PediaCast 168 * Hand Foot Mouth Disease
Today Dr. Mike discusses the infectious Hand Foot Mouth Disease with special guest Dr. Katalin Koranyi of the Pediatric Infectious Disease center in Nationwide Children's Hospital.
Hand Foot Mouth Disease
- Dr Katalin Koranyi
Pediatric Infectious Disease
Nationwide Children's Hospital
Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike!
Dr. Mike Patrick: Hello everyone, and welcome to PediaCast, a pediatric podcast for moms and dads. It is episode 168 for Tuesday July 5th 2011. And we’re calling this one Hand, Foot and Mouth Disease. I have a very special guest in the studio today, Dr. Katalin Koranyi. She’s an infectious disease specialist at Nationwide Children’s. We’re going to talk about a very common summer problem that I’m sure most of you have either dealt within your own children or heard about because someone’s put a sign up in Day Care that says, “Hey there’s a hand, foot, mouth disease here.” So a lot of the parents have questions about that. So we are going to address it.
Before we get started, I want to remind you if there’s a topic that you would like us to talk about or a question for us here at PediaCast, it’s easy to get hold of this. Just go to pediacast.org and you can click on the contact link. You can also email firstname.lastname@example.org or call the voice line at 347-404-KIDS. That’s 347-404-K-I-D-S. I also want to remind you the information presented in every episode of PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individual. So if you have a concern about your child’s health, make sure to call your doctor, and arrange a face-to-face interview and hands on physical examination.
Her clinical interests include education of medical students and residents in the management of children with infectious diseases, particularly HIV infection. Her research activities are focused on clinical trials dealing with vaccine development, pediatric HIV infections and anti-microbial agents or antibiotics and other things in the treatment of infectious diseases. She is also a co-investigator of the Ryan White IV Project with the focus on delivering family-centered care to HIV infected children and their families. So welcome to PediaCast, Dr. Koranyi.
Dr. Katalin Koranyi: Thank you very much, Mike.
Dr. Mike Patrick: You know it sounds from your introduction I should have brought here to talk about HIV and the International Adoption, which are topics that we can to in the future episodes, so hopefully you’ll be willing to come back to the studio and talk about those things. But I have had a lot of comments recently from people asking about Hand, Foot and Mouth Disease. And it’s summertime, so we see a lot of it more than, and I just wanted to get you here to talk about that a little bit.
Before we get started though, you talked about in your bio there, Medical Student and Resident Education, which I know is another important topic to you. And you are actually one of my mentors as a resident. I remember being on the ID Service with you.
Dr. Katalin Koranyi: I remember that too.
Dr. Mike Patrick: Way back when?
Dr. Katalin Koranyi: Fifteen years ago?
Dr. Mike Patrick: Yeah, right.
Dr. Katalin Koranyi: Yeah, probably.
Dr. Mike Patrick: That’s why it’s great having you here, really it is.
Dr. Katalin Koranyi: Thank you.
Dr. Mike Patrick: So just in terms of getting started, if you could just define for our audience what exactly is hand, foot and mouth disease.
Dr. Katalin Koranyi: Hand, foot and mouth disease is an infectious disease very common as you mentioned, in the summertime particularly in children although occasionally we see it in adult. As the name implies, there is a rash that involves the hands and the feet, as well as sores or lesions inside of the mouth. Now sometimes, the lesions or the rash is not only on the hands and the feet but also present in the lower extremities particularly in the buttocks.
If you may remember, if I had you in the summer I usually don’t call it hand, foot and mouth disease. I call it hand, foot, mouth and buttocks disease because you can see the rash in about 40% of the children in the lower extremities including the buttocks.
Dr. Mike Patrick: I do remember you saying that actually and used it during my 10 years of private practice I used that. I passed that along. Now, how common is it in the summertime? Do you see a lot of kids with it?
Dr. Katalin Koranyi: Yes, we do. And most often the children don’t come to the emergency room or to the urgent care. They may seek medical attention in their doctor’s offices. Occasionally, I think I mentioned sometimes in the radio or in the television that notices if your child has such as rash and sores in the mouth, that’s hand, foot, mouth disease and you don’t need to seek medical attention.
Dr. Mike Patrick: Why?
Dr. Katalin Koranyi: Certain years, as you know this is caused by virus called Coxsackie virus. In some years, we see more cases – other years fewer. But you can bet that you will see hand, foot, and mouth disease in the summertime in particular.
Dr. Mike Patrick: Now, why is that? Why are some viruses more prevalent in the summer, and other viruses like influenza and RSV more prevalent in the winter?
Dr. Katalin Koranyi: Nobody knows that for sure. But in the case of hand, foot and mouth disease, which is caused by Coxsackie virus which belongs to a large family of close to 74 or more viruses called Enteroviruses. They are often transmitted from the mouth and also through the intestinal track to the saliva and the stool. So children who go to the swimming pool may acquire this type of viruses – hand, foot and mouth disease. So maybe that’s the reason why we see it more in the summer. But keep in mind that Enteroviruses can be seen throughout the year and we have seen cases in the middle of December.
Dr. Mike Patrick: Great. Now, you talked about the Coxsackie virus being a cause of it. What exactly, how does the Coxsackie virus cause this illness? What exactly does it do?
Dr. Katalin Koranyi: The virus – and many of the viruses they do the same thing, enter through the mouth and then get into the gastrointestinal tract and from there it goes into the blood stream and then appears – in the case of Coxsackie, appears in causing sores in the mouth and the rash on the skin.
Dr. Mike Patrick: Do we know why that particular virus sort of aims at those places, like why it goes to the mouth or why it goes to the – we really…
Dr. Katalin Koranyi: No. We really don’t know that, and that’s true for most viral illnesses. Some viruses have particular, it’s called tropism or predilection to get into the central nervous system causing viral meningitis. Other viruses get into the lymph nodes. And in this case besides in the mouth as I said we can see the rash.
Dr. Mike Patrick: On the skin too.
Dr. Katalin Koranyi: On the skin. But why? It’s not clear.
Dr. Mike Patrick: And part of that is because since it’s a mild disease, there’s not a lot of research money to go to since it’s self limiting and goes away. So that’s one of the reason we don’t probably know.
Dr. Katalin Koranyi: Exactly, correct.
Dr. Mike Patrick: If you kind of have a description of the disease from the time you’re exposed sort of natural progression of it, what is that look like?
Dr. Katalin Koranyi: As I’ve said before, usually we see it the young children. Although, all the children, adolescents and adults can get hand, foot and mouth sometimes. The children most of these time are not very ill. They may have fever, and is usually low-grade fever which lasts for two, three, four, five days at the most. And then the first symptom besides the fever is going to be sore mouth. Usually, there may be 10 to 15 sores or ulcers in the tongue and on the tonsils.
And then the next day or maybe a couple of days later, one can see the rash, which characteristically are again vesicles or blisters on the palms and the hands and the soles. At times also there’s a rash usually pink to red bumps on the buttocks and the lower extremities. It is rare to get a generalized all over rash but sometimes that happens too.
Dr. Mike Patrick: And we have a lot of medical folks who also listen to the show, medical students and pediatricians and nurses. And we’d like to talk a little bit about differential diagnosis. So what other – if you look at that set of symptoms, what other illnesses or viruses can cause something similar to that?
Dr. Katalin Koranyi: So the main infectious disease that one needs to differentiate hand, foot and mouth disease is going to be herpes virus, gingivostomatitis, meaning ulcerations or vesicles and ulcers inside of the mouth. Herpes virus can occur throughout the year so there is no summertime preference.
And the other aspect that differentiates herpes from hand, foot and mouth disease is the height of the fever. Usually with herpes infection there is significant fever 103-104 degrees last longer than hand, foot and mouth disease and the pain of the oral ulcerations is much more severe. In addition and as probably the key point is that with herpes there is gingivitis, meaning the gums are swollen, red, friable, very painful. With hand, foot and mouth disease, the ulcerations are not present on the gums and the gums are not swollen.
The other infectious disease again, summer infectious disease caused by Coxsackie viruses that can be confused with hand, foot and mouth is called herpangina. Herpangina again is caused by the same group of viruses, Coxsackie, the hand, foot and mouth disease but it does not cause a rash. So the lesions or the ulcers are mostly on the back of the throat. Again, it’s self limited goes away on its own, last one, two, three, four days at the most. And the main symptom of hand, foot and mouth disease and herpangina is pain so the child may not want to eat, may not want to drink. Occasionally, they drool because they really don’t want to swallow saliva – children are rather smart, so if it hurts they going to avoid it. So sometimes, there is drooling.
Dr. Mike Patrick: Now, the difference between hand, foot and mouth disease and herpangina both being caused by Coxsackie virus, is there a difference in the strain of Coxsackie that’s doing it or it’s just the person’s body and their immune system that makes it different?
Dr. Katalin Koranyi: Most of the time is the difference in the strain. The Coxsackie A but different number of Coxsackie A. Clinically, as I said in the first day, it may not be one cannot tell whether it’s hand, foot and mouth disease or herpangina because it takes one or two days for the rash on the palms and the soles to show up. But it probably doesn’t matter. Both of them are viral illnesses. Both cases we treat the symptoms. If the physician sees the child the first day, may tell the parent. Well, if it’s going to be hand, foot and mouth disease, next day or the day after you are going to see a rash on the hands and the feet.
Dr. Mike Patrick: Right. Now, when you’re talking about the Herpes virus causing similar symptoms, do you get a rash on the hand and feet with that one?
Dr. Katalin Koranyi: No. You don’t get the rash. It’s just as the name implies gingivostomatitis, meaning there is gingivitis or swelling of the gums and stomatitis, which refers to the ulcers or the lesions in the mouth.
Dr. Mike Patrick: OK. So, to diagnose hand, foot and mouth disease it’s really the history and physical exam that does it.
Dr. Katalin Koranyi: Correct.
Dr. Mike Patrick: Now, let’s say that you decided that it’s the herpes instead of a hand, foot and mouth disease. Are there differences on your treatment based on that?
Dr. Katalin Koranyi: Definitely, there is difference in the treatment. And as you said for diagnosis for both herpes gingivostomatitis and hand, foot and mouth disease. It’s a clinical diagnosis just examination of the child. In some instances for special reasons we need to confirm the diagnosis so there are laboratory tests particularly culture and also was called PCR tests, which will give use the diagnosis. But the treatment is different for herpes gingivostomatitis, we have an antiviral agent it’s called Acyclovir and that’s really it’s not a miracle cure but definitely shortens the clinical course so the child is going to have fever for few days and the lesions, the sores in the mouth will disappear much faster if Acyclovir is prescribed.
Dr. Mike Patrick: And this is an advanced question for the docs out there.
Dr. Katalin Koranyi: Yes.
Dr. Mike Patrick: If you have a kid so you think does have the herpetic herpes disease and you’re thinking about doing Acyclovir, does it make a difference how long the kids had symptoms whether you should start Acyclovir or not?
Dr. Katalin Koranyi: The sooner Acyclovir started, the better the outcome. But if the child comes to your office on day four of illness and still has high fever, horrible mouth sores, very, very painful lesions, the child doesn’t want to eat or drink. I would still prescribe Acyclovir. But the best effect if it’s given within the first 48 hours of the illness.
Dr. Mike Patrick: OK. But for hand, foot and mouth disease, which is caused by the Coxsackie virus or herpangina which is caused by other strains without the skin rash, Acyclovir is not for that because it’s a different type of virus and Acyclovir is not going to kill it.
Dr. Katalin Koranyi: Yes, correct. We don’t have an antiviral agent for the Coxsackie viruses.
Dr. Mike Patrick: Great. Now, you talk about treating basically the treatment for hand, foot and mouth disease that is aimed at symptoms, trying to make the child more comfortable. What are some ways that you can do that?
Dr. Katalin Koranyi: The most important aspect that the parents need to consider is to keep the child well hydrated. So we usually recommend for the pain and for the fever either Tylenol, acetaminophen or ibuprofen such as Motrin, and then soft diet; pudding ice cream, Popsicle, juices, trying to avoid citric juices because there will be sting. That’s what the parents need to do to make sure the child is well hydrated. I always tell the parent don’t worry your child eating if he doesn’t want to eat, may lose few ounces, it will gain back. The important thing is to keep the child comfortable and well hydrated.
Dr. Mike Patrick: Great, and again more of advanced question. What about using like Tylenol with codeine and then there’s also some folks like to use like Benadryl/Maalox combination or Viscous Lidocaine. Is there is a role for those types of things or no?
Dr. Katalin Koranyi: Some physicians prescribe it or use it. I usually don’t. I personally tried the mixture of Benadryl with Maalox to keep in my mouth. You have to keep it in the mouth at least for one or two minutes before a very mild local anesthetic effect occurs. Most children and we said these are generally young children – most children are not going to do that. They swallow the Benadryl, so may get a little sleepy maybe helpful that way, I usually don’t prescribe that. Viscous Xylocaine for an adolescent for an older child, adolescent or adult it works switch and spit. You have to careful if you give it to younger children because again they tend it and one can get an overdose.
Dr. Mike Patrick: Great, great advise. And I know sometimes parents will talk to other parents and their doctor prescribed something and they get upset when their doctor doesn’t do the same thing. So really, I think it’s important when doctors when you get a different of opinion just ask your doctor, “Hey why are you doing this or why aren’t you doing this.” So they can explain. And I tried the Benadryl with Maalox once upon a time myself too and I agree I didn’t think it worked very well at all. Ibuprofen for me seems to be the best.
Dr. Katalin Koranyi: Sure. I mean, especially for herpes gingivostomatitis but even for some children with hand, foot and mouth disease, Tylenol with codeine. As long as you don’t use it for too long or don’t use very high dose, occasionally can help and may allow the child to begin to eat or to begin to drink.
Dr. Mike Patrick: Right. Now, parents out there may do like a Google search on the Internet for Coxsackie virus and they’ll come across heart infection and meningitis and encephalitis, which can also be caused by Coxsackie virus. So then the next question becomes I think in parents mind if my child has hand, foot and mouth disease and is caused by Coxsackie virus, could that lead to a heart infection or meningitis or encephalitis.
Dr. Katalin Koranyi: The Coxsackie viruses as I mentioned before they belong to the family of the Enteroviruses. There are over 74 strains. We only have vaccine for three vaccines for three strains which are the polio viruses, polio virus 1, 2 and 3. So there are 70 plus viruses that will cause a number of different illnesses including hearth infection or inflammation and meningitis or encephalitis particularly in the summertime.
The child who has hand, foot and mouth disease usually doesn’t develop meningitis from that particular Coxsackie causing the hand, foot and mouth disease. Actually, I don’t recall ever seeing that. But on the other hand, in the summertime, children can get other Enteroviruses and have meningitis or myocarditis, which is inflammation of the heart or just fever or fever with a rash, which is not hand, foot and mouth disease.
Dr. Mike Patrick: So while Coxsackie virus different strains of it can cause those things, it would be very unusual and very rare for the hand, foot and mouth disease strain of virus to caught one that caused those.
Dr. Katalin Koranyi: Exactly, I don’t really think it happens.
Dr. Mike Patrick: Great. And then just in terms the complications the other things that another thing the parent should think about is bacterial infection on top of this specially if kids are picking at the lesions or scratching, they can get a skin infection with bacteria on top of the sores that are there.
Dr. Katalin Koranyi: That’s very, very rare. To me it’s very interesting and I don’t have a good explanation as to why the lesions, the sores inside of the mouth are quite painful, but the blisters on the hand and feet, you know the rash generally doesn’t itch and it doesn’t really hurt so I think it will be not impossible but quite unlikely that a child would get a secondary bacterial infection.
Dr. Mike Patrick: Something else I hear parents talk about is. Is it related to hoof and mouth disease, or the animal disease?
Dr. Katalin Koranyi: No it is not. Not at all.
Dr. Mike Patrick: So not at all. You’re not going to give your cows if you’re a farmer. You’re not going to give your cows this and catch it from.
Dr. Katalin Koranyi: And vice versa, you don’t get it from the cows. You get it from other children.
Dr. Mike Patrick: Great. Now, how long these symptoms usually last then and how long your kids contagious?
Dr. Katalin Koranyi: OK. So the symptoms usually last for about three to five days. Definitely the whole infection resolves in about a week or sometimes even fewer days. Exactly how long the children are contagious? We don’t know. We know that these group of viruses including Coxsackie can be excreted come out in the stool in the intestinal tract up to two or three months. We know that from the history of polio viruses. However, we assume that with hand, foot and mouth disease and many of the other Enteroviruses, children are most contagious the first three to five days of the illness.
Dr. Mike Patrick: But there still mild contagiousness that’s possible for a long time afterwards. So it’s not one of those things where you can say once the fever is gone, they’re not contagious anymore.
Dr. Katalin Koranyi: You cannot say, but that probably might just less contagious.
Dr. Mike Patrick: Great. Once you’ve had it, can you get again?
Dr. Katalin Koranyi: That is very rare. It may happen occasionally but most of the time hand, foot and mouth disease you only get it once.
Dr. Mike Patrick: Great, so your body makes antibodies against this. So the next time that virus comes along, you’ll able to fight it off before you get sick.
Dr. Katalin Koranyi: Correct.
Dr. Mike Patrick: Is there any way to prevent it?
Dr. Katalin Koranyi: Well, I think hand hygiene as for many of the viral infections is very important. The virus as I mentioned is in the saliva and also in the stool in the gastrointestinal tract, so not eating or drinking after each other, so children should not be sharing water bottles for example or sharing in the Coke. That’s one way to prevent.
In the summertime, it’s important to tell the children although I don’t know if you can avoid it 100% of the time is not to drink the pool water because again that’s the way too. That’s the way it can also be transmitted. And again, washing hands is important.
Dr. Mike Patrick: Great. And we’re going to have a link in the show notes over at pediacast.org that people can click on that takes you to a Hand, Foot and Mouth Disease Information Page at the Nationwide Children’s website so we have that resource available to you for folks who would like it sort of written printed format. I really appreciate you’re stopping the studio today. One question that we always asked every guest that comes by, we’re really to encourage families to do things together as a family, and get away from watching so much television and computer games and that sort of thing. And from my own childhood, and one of my kids are younger and even now to some degree we like to play board games. Do you have a favorite board game that you remember playing in the past?
Dr. Katalin Koranyi: Monopoly.
Dr. Mike Patrick: Monopoly. Me and my kids love to play Monopoly and it just takes so long.
Dr. Katalin Koranyi: Yes, we do the shortened version.
Dr. Mike Patrick: We pass out the cards ahead of time and then start doing the trading. And that’s the other thing is getting – my son always wants to make crazy trades and then gets upset when no one wants to go along with it. So Monopoly, we’ll add that to our list of our favorite board games, so thanks for that.
All right, and we hope to have you back some time to talk about HIV and I think International Adoption is also a really popular topic you know in terms of is there a place to get kids evaluated and how do you know procedures to make sure if kids have special needs.
Dr. Katalin Koranyi: I will be very happy coming back.
Dr. Mike Patrick: Great, thanks. I want to remind all of you out there. Thank you for listening PediaCast. One of the ways that you can help us spread the word about the show is to tell your doctor when you go in for a sick visit or well checkup, just say hey we found this great evidence based pediatric podcasts that talks to parents and just let them know that they can find it at pediacast.org and they can tell their other patients about that.
And again if you have a topic that you’d like us to talk about, just go to pediacast.org and click on the contact link. You can also email us at email@example.com or call the voice line 347-404-KIDS. That’s 347-404-K-I-D-S. And until next time, this is Dr. Mike saying stay safe stay healthy and stay involve with your kids. So long everyone.
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