Atypical Forms of Hand, Foot, and Mouth Disease: A Prospective Study of 47 Italian Children.
BACKGROUND
Atypical forms of hand, foot, and mouth disease (HFMD) caused by coxsackievirus A6 have been reported in recent years. High fever and severe cutaneous lesions are common, whereas neurologic complications are rare. Eczematous areas of patients with atopic dermatitis show more lesions. The goal of the current study was to describe the clinical characteristics of children with atypical HFMD and to investigate the involvement of the different enterovirus serotypes associated.


METHODS
All patients referred to our service for atypical HFMD from January 2012 to February 2014 were enrolled and classified as having the diffuse form (lesions extended to the trunk), the acral form (lesions with a mainly acral distribution), or eczema coxsackium (lesions on preexisting eczematous areas).


RESULTS
Data from 47 patients were analyzed (median age 22 months [range 4-84 mos]); viral genotyping was performed in 11 cases. Sixty-two percent of the subjects developed the acral form, 23% eczema coxsackium, and 15% the diffuse form. Most patients had a nonclassical vesicular eruption and moderate to severe extent of cutaneous involvement. Approximately 80% of patients had palmoplantar purpuric macules. Most children younger than 2 years old had the acral form, most patients with eczema coxsackium were age 2 years and older, and the diffuse form was similarly distributed between the two age groups. Coxsackievirus A6 was detected in 9 of 11 genotyped cases.


CONCLUSIONS
Our prospective study allowed the identification of three HFMD phenotypes differing from the classical form. Clinical care of these patients should include symptomatic treatment of extracutaneous features and, if necessary, hospitalization for complications.
Dermatology Unit, Department of Specialistic, Diagnostic and Experimental Medicine, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
Iria
I
Neri
Dermatology Unit, Department of Specialistic, Diagnostic and Experimental Medicine, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.|Pediatric Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
Arianna
A
Dondi
Department of Dermatology and Allergy, Ludwig-Maximilian University, Munich, Germany.
Andreas
A
Wollenberg
Dermatology Unit, Department of Specialistic, Diagnostic and Experimental Medicine, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
Lorenza
L
Ricci
Pediatric Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
Giampaolo
G
Ricci
Department of Specialistic, Diagnostic and Experimental Medicine, Operative Unit of Clinical Microbiology, Laboratory of Virology, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
Giulia
G
Piccirilli
Department of Specialistic, Diagnostic and Experimental Medicine, Operative Unit of Clinical Microbiology, Laboratory of Virology, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
Tiziana
T
Lazzarotto
Dermatology Unit, Department of Specialistic, Diagnostic and Experimental Medicine, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
Annalisa
A
Patrizi
D002648:Child; D002675:Child, Preschool; D029821:Enterovirus A, Human / Q000235:genetics / Q000302:isolation & purification*; D004769:Enterovirus Infections / Q000175:diagnosis* / Q000821:virology; D005260:Female; D005838:Genotype; D006232:Hand, Foot and Mouth Disease / Q000175:diagnosis* / Q000821:virology; D006801:Humans; D007223:Infant; D007558:Italy; D008297:Male; D011446:Prospective Studies