Hand, foot and mouth disease
The hand-foot-mouth disease (also hand-foot-mouth rash, false foot and mouth disease ) is a viral , globally occurring, highly contagious infectious disease that is repeatedly epidemic in Southeast Asia , in Germany and other countries but so far mostly only occurs sporadically. In most cases it is harmless and affects primarily children under ten years of age, but can also occur in adults. Hand, foot and mouth disease is diagnosed year-round, but particularly high levels occur in late summer and autumn.
Hand, foot and mouth disease is primarily caused by group A enteroviruses (EV-A). These include Coxsackie A viruses (A2-A8, A10, A12, A14, A16), the human enterovirus 71 (EV71) and newer serotypes . Overall, coxsackie A16 viruses are the most common cause of hand, foot and mouth disease to date, and coxsackievirus A6 and coxsackievirus A10 are also frequently associated with the disease. Different strains of the virus can circulate during an outbreak .
The pathogen is transmitted directly from person to person through direct contact with body fluids such as saliva, droplets, secretion from vesicles or faecal-oral , in the first days of infection also from vesicles of the oral mucosa via aerosols when the patient coughs. The pathogens enter the body via the oral mucosa or the small intestine and enter the bloodstream via the regional lymph nodes after three days ( viraemia ). Indirect transmission via surfaces contaminated with saliva or stool is also possible. Asymptomatic people can also spread the disease.
In practice, a visual diagnosis of the disease is usually made taking into account the epidemic situation , but the pathogens in the stool and in the skin vesicles can be detected with certainty by isolation in a special laboratory. Due to the reliable clinical diagnosis and the mild course, laboratory diagnostics are not initiated in most cases.
Mainly chickenpox (varicella) and (in milkers) foot-and-mouth disease are to be thought of. A severe sore throat and blistering in the mouth without the other symptoms typical of hand, foot and mouth disease can also be herpangina .
Course of disease
A study in Taiwan found that 70% of infections are asymptomatic ( inapparent infection ).
After an average incubation period of three to seven days, a maximum of two weeks, typical courses initially lead to illness with flu-like symptoms such as fever, loss of appetite and sore throat. One to two days after the onset of a fever, painful enanthemums usually develop in the oral mucosa, which can manifest themselves and ulcerate with short-lived vesicles four to eight millimeters in diameter, especially in the area of the tongue , the hard palate , the gums and the cheek mucosa . Lips, soft palate, tonsils and pharynx remain free or are rarely affected. These vesicles change into shallow, greasy, painful erosions ( aphthae ).
Simultaneously or just a short time later, a symmetrical rash ( exanthem ) with blistering on the palms of the hands, soles of the feet and buttocks follows . The changes can be observed increasingly on the flexors of the fingers and toes or their side surfaces, but also on the soles of the feet (heels) and palms. Hands and feet can have a sharp or tense pain and severe itching. The vesicles usually heal after eight to twelve days without crusting.
Sometimes onychomadesis ( onychomadesis ) occurs, i.e. the proximal detachment of a nail plate in layers, presumably as a result of an interruption in nail growth (peeling) . In some cases - usually within four weeks of the infection - fingernails and toenails may be lost, but they will grow back again.
The disease leaves an immunity only against the causative agent; a renewed hand-foot-mouth disease caused by one of the other pathogens is therefore possible.
Especially in the case of an infection with the human enterovirus 71 , which is more common in Asia, brainstem encephalitis, acute flaccid paralysis (similar to poliomyelitis ) or aseptic meningitis can occur very rarely - especially in children under five years of age . In flaccid paralysis, the lower motor neurons in the anterior horn of the spinal cord are irrevocably destroyed by a lytic infection , so that permanent paralysis usually results. Aseptic meningitis, on the other hand, usually heals completely. Brainstem encephalitis is the most dangerous complication, with severe inflammation localized in the hypothalamus , brainstem, and spinal cord, as well as in the dentate nucleus of the cerebellum . The onset of the disease is usually acute and rapid within hours with myoclonus , tremor , ataxia , nystagmus and cranial nerve paralysis . Acute and severe neurogenic pulmonary edema often occurs , which can develop within 24 to 36 hours and is highly lethal . In these cases there is seldom a complete healing, usually severe neurological disorders remain.
Strict adherence to hygiene measures such as hand washing with soap is recommended , especially after changing diapers and using the toilet. Close contact with the sick should be avoided (kissing, hugging, sharing cutlery or cups, etc.).
A vaccine against EV71 (“Sinuvac EV71”) was developed in China and has been in use since December 2015. It is very likely that it leads to protection against EV71, but not against other pathogens that cause hand, foot and mouth disease. Therefore, but also for other reasons, the importance of this vaccine was cautiously assessed by its own developers at the beginning of 2017. It is questionable whether the use of this vaccine will also make sense in other countries, since the spectrum of the causative viruses may differ from country to country, and since RNA viruses have a high mutation rate. Therefore, there is currently no approval of this vaccine in the EU and there has not yet been a preliminary examination by the WHO.
So far, the therapy can only be symptomatic. Avoiding sour or spicy foods is recommended. Cold liquids or water ice can help relieve pain. The symptomatic therapy with medication is carried out with pain relieving oral gels or solutions and paracetamol or ibuprofen . Synthetic tannins and chlorhexidine mouthwashes can prevent secondary infections, for example from scratching. The painful changes in the oral mucosa can lead to reduced fluid and food intake. To avoid dehydration , fluids can be consumed with a drinking straw . To date, there are no antiviral drugs approved for the treatment of hand, foot and mouth disease.
The disease was first described by Dalldorf and Sickles in 1948. The human enterovirus 71 was not identified until 1969 in the USA , later individual epidemics were described in Bulgaria in 1975 and Hungary in 1978. It is a growing problem in Southeast Asia and the Pacific. In 1997, 41 children in Malaysia died of an epidemic, and in 1998 in Taiwan 78 patients out of 1.5 million infected. Since then, regular epidemics have been reported from Southeast Asia, but also from France, including annual outbreaks in China . In the past decade, an estimated six million people worldwide have contracted enterovirus 71 and more than 2000 have died from it. In Germany, too, there are sporadic Enterovirus 71 diseases, which, however, as far as is known, proceed without serious complications. Large outbreaks have only been reported from Southeast Asia for the past decade. The cause of the differences between the potency and the epidemic spread and the pathopotency of the pathogen between Southeast Asia and Europe has not been clarified.
According to the Infection Protection Act (IfSG), hand-foot-mouth disease is neither a reportable disease nor a disease in which people suspected of having the disease or confirmed disease are subject to special health requirements or the health department may impose certain conditions. For example, children or adults who are suspected of having the disease or who have been diagnosed with the disease may continue to visit community facilities such as kindergartens or schools.
In Austria, the health authorities describe this infectious disease as "widespread, highly contagious, but harmless"; there is also no obligation to report, but the need for strict hygiene measures is pointed out. For example, children or adults with suspected illness or confirmed illness may only visit community facilities such as kindergartens or schools after the illness has subsided (medical certificate).
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