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Atypical Presentations of Adult Hand-Foot-Mouth Disease: A case series
Lindsay M. Bicknell MD, Arathi Ramamurthi BA, Palak Parekh MD
Scott & White Healthcare and Texas A&M Health Science Center College of Medicine, Temple, TX 76508
INTRODUCTION
FIGURES
Hand-Foot-Mouth disease (HFMD) is an acute viral illness commonly caused by
members of the enterovirus family. The most common pathogens are Coxsackie virus
A16 and Enterovirus E71, and transmission is usually via fecal-oral route. Following
exposure, signs and symptoms are observed within three to seven days and include
fever followed by a papulovesicular eruption on the palms and soles, as well as
stomatitis of the oral mucosa and involvement of the buttock.1,2 This self-limited
condition typically follows a benign course and is most commonly observed in children
and infants in the spring and summer months.1,2. Here we describe 4 unusual, severe
cases of hand-foot-mouth disease in adults, as well as treatment options and explore
the emerging trend of adult CV-A6 HFMD.
PATIENT A
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CASE PRESENTATIONS
PATIENT A
DISCUSSION
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Patient A, Figure 1
Vesicles on the helical rim.
Patient A, Figure 2a and 2b
Erythematous papules and vesicles on the dorsal hands and plantar feet
A 37-year-old Hispanic male was evaluated in the clinic for a 4-day history of rash on
the face and ears. Vital signs were unremarkable. Physical exam revealed small vesicles
on bilateral auricular helices. An erythematous papulovesicular eruption was noted on
the dorsal and palmar aspects of the hands as well as the plantar surface of feet
bilaterally. Vesicles were observed on the elbows. Small crusted papules were noted on
the cheeks and forehead bilaterally, as well. Observation of the oral mucosa revealed
ulcers in the oropharynx. Preliminary laboratory studies including CBC and CMP were
unremarkable. Enterovirus PCR of vesicular swab was positive.
PATIENT B
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PATIENT B
A 79-year-old Caucasian male was evaluated in the hospital for a 3-day history of pain
in his right foot. Vitals signs were unremarkable. Physical exam revealed scattered 5-20
mm erythematous, infiltrated papules and plaques over the soles of feet bilaterally
with pustules on the right posterior heel. An unroofed bulla with denuded skin was
noted over the right medial plantar surface with warmth and erythema. Erythematous,
infiltrated papules were present on the left sole and dorsum of left fifth toe. No
warmth was noted on exam of the left foot. Faded, pink macules 3-5 mm in size were
noted on the palms bilaterally; no erythema or warmth was noted. Two 2-3 mm
erythematous papules were present on the right earlobe. Preliminary laboratory
studies were unremarkable. Extensive infectious work-up was conducted, including IgM
titer for Rocky Mountain Spotted Fever (RMSF) which was found to be positive (1:256) .
PCR performed on tissue biopsy of one of the vesicles was found to be positive for
enterovirus. This was considered to be the cause of the patient’s acute illness.
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Patient B, Figure 5
Erythematous, infiltrated papules and pustules on the
right plantar surface and heel
Patient B, Figure 6
Erythematous macules on the palms.
PATIENT C
CONCLUSIONS
PATIENT C
A 60-year-old Caucasian male was evaluated in the clinic for a 3-day history of a painful
rash associated with sore throat and flu-like symptoms. Vitals signs were unremarkable.
Physical exam revealed erythematous tender papulovesicles on the face, palms, and
soles. Gray “football-shaped” vesicles were present on the hands. Involvement of the
oral mucosa was not observed. Laboratory studies revealed positive enterovirus PCR
from vesicle swab sample. Additionally, PCR study of tissue biopsy was found to be
positive for enterovirus.
PATIENT D
A 48-year-old male was evaluated in the emergency department for a 3-day history of
pain and swelling in his hands and feet. Vital signs were notable for temperature of
100.5⁰ Fahrenheit. Physical exam revealed edema of the hands and feet bilaterally, and
large hemorrhagic bullae on the ulnar aspects of the hands and plantar surfaces of the
feet. Discrete clear vesicles were noted on the dorsal aspect of the hands, forearms,
and upper arms, as well as erythematous patches with crust and vesicles on the cheeks
and lateral eyebrows. Involvement of the conjunctivae, nasal, and oropharyngeal
mucosa was not observed. Preliminary laboratory studies were notable for
pancytopenia with white blood cell count of 3.7x109/L, hemoglobin of 11.2gm/dL, and
platelet count of 103x109/L. Extensive infectious workup was conducted, and PCR of a
vesicle swab sample was found to be positive for enterovirus. Early in his
hospitalization, the patient was started on IV acyclovir given extensive involvement.
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Hand-Foot-Mouth disease (HFMD) is a highly contagious febrile illness characterized
by maculopapular or vesicular eruption of the palms and soles. Pharyngeal
ulceration may be present, as well. It usually follows a benign course and
spontaneous resolution usually occurs within 10 days.1,2
Children are predominantly affected in the spring and summer months. The most
common causative agents are Coxsackie A16 and Enterovirus 71.1-3
Hand-Foot-Mouth disease in adults is rare, and limited reports exist. Approximately
11% of exposed adults will manifest symptoms of infection. 4,5
A worldwide rise in incidence of adult HFMD has recently been reported. This has
been attributed to viral evolution and the increase in global travel over time. The
increase has also been linked to the emergence of the highly virulent strain
Coxsackie virus A6.1,4,5
Coxsackie virus A6 (CVA6) is most commonly seen in adults and causes a more
severe, atypical disease. As seen in our cases, cutaneous involvement is diffuse and
extends beyond the palms and soles. Widespread vesiculobullous lesions of the
dorsal hands and feet, perioral region, scalp, torso, and extremities have been
reported.1,4
HFMD should be included in the differential diagnosis of adult diseases with
widespread maculopapular or vesicular eruptions. Lesions can mimic secondary
syphilis and rickettsial infections.1
The main treatment of this self-limited illness is supportive care. Antiviral agents
including Acyclovir and Pleconaril have been suggested for severe disease, but
efficacy remains controversial .3,6,7
The active form of acyclovir is produced following phosphorylation by viral
thymidine kinase. Because enteroviruses responsible for HFMD lack thymidine
kinase, acyclovir theoretically should not prove effective. It has been suggested the
therapeutic effects are likely due to acyclovir’s ability to enhance the body’s natural
interferon.3
Patient D likely represents the third report of acyclovir efficacy in the treatment of
HFMD. Remarkably, he showed complete resolution by Day 7 of IV acyclovir.3,7
Pleconaril inhibits the production of new viral progeny by inhibiting virion
attachment to the host cell surface receptor. Several clinical trials have
demonstrated broad anti-picornaviral activity, and it has been implicated in the
treatment of HFMD. 6,8
Patient C, Figure 7A
Erythematous, tender papulovesicles on the right
cheek and perioral area
Patient C, Figure 8a, 8b, and 8c
Erythematous and gray elliptical vesicles on the hands.
• This case series describes severe, unusual presentations of Hand-Foot-Mouth disease
in adults. Our patients presented during the summer and winter months with
widespread cutaneous distribution. Lesions ranged from small macules to
maculopapular and vesicular lesions.
• HFMD in adults is likely due to infection with the highly virulent pathogen, CVA6.
• Presentation may mimic other infectious or autoimmune etiologies, including RMSF.
• Providers should be aware of the emerging increase of Hand-Foot-Mouth disease in
the adult population.
REFERENCES
PATIENT D
Patient D, Figure 9a, and 9b
Hemorrhagic bullae on the ulnar surface of the right hand, as
well as desquamation on the left plantar foot.
Patient D, Figure 11
Erythematous patches and papules with crusting
on the cheeks.
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