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Introdução: A doença da mão, pé e boca (DMPB) é uma infecção viral contagiosa que afeta principalmente crianças, mas também pode afetar adultos. É causada por diferentes tipos de enterovírus, sendo o CV-A16 e o EV-A71 os mais comuns. A transmissão ocorre pelo contato direto com fluidos corporais infectados ou por meio de objetos contaminados. Apresenta sintomas como febre, dor de garganta, falta de apetite e erupções cutâneas nas mãos, pés e boca. Embora a maioria dos casos seja leve e resolva- se espontaneamente, complicações graves, incluindo problemas neurológicos, podem ocorrer. O diagnóstico geralmente é clínico, com base nos sintomas e nas características das lesões. O tratamento é sintomático, com o uso de analgésicos e antitérmicos para aliviar a dor e a febre. No caso de lesões bucais graves a terapia fotodinâmica antimicrobiana (aPDT) em combinação com a fotobiomodulação com laser de baixa potência tem sido utilizada como uma abordagem promissora. A aPDT é capaz de eliminar microrganismos, incluindo vírus, independentemente de sua resistência aos antimicrobianos, e a fotobiomodulação auxilia na modulação da resposta inflamatória, alívio da dor e na cicatrização. Os lasers de baixa potência são a fonte de luz mais adequada para a fotoinativação viral, devido à sua interação precisa com o fotossensibilizante e a capacidade de fornecer a energia necessária para o efeito virucida. Metodologia: Relato de caso qualitativo e descritivo. Objetivo: Este relato de caso tem como objetivo descrever o tratamento de lesões bucais graves da DMPB combinando aPDT e fotobiomodulação com laser de baixa potência. Resultados: O tratamento mostrou resultados promissores no alívio dos sintomas e na melhora do quadro clínico. Conclusão: Mesmo em manifestações exacerbadas da doença de mão, pé e boca, podemos notar melhoras significativas nas lesões bucais após a aPDT com azul de metileno em combinação com a fotobiomodulação com laser de baixa potência.

Introduction: Hand, foot and mouth disease (HFMD) is a contagious viral infection that mainly affects children, but can also affect adults. It is caused by different types of enterovirus, with CV-A16 and EV-A71 being the most common. Transmission occurs through direct contact with infected body fluids or through contaminated objects. Symptoms include fever, sore throat, lack of appetite and rashes on the hands, feet and mouth. Although most cases are mild and resolve spontaneously, serious complications, including neurological problems, can occur. Diagnosis is usually clinical, based on the symptoms and characteristics of the lesions. Treatment is symptomatic, with the use of analgesics and antipyretics to relieve pain and fever. In the case of severe mouth lesions, antimicrobial photodynamic therapy (aPDT) in combination with low-power laser photobiomodulation has been used as a promising approach. aPDT is capable of eliminating microorganisms, including viruses, regardless of their resistance to antimicrobials, and photobiomodulation helps to modulate the inflammatory response, relieve pain and promote healing. Low-power lasers are the most suitable light source for viral photoinactivation, due to their precise interaction with the photosensitizer and their ability to provide the necessary energy for the virucidal effect. Methodology: Qualitative and descriptive case report. Objetive: This case report aims to describe the treatment of severe oral lesions of BPPD by combining aPDT and low-power laser photobiomodulation. Results: The treatment showed promising results in relieving symptoms and improving the clinical picture. Conclusion: Even in exacerbated manifestations of hand, foot and mouth disease, we can see significant improvements in mouth lesions after aPDT with methylene blue in combination with low-power laser photobiomodulation.

Introducción: La enfermedad de manos, pies y boca (EMPB) es una infección vírica contagiosa que afecta principalmente a los niños, aunque también puede afectar a los adultos. Está causada por diferentes tipos de enterovirus, siendo el CV-A16 y el EV-A71 los más comunes. La transmisión se produce por contacto directo con fluidos corporales infectados o a través de objetos contaminados. Los síntomas incluyen fiebre, dolor de garganta, falta de apetito y erupciones en manos, pies y boca. Aunque la mayoría de los casos son leves y se resuelven espontáneamente, pueden producirse complicaciones graves, incluidos problemas neurológicos. El diagnóstico suele ser clínico, basado en los síntomas y las características de las lesiones. El tratamiento es sintomático, con el uso de analgésicos y antipiréticos para aliviar el dolor y la fiebre. En el caso de lesiones bucales graves, la terapia fotodinámica antimicrobiana (aPDT) en combinación con la fotobiomodulación láser de baja potencia se ha utilizado como un enfoque prometedor. La aPDT es capaz de eliminar los microorganismos, incluidos los virus, independientemente de su resistencia a los antimicrobianos, y la fotobiomodulación ayuda a modular la respuesta inflamatoria, aliviar el dolor y favorecer la cicatrización. Los láseres de baja potencia son la fuente de luz más adecuada para la fotoinactivación viral, debido a su interacción precisa con el fotosensibilizador y a su capacidad para proporcionar la energía necesaria para el efecto virucida. Metodología: Caso clínico cualitativo y descriptivo. Objetivo: Este caso clínico pretende describir el tratamiento de lesiones orales severas de BPPD mediante la combinación de aPDT y fotobiomodulación con láser de baja potencia. Resultados: El tratamiento mostró resultados prometedores en el alivio de los síntomas y la mejora del cuadro clínico. Conclusión: Incluso en las manifestaciones exacerbadas de la enfermedad de manos, pies y boca, podemos observar mejoras significativas en las lesiones bucales tras la aPDT con azul de metileno en combinación con fotobiomodulación con láser de baja potencia.

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Hand, foot, and mouth disease is a viral rickettsial disease caused by Coxsackievirus A16 and Enterovirus 71 in most cases. It is commonly seen in children under ten years old, who present oral enanthema and a macular, maculopapular, or vesicular rash on their hands and feet. However, an increase in cases caused by other viral serotypes was observed in adults in recent years with various clinical presentations and a troublesome diagnosis. Three cases of hand, foot, and mouth disease are reported to show the clinical variability and diagnostic complexity that this disease may present in adult patients.

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ABSTRACT Hand-foot-and-mouth disease (HFMD) is a highly contagious viral disease commonly associated to Enteroviruses (EV). During 2018, Brazil faced massive HFMD outbreaks spread across the country. This study aimed to characterize the EV responsible for the HFMD outbreak that occurred in Paraiba State, Brazilian Northeastern region, in 2018, followed by a phylogenetic analysis to detail information on its genetic diversity. A total of 49 serum samples (one from each patient) collected from children ≤ 15 years old, clinically diagnosed with HFMD were tested for EV using conventional RT-PCR and RT-qPCR. EV infection was confirmed in 71.4% (35/49) of samples. The mean and median ages were 1.83 years and one year old, respectively. Twenty-two EV-positive samples were successfully sequenced and classified as EV-A species; 13 samples were also identified with the CV-A6 genotype. The phylogenetic analysis (VP1 region) of three samples revealed that the detected CV-A6 strains belonged to sub-lineage D3. The CV-A6 strains detected here clustered with strains from South America, Europe and West Asia strains that were also involved in HFMD cases during the 2017-2018 seasons, in addition to the previously detected Brazilian CV-A6 strains from 2012 to 2017, suggesting a global co-circulation of a set of different CV-A6 strains introduced in the country at different times. The growing circulation of the emerging CV-A6 associated with HFMD, together with the detection of more severe cases worldwide, suggests the need for a more intense surveillance system of HFMD in Brazil. In addition, this investigation was performed exclusively on serum samples, and the analysis of whole blood samples should be considered and could have shown advantages when employed in the diagnosis of enteroviral HFMD outbreaks.

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Abstract Hand, foot, and mouth disease is a viral rickettsial disease caused by Coxsackievirus A16 and Enterovirus 71 in most cases. It is commonly seen in children under ten years old, who present oral enanthema and a macular, maculopapular, or vesicular rash on their hands and feet. However, an increase in cases caused by other viral serotypes was observed in adults in recent years with various clinical presentations and a troublesome diagnosis. Three cases of hand, foot, and mouth disease are reported to show the clinical variability and diagnostic complexity that this disease may present in adult patients.

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BACKGROUND: Although most enterovirus (EV) infections can be asymptomatic, these viral agents can cause serious conditions associated with central nervous system, respiratory disease and uncommon manifestations of hand, foot and mouth disease (HFMD). EV-coinfections have been rarely reported with development of complications and severe clinical outcome. An atypical case of a child presenting HFMD and severe acute respiratory syndrome, co-infected with EV-D68 and CVA6, is reported herein. CASE PRESENTATION: A 3-year-old boy was admitted in the emergency department unit showing fever, abdominal pain and tachycardia. Twenty-four hours after hospitalization the child developed severe clinical symptoms associated with HFMD and was discharged after recovery. Two days later, the child was readmitted with fever, cough and respiratory distress. RT-PCR and Sanger sequencing confirmed positivity for EV-D68 and CVA6 in oro and nasopharynges swabs and vesicles fluid, respectively. Phylogenetic analysis based on VP1 gene sequences suggested that CVA6 was closely related with HFMD viruses circulating in Turkey, while EV-D68 was genetically related to a Chinese strain. CONCLUSIONS: To the best of our knowledge, this case is the first report of a double infection caused by CVA6 and EV-D68, which shed light on the pathogenesis of enterovirus infections. Further studies must be conducted to ascertain the role and clinical significance of EV co-infections, as well as a potential synergistic pathway between these viruses.

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La enfermedad mano-pie-boca (EMPB) típica es exantemática, con sintomatología clásica de fiebre, exantema papulovesicular en las manos y los pies, asociada o no a herpangina. Es causada, principalmente, por enterovirus 71 y virus Coxsackie A16, miembros del género Enterovirus. En los últimos años, se han descrito brotes mundiales de EMPB con manifestaciones atípicas causadas, sobre todo, por el virus Coxsackie A6. La EMPB atípica se considera emergente con características clínicas y epidemiológicas peculiares: la afección de adultos, el predominio en invierno y un amplio espectro de manifestaciones clínicas en la extensión y la distribución de las lesiones. Las características morfológicas de las lesiones son muy variables: pueden simular varicela, impétigo o vasculitis.Se describe el caso de un niño de 4 años con EMPB atípica. Se detalla su forma de presentación, evolución clínica, metodología diagnóstica y terapéutica empleada.

Typical hand-foot-mouth disease (HFMD) is an exanthematous viral disease with a classic symptomatology of fever, papulovesicular rash on the hands and feet with or without herpangina. It is usually caused by enterovirus 71 and Coxsackievirus A16, members of the genus Enterovirus. Recently, worldwide outbreaks of HFMD with atypical manifestations caused by Coxsackievirus A6 have been described. Atypical HFMD is considered an emerging disease due to its peculiar clinical and epidemiological characteristics: it affects adults, has a wide spectrum of clinical manifestations in the extension and distribution of the lesions and occurs in winter. The morphological characteristics of the lesions are very variable and can be misdiagnosed as chickenpox, impetigo or vasculitis. Here we describe the symptoms, clinical evolution, diagnostic methodology and treatment employed on a 4-year-old male patient with atypical HFMD.

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We present two groups of cases of atypical hand, foot, and mouth disease (HFMD) caused by Coxsackievirus A6 (CV-A6) detected in Argentina in 2015. The first group involved 14 patients from Chubut province and the second group affected 12 patients from San Luis province. Molecular analysis of the complete VP1 protein gene revealed the circulation of E2 sublineage, the most predominant worldwide. To our knowledge, this is the first report of CV-A6 infections associated with atypical HFMD in Argentina and South America.

Se describen dos grupos de casos de enfermedad de mano-pie-boca (HFMD) atípica causada por el virus Coxsackie A6 (Coxsackievirus A6, CV-A6) detectados en Argentina en el año 2015. El primero de los grupos involucró a 14 pacientes de Chubut y el segundo a 12 pacientes de San Luis. El análisis molecular del gen de la proteína VP1 completa reveló la circulación del sublinaje E2, el predominante a nivel global. Hasta donde sabemos, este es el primer reporte de infecciones CV-A6 asociadas con HFMD atípica en Argentina y Sudamérica.

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Se presenta el caso clínico de un lactante de 9 meses de edad, atendido en el cuerpo de guardia del Policlínico Docente José Martí de la provincia de Santiago de Cuba, por presentar lesiones exantemáticas y eritematosas en la piel, con ampollas alrededor de la boca, así como en manos, piernas y ambos pies, además de fiebre. Se le diagnosticó la enfermedad de boca, mano y pie, teniendo en cuenta la clínica y el incremento de esta afección trasmitida por el virus de Coxsackie en el municipio, por lo cual fue ingresado en el hogar, con vigilancia y seguimiento por su médico y enfermera de la familia, quienes indicaron las medidas para el control higiénico sanitario y de sostén que deben conocerse y aplicarse en el medio familiar para disminuir el riesgo de la infección.

The case report of a 9 months of age infant assisted in the emergency room of José Martí Teaching Polyclinic in Santiago de Cuba is presented, due to exanthematic and erythematous lesions in the skin, with bladders around the mouth, as well as in hands, legs and both feet, besides fever. The mouth, hand and foot disease was diagnosed, keeping in mind the clinic and the increment of this disorder transmitted by the Coxsackie virus in the municipality, reason why he was admitted at home, with medical supervision and followed by the family nurse and physician who indicated the measures for the health control that should be known and applied in the family to decrease the risk of infection.

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We present two groups of cases of atypical hand, foot, and mouth disease (HFMD) caused by Coxsackievirus A6 (CV-A6) detected in Argentina in 2015. The first group involved 14 patients from Chubut province and the second group affected 12 patients from San Luis province. Molecular analysis of the complete VP1 protein gene revealed the circulation of E2 sublineage, the most predominant worldwide. To our knowledge, this is the first report of CV-A6 infections associated with atypical HFMD in Argentina and South America.

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La enfermedad boca mano pie es una infección altamente contagiosa, causada por el virus Coxsackie A16 y el enterovirus 71. La transmisión ocurre por contacto directo con secreciones nasales, orales, materia fecal y gotas aerolizadas, en una ruta fecal-oral o ruta oral-oral, y a través de objetos contaminados. Se presenta el caso de un paciente de cuatro años de edad que acudió a la consulta de estomatología por la presencia de vesículas dolorosas en la mucosa bucal, las cuales dificultaban su alimentación. Además presentaba rash en manos y pies. Luego de indicársele tratamiento estomatológico, fue remitido al pediatra de su área de salud, quien concluyó el diagnostico de enfermedad boca mano pie. El componente bucal de esta entidad constituye, por lo general, el principal síntoma y el motivo de consulta, sin embargo, es poco conocida en el perfil estomatológico. En ello radica el interés de la presentación, ya que el conocimiento de la fisiopatología y el cuadro clínico de la afección, permite al estomatólogo realizar el diagnóstico diferencial y sospechar clínicamente la enfermedad. 

Foot, hand and mouth disease is a highly contagious disease, caused by the A16 Coxsackie virus and 71 enterovirus. The transmission occurs by the direct contact with nasal and oral secretions or fecal material and sprayed drops, in an oral fecal or fecal oral route and through contaminated objects. A case of a 4 year old patient came to the dental office due to the presence of painful blisters in the oral mucosa which made his feeding difficult. In addition he had a rash in hands and feet. After prescribing dental treatment he was referred to the pediatrician of his health area who conclude the diagnosis of foot, hand and mouth disease. The oral component is generally the main symptom and the chief complaint, however, its almost unknown in its oral profile. That is the reason for the interest of this presentation because knowing its physiopathology and the clinical characteristics of the presentation allows differential diagnosis and clinically suspect the disease.

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RESUMEN La enfermedad de mano, pie y boca (EMPB) es una enfermedad exantemática viral, causada principalmente por Coxsackie A16, con una sintomatología típica consistente en fiebre; exantema pápulo-vesicular en manos, pies y genitales; y un enantema ulceroso en boca. En el verano del 2016 se presentó una diversidad de casos en un hospital del Callao en niños y adultos, con una sintomatología compatible con EMPB; el diagnóstico fue clínico, se aplicó terapia de soporte con resolución final de síntomas. En la última década se han presentado reportes en algunos países con una afectación atípica causada por el Coxsackie A6, produciendo lesiones más extensas y en adultos. Sin embargo, el diagnóstico sigue siendo clínico, solo necesitando confirmación virológica en casos atípicos o cuando el diagnóstico no es claro. La importancia de este reporte radica en describir los casos del Callao ocurridos en el verano del 2016, para servir de apoyo a los profesionales de la salud en el diagnóstico y manejo de pacientes con similar sintomatología.

ABSTRACT Hand, foot, and mouth disease (HFMD) is an exanthematous viral disease caused mainly by Coxsackie A16 with a typical symptomatology of fever, papulovesicular rash on the hands, feet, and genitals, and an ulcerous enanthem in the mouth. In the summer of 2016, a variety of cases presented at a hospital in Callao in children and adults with a symptomatology consistent with HFMD. A clinical diagnosis was made, and support therapy was applied, resulting in the resolution of symptoms. In the last decade, reports have emerged in some countries of an atypical involvement caused by Coxsackie A6, producing lesions that are more widely distributed in adults. However, the diagnosis remains clinical, only requiring virological confirmation in atypical cases or when the diagnosis is unclear. The importance of this report stems from its description of the cases in Callao that occurred in the summer of 2016 and serve as an example for health professionals in the diagnosis and management of patients with similar symptomatology.

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Hand-foot-and-mouth disease (HFMD) is becoming one of the extremely common airborne and contact transmission diseases in Guangzhou, southern China, leading public health authorities to be concerned about its increased incidence. In this study, it was used an ecological study plus the negative binomial regression to identify the epidemic status of HFMD and its relationship with meteorological variables. During 2008-2012, a total of 173,524 HFMD confirmed cases were reported, 12 cases of death, yielding a fatality rate of 0.69 per 10,000. The annual incidence rates from 2008 to 2012 were 60.56, 132.44, 311.40, 402.76, and 468.59 (per 100,000), respectively, showing a rapid increasing trend. Each 1 °C rise in temperature corresponded to an increase of 9.47% (95% CI 9.36% to 9.58%) in the weekly number of HFMD cases, while a one hPa rise in atmospheric pressure corresponded to a decrease in the number of cases by 7.53% (95% CI -7.60% to -7.45%). Similarly, each one percent rise in relative humidity corresponded to an increase of 1.48% or 3.3%, and a one meter per hour rise in wind speed corresponded to an increase of 2.18% or 4.57%, in the weekly number of HFMD cases, depending on the variables considered in the model. These findings revealed that epidemic status of HFMD in Guangzhou is characterized by high morbidity but low fatality. Weather factors had a significant influence on the incidence of HFMD.

A doença de mão-pé-e-boca (HFMD) está se tornando doença extremamente comum transmitida pelo ar e contato em Guangzhou, sul da China, levando preocupação às autoridades de saúde pública acerca da sua incidência aumentada. Neste estudo foi usada parte ecológica e regressão binomial negativa para identificar o status epidêmico da HFMD e sua relação com variáveis meteorológicas. Durante 2008-2012 um total de 173.524 casos confirmados de HFMD foram apresentados, 12 com morte, elevando o índice de fatalidade a 0,69 por 10.000. As incidências anuais de 2008 a 2010 foram 60,56, 132,44, 311,40, 402,76 e 468,59 por 100.000, respectivamente, mostrando tendência de rápido aumento. Cada 1 °C de aumento da temperatura correspondeu a aumento de 9,47% (95% CI 9,36% a 9,58%) no número semanal de casos de HFMD, enquanto a 1 hPa de aumento da pressão atmosférica correspondeu a decréscimo no número de casos de 7,53% (95% CI - 7,60% a - 7,45%). De maneira semelhante cada aumento de 1% na humidade relativa correspondeu a aumento de 1,48% ou 3,3% e a um aumento de 1 metro por hora na velocidade do vento correspondeu a um aumento de 2,18% ou 4,57%, no número de casos semanais de HFMD, dependendo das variáveis consideradas no modelo. Estes achados revelaram que o status epidêmico do HFMD em Guangzhou é caracterizado por alta morbidade, mas baixa fatalidade. Fatores referentes ao tempo tiveram influência significante na incidência do HFMD.

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OBJECTIVES: This study aimed to review etiological and epidemiological data for hand, foot, and mouth disease (HFMD) cases that occurred between 2008 and 2010 in Guangzhou City, to help develop and implement precautionary measures applicable for future outbreaks. METHODS: The characteristics of 4,753 HFMD episodes were retrospectively reviewed in 4,636 patients reported between 2008 and 2010 by the Guangdong Women and Children's Hospital, which is the national enterovirus monitoring agent and the designated hospital in China for treating severe HFMD. RESULTS: Out of 4,753 incident episodes reviewed, 525 patients were hospitalized; 60% were males. Most patients (93.8%) were children under 5 years old, with a median age at onset of 2.4 years. HFMD incidence peaked in April/May and September/October. From the total, 1,067 (22.4%) infections were positive for human enterovirus 71 (HEV71), 1,094 (23.0%) were positive for coxsackievirus A16 (CA16), and 941 (19.8%) were positive for other common enteroviruses. In contrast, 1,666 (35.0%) cases were negative to HEV71, CA16, and other common enteroviruses. Cross-correlation coefficients demonstrated associations between the number of cases, seasonal temperatures, and humidity. Among hospitalized cases, HEV71 was positive in 261 (24.5%), and 42 (3.9%) critical cases were positive for HEV71. CONCLUSION: Seasonal fluctuations and HEV71 and CA16 were the two key factors influencing the Guangzhou HFMD epidemic. The infection predominantly affected children younger than 5 years old.

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