CASE REPORT

Year: 2019 I Volume: 2 I Issue: 1 I Page: 19-21

Hand, foot and mouth disease in an immunocompetent adult- A rarity

Dr. Khushboo Modasia¹, Dr. Aishini Shah¹, Dr. Trisha Patel¹, Dr. Jinal Tandel¹, Dr. Rita Vora¹

¹ Department of Dermatology, Shree Krishan Hospital, Pramukh Swami Medical College, Karamsad, Anand

Corresponding Author:
Dr. Rita Vora
B-4, Om Villa,Raja Babu Lane, Opp. Big Bazar, Anand, Gujarat, India, Gujarat 388001
Email : ritavv@charutarhealth.org

How to cite this article:
Modasia K, Shah A, Patel T, Tandel J, Vora R. Hand, foot and mouth disease in an immunocompetent adult- Ararity. JDAIndian Journal of Clinical Dermatology 2019;2:19-21.

Abstract:

Hand, foot and mouth disease (HFMD) is a highly contagious viral infection in childhood or immunocompromised adults manifesting with low grade fever along with vesicles or papules over oral mucosa, palms, soles and buttocks. A 24-year old male presented with complains of fever since 3 days followed by lesions in mouth andover palms and soles for 2 days with history of malaise and throat pain. On examination there were multiple, discrete, ill-defined erythematous maculopapular rash present over palms, soles and soft palate. Routine investigations were within normal limits along with seronegativity for HIV and syphilis. Symptomatic treatment resulted in resolving of lesions. HFMD is predominantly a childhood or immunodeficiency-associated disease spreading through feco-oral, oro-oral and fluids of the vesicles. Our case was a male in his mid twenties, suggesting that it can occur in immunocompetent adult also without any history of close contact.

Key words: Hand, foot and mouth disease, immunocompetent adult, viral infection

Introduction:

Hand, foot and mouth disease (HFMD) is a highly contagious viral infection in childhood or immunocompromised adults. HFMD was clinically defined as any patient with an acute onset of vesicular eruptions on the hands and feet in association with oral sores.[1]Coxsackievirus A16and enterovirus 71 being the most common cause of HFMD[2],CVA6 has also been identified in adult patients.[3-5]Here we report a case of an immunocompetent male with vesicular eruption and oral manifestations diagnosed as having HFMD.

Case report:

A 24 year old male presented to skin opd in monsoon season with complains of fever since 3 days followed by lesions in

Figure 1: multiple, discrete, ill-defined erythematous macule and papules present over palms. Click here to view

Figur 2: multiple, discrete, ill-defined erythematous macule and papules present over dorsa of feet. Click here to view

mouth,palms and soles for 2 days with history of malaise and throat pain. No history of herpes simplex infection, history of drug intake within the preceding 2 weeks (prior to the onset of skin lesions) were noted and no history ofclose contact with any infected child or adult was given. On examination there were multiple, discrete, ill-defined erythematous maculopapular lesions present over palms, soles and soft palate. (Fig 1,2,3) Multiple clear fluid filled vesicles over bilateral ears (fig 4), multiple pustular lesions with crusting over buttocks. The results of hematological investigations were normal along with seronegativity for HIV and syphilisand Tzanck smears showed nonspecific inflammatory cells. Laboratory confirmationby electron microscopy of the pathogen causing the disease was not done due to resource constraints.Symptomatic treatment resulted in resolving of lesions.

Figure 3 : multiple, discrete, ill-defined erythematous macule and papules present soft palate Click here to view

Discussion:

HFMD was clinically defined as any patient with an acute onset of vesicular eruptions on the hands and feet in association with oral sores.[1]HFMD predominantly occurs in children less than 10 years of age [6] and in immunocompromised adults, but can rarely be seen in immunocompetent adults.Coxsackie has been considered the most common cause of HFMD but traces of A5,A10 and not uncommonly human enterovirus 71 have been found.[2]Most cases are in young children during the autumn months, but outbreaks have occurred in communities of adults. Certain reports have shown that 25% adults wereaffected in several outbreaks in western countries between 2011 and 2012.[4]The disease is usually mild with an incubation period of 5-7

Figure 4 : Multiple clear fluid filled vesicles over bilateral ears Click here to view

days, and lasting for about 7days. In children it can be asymptomatic butin adults it can present with painful stomatitis. Fever accompanies the lesions. Skin lesions are mainly small vesicles upto 5mm in diameter, thin walled, pearly grey, most commonly over hands. Lesions heal spontaneously in 2 weeks without scarring.Atypical HFMD presents with more variable and severe manifestation such as diffuse rash, purpuric lesions and adult-age predilection.[7,8]A clinical diagnosis usually suffice the proof for HFMD but if histology is performed it usually shows spongiosis, intraepidermal splits progressing to vesicle formation, mononuclear cells entering the epidermis, and necrosis of individual keratinocytes. Laboratory tests include microneutralization test, reverseTranscriptase – Polymerase Chain Reaction, culture method, neutralizing antibody detection, and enzyme-linked immunosorbent assay.[9,10]Though HFMD is a self-limiting disease there should be surveillance maintenance as there is no effective chemoprophylaxis or vaccine available. Treatment is symptomatic. Maintenance of personal hygiene, social distancing and disinfection of the environment are probably the mosteffective measures to avoid spreading of the disease to the community. To our knowledge, only a few HFMD cases have been described in the literature in immunocompetent adults.[9,11,12]Public health personnel should be enabled proper epidemiological knowledge of HFMD to predict outbreaks of the disease and implement effective interventions so as to reduce the burden of disease in the society.

Conclusion:

The current scenario states that the diagnosis of HFMDshould be kept in mind whenever a patient presents with vesicles or maculopapular rash over palms, soles and oral mucosa to prevent its spread and complications, as itcan rarely affect immunocompetent adults also.

References:

1. Ho M, Chen ER, Hsu KH, Twu SJ, Chen KT, Tsai SF, etal. An epidemic of enterovirus 71 infection in Taiwan.Taiwan Enterovirus Epidemic Working Group. N Engl J Med 1999;341:929-35

2. Belazarian L, Lorenzo ME, Pace NC, Sweeney SM, Wiss KM. Exanthematous viral diseases. In: Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffel DJ, editors. Fitzpatrick’sDermatology in General Medicine. 7th ed. New York: McGraw- Hill; 2008. p. 1851-72.

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5. Lonnberg AS, Elberling J, Fischer TK, Skov L. Two cases of hand,foot and mouth disease involving the scalp. Ann Derma Venereol2013;93:467-8.

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7. Banta J, Lenz B, Pawlak M, et al. Notes from the field: outbreak of hand, foot, and mouth disease caused by coxsackievirus A6 among basic military trainees – Texas, 2015. MMWR Morb Mortal Wkly Rep. 2016;65(26):678-80.

8. Ramirez-Fort MK, Downing C, Doan HQ, et al. Coxsackievirus A6 associated hand, foot and mouth disease in adults: clinical presentation and review of the literature. J ClinVirol. 2014;60(4):381-6.

9. Centers for Disease Control and Prevention (CDC): Notes from the field: severe hand, foot, and mouth disease associated with coxsackievirus A6 – Alabama, Connecticut, California, and Nevada, November 2011– February 2012. MMWR Morb Mortal Wkly Rep 2012;61:213–214.

10. Shea YF, Chan CY, Hung IF, Chan KH: Hand, foot and mouth disease in an immunocompetent adult due to Coxsackievirus A6. Hong Kong Med J 2013;19:262–264.

11. Sarma N. Hand, foot, and mouth disease: Current scenario and Indian perspective. Indian J DermatolVenereolLeprol 2013;79:165-75.

12. Shin JU, Oh SH, Lee JH: A case of hand-foot-mouth disease in an immunocompetent adult. Ann Dermatol 2010;22:216–218.