompromised adult treated with aciclovir. Australas J Dermatol 2003;44:203‑6.

13. Rao PK, Veena KM, Jagadishchandra H, Bhat SS, Shetty SR. Hand foot and mouth disease – Changing Indian scenario. Int J Dent Case Rep 2011;1:29‑33.

14. Muppa R, Bhupatiraju P, Duddu M, Dandempally A. Hand, foot and mouth disease. J Indian Soc Pedod Prev Dent 2011;29:165‑7.

15. Kiener TK, Jia Q, Lim XF, He F, Meng T, Chow VT, et al. Characterization and specificity of the linear epitope of the enterovirus 71 VP2 protein. Virol J 2012;9:55.

16. Toida M, Watanabe F, Goto K, Shibata T. Usefulness of low‑level laser for control of painful stomatitis in patients with hand‑foot‑and‑mouth disease. J Clin Laser Med Surg 2003;21:363‑7.

How to cite this article: Rao R, Hegde S, Suvarna R, Babu S. Hand foot and mouth disease: A case report from India. J Cranio Max Dis 2013;2:75-8.Source of Support: Nil. Conflict of Interest: None declared.Submission: May 22, 2012, Acceptance: November 02, 2012

Commentary

Hand, foot, and mouth disease (HFMD) is a highly infectious disease characterized by multiple vesicles on the hands and feet and in the oral cavity.[1] Coxsackievirus A16 is the most common virus causing HFMD; other causative viruses include coxsackieviruses A5, A7, A9, A10, B2, B5, and enterovirus 71.[1,2] HFMD usually affects children under 10 years of age.[3] Infection generally occurs via the fecal‑oral route or via contact with skin lesions and oral secretions. Viremia develops, followed by invasion of the skin and mucous membranes. Widespread apoptosis likely results in the characteristic lesion formation.[4] The initial presentation includes erythematous papules on the palms, feet and in the oral cavity, accompanied by prodromal symptoms such as myalgia, mild fever and abdominal pain. The lesions usually evolve into vesicles and then spontaneously resolve within 1 or 2 weeks.[5] Lesions are usually asymptomatic, but in some cases, pressure and touch can provoke pain. In addition, oral lesions may occur without cutaneous lesions,[6] and HFMD without oral mucosal lesions has also been reported in an immunocompromised adult.[7] Treatment is symptomatic, and the disease resolves spontaneously without complications within 7‑10 days.[8] Children are particularly infectious until the blisters have disappeared. Exclusion from school or childcare is not practical as the virus may be present in the faces for several weeks.[4] Low‑level laser therapy has been shown to reduce or shorten the duration

of oral ulcers but necessary in all cases.[9] However, there have been rare reports of severe complications such as pneumonia, cardiomyositis, and aseptic meningitis.[8,10]

As described in the present article,[11] the recognition of HFMD is important for both pediatricians and pedodontists as oral manifestations are the first signs and may mimic many other conditions like acute herpetic gingivostomstomatitis, apthous stomatitis, chickenpox, erythema multiforme and misdiagnosis may involve an inappropriate prescription of medication[12] and moreover, pedodontists have a key role in educating the patients on good oral hygiene and avoidance of rupture of the blisters.

Gamze ArenDepartment of Pedodontics, Faculty of Dentistry,

University of Istanbul, Istanbul, Turkey

Correspondence to:Dr. Gamze Aren,

Department of Pedodontics, Faculty of Dentistry, University of Istanbul, Istanbul, Turkey.

E‑mail: gamzearen@hotmail.com

REFERENCES1. Shin JU, Oh SH, Lee JH. A Case of Hand‑foot‑mouth

disease in an immunocompetent adult. Ann Dermatol 2010;22:216‑8.

2. Robinson CR, Doane FW, Rhodes AJ. Report of an outbreak of

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