Speediatrics – what is the cause of this child's facial rash?

The next in our series of quick quizzes in paediatric care asks – what is the likely diagnosis in this case of a child who has developed a facial rash following recent mild fever and sore throat?

The Case

A three year old girl presents with a rash in and around the mouth for a couple of days which was preceded by a mild fever and sore throat.

Picture

The child had similar spots on some fingers, on her thighs and buttocks and on the sides of her feet.

What’s the diagnosis?

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Fast Facts: Hand, Foot, and Mouth Syndrome (HFMD) in Children

Clinical Features:

Initial Symptoms:
- Often starts with mild fever, malaise, and sore throat.
- Reduced appetite and irritability may be present.
Rash and Mouth Lesions:
- Oral Lesions: Painful vesicles or ulcers on the tongue, gums, and inside of the cheeks. These may make eating or drinking difficult and can extend to the lips and peri-oral area.
- Hand and Foot Rash: Small, red, flat, or raised spots that may develop into vesicles on the hands and feet, and occasionally on the buttocks, thighs and genital area.
- Distribution: Lesions are often on the dorsal surface of hands and feet, unlike other conditions.
Duration:
- Symptoms typically last 7–10 days and are self-limiting.

Epidemiology:

Age Group:
- Most commonly affects children under 5 years, but can occur in older children and adults.
Causative Agents:
- Most commonly caused by Coxsackievirus A16 or Enterovirus 71.
Transmission:
- Spread via direct contact with nasal secretions, saliva, stool, or fluid from blisters.
- Highly contagious, particularly in nurseries and schools.
Seasonality:
- More common in the late summer and early autumn months.

Diagnosis:

Clinical Diagnosis:
- Based on the characteristic appearance of the vesicular rash on hands, feet, and mouth, and typical history of a mild prodrome (fever, malaise).
Laboratory Tests:
- Diagnosis is usually clinical; laboratory confirmation (e.g., viral PCR of throat swabs, stool, or vesicular fluid) is rarely required unless in atypical or severe cases.

Differential Diagnosis:

Varicella (Chickenpox):
- More generalized vesicular rash, starting on the trunk, rather than being localized to hands, feet, and mouth.
- Associated with a more pronounced fever and malaise.
Herpetic Gingivostomatitis:
- Caused by HSV-1. Primarily affects the oral mucosa with painful ulcers, but lacks the characteristic hand and foot rash.
- Often more severe in presentation with higher fever and systemic upset.
Kawasaki Disease:
- Distinguished by persistent fever for over 5 days, strawberry tongue, conjunctivitis, rash, and peeling of the skin, particularly on the palms and soles.
- No vesicular lesions and may involve coronary artery aneurysms.
Erythema Multiforme:
- Target lesions often involving the palms and soles, but typically no oral or systemic involvement unless more severe (e.g., Stevens-Johnson Syndrome).

Red Flags:

Severe Neurological Symptoms:
- Enterovirus 71 can cause serious complications such as encephalitis, aseptic meningitis, or acute flaccid paralysis.
- Look for signs like altered consciousness, seizures, or difficulty walking.
Dehydration:
- Painful oral lesions may prevent adequate fluid intake. Signs include dry mucous membranes, reduced urine output, or lethargy.
Persistent or Worsening Fever:
- A fever lasting more than 3-5 days or worsening illness may indicate secondary bacterial infection or more severe enterovirus strain.

Management:

Supportive Care:
- Analgesia: Paracetamol or ibuprofen to relieve pain, especially from oral lesions.
- Hydration: Encourage oral fluids; cold drinks, ice lollies, or soft foods can help alleviate discomfort. Monitor for dehydration.
Oral Care:
- Encourage good oral hygiene; topical anaesthetics may be used to relieve mouth pain.
Isolation:
- Advise parents that children should be kept off nursery or school only while they are feeling unwell.
Antiviral or Antibiotic Therapy:
- Not indicated for uncomplicated cases. Antibiotics are only needed if there is a secondary bacterial infection.

Patient Education:

Understanding the Condition:
- Reassure parents that HFMD is usually mild and self-limiting, lasting 7-10 days.
- Explain the contagious nature and the importance of handwashing and hygiene to prevent spread.
Managing Oral Discomfort:
- Suggest giving cold foods (e.g., yogurt, ice lollies) and avoiding acidic or spicy foods that can irritate oral lesions.
Preventing Spread:
- Encourage frequent handwashing, particularly after changing nappies, and cleaning toys or surfaces that may be contaminated.
When to Seek Help:
- Advise parents to return if there are signs of dehydration, (difficulty breathing, or if the child develops severe headache, neck stiffness, or drowsiness.