A 9-year-old boy is brought to the office due to throat pain and rash. Two days ago, the patient was sent home early from summer camp because of fever, sore throat, pain with eating, and rash on his extremities. He has no prior medical conditions and is up to date on immunizations. Temperature is 37.2 C (99 F); vital signs are otherwise normal. On physical examination, the conjunctivae are normal, and the tympanic membranes are clear. Several superficial ulcers are present on the buccal mucosa and soft palate; the tonsils appear normal and do not have exudate. Skin examination findings are shown in the exhibit.
The infectious agent most likely responsible for this patient's current condition is also associated with which of the following?

Question

A 9-year-old boy is brought to the office due to throat pain and rash.  Two days ago, the patient was sent home early from summer camp because of fever, sore throat, pain with eating, and rash on his extremities.  He has no prior medical conditions and is up to date on immunizations.  Temperature is 37.2 C (99 F); vital signs are otherwise normal.  On physical examination, the conjunctivae are normal, and the tympanic membranes are clear.  Several superficial ulcers are present on the buccal mucosa and soft palate; the tonsils appear normal and do not have exudate.  Skin examination findings are shown in the exhibit.  
The infectious agent most likely responsible for this patient's current condition is also associated with which of the following?

Quizplus · Accepted Answer

11ec160b_382b_360c_9249_81d09dbba1a6_MD0001_00 This patient has mouth ulcers and vesicular lesions on his hands, raising strong suspicion for hand-foot-and-mouth disease (HFMD). HFMD is caused by several different species of Enterovirus (Picornaviridae family), most often coxsackievirus A or Human enterovirus A. Most cases are transmitted by the fecal-oral route, and outbreaks often occur in communal settings (eg, day care, summer camp, schools) during the summer or early autumn; children age <7 are primarily affected. The 2 most common presentations of enterovirus infection are: HFMD, which is marked by low-grade fever, oral enanthem (vesicles/ulcers) on the tongue and buccal mucosa, and macular/vesicular exanthem on the hands, feet, buttocks, legs, and/or arms herpangina, which is characterized by high fever, oral ulcers, and no skin findings Patients with enterovirus infection usually have self-limited disease. However, significant viremia occurs prior to the development of protective antibodies. Although generally asymptomatic and not associated with morbidity, a small minority of patients develop serious myocarditis (eg, congestive heart failure) or CNS disease (eg, aseptic meningitis). (Choice A) Facial nerve palsy (Bell palsy) is associated with Lyme disease, which usually presents with a classic bull's-eye rash (erythema migrans) rather than ulcerative enanthem/exanthem. (Choices B and E) Keratitis (cornea infection) and temporal lobe encephalitis are serious complications of herpes simplex virus (HSV). HSV gingivostomatitis presents with vesicles on the anterior oral mucosa, particularly the lips. Patients may also have concomitant herpetic whitlow, which usually appears as clusters of vesicles on the fingers (not diffuse blisters on the palm). Enterovirus is not associated with keratitis, and although it can cause CNS infection, temporal lobe encephalitis is more specific for HSV. (Choice D) Parvovirus B19 infection can cause a classic "slapped-cheek" rash (fifth disease) or a diffuse, reticulated rash. In some cases, particularly in adolescent girls or adult women, the infection is followed 1-2 weeks later by polyarthralgia or polyarthritis. Enterovirus does not usually cause joint manifestations. Educational objective: Hand-foot-and-mouth disease (oral ulceration and extremity rash) and herpangina (oral ulcerations without rash) are the most common manifestations of enteroviral infection. Rare but serious complications of infection include myocarditis and central nervous system disease (eg, aseptic meningitis). __________ References: Tissue tropism, pathology and pathogenesis of enterovirus infection. (http://www.ncbi.nlm.nih.gov/pubmed/25211036) The seasonality of nonpolio enteroviruses in the United States: patterns and drivers. (http://www.ncbi.nlm.nih.gov/pubmed/29507246)

A 9-Year-Old Boy Is Brought to the Office Due to Throat