title: An outbreak of coxsackievirus A6 hand, foot, and mouth disease associated with onychomadesis in Taiwan, 2010.
abstract: BACKGROUND
  In 2010, an outbreak of coxsackievirus A6 (CA6) hand, foot and mouth disease (HFMD) occurred in Taiwan and some patients presented with onychomadesis and desquamation following HFMD. Therefore, we performed an epidemiological and molecular investigation to elucidate the characteristics of this outbreak.
  
  
  METHODS
  Patients who had HFMD with positive enterovirus isolation results were enrolled. We performed a telephone interview with enrolled patients or their caregivers to collect information concerning symptoms, treatments, the presence of desquamation, and the presence of nail abnormalities. The serotypes of the enterovirus isolates were determined using indirect immunofluorescence assays. The VP1 gene was sequenced and the phylogenetic tree for the current CA6 strains in 2010, 52 previous CA6 strains isolated in Taiwan from 1998 through 2009, along with 8 reference sequences from other countries was constructed using the neighbor-joining command in MEGA software.
  
  
  RESULTS
  Of the 130 patients with laboratory-confirmed CA6 infection, some patients with CA6 infection also had eruptions around the perioral area (28, 22%), the trunk and/or the neck (39, 30%) and generalized skin eruptions (6, 5%) in addition to the typical presentation of skin eruptions on the hands, feet, and mouths. Sixty-six (51%) CA6 patients experienced desquamation of palms and soles after the infection episode and 48 (37%) CA6 patients developed onychomadesis, which only occurred in 7 (5%) of 145 cases with non-CA6 enterovirus infection (p < 0.001). The sequences of viral protein 1 of CA6 in 2010 differ from those found in Taiwan before 2010, but are similar to those found in patients in Finland in 2008.
  
  
  CONCLUSIONS
  HFMD patients with CA6 infection experienced symptoms targeting a broader spectrum of skin sites and more profound tissue destruction, i.e., desquamation and nail abnormalities.
authors.affiliation: Taiwan Centers for Disease Control, Taipei, Taiwan.
authors.forename: Sung-Hsi
authors.initials: SH
authors.lastname: Wei
authors.forename: Yuan-Pin
authors.initials: YP
authors.lastname: Huang
authors.forename: Ming-Chih
authors.initials: MC
authors.lastname: Liu
authors.forename: Tsung-Pei
authors.initials: TP
authors.lastname: Tsou
authors.forename: Hui-Chen
authors.initials: HC
authors.lastname: Lin
authors.forename: Tsuey-Li
authors.initials: TL
authors.lastname: Lin
authors.forename: Chen-Yen
authors.initials: CY
authors.lastname: Tsai
authors.forename: Yen-Nan
authors.initials: YN
authors.lastname: Chao
authors.forename: Luan-Yin
authors.initials: LY
authors.lastname: Chang
authors.forename: Chun-Ming
authors.initials: CM
authors.lastname: Hsu
mesh_terms: D000293:Adolescent; D000328:Adult; D036022:Capsid Proteins / Q000235:genetics; D002648:Child; D002675:Child, Preschool; D004196:Disease Outbreaks; D004770:Enterovirus / Q000145:classification / Q000235:genetics / Q000302:isolation & purification*; D005260:Female; D006232:Hand, Foot and Mouth Disease / Q000453:epidemiology* / Q000821:virology; D006801:Humans; D007223:Infant; D008297:Male; D009260:Nail Diseases / Q000453:epidemiology / Q000821:virology*; D010802:Phylogeny; D012367:RNA, Viral / Q000235:genetics; D020133:Reverse Transcriptase Polymerase Chain Reaction; D017423:Sequence Analysis, RNA; D017193:Skin Diseases, Viral / Q000453:epidemiology / Q000821:virology; D013624:Taiwan / Q000453:epidemiology; D055815:Young Adult
chemical_list: D036022:Capsid Proteins; D012367:RNA, Viral