A 32-year-old previously healthy woman comes to the clinic for evaluation of a rash on the soles of her feet and palms of her hands for 2 days. She also has had intermittent fever, chills, decreased appetite, and malaise. Three days before the rash appeared, the patient visited a children's water park with her 2-year-old niece. She has no known chronic medical conditions. Temperature is 37.8 C (100 F), blood pressure is 113/78 mm Hg, pulse is 65/min, and respirations are 14/min. Oropharyngeal examination shows several ulcers on the soft palate, buccal mucosa, and posterior oropharynx; gingiva and dentition are normal. Examination of the skin on her sole, foot, and hands is shown in the exhibits. The remainder of the examination is unremarkable. Which of the following is the best next step in management of this patient?
Hand-foot-and-mouth disease | |
Pathogenesis & epidemiology |
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Clinical features |
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Complications |
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Management |
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This patient has oral ulcers and a rash on her palms and soles, which are findings characteristic of hand-foot-and-mouth disease (HFMD) caused by coxsackievirus. Transmission is via fecal-oral spread or contact with respiratory droplets, oral secretions, or vesicular fluid, and infection often occurs in outbreaks involving communal settings (eg, water parks). HFMD usually affects children age <7 but can present in adolescents and adults, as in this patient.
HFMD presents with a painful oral enanthem consisting of vesicles/ulcers usually affecting the tongue, buccal mucosa, or soft palate as well as a maculopapular or vesicular exanthem on the hands and feet (including the palms and soles); the rash is typically nonpruritic but may be painful. Systemic symptoms (eg, fever, decreased appetite, malaise) can also occur, as seen here.
Diagnosis of HFMD is clinical (ie, no additional testing required), and management is supportive care (eg, hydration, analgesics) because the illness is typically self-limited.
(Choice A) Antinuclear antibodies are usually positive in systemic lupus erythematosus (SLE), which can present with systemic symptoms (eg, fever, malaise), rash, and oral ulcers. However, unlike this case, the malar rash in SLE involves the cheeks/nasal bridge, not the palms and soles, and the ulcers are painless.
(Choices B) Valvular vegetations on echocardiogram and positive blood cultures are findings in infective endocarditis (IE), which may present with Janeway lesions (painless, erythematous macules) or Osler nodes (painful, violaceous nodules) on the palms and soles. However, most patients have associated risk factors (eg, structural heart disease, poor dentition) and a murmur, findings not seen in this patient. In addition, oral ulcerations do not occur.
(Choice D) Skin biopsy with direct immunofluorescence can diagnose IgA vasculitis (Henoch-Schönlein purpura), which causes palpable purpura on gravity-dependent areas, such as the buttocks and lower extremities. However, maculopapular lesions of the palms and oral ulcerations would not be expected.
(Choice E) Acute rheumatic fever due to untreated group A streptococcal pharyngitis may cause a truncal rash, or erythema marginatum, and subcutaneous nodules over bony areas, not erythematous lesions on the palms and soles. In addition, preceding infection (which is not associated with discrete oral lesions) is typically resolved, so oropharyngeal examination would be normal and throat culture would be negative.
Educational objective:
Hand-foot-and-mouth disease caused by coxsackievirus presents with oral vesicles and ulcers in addition to a maculopapular or vesicular exanthem classically involving the palms and soles. Diagnosis is clinical, and treatment is supportive.