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

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.