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*The professional part involved in this article is only for medical professionals to read for reference.
Can you identify these skin lesions? With the warmer weather, cases of hand-foot-mouth disease have gradually increased like the temperature
.
We all know that hand, foot and mouth disease is caused by enteroviruses.
Typical skin lesions are mainly in the oral mucosa, palms, soles and buttocks
.
In recent years, more and more atypical hand-foot-mouth diseases have been reported clinically
.
Some special skin lesions have been given special names, such as Coxsackie's eczema, Boston rash, and so on.
These disease names sound unusual? Therefore, the author briefly describes the skin damage caused by enterovirus for readers
.
Classification and pathogenesis of enteroviruses At present, the International Committee for Classification of Viruses has confirmed more than 100 enterovirus serotypes, which are divided into 4 categories: type A, type B, type C, type D human enterovirus [1], we Common Coxsackie viruses 6, 16, EV-71 belong to type A; Echoviruses mostly belong to type B; some polioviruses belong to type C[2]
.
Clinically, enteroviruses can be divided into polio and non-polio enteroviruses according to different clinical patterns and results
.
The polio virus can cause polio, which can lead to muscle paralysis
.
I won't repeat it here
.
Non-polio enteroviruses usually cause diseases such as hand, foot and mouth disease, herpes angina, and conjunctivitis, but they can also cause more serious diseases such as aseptic meningitis and myocarditis
.
Enterovirus enters the human host through the gastrointestinal or respiratory tract.
The cell surface of the gastrointestinal tract functions as a virus receptor.
The initial replication starts in the lymphatic tissues of the gastrointestinal tract
.
If local replication is restricted, the patient is in an asymptomatic state; if the virus enters the regional lymph nodes and reticuloendothelial system organs, it may develop into a mild or non-specific disease; if the virus is transmitted through blood, it can cause more serious disease And characteristic systemic diseases
.
Diseases that can be caused by enterovirus (1) Herpes angina: The main pathogen is Coxsackie A virus, but Coxsackie B virus, Echo virus, adenovirus and other enteroviruses can also cause [3]
.
The disease has fever, headache, sore throat, difficulty swallowing, loss of appetite, occasional vomiting and abdominal pain (as shown in Figure 1)
.
Figure 1.
Herpetic angina: Scattered herpes on the posterior wall of the pharynx, partially ulcerated
.
(2) Typical hand, foot and mouth disease: It is most commonly associated with Coxsackie A16, and it can also be caused by Coxsackie B virus and Echo virus
.
Enterovirus 71 (EV71) is often one of the serious causes of hand, foot and mouth disease (as shown in Figure 2)
.
Figure 2.
Typical hand-foot-mouth disease: oral herpes, palmar plantar rash
.
(3) Boston herpes: Echo virus 16 is the cause of Boston's herpes
.
It was endemic in Boston, USA in the summer of 1957, hence the name .
The incubation period of the disease is 3 to 8 days, and symptoms such as fever, headache, sore throat, muscle aches and burning sensation in the eyes are onset
.
After 1 to 2 days, the body temperature drops, and light red macules or maculopapular rashes appear, which are scattered and can also merge with each other.
In severe cases, measles-like rashes or even vesicular rashes may appear
.
It mainly occurs on the face, chest and back, and then extends to the limbs, palms, plantars, and even the whole body
.
In 50% of patients, scattered red dots or yellowish-white erosions may occur in the throat, gums or buccal mucosa
.
May be accompanied by conjunctivitis, mild swelling of lymph nodes and aseptic meningitis
.
(4) Explosive pseudohemangioma disease: It has been confirmed to be related to Echo virus 25 and 32 infection [4], and Epstein-Barr virus infection can also cause this
.
Clinical manifestations: Sudden appearance of red papules with a size of 2~4mm and fading, similar to hemangioma, with a pale halo of 1~2mm around, about 10 skin rashes, but there are also a large number of rashes
.
It usually occurs in the facial limbs and can also occur in the trunk
.
Children who get sick often have systemic symptoms of viral infection, such as malaise, fever, headache, sore throat, muscle aches and loss of appetite, while adults often have no symptoms
.
Histopathological changes include dilation of superficial dermis and swelling of the vascular endothelium, but no vascular proliferation
.
The disease is self-limiting, can recur, has no special treatment, has systemic symptoms, and can be treated symptomatically (as shown in Figure 3)
.
Figure 3.
Explosive pseudohemangiomatosis: red papules with pale halos around them
.
(5) Coxsackie eczema: This symptom is caused by infection with Coxsackie virus A6 and A16 on the basis of atopic dermatitis [5]
.
Clinical manifestations: Many blisters and even generalized blisters occur on the skin lesions of atopic dermatitis (such as eczema), which are very similar to Kaposi's varicella-like skin lesions
.
Hand, foot and mouth disease caused by Coxsackie A6 often presents as atypical skin lesions (as shown in Figure 4)
.
Figure 4.
Atypical hand-foot-mouth disease caused by Coxsackie A6, the site is different from the typical hand-foot-mouth disease, and the skin lesions further aggravated on the basis of atopic rash
.
Note: Kaposi varicella-like rash is a skin disease caused by infection with herpes simplex virus on the basis of eczema, atopic dermatitis or other skin diseases
.
The clinical manifestations are characterized by the sudden occurrence of umbilical fossa-shaped blisters in the skin lesion area, accompanied by systemic symptoms
.
(6) Bornholm disease (Bornholm disease): It is a rare epidemic.
Coxsackie virus B3, B5 infection causes severe chest and abdomen muscle pain.
The pain will aggravate with breathing or coughing.
Severe pain can cause profuse sweating and can cause periodic breathing difficulties
.
Systemic symptoms often include fever, headache, anorexia, nausea and vomiting
.
(7) Other related conditions: ① Acute hemorrhagic conjunctivitis: Enterovirus 70, Coxsackie A24 related [6]
.
②Pustular stomatitis associated with erythema multiforme: Coxsackie B5 related
.
③Extensive vesicular herpes: Coxsackie A4 related
.
④Gianotti-Crosti-like outbreak: Coxsackie A16 related
.
Gianotti-Crosti syndrome, also known as pediatric papular acrodermatitis, is an acute and transient papular dermatitis in children, accompanied by fever and general malaise
.
The characteristics of the rash are: monomorphic red papules, non-itching, 1~5mm in size, which suddenly appear on the face, limbs and buttocks
.
The papules on the cheeks can be fused into pieces, and the rashes on the limbs are sparse
.
The skin lesions are relatively stubborn and can last for many days, accompanied by desquamation after slowly subsiding
.
There is no mucosal rash; lymph nodes in the groin or axilla may be enlarged
.
⑤ Rubella-like outbreak: Echovirus 2 related
.
⑥Measles-like outbreak: Echo virus 6, 11 and 25 are related
.
⑦Ecchymosis: Echo virus 11 and 19 are related
.
⑧Pickled macular rash: Echo virus 19 is related
.
⑨ Coxsackie virus infection, especially type B Coxsackie virus, is related to the induction or exacerbation of type 1 diabetes [7]
.
Differential diagnosis of related rash The 8th edition of Pediatrics has a chart for the differential diagnosis of rash in children [8], as shown in Figure 5 below
.
Figure 5.
Differential diagnosis of some outpatient diseases and some diseases, such as erythema multiforme and sandy soil dermatitis, need to be differentiated
.
The rash of erythema multiforme is polymorphous, including erythema, papules, wind masses, blisters, etc.
The characteristic skin lesions are target-shaped lesions, i.
e.
iris-like rashes (circular lesions with blood bubbles in the center), with varying degrees of mucosal damage ( As shown in Figure 6 below)
.
The causes are diverse, with herpes simplex virus infection being the most common
.
Figure 6.
Erythema multiforme: target-shaped lesions, also known as iris-like rashes
.
Sandy dermatitis is also known as friction lichenoid eruption and juvenile papular dermatitis
.
It is a kind of papular dermatitis that is common in preschool children and occurs on the back of the hands, forearms, elbows and knees
.
The etiology of the disease is unknown, and it is mainly thought to be related to non-specific mechanical irritation, such as playing with sand and being rubbed by blankets
.
Some think it is related to sun exposure and virus infection
.
Skin lesion features: polygonal or round small papules, normal skin color or light red, diameter of 1~3mm, flat top or dome, and the surface is covered with fine chaff-like scales, which may look like
.
Generally, there are no symptoms, and it may be mildly itchy (as shown in Figure 7 below)
.
Figure 7.
Sandy dermatitis.
In short, it is sometimes difficult to identify skin lesions caused by enterovirus infection
.
For hospitals or scientific research institutes with a high level of laboratories, virus-related inspections are the main basis for diagnosis
.
For medical institutions without laboratory conditions, detailed medical history and careful observation of the appearance of skin lesions may reveal some clues
.
Fortunately, many diseases caused by enteroviruses are not so critical
.
It is necessary to carefully observe the changes in the condition and early warning and prediction of critical diseases .
The treatment is mainly anti-virus, symptomatic treatment, and strengthening the care of skin lesions
.
References: [1] Krasota A, Loginovskih N, Ivanova O, Lipskaya G.
Direct Identification of Enteroviruses in Cerebrospinal Fluid of Patients with Suspected Meningitis by Nested PCR Amplification.
Viruses.
2016 Jan.
8(1):E10.
[2] Pons-Salort M,Parker EPK,Grassly NC.
The epidemiology of non-polio enteroviruses:recent advances and outstanding questions.
Curr Opin Infect Dis.
2015 Oct.
28(5):479-87.
[3]Park K,Lee B ,Baek K,Cheon D,Yeo S,Park J,et al.
Enteroviruses isolated from herpangina and hand-foot-and-mouth disease in Korean children.
Virol J.
2012 Sep 17.
9(1):205.
[4]Prose NS ,Tope W,Miller SE,Kamino H.
Eruptive pseudoangiomatosis:a unique childhood exanthem?.
J Am Acad Dermatol.
1993 Nov.
29(5 Pt 2):857-9.
[5]Miller PK,Zain-Ul-Abideen M , Paul J, Perry AE, Linos K, Carter JB, et al.
A case of eczema coxsackium with erythema multiforme-like histopathology in a 14-year-old boy with chronic graft-versus-host disease.
JAAD Case Rep.
2017 Jan.
3(1):49-52.
[6]Oberste MS, Michele SM,Maher K,et al.
Molecular identification and characterization of two proposed new enterovirus serotypes,EV74 and EV75.
J Gen Virol.
2004 Nov.
85:3205-12.
[7]Richer MJ,Horwitz MS.
Coxsackievirus infection as an environmental factor in the etiology of type 1 diabetes.
Autoimmun Rev.
2009 Jun.
8(7):611-5.
[8]Wang Weiping editor in chief.
Pediatrics (8th) edition.
People's Medical Publishing House, (Beijing):197.
Coxsackievirus infection as an environmental factor in the etiology of type 1 diabetes.
Autoimmun Rev.
2009 Jun.
8(7):611-5.
[8]Wang Weiping editor.
Pediatrics (8th) edition.
People's Medical Publishing House, (Beijing ): 197.
Coxsackievirus infection as an environmental factor in the etiology of type 1 diabetes.
Autoimmun Rev.
2009 Jun.
8(7):611-5.
[8]Wang Weiping editor.
Pediatrics (8th) edition.
People's Medical Publishing House, (Beijing ): 197.
Can you identify these skin lesions? With the warmer weather, cases of hand-foot-mouth disease have gradually increased like the temperature
.
We all know that hand, foot and mouth disease is caused by enteroviruses.
Typical skin lesions are mainly in the oral mucosa, palms, soles and buttocks
.
In recent years, more and more atypical hand-foot-mouth diseases have been reported clinically
.
Some special skin lesions have been given special names, such as Coxsackie's eczema, Boston rash, and so on.
These disease names sound unusual? Therefore, the author briefly describes the skin damage caused by enterovirus for readers
.
Classification and pathogenesis of enteroviruses At present, the International Committee for Classification of Viruses has confirmed more than 100 enterovirus serotypes, which are divided into 4 categories: type A, type B, type C, type D human enterovirus [1], we Common Coxsackie viruses 6, 16, EV-71 belong to type A; Echoviruses mostly belong to type B; some polioviruses belong to type C[2]
.
Clinically, enteroviruses can be divided into polio and non-polio enteroviruses according to different clinical patterns and results
.
The polio virus can cause polio, which can lead to muscle paralysis
.
I won't repeat it here
.
Non-polio enteroviruses usually cause diseases such as hand, foot and mouth disease, herpes angina, and conjunctivitis, but they can also cause more serious diseases such as aseptic meningitis and myocarditis
.
Enterovirus enters the human host through the gastrointestinal or respiratory tract.
The cell surface of the gastrointestinal tract functions as a virus receptor.
The initial replication starts in the lymphatic tissues of the gastrointestinal tract
.
If local replication is restricted, the patient is in an asymptomatic state; if the virus enters the regional lymph nodes and reticuloendothelial system organs, it may develop into a mild or non-specific disease; if the virus is transmitted through blood, it can cause more serious disease And characteristic systemic diseases
.
Diseases that can be caused by enterovirus (1) Herpes angina: The main pathogen is Coxsackie A virus, but Coxsackie B virus, Echo virus, adenovirus and other enteroviruses can also cause [3]
.
The disease has fever, headache, sore throat, difficulty swallowing, loss of appetite, occasional vomiting and abdominal pain (as shown in Figure 1)
.
Figure 1.
Herpetic angina: Scattered herpes on the posterior wall of the pharynx, partially ulcerated
.
(2) Typical hand, foot and mouth disease: It is most commonly associated with Coxsackie A16, and it can also be caused by Coxsackie B virus and Echo virus
.
Enterovirus 71 (EV71) is often one of the serious causes of hand, foot and mouth disease (as shown in Figure 2)
.
Figure 2.
Typical hand-foot-mouth disease: oral herpes, palmar plantar rash
.
(3) Boston herpes: Echo virus 16 is the cause of Boston's herpes
.
It was endemic in Boston, USA in the summer of 1957, hence the name .
The incubation period of the disease is 3 to 8 days, and symptoms such as fever, headache, sore throat, muscle aches and burning sensation in the eyes are onset
.
After 1 to 2 days, the body temperature drops, and light red macules or maculopapular rashes appear, which are scattered and can also merge with each other.
In severe cases, measles-like rashes or even vesicular rashes may appear
.
It mainly occurs on the face, chest and back, and then extends to the limbs, palms, plantars, and even the whole body
.
In 50% of patients, scattered red dots or yellowish-white erosions may occur in the throat, gums or buccal mucosa
.
May be accompanied by conjunctivitis, mild swelling of lymph nodes and aseptic meningitis
.
(4) Explosive pseudohemangioma disease: It has been confirmed to be related to Echo virus 25 and 32 infection [4], and Epstein-Barr virus infection can also cause this
.
Clinical manifestations: Sudden appearance of red papules with a size of 2~4mm and fading, similar to hemangioma, with a pale halo of 1~2mm around, about 10 skin rashes, but there are also a large number of rashes
.
It usually occurs in the facial limbs and can also occur in the trunk
.
Children who get sick often have systemic symptoms of viral infection, such as malaise, fever, headache, sore throat, muscle aches and loss of appetite, while adults often have no symptoms
.
Histopathological changes include dilation of superficial dermis and swelling of the vascular endothelium, but no vascular proliferation
.
The disease is self-limiting, can recur, has no special treatment, has systemic symptoms, and can be treated symptomatically (as shown in Figure 3)
.
Figure 3.
Explosive pseudohemangiomatosis: red papules with pale halos around them
.
(5) Coxsackie eczema: This symptom is caused by infection with Coxsackie virus A6 and A16 on the basis of atopic dermatitis [5]
.
Clinical manifestations: Many blisters and even generalized blisters occur on the skin lesions of atopic dermatitis (such as eczema), which are very similar to Kaposi's varicella-like skin lesions
.
Hand, foot and mouth disease caused by Coxsackie A6 often presents as atypical skin lesions (as shown in Figure 4)
.
Figure 4.
Atypical hand-foot-mouth disease caused by Coxsackie A6, the site is different from the typical hand-foot-mouth disease, and the skin lesions further aggravated on the basis of atopic rash
.
Note: Kaposi varicella-like rash is a skin disease caused by infection with herpes simplex virus on the basis of eczema, atopic dermatitis or other skin diseases
.
The clinical manifestations are characterized by the sudden occurrence of umbilical fossa-shaped blisters in the skin lesion area, accompanied by systemic symptoms
.
(6) Bornholm disease (Bornholm disease): It is a rare epidemic.
Coxsackie virus B3, B5 infection causes severe chest and abdomen muscle pain.
The pain will aggravate with breathing or coughing.
Severe pain can cause profuse sweating and can cause periodic breathing difficulties
.
Systemic symptoms often include fever, headache, anorexia, nausea and vomiting
.
(7) Other related conditions: ① Acute hemorrhagic conjunctivitis: Enterovirus 70, Coxsackie A24 related [6]
.
②Pustular stomatitis associated with erythema multiforme: Coxsackie B5 related
.
③Extensive vesicular herpes: Coxsackie A4 related
.
④Gianotti-Crosti-like outbreak: Coxsackie A16 related
.
Gianotti-Crosti syndrome, also known as pediatric papular acrodermatitis, is an acute and transient papular dermatitis in children, accompanied by fever and general malaise
.
The characteristics of the rash are: monomorphic red papules, non-itching, 1~5mm in size, which suddenly appear on the face, limbs and buttocks
.
The papules on the cheeks can be fused into pieces, and the rashes on the limbs are sparse
.
The skin lesions are relatively stubborn and can last for many days, accompanied by desquamation after slowly subsiding
.
There is no mucosal rash; lymph nodes in the groin or axilla may be enlarged
.
⑤ Rubella-like outbreak: Echovirus 2 related
.
⑥Measles-like outbreak: Echo virus 6, 11 and 25 are related
.
⑦Ecchymosis: Echo virus 11 and 19 are related
.
⑧Pickled macular rash: Echo virus 19 is related
.
⑨ Coxsackie virus infection, especially type B Coxsackie virus, is related to the induction or exacerbation of type 1 diabetes [7]
.
Differential diagnosis of related rash The 8th edition of Pediatrics has a chart for the differential diagnosis of rash in children [8], as shown in Figure 5 below
.
Figure 5.
Differential diagnosis of some outpatient diseases and some diseases, such as erythema multiforme and sandy soil dermatitis, need to be differentiated
.
The rash of erythema multiforme is polymorphous, including erythema, papules, wind masses, blisters, etc.
The characteristic skin lesions are target-shaped lesions, i.
e.
iris-like rashes (circular lesions with blood bubbles in the center), with varying degrees of mucosal damage ( As shown in Figure 6 below)
.
The causes are diverse, with herpes simplex virus infection being the most common
.
Figure 6.
Erythema multiforme: target-shaped lesions, also known as iris-like rashes
.
Sandy dermatitis is also known as friction lichenoid eruption and juvenile papular dermatitis
.
It is a kind of papular dermatitis that is common in preschool children and occurs on the back of the hands, forearms, elbows and knees
.
The etiology of the disease is unknown, and it is mainly thought to be related to non-specific mechanical irritation, such as playing with sand and being rubbed by blankets
.
Some think it is related to sun exposure and virus infection
.
Skin lesion features: polygonal or round small papules, normal skin color or light red, diameter of 1~3mm, flat top or dome, and the surface is covered with fine chaff-like scales, which may look like
.
Generally, there are no symptoms, and it may be mildly itchy (as shown in Figure 7 below)
.
Figure 7.
Sandy dermatitis.
In short, it is sometimes difficult to identify skin lesions caused by enterovirus infection
.
For hospitals or scientific research institutes with a high level of laboratories, virus-related inspections are the main basis for diagnosis
.
For medical institutions without laboratory conditions, detailed medical history and careful observation of the appearance of skin lesions may reveal some clues
.
Fortunately, many diseases caused by enteroviruses are not so critical
.
It is necessary to carefully observe the changes in the condition and early warning and prediction of critical diseases .
The treatment is mainly anti-virus, symptomatic treatment, and strengthening the care of skin lesions
.
References: [1] Krasota A, Loginovskih N, Ivanova O, Lipskaya G.
Direct Identification of Enteroviruses in Cerebrospinal Fluid of Patients with Suspected Meningitis by Nested PCR Amplification.
Viruses.
2016 Jan.
8(1):E10.
[2] Pons-Salort M,Parker EPK,Grassly NC.
The epidemiology of non-polio enteroviruses:recent advances and outstanding questions.
Curr Opin Infect Dis.
2015 Oct.
28(5):479-87.
[3]Park K,Lee B ,Baek K,Cheon D,Yeo S,Park J,et al.
Enteroviruses isolated from herpangina and hand-foot-and-mouth disease in Korean children.
Virol J.
2012 Sep 17.
9(1):205.
[4]Prose NS ,Tope W,Miller SE,Kamino H.
Eruptive pseudoangiomatosis:a unique childhood exanthem?.
J Am Acad Dermatol.
1993 Nov.
29(5 Pt 2):857-9.
[5]Miller PK,Zain-Ul-Abideen M , Paul J, Perry AE, Linos K, Carter JB, et al.
A case of eczema coxsackium with erythema multiforme-like histopathology in a 14-year-old boy with chronic graft-versus-host disease.
JAAD Case Rep.
2017 Jan.
3(1):49-52.
[6]Oberste MS, Michele SM,Maher K,et al.
Molecular identification and characterization of two proposed new enterovirus serotypes,EV74 and EV75.
J Gen Virol.
2004 Nov.
85:3205-12.
[7]Richer MJ,Horwitz MS.
Coxsackievirus infection as an environmental factor in the etiology of type 1 diabetes.
Autoimmun Rev.
2009 Jun.
8(7):611-5.
[8]Wang Weiping editor in chief.
Pediatrics (8th) edition.
People's Medical Publishing House, (Beijing):197.
Coxsackievirus infection as an environmental factor in the etiology of type 1 diabetes.
Autoimmun Rev.
2009 Jun.
8(7):611-5.
[8]Wang Weiping editor.
Pediatrics (8th) edition.
People's Medical Publishing House, (Beijing ): 197.
Coxsackievirus infection as an environmental factor in the etiology of type 1 diabetes.
Autoimmun Rev.
2009 Jun.
8(7):611-5.
[8]Wang Weiping editor.
Pediatrics (8th) edition.
People's Medical Publishing House, (Beijing ): 197.
