A 3-year-old girl is brought to the office due to 2 days of fever and rash. Her mother says the patient has also been refusing to eat or drink. She has no prior medical conditions and is up to date with recommended vaccinations. None of the family members have had recent febrile illness, but the patient recently started attending day care. Temperature is 38.3 C (101 F). Physical examination shows multiple small vesicles and ulcers with an erythematous base on the buccal mucosa and tongue. There are similar vesicular lesions on the distal extremities. Which of the following is the most likely underlying cause of this patient's rash?

Question

A 3-year-old girl is brought to the office due to 2 days of fever and rash.  Her mother says the patient has also been refusing to eat or drink.  She has no prior medical conditions and is up to date with recommended vaccinations.  None of the family members have had recent febrile illness, but the patient recently started attending day care.  Temperature is 38.3 C (101 F).  Physical examination shows multiple small vesicles and ulcers with an erythematous base on the buccal mucosa and tongue.  There are similar vesicular lesions on the distal extremities.  Which of the following is the most likely underlying cause of this patient's rash?

Quizplus · Accepted Answer

11ec160b_38f5_8b14_9249_c72c1ab351fa_MD0001_00 This patient's vesicular rash on the buccal mucosa, tongue, and distal extremities likely indicates hand-foot-and-mouth disease (HFMD), a common childhood illness caused by species of Enterovirus (eg, Coxsackievirus). Transmission largely occurs via the fecal-oral route, and outbreaks are common in day cares and elementary schools. The virus initially replicates in gastrointestinal lymphatic tissue and subsequently disseminates through the reticuloendothelial system and bloodstream to other organs (eg, heart, liver, brain, skin). Patients generally develop low-grade fever and the following mucocutaneous findings: Most cases can be managed with supportive care and resolve spontaneously within a week. However, viral shedding in the stool continues for >6 weeks, which can propagate transmission. (Choice A) Pemphigus vulgaris is characterized by autoantibody-mediated acantholysis, which leads to the formation of painful mucous membrane and cutaneous erosions. Vesicles on an erythematous base would be atypical; in addition, the palms and soles are generally spared and HFMD is far more common in children. (Choice C) Stevens-Johnson syndrome is a hypersensitivity reaction that is typically triggered by medication (eg, allopurinol) or infection (eg, Mycoplasma). It is characterized by necrosis and detachment of the epidermis, leading to high fever; hemorrhagic oral erosions; and coalescing, erythematous skin macules/bullae with purpuric centers. (Choice D) Scarlet fever is a delayed-type immune response to a pyrogenic exotoxin produced by Streptococcus pyogenes. Patients usually have a history of streptococcal infection (eg, pharyngitis, cellulitis) and then develop a diffuse, erythematous, papular rash that has a "sandpaper" quality. Vesicles are not typically seen, and the oral cavity is not usually involved. (Choice E) Kawasaki disease is an inflammatory childhood vasculitis that primarily affects medium-sized blood vessels. Patients generally have high fever, mucositis (eg, red lips, strawberry tongue), and a macular or targetoid rash. The presence of vesicles and ulcers makes this diagnosis unlikely. Educational objective: Hand-foot-and-mouth disease is a common childhood illness characterized by painful, vesicular mouth lesions; ulcers on the extremities; and low-grade fever. It is caused by the ingestion and subsequent dissemination of an enterovirus (eg, Coxsackievirus).

A 3-Year-Old Girl Is Brought to the Office Due to 2