An 18-month-old girl is brought to an urgent care center by her father for evaluation of a fever and rash. Yesterday she developed a fever of 38.2 C (100.7 F), which was treated with acetaminophen. This morning she appeared more tired than usual and did not eat her breakfast. She has been drinking milk and water but refuses to hold her cup due to discomfort from a new rash on her hands. The patient started attending daycare last week, but her parents are not sure if other children have been ill. She has been playing outdoors frequently this summer and has had occasional insect bites, but has stayed inside the past 2 days while sick. The patient has had no rhinorrhea, cough, vomiting, or diarrhea. She was born at term and has no chronic medical conditions. Temperature is 38.1 C (100.5 F). Physical examination shows a mildly ill-appearing patient with 8 small ulcers scattered across the buccal mucosa. Mucous membranes are moist, and the oropharynx is otherwise clear and without erythema or exudates. Cardiopulmonary and abdominal examinations are normal. Skin examination shows multiple lesions on both palms; no other lesions are visualized. Which of the following is the most likely etiology of this patient's examination findings?

Question

An 18-month-old girl is brought to an urgent care center by her father for evaluation of a fever and rash.  Yesterday she developed a fever of 38.2 C (100.7 F), which was treated with acetaminophen.  This morning she appeared more tired than usual and did not eat her breakfast.  She has been drinking milk and water but refuses to hold her cup due to discomfort from a new rash on her hands.  The patient started attending daycare last week, but her parents are not sure if other children have been ill.  She has been playing outdoors frequently this summer and has had occasional insect bites, but has stayed inside the past 2 days while sick.  The patient has had no rhinorrhea, cough, vomiting, or diarrhea.  She was born at term and has no chronic medical conditions.  Temperature is 38.1 C (100.5 F).  Physical examination shows a mildly ill-appearing patient with 8 small ulcers scattered across the buccal mucosa.  Mucous membranes are moist, and the oropharynx is otherwise clear and without erythema or exudates.  Cardiopulmonary and abdominal examinations are normal.  Skin examination shows multiple lesions on both palms; no other lesions are visualized.  Which of the following is the most likely etiology of this patient's examination findings?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c170_d349_8f63_1d2c0e9c064f_MD0005_00 This patient's examination is consistent with hand-foot-mouth disease (HFMD) caused by coxsackievirus. This infection typically occurs in infants and young children during the summer and can spread quickly through daycare centers, schools, and camps. The virus is shed in the stool and transmitted by the fecal-oral route (eg, diaper changes) or by direct contact with respiratory, oral, or vesicular secretions. Patients typically present with fever, mouth pain, and decreased oral intake. Examination reveals a characteristic exanthem and/or oral enanthem. A nonpruritic macular, maculopapular, or vesicular rash often appears on the palms, soles, and/or buttocks. Painful vesicles appear on the anterior oral mucosa (eg, tongue, buccal mucosa) and rupture to form oral ulcers. Although herpangina is also caused by coxsackievirus, these oral lesions can be distinguished from HFMD by their location on the posterior oropharynx. oral ulcers Treatment of HFMD is supportive and directed at maintaining adequate hydration and relieving pain. Oral and skin lesions typically self-resolve within a week. However, handwashing is extremely important as the virus can be contagious for several weeks after rash resolution. (Choice B) Human herpesvirus 6 causes roseola infantum, an illness characterized by high fever followed by the appearance of a rash once the fever resolves. Rash begins on the neck/trunk and is uncommon on the palms. (Choice C) Primary herpes simplex virus type 1 causes gingivostomatitis in children. Although the buccal mucosa, tongue, and pharynx may be involved, the gingiva and lips are typically inflamed with vesicles that coalesce into large ulcers that bleed and crust. Vesicles on the hands or fingers (herpetic whitlow) can occur by autoinoculation from oral lesions but are typically unilateral in contrast to the bilateral lesions of HFMD. (Choice D) Rocky Mountain spotted fever, a rickettsial illness transmitted via tick bite, causes fever, headache, and an erythematous or petechial rash that may involve the palms and soles. Oral ulcers are not associated. (Choice E) The varicella zoster virus causes chickenpox, which generally presents with fever and a widespread vesicular rash on the face, trunk, and extremities. Lesions are usually pruritic and rarely affect the palms. Educational objective: Hand-foot-mouth disease is typically caused by coxsackievirus. Clinical features include a rash on the palms, soles, and/or buttocks and painful oral ulcers. References: Coxsackievirus A16: epidemiology, diagnosis, and vaccine. (http://www.ncbi.nlm.nih.gov/pubmed/24231751)

An 18-Month-Old Girl Is Brought to an Urgent Care Center