title: "Eczema coxsackium" and unusual cutaneous findings in an enterovirus outbreak.
abstract: OBJECTIVE
  To characterize the atypical cutaneous presentations in the coxsackievirus A6 (CVA6)-associated North American enterovirus outbreak of 2011-2012.
  
  
  METHODS
  We performed a retrospective case series of pediatric patients who presented with atypical cases of hand, foot, and mouth disease (HFMD) from July 2011 to June 2012 at 7 academic pediatric dermatology centers. Patients were included if they tested positive for CVA6 or if they met clinical criteria for atypical HFMD (an enanthem or exanthem characteristic of HFMD with unusual morphology or extent of cutaneous findings). We collected demographic, epidemiologic, and clinical data including history of skin conditions, morphology and extent of exanthem, systemic symptoms, and diagnostic test results.
  
  
  RESULTS
  Eighty patients were included in this study (median age 1.5 years, range 4 months-16 years). Seventeen patients were CVA6-positive, and 63 met clinical inclusion criteria. Ninety-nine percent of patients exhibited a vesiculobullous and erosive eruption; 61% of patients had rash involving >10% body surface area. The exanthem had a perioral, extremity, and truncal distribution in addition to involving classic HFMD areas such as palms, soles, and buttocks. In 55% of patients, the eruption was accentuated in areas of eczematous dermatitis, termed "eczema coxsackium." Other morphologies included Gianotti-Crosti-like (37%), petechial/purpuric (17%) eruptions, and delayed onychomadesis and palm and sole desquamation. There were no patients with serious systemic complications.
  
  
  CONCLUSIONS
  The CVA6-associated enterovirus outbreak was responsible for an exanthem potentially more widespread, severe, and varied than classic HFMD that could be confused with bullous impetigo, eczema herpeticum, vasculitis, and primary immunobullous disease.
authors.affiliation: Departments of Dermatology and Pediatrics, University of California, San Francisco, San Francisco, CA 94143, USA. mathese@derm.ucsf.edu
authors.forename: Erin F
authors.initials: EF
authors.lastname: Mathes
authors.forename: Vikash
authors.initials: V
authors.lastname: Oza
authors.forename: Ilona J
authors.initials: IJ
authors.lastname: Frieden
authors.forename: Kelly M
authors.initials: KM
authors.lastname: Cordoro
authors.forename: Shigeo
authors.initials: S
authors.lastname: Yagi
authors.forename: Renee
authors.initials: R
authors.lastname: Howard
authors.forename: Leonard
authors.initials: L
authors.lastname: Kristal
authors.forename: Christine C
authors.initials: CC
authors.lastname: Ginocchio
authors.forename: Julie
authors.initials: J
authors.lastname: Schaffer
authors.forename: Sheilagh
authors.initials: S
authors.lastname: Maguiness
authors.forename: Susan
authors.initials: S
authors.lastname: Bayliss
authors.forename: Irene
authors.initials: I
authors.lastname: Lara-Corrales
authors.forename: Maria Teresa
authors.initials: MT
authors.lastname: Garcia-Romero
authors.forename: Dan
authors.initials: D
authors.lastname: Kelly
authors.forename: Maria
authors.initials: M
authors.lastname: Salas
authors.forename: M Steven
authors.initials: MS
authors.lastname: Oberste
authors.forename: W Allan
authors.initials: WA
authors.lastname: Nix
authors.forename: Carol
authors.initials: C
authors.lastname: Glaser
authors.forename: Richard
authors.initials: R
authors.lastname: Antaya
mesh_terms: D000046:Academic Medical Centers; D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D003384:Coxsackievirus Infections / Q000175:diagnosis* / Q000453:epidemiology / Q000821:virology; D003430:Cross-Sectional Studies; D003937:Diagnosis, Differential; D004196:Disease Outbreaks; D004485:Eczema / Q000175:diagnosis* / Q000453:epidemiology / Q000821:virology; D005260:Female; D006232:Hand, Foot and Mouth Disease / Q000175:diagnosis* / Q000453:epidemiology / Q000821:virology; D006801:Humans; D007223:Infant; D008297:Male; D009656:North America; D012189:Retrospective Studies
keywords: atopic dermatitis; coxsackievirus; exanthem; hand, foot, and mouth disease