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Hand, foot, and mouth disease (HFMD) is a common infection caused by a group of
enterovirus ''Enterovirus'' is a genus of positive-sense single-stranded RNA viruses associated with several human and mammalian diseases. Enteroviruses are named by their transmission-route through the intestine ('enteric' meaning intestinal). Serologic ...
es. It typically begins with a
fever Fever or pyrexia in humans is a symptom of an anti-infection defense mechanism that appears with Human body temperature, body temperature exceeding the normal range caused by an increase in the body's temperature Human body temperature#Fever, s ...
and feeling generally unwell. This is followed a day or two later by flat discolored spots or bumps that may blister, on the hands, feet and mouth and occasionally buttocks and groin. Signs and symptoms normally appear 3–6 days after exposure to the virus. The rash generally resolves on its own in about a week. The viruses that cause HFMD are spread through close personal contact, through the air from coughing, and via the feces of an infected person. Contaminated objects can also spread the disease.
Coxsackievirus Coxsackieviruses are a few related enteroviruses that belong to the ''Picornaviridae'' family of viral envelope, nonenveloped, linear, positive-sense single-stranded RNA viruses, as well as its genus ''Enterovirus'', which also includes poliovi ...
A16 is the most common cause, and enterovirus 71 is the second-most common cause. Other strains of coxsackievirus and
enterovirus ''Enterovirus'' is a genus of positive-sense single-stranded RNA viruses associated with several human and mammalian diseases. Enteroviruses are named by their transmission-route through the intestine ('enteric' meaning intestinal). Serologic ...
can also be responsible. Some people may carry and pass on the virus despite having no symptoms of disease. Other animals are not involved. Diagnosis can often be made based on symptoms. Occasionally, a throat or stool sample may be tested for the virus. Most people with hand, foot, and mouth disease get better on their own in 7 to 10 days. Most cases require no specific treatment. No
antiviral medication Antiviral drugs are a class of medication used for treating viral infections. Most antivirals target specific viruses, while a broad-spectrum antiviral is effective against a wide range of viruses. Antiviral drugs are a class of antimicrobial ...
or
vaccine A vaccine is a biological Dosage form, preparation that provides active acquired immunity to a particular infectious disease, infectious or cancer, malignant disease. The safety and effectiveness of vaccines has been widely studied and verifi ...
is available, but development efforts are underway. For fever and for painful mouth sores, over-the-counter
pain medication An analgesic drug, also called simply an analgesic, antalgic, pain reliever, or painkiller, is any member of the group of drugs used for pain management. Analgesics are conceptually distinct from anesthetics, which temporarily reduce, and in so ...
s such as
ibuprofen Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that is used to relieve pain, fever, and inflammation. This includes dysmenorrhea, painful menstrual periods, migraines, and rheumatoid arthritis. It can be taken oral administration, ...
may be used, though aspirin should be avoided in children. The illness is usually not serious. Occasionally, intravenous fluids are given to children who are dehydrated. Very rarely,
viral meningitis Viral meningitis, also known as aseptic meningitis, is a type of meningitis due to a viral infection. It results in inflammation of the meninges (the membranes covering the brain and spinal cord). Symptoms commonly include headache, fever, photop ...
or
encephalitis Encephalitis is inflammation of the Human brain, brain. The severity can be variable with symptoms including reduction or alteration in consciousness, aphasia, headache, fever, confusion, a stiff neck, and vomiting. Complications may include se ...
may complicate the disease. Because HFMD is normally mild, some jurisdictions allow children to continue to go to child care and schools as long as they have no fever or uncontrolled drooling with mouth sores, and as long as they feel well enough to participate in classroom activities. HFMD occurs in all areas of the world. It often occurs in small
outbreaks In epidemiology, an outbreak is a sudden increase in occurrences of a disease when cases are in excess of normal expectancy for the location or season. It may affect a small and localized group or impact upon thousands of people across an entire ...
in nursery schools or kindergartens. Large outbreaks have been occurring in Asia since 1997. It usually occurs during the spring, summer, and fall months. Typically it occurs in children less than five years old but can occasionally occur in adults. HFMD should not be confused with
foot-and-mouth disease Foot-and-mouth disease (FMD) or hoof-and-mouth disease (HMD) is an infectious disease, infectious and sometimes fatal virus (biology), viral disease that primarily affects even-toed ungulates, including domestic and wild Bovidae, bovids. The vir ...
(also known as hoof-and-mouth disease), which mostly affects livestock.


Signs and symptoms

Common constitutional signs and symptoms of HFMD include fever, nausea, vomiting, feeling tired, generalized discomfort,
loss of appetite Anorexia is a medical term for a loss of appetite. While the term outside of the scientific literature is often used interchangeably with anorexia nervosa, many possible causes exist for a loss of appetite, some of which may be harmless, while o ...
, and irritability in infants and toddlers. Skin lesions frequently develop in the form of a rash of flat discolored spots and bumps which may be followed by vesicular sores with
blister A blister is a small pocket of body fluid (lymph, serum, plasma, blood, or pus) within the upper layers of the skin, usually caused by forceful rubbing (friction), burning, freezing, chemical exposure or infection. Most blisters are filled ...
s on palms of the hands, soles of the feet, buttocks, and sometimes on the lips. The rash is rarely itchy for children, but can be extremely itchy for adults.
Pain Pain is a distressing feeling often caused by intense or damaging Stimulus (physiology), stimuli. The International Association for the Study of Pain defines pain as "an unpleasant sense, sensory and emotional experience associated with, or res ...
ful facial
ulcer An ulcer is a discontinuity or break in a bodily membrane that impedes normal function of the affected organ. According to Robbins's pathology, "ulcer is the breach of the continuity of skin, epithelium or mucous membrane caused by sloughin ...
s,
blister A blister is a small pocket of body fluid (lymph, serum, plasma, blood, or pus) within the upper layers of the skin, usually caused by forceful rubbing (friction), burning, freezing, chemical exposure or infection. Most blisters are filled ...
s, or lesions may also develop in or around the nose or
mouth A mouth also referred to as the oral is the body orifice through which many animals ingest food and animal communication#Auditory, vocalize. The body cavity immediately behind the mouth opening, known as the oral cavity (or in Latin), is also t ...
. HFMD usually resolves on its own after 7–10 days. Most cases of the disease are relatively harmless, but complications including encephalitis, meningitis, and paralysis that mimics the neurological symptoms of polio can occur. Image:Characteristic rash of hand, foot, and mouth disease, on human hands.jpg, Rash on palms of the hands File:Hand Foot Mouth Disease Adult 36Years.jpg, Rash on hands and feet of a 36-year-old man File:Hand foot and mouth disease on child feet.jpg, Rash on the soles of a child's feet


Cause

The viruses that cause the disease are of the ''Picornaviridae''
family Family (from ) is a Social group, group of people related either by consanguinity (by recognized birth) or Affinity (law), affinity (by marriage or other relationship). It forms the basis for social order. Ideally, families offer predictabili ...
.
Coxsackievirus Coxsackieviruses are a few related enteroviruses that belong to the ''Picornaviridae'' family of viral envelope, nonenveloped, linear, positive-sense single-stranded RNA viruses, as well as its genus ''Enterovirus'', which also includes poliovi ...
A16 is the most common cause of HFMD. Enterovirus 71 (EV-71) is the second-most common cause. Many other strains of coxsackievirus and
enterovirus ''Enterovirus'' is a genus of positive-sense single-stranded RNA viruses associated with several human and mammalian diseases. Enteroviruses are named by their transmission-route through the intestine ('enteric' meaning intestinal). Serologic ...
can also be responsible.


Transmission

HFMD is highly contagious and is transmitted by nasopharyngeal secretions such as saliva or nasal mucus, by direct contact, or by fecal–oral transmission. It is possible to be infectious for days to weeks after the symptoms have resolved. Childcare settings are the most common places for HFMD to be contracted because of toilet training, diaper changes, and children's propensity to put their hands into their mouths. HFMD is contracted through nose and throat secretions such as saliva, sputum, and nasal mucus as well as fluid in blisters, and stool.


Diagnosis

A diagnosis usually can be made by the presenting signs and symptoms alone. If the diagnosis is unclear, a throat swab or stool specimen may be taken to identify the virus by culture. The common
incubation period Incubation period (also known as the latent period or latency period) is the time elapsed between exposure to a pathogenic organism, a chemical, or ionizing radiation, radiation, and when symptoms and signs are first apparent. In a typical infect ...
(the time between infection and onset of symptoms) ranges from three to six days. Early detection of HFMD is important in preventing an outbreak in the pediatric population.


Prevention

Preventive measures include avoiding direct contact with infected individuals (including keeping infected children home from school), proper cleaning of shared utensils, disinfecting contaminated surfaces, and proper hand hygiene. These measures are effective in decreasing the transmission of the viruses responsible for HFMD. Protective habits include hand washing and disinfecting surfaces in play areas. Breastfeeding has also been shown to decrease rates of severe HFMD, though does not reduce the risk of the infection of the disease.


Vaccine

A vaccine known as the EV71 vaccine is available to prevent HFMD in China . No vaccine is currently available in the United States.


Treatment

Medications are usually not needed as hand, foot, and mouth disease is a viral disease that typically resolves on its own. Currently, there is no specific curative treatment for hand, foot, and mouth disease. Disease management typically focuses on achieving symptomatic relief. Pain from the sores may be eased with the use of analgesic medications. Infection in older children, adolescents, and adults is typically mild and lasts approximately 1 week, but may occasionally run a longer course. Fever reducers can help decrease body temperature. A minority of individuals with hand, foot, and mouth disease may require hospital admission due to complications such as inflammation of the brain, inflammation of the meninges, or
acute flaccid paralysis Flaccid paralysis is a neurological condition characterized by weakness or paralysis and reduced muscle tone without other obvious cause (e.g., trauma). This abnormal condition may be caused by disease or by trauma affecting the nerves associ ...
. Non-neurologic complications such as
inflammation of the heart Inflammation (from ) is part of the biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. The five cardinal signs are heat, pain, redness, swelling, and loss of function (Latin ''calor'', '' ...
, fluid in the lungs, or bleeding into the lungs may also occur.


Complications

Complications from the viral infections that cause HFMD are rare but require immediate medical treatment if present. HFMD infections caused by Enterovirus 71 tend to be more severe and are more likely to have neurologic or cardiac complications including death than infections caused by Coxsackievirus A16. Viral or aseptic meningitis can occur with HFMD in rare cases and is characterized by fever,
headache A headache, also known as cephalalgia, is the symptom of pain in the face, head, or neck. It can occur as a migraine, tension-type headache, or cluster headache. There is an increased risk of Depression (mood), depression in those with severe ...
, stiff neck, or back pain. The condition is usually mild and clears without treatment; however, hospitalization for a short time may be needed. Other serious complications of HFMD include
encephalitis Encephalitis is inflammation of the Human brain, brain. The severity can be variable with symptoms including reduction or alteration in consciousness, aphasia, headache, fever, confusion, a stiff neck, and vomiting. Complications may include se ...
(inflammation of the brain), or
flaccid paralysis Flaccid paralysis is a neurological condition characterized by weakness or paralysis and reduced muscle tone without other obvious cause (e.g., trauma). This abnormal condition may be caused by disease or by trauma affecting the nerves associ ...
in rare circumstances. Fingernail and toenail loss have been reported in children 4–8 weeks after having HFMD. The relationship between HFMD and the reported nail loss is unclear; however, it is temporary and nail growth resumes without treatment. Minor complications due to symptoms can occur such as dehydration, due to mouth sores causing discomfort with intake of foods and fluid.


Epidemiology

Hand, foot and mouth disease most commonly occurs in children under the age of 10 and more often under the age of 5, but it can also affect adults with varying symptoms. It tends to occur in outbreaks during the spring, summer, and autumn seasons. This is believed to be due to heat and humidity improving spread. HFMD is more common in rural areas than urban areas; however, socioeconomic status and hygiene levels need to be considered. Poor hygiene is a risk factor for HFMD.


Outbreaks

* In 1997, an
outbreak In epidemiology, an outbreak is a sudden increase in occurrences of a disease when cases are in excess of normal expectancy for the location or season. It may affect a small and localized group or impact upon thousands of people across an entire ...
occurred in
Sarawak Sarawak ( , ) is a States and federal territories of Malaysia, state of Malaysia. It is the largest among the 13 states, with an area almost equal to that of Peninsular Malaysia. Sarawak is located in East Malaysia in northwest Borneo, and is ...
, Malaysia with 600 cases and over 30 children died. * In 1998, there was an outbreak in
Taiwan Taiwan, officially the Republic of China (ROC), is a country in East Asia. The main geography of Taiwan, island of Taiwan, also known as ''Formosa'', lies between the East China Sea, East and South China Seas in the northwestern Pacific Ocea ...
, affecting mainly children. There were 405 severe complications, and 78 children died. The total number of cases in that epidemic is estimated to have been 1.5 million. * In 2008 an outbreak in China, beginning in March in
Fuyang, Anhui Fuyang (, Chinese postal romanization, previously romanized as Fowyang) is a prefecture-level city in northwestern Anhui provinces of China, province, China. It is bordered by Henan province to the west and the cities of Bozhou to the northeast, ...
, led to 25,000 infections, and 42 deaths, by May 13. Similar outbreaks were reported in Singapore (more than 2,600 cases as of April 20, 2008), Vietnam (2,300 cases, 11 deaths), Mongolia (1,600 cases), and Brunei (1,053 cases from June–August 2008). * In 2009 17 children died in an outbreak during March and April 2009 in China's eastern Shandong Province, and 18 children died in the neighboring
Henan Province Henan; alternatively Honan is a province in Central China. Henan is home to many heritage sites, including Yinxu, the ruins of the final capital of the Shang dynasty () and the Shaolin Temple. Four of the historical capitals of China, Luo ...
. Out of 115,000 reported cases in China from January to April, 773 were severe and 50 were fatal. * In 2010 in China, an outbreak occurred in southern China's Guangxi Autonomous Region as well as Guangdong, Henan, Hebei, and Shandong provinces. Until March, 70,756 children were infected and 40 died from the disease. By June, the peak season for the disease, 537 had died. * The
World Health Organization The World Health Organization (WHO) is a list of specialized agencies of the United Nations, specialized agency of the United Nations which coordinates responses to international public health issues and emergencies. It is headquartered in Gen ...
reporting between January and October 2011 (1,340,259) states the number of cases in China had dropped by approx 300,000 from 2010 (1,654,866) cases, with new cases peaking in June. There were 437 deaths, down from 2010 (537 deaths). * In December 2011, the
California Department of Public Health The California Department of Public Health (CDPH) is the state department responsible for public health in California. It is a subdivision of the California Health and Human Services Agency. It enforces some of the laws in the California Health ...
identified a strong form of the virus, coxsackievirus A6 (CVA6), where nail loss in children is common. * In 2012 in
Alabama Alabama ( ) is a U.S. state, state in the Southeastern United States, Southeastern and Deep South, Deep Southern regions of the United States. It borders Tennessee to the north, Georgia (U.S. state), Georgia to the east, Florida and the Gu ...
, United States there was an outbreak of an unusual type of the disease. It occurred in a season when it is not usually seen and affected teenagers and older adults. There were some hospitalizations due to the disease but no reported deaths. * In 2012 in
Cambodia Cambodia, officially the Kingdom of Cambodia, is a country in Southeast Asia on the Mainland Southeast Asia, Indochinese Peninsula. It is bordered by Thailand to the northwest, Laos to the north, and Vietnam to the east, and has a coastline ...
, 52 of 59 reviewed cases of children reportedly dead () due to a mysterious disease were diagnosed to be caused by a virulent form of HFMD. Although a significant degree of uncertainty exists with reference to the diagnosis, the WHO report states, "Based on the latest laboratory results, a significant proportion of the samples tested positive for enterovirus 71 (EV-71), which causes hand foot and mouth disease (HFMD). The EV-71 virus has been known to generally cause severe complications amongst some patients." * HFMD infected 1,520,274 people with up to 431 deaths reported at the end of July in 2012 in China. * In 2018, more than 50,000 cases occurred through a nationwide outbreak in Malaysia with two deaths also reported.


India 2022

An outbreak of an illness referred to as ''tomato fever'' or ''tomato flu'' was identified in the
Kollam district Kollam district (), (formerly Quilon district) is one of 14 List of districts in Kerala, districts of the state of Kerala, India. The district has a cross-section of Kerala's natural attributes; it is endowed with a long coastline, a major La ...
on May 6, 2022. The illness is endemic to
Kerala Kerala ( , ) is a States and union territories of India, state on the Malabar Coast of India. It was formed on 1 November 1956, following the passage of the States Reorganisation Act, by combining Malayalam-speaking regions of the erstwhile ...
, India and gets its name because of the red and round
blister A blister is a small pocket of body fluid (lymph, serum, plasma, blood, or pus) within the upper layers of the skin, usually caused by forceful rubbing (friction), burning, freezing, chemical exposure or infection. Most blisters are filled ...
s it causes, which look like
tomato The tomato (, ), ''Solanum lycopersicum'', is a plant whose fruit is an edible Berry (botany), berry that is eaten as a vegetable. The tomato is a member of the nightshade family that includes tobacco, potato, and chili peppers. It originate ...
es. The disease may be a new variant of the viral HFMD or an effect of
chikungunya Chikungunya is an infection caused by the chikungunya virus (CHIKV). The disease was first identified in 1952 in Tanzania and named based on the Kimakonde words for "to become contorted". Chikungunya has become a global health concern due to ...
or
dengue fever Dengue fever is a mosquito-borne disease caused by dengue virus, prevalent in tropical and subtropical areas. Asymptomatic infections are uncommon, mild cases happen frequently; if symptoms appear, they typically begin 3 to 14 days after i ...
. ''Flu'' may be a misnomer. The condition mainly affects children under the age of five. An article in ''
The Lancet ''The Lancet'' is a weekly peer-reviewed general medical journal, founded in England in 1823. It is one of the world's highest-impact academic journals and also one of the oldest medical journals still in publication. The journal publishes ...
'' states that the appearance of the blisters is similar to that seen in
Mpox Mpox (, ; formerly known as monkeypox) is an infectious viral disease that can occur in humans and other animals. Symptoms include a rash that forms blisters and then crusts over, fever, and swollen lymph nodes. The illness is usually mild, ...
, and the illness is not thought to be related to
SARS-CoV-2 Severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2) is a strain of coronavirus that causes COVID-19, the respiratory illness responsible for the COVID-19 pandemic. The virus previously had the Novel coronavirus, provisional nam ...
. Symptoms, treatment and prevention are similar to HFMD.


History

HFMD cases were first described clinically in Canada and New Zealand in 1957. The disease was termed "Hand Foot and Mouth Disease", by Thomas Henry Flewett, after a similar outbreak in 1960.


Research

Novel antiviral agents to prevent and treat infection with the viruses responsible for HFMD are currently under development. Preliminary studies have shown inhibitors of the EV-71 viral capsid to have potent antiviral activity.


References


External links

* * {{DEFAULTSORT:Hand, Foot And Mouth Disease Enterovirus-associated diseases Oral mucosal pathology Wikipedia medicine articles ready to translate Wikipedia emergency medicine articles ready to translate Virus-related cutaneous conditions