HAND – FOOT – MOUTH DISEASE

Prepared by: Dr. NGUYEN QUANG DIEN Prepared by: Dr. NGUYEN QUANG DIEN Emergency Department Emergency Department

HAND – FOOT – MOUTH DISEASE

HFM disease is a viral syndrome with a distinct exanthem – enanthem.

This clearly recognizable syndrome is characterized by vesicular lesions on the mouth and an exanthem on the hands and feet (and buttocks) in association with fever.

HAND – FOOT – MOUTH DISEASE

The lower lip has an ulcer with an erythematous halo.

The tongue has an ulcer with an erythematous halo.

A typical cutaneous lesion has an elliptical vesicle surrounded by an erythematous halo. The long axis of the lesion is oriented along the skin lines.

HAND – FOOT – MOUTH DISEASE

Pathophysiology

Hand-foot-and-mouth disease is caused by a group of

RNA viruses called enteroviruses. The most commonly

implicated enterovirus is coxsackievirus A16.[1] However,

coxsackieviruses A5, A9, A10, A16, B1, and B3; human

enterovirus 71 (HEV71); as well as herpes simplex viruses

(HSV) can cause the illness. HEV71 is of the most care

because HEV71 has been recently implicated in several

large outbreaks with severe complications and deaths.

Pathophysiology

Cases are commonly spread via the fecal-oral or oral-oral

route. Respiratory droplet transmission also may occur but

is less likely. Typically, the virus seeds the GI tract via the

buccal mucosa or the ileum. Over the next 72 hours

(accounting for the incubation period), a viremia is

established via spread through nearby lymph nodes.

In Vietnam , the peak incident is in April & May .

HAND – FOOT – MOUTH DISEASE

Mortality/ Morbidity

Severe complications may occur when CNS or

cardiopulmonary involvement is present .

Age

More common among infants and children younger

than 5 years.

History

The usual incubation period of hand-foot-and-mouth (HFM) disease is 4-6 days.

The prodrome is associated with the following: Low-grade fever Malaise Anorexia Abdominal pain Sore mouth

The prodrome precedes the development of oral lesions, followed shortly by skin lesions, primarily on the hands and feet and occasionally on the buttocks.

Physical

Hand-foot-and-mouth disease is the most common cause of mouth sores in

pediatric patients.

Physical

These primarily occur on the labial and buccal mucosal surfaces but may be observed on the tongue, palate, uvula, anterior tonsillar pillars, or gums. Unlike herpetic gingivostomatitis, perioral lesions are uncommon. Coxsackie A virus also causes herpangina, mostly described as palatal and posterior oropharyngeal lesions without any associated exanthem.

The oral ulcers are painful. Children younger than 5 years are predominately more symptomatic than older patients.

Yellow ulcers surrounded by red halos characterize the oral lesions

Physical

These lesions may be asymptomatic or pruritic.

They usually begin as erythematous macules that rapidly progress to thick-walled grey vesicles with an erythematous base.

In young infants, these lesions may also be observed on the trunk, thighs, and buttocks.

The rash is usually self-limited, lasting approximately 3-6 days.

Case reports have documented subacute, chronic, and recurring skin lesions.

The exanthem typically involves the dorsal surfaces but frequently may include the palmar, plantar, and interdigital surfaces of the hands and feet.

Complications Neurologic complications :

1. Encephalitis aseptic : Wake up with a start

Myoclonal jerk

Limbs trembling

Nystagmus

Cerebellar ataxia

Transverse myelitis >> limbs weakness

2. Cranial nerves paralysis

3. Convulsion , coma coupled with respiratory failure ,

cardiovascular failure .

Complications Cardiopulmonary complications:

Pulse > 150 bpm , mottled skin , capillary refill > 2s

BP : normal or increasing

RR increasing , laboured breathing , rose froths , wet rales

Cyanosis

Diagnosis

Positive :

Clinical exam. is the cornerstone with Exanthem – Enanthem

( oral ulcers & skin lesions )

DiagnosisSeverity degrees :

1. Buccal ulcers +/- skin lesions : recovery in 01 week , no sequelae

2. Encephalomyelitis risk: Myoclonal jerk , restlessness , hands reaching up repeatedly , flounder .

DiagnosisSeverity degrees :

2a/. Less starts : not found on exam.

2b/. More starts : > 2times / min or found on exam,

frequent starts coupled with : Hands reaching up repeatedly

Trembling

Flounder

Somnolence

P> 150bpm

Fever > 39 dC not relieved

Limbs weakness / paralysis

DiagnosisSeverity degrees :

3. Diaphoresis , RR increasing , P > 170bpm ,

BP increasing , convulsion , coma

(glasgow <10)

4. Respiratory failure , Cardiovascular failure.

TREATMENT :

Symptomatic treatment

Close monitoring

Complications treatments

Early sedations >> decreasing irritation

>> treat increased ICP

TREATMENTI – Outpatient: (stage 1st and 2nd a )

Fever relief

Oral higiene

Rest and prevent irritation

Recs everyday or every

other day in 7 days

Recs immediately if :

Fever >39dC

Laboured breathing

Starts , trembling , crying ,

hands reaching up repeatedly

Convulsion , coma

Limbs weakness

Mottled skin

TREATMENTII – Admission: ( Degree 2b backwards ) if meet one of following criteria:

Fever : < 3yos : > 38dC w/o time mentioned

>=3yos : > 38dC and > 3 days

HR : < 3yos : > 150 bpm

>= 3yos : > 120bpm

RR : < 3yos : >40 / min

>= 3yos : > 30/min

TREATMENTII – Admission: ( Degree 2b backwards ) if meet one of following criteria:

Any of :

○ Refuse to eat

○ Vomiting all the time

○ Fatigue

○ Mottled skin

○ Look bad .

Signs of :

○ Meningitis

○ Myocarditis

○ Encephalitis

○ Acute limbs weakness /

paralysis

Indications for Immunoglobulin at Peadiatric N.1 Hospital:

Neurologic Complications:

Mental status disorder : Glasgow<10.

Frequent starts , restlessly exciting .

Neurologic deficit (limbs weakness /

paralysis, cranial nerves paralysis).

Convulsion (febrile convulsion ruled out).

Indications for Immunoglobulin at Peadiatric N.1 Hospital:

Cardiorespiratory complications :

Abnormal RR (rapid RR , Irregular RR , and no pneumonia

signs / chest Xray ).

Pulmonary Edema .

Tachycardia, HR >150 bpm, Capillary refill > 2 s.

HTN.

Immunoglobulin is not effective in severe shock, deep

coma

THANKS FOR YOUR ATTENTION!

Dr NGUYEN QUANG DIEN