HAND FOOT MOUTH DISEASE

Prepared by: Dr. NGUYEN QUANG DIEN 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 Yellow ulcers surrounded by red
halos characterize the oral lesions

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.
 Physical The exanthem typically involves the
dorsal surfaces but frequently may
include the palmar, plantar, and
interdigital surfaces of the hands and
feet.
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.
 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 )
 Diagnosis
Severity degrees :

1. Buccal ulcers +/- skin lesions : recovery

in 01 week , no sequelae

2. Encephalomyelitis risk: Myoclonal jerk ,

restlessness , hands reaching up
repeatedly , flounder .
 Diagnosis
Severity 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
 Diagnosis
Severity 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

 TREATMENT
I Outpatient: (stage 1st and 2nd a )
Fever relief Recs immediately if :

Fever >39dC
Oral higiene
Laboured breathing
Starts , trembling , crying ,
Rest and prevent irritation
hands reaching up repeatedly
Convulsion , coma
Recs everyday or every
Limbs weakness
other day in 7 days
Mottled skin
 TREATMENT
II 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

 TREATMENT
II Admission: ( Degree 2b backwards )
if meet one of following criteria:

Any of : Signs of :

Refuse to eat Meningitis

Vomiting all the time Myocarditis

Fatigue Encephalitis

Mottled skin Acute limbs weakness /

paralysis
Look bad .
 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