title: Prevalence of Coxsackievirus A6 and Enterovirus 71 in Hand, Foot and Mouth Disease in Nanjing, China in 2013.
abstract: BACKGROUND
  Although hand, foot and mouth disease (HFMD) has been strongly associated with enterovirus 71 (EV71), coxsackievirus A16 (CVA16) and other enteroviruses, studies regarding coxsackievirus A6 (CVA6) infection in HFMD are limited. The aim of this study was to identify the major etiological agents causing HFMD in Nanjing in 2013 and explore the clinical and genetic characteristics of the prevalent enterovirus (EV) types in HFMD.
  
  
  METHODS
  A total of 394 throat swabs were collected from hospitalized children diagnosed with HFMD from April to July 2013. EVs were detected by reverse transcription polymerase chain reaction of 5' UTR sequences. Genotyping and phylogenetic analysis were based on VP4 sequences. Demographic and clinical data were obtained.
  
  
  RESULTS
  Of the specimens, 68.5% (270/394) were positive for EVs. The genotypes and detection rates were CVA6, 30.00% (81/270); EV71, 17.41% (47/270); HRV, 11.11% (30/270); CVA10, 3.33% (9/270); CVA2, 1.11% (3/270); CVA16, 0.74% (2/270); EV68, 0.37% (1/270); echovirus 6, 0.37% (1/270); echovirus 9, 0.37% (1/270), respectively. Patients infected with CVA6 displayed symptoms atypical of HFMD, including larger vesicles on their limbs and buttocks. Phylogenetic analysis revealed 2 genetically distinct CVA6 strains that circulated independently within the region. Patients infected with CVA6 were more likely to have abnormal periphery blood white blood cell and C-reactive protein levels, while EV71 was more likely to infect the central nervous system, as indicated by clinical manifestations and white blood cell analysis of cerebrospinal fluid.
  
  
  CONCLUSIONS
  Multiple EV genotypes contributed to HFMD in Nanjing in 2013, and CVA6 was the dominant genotype. The clinical presentation of CVA6 infection differs from that of EV71 infection in HFMD.
authors.affiliation: From the *Nanjing Children's Hospital, Nanjing Medical University, Nanjing, People's Republic of China; and †National Institute for Viral Disease Control and Prevention, Chinese Center for Viral Disease Control and Prevention, Beijing, People's Republic of China.
authors.forename: Ya-Qian
authors.initials: YQ
authors.lastname: Hu
authors.forename: Guang-Cheng
authors.initials: GC
authors.lastname: Xie
authors.forename: Dan-Di
authors.initials: DD
authors.lastname: Li
authors.forename: Li-Li
authors.initials: LL
authors.lastname: Pang
authors.forename: Jing
authors.initials: J
authors.lastname: Xie
authors.forename: Peng
authors.initials: P
authors.lastname: Wang
authors.forename: Ying
authors.initials: Y
authors.lastname: Chen
authors.forename: Jing
authors.initials: J
authors.lastname: Yang
authors.forename: Wei-Xia
authors.initials: WX
authors.lastname: Cheng
authors.forename: Qing
authors.initials: Q
authors.lastname: Zhang
authors.forename: Yu
authors.initials: Y
authors.lastname: Jin
authors.forename: Zhao-Jun
authors.initials: ZJ
authors.lastname: Duan
mesh_terms: D020121:5' Untranslated Regions; D002648:Child; D002675:Child, Preschool; D002681:China / Q000453:epidemiology; D004770:Enterovirus / Q000302:isolation & purification*; D029821:Enterovirus A, Human / Q000302:isolation & purification*; D005260:Female; D060005:Genotyping Techniques; D006232:Hand, Foot and Mouth Disease / Q000453:epidemiology* / Q000821:virology*; D006801:Humans; D007223:Infant; D008297:Male; D017720:Molecular Epidemiology; D010614:Pharynx / Q000821:virology; D010802:Phylogeny; D015995:Prevalence; D020133:Reverse Transcriptase Polymerase Chain Reaction; D017422:Sequence Analysis, DNA; D015678:Viral Structural Proteins
chemical_list: D020121:5' Untranslated Regions; D015678:Viral Structural Proteins