Review Question - QID 214814

This patient has a 1-week history of fever, sore throat, mouth ulcers, and a rash on the palms and soles (demonstrating vesicles with an erythematous base). This constellation of symptoms is most consistent with a coxsackievirus infection (hand, foot, and mouth disease).

Hand, foot, and mouth disease (HFMD) is an acute, self-limited viral illness caused by coxsackievirus (A-16). Coxsackievirus is an enterovirus that is part of the picornavirus family of positive-sense RNA viruses. HFMD is characterized by a fever and sore throat on days 1-2 followed by oral ulcers and an erythematous, maculopapular rash on days 2-3, most notably involving the hands and feet. The maculopapular rash evolves into a vesicular rash 1-2 days after initiation. HFMD usually affects children of preschool age who attend daycare, as the virus is extremely contagious and spread by fecal-oral route or direct contact with the infected patient's saliva or blister fluid. This self-limited viral illness usually lasts between 7-10 days. Treatment involves supportive care with antipyretics.

El-Asmar et al. studied a case of acute pericarditis and tamponade in an adult patient with Coxsackie B3 virus. The authors found that the patient had received an allogeneic hematopoietic cell transplant (allo-HCT), placing him at increased risk for severe viral infections. The authors recommend that while severe complications from coxsackie virus are rare in the allo-HCT population, patients should be closely monitored and careful infection prevention measures should be taken.

Figure/Illustration A demonstrates a palmar rash with multiple vesicles on an erythematous base (yellow arrows).

Incorrect Answers:
Answer 2: Erythema multiforme describes dermatologic lesions secondary to viral illnesses (most commonly Mycoplasma pneumoniae) or drugs. It is characterized by well-demarcated targetoid lesions with 3 distinct zones: a central dusky or red center, a surrounding pale pink edematous ring, and an outer bright red circle. This patient’s lesions are more consistent with coxsackievirus infection.

Answer 3: Herpes simplex virus can present primarily as herpetic gingivostomatitis with painful, yellow ulcers on the oral mucosa. Recurrent disease is characterized by grouped umbilicated vesicles, located primarily on the lips and face. Lesions on the palms and soles, as seen in this patient, are not characteristic of herpes simplex virus infection.

Answer 4: Measles (rubeola) infections are characterized by a prodrome with a fever up to 105°F (40.6°C), coryza, cough, and conjunctivitis. On days 3-4 of the illness, Koplick spots (white papules on the oral mucosa) can be seen. A maculopapular rash also develops, beginning at the forehead and behind the ears and eventually spreading in a cephalocaudal progression.

Answer 5: Varicella infections are characterized by a prodrome of fever and myalgias with an initial acute eruption of erythematous macules and papules that start on the face and oral mucosa and spread to the trunk and extremities. Lesions evolve into vesicles on an erythematous base and then to pustules with an overlying crust but do not affect the palms and soles.

Bullet Summary:
Coxsackievirus presents in children with a fever, sore throat, mouth ulcers, and a rash on the palms and soles (vesicles with an erythematous base).