Coxsackievirus A6 associated hand, foot and mouth disease in adults: Clinical presentation and review of the literature

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Highlights

  • •

    CVA6 (coxsackievirus A6) has been linked to several worldwide outbreaks since 2008.

  • •

    This series demonstrates that there is a wide array of disease presentation of CVA6 associated HFMD in adults.

  • •

    qRT-PCR is the diagnostic test of choice for CVA6, as commercial serologic assays against CVA6 are not available.

  • •

    CVA6 may be associated with peri-oral involvement, desquamation of the palms and soles, and onchyomadesis.

Abstract

Background

Hand, foot, and mouth disease (HFMD) is generally considered a rare illness in adults. Classically, HFMD has been strongly associated with coxsackievirus strain A16 and enterovirus 71. The coxsackievirus A6 (CVA6) strain has been linked to severe worldwide outbreaks since 2008. CVA6 is associated with a more severe and profound course of disease, affecting both children and adults.

Objectives

To present a series of five adult patients diagnosed with HFMD due to CVA6. We investigate method of diagnosis and compare clinical presentation of adult cases to those in children.

Study design

Each patient underwent a full-body skin exam as well as inspection of the oral cavity. Rapid plasma reagin (RPR) and serologic assays by complement fixation against coxsackievirus B (1–6) and A (2,4,7,9,10,16) were performed as indicated. As standard serological testing does not detect CVA6, real-time reverse transcription-polymerase chain reaction (qRT-PCR) of serum, buccal swabs, and skin scrapings were performed by the Centers for Disease Control and Prevention (CDC).

Results

Each patient had clinical findings consistent with various stages of HFMD. One patient presented with delayed onychomadesis and desquamation of the palms and soles. RPR and serologic assays by complement fixation against CVB (1–6) and CVA (2,4,7,9,10,16) were mostly negative, although elevated in two patients due to cross-reactivity. qRT-PCR identified CVA6 genetic material in samples from all patients.

Conclusion

This series demonstrates that there is a wide array of disease presentation of CVA6 associated HFMD in adults.

Section snippets

Background

Hand, foot and mouth disease (HFMD) is an illness caused by several enteroviruses; typically coxsackievirus (CV) A16 and enterovirus 71. HFMD generally infects approximately 11% of exposed adults [1], but fewer than 1% of infected adults develop clinical manifestations of disease. Other coxsackie A viruses such as CVA6, CVA9, and CVA10 may also be associated with the disease [2], [3], [4]. There have been increasing reports of adult HFMD caused by a more virulent enterovirus, particularly CVA6.

Objectives

To present a series of five adult patients diagnosed with HFMD due to CVA6. We investigate methods of diagnosis and compare clinical presentation of adult cases to those in children. We performed a retrospective chart review to analyze data.

Methods

We reviewed medical records of adult patients presenting to an outpatient dermatology clinical in Houston, Texas, with CVA6 associated HFMD. Five patients were identified. Patients 1 and 2 presented in August of 2012, while patients 3–5 presented between the months of June and August of 2013. All patients were received as dermatology consults for diagnostic assistance from primary care physicians or emergency care facilities. Since HFMD is a disease classically affecting the younger pediatric

Results

We identified five adult cases of CVA6-confirmed HFMD during the summer months of 2012 and 2013 (Table 1). Prodromal symptoms were observed in all of our patients. None of our patients experienced other reported systemic manifestations such as encephalitis, meningitis, pulmonary edema or myocarditis, or were hospitalized, unlike what has been previously reported in pediatric cases [20], [21]. One patient in the series did suffer from gastroenteritis. It is known that infants tend to have a

Discussion

Most cases of HFMD occur in children. While the disease is self-limiting and severity varies among different strains, our findings suggest that if an adult patient presents with the clinical diagnosis of HFMD, the involvement of a more virulent strain of an enterovirus should be suspected.

Commercial serologic assays by complement fixation against CVA6 are not available. Importantly, infection by CVA6 may result in falsely increased antibody titers to other coxackieviruses due to

Funding

None.

Competing interests

None declared.

Ethical approval

None required.

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