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
 Oral higiene
 Recs immediately if :

Fever >39dC

Laboured breathing

Starts , trembling , crying ,
hands reaching up repeatedly

Convulsion , coma

Limbs weakness

Mottled skin
 Rest and prevent irritation
 Recs everyday or every
other day in 7 days
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 /
○ Look bad .
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