Outbreak of hand, foot, and mouth disease in udaipur.

Sir,

Hand, foot, and mouth disease (HFMD) is a febrile, self-limiting viral illness, characterized by oral and cutaneous papulovesicular lesions. HFMD was first reported in India from Kerala in 2003.[1] Thereafter, there have been reports from Nagpur,[2] Jorhat,[3] Kolkata,[456] and Bhubaneswar.[7] We report an outbreak of HFMD in Udaipur district in Rajasthan, wherein we managed 38 cases over a 3-month period in 2012.

The study included children with papulovesicular exanthem, which were clinically diagnosed to have HFMD by two independent dermatologists. The period of the outbreak was from early July to September 2012. A detailed history was obtained. Physical examination, routine hematological investigations, and Tzanck smears were carried out. The patients were symptomatically managed and followed up till the lesions healed completely.

Thirty-eight patients, 20 males and 18 females, were diagnosed with HFMD. Their ages ranged from 7 months to 10 years, with a mean age of 4.15 years. All patients presented with papulovesicular lesions over the skin, predominantly over distal extremities. The lesions were predominantly oval, and more painful than itchy. At the time of presentation, the palms were the most commonly affected site [Figure 1], found in 22 patients (57.8%). Dorsum of hands (n = 18, 47.3%, Figure 2), soles (n = 17, 44.7%), dorsum of feet (n = 16, 42.1%), buttocks (n = 15, 39.4%, Figure 3), knees (n = 14, 36.8%), and elbows (n = 14, 36.8%) were other commonly involved cutaneous sites. Oral lesions were present in 28 patients (73.6%) and included papulovesicular lesions on an erythematous base [Figure 4], many of which had eroded to form aphthous-like lesions. In some patients, they were a cause of considerable morbidity due to pain, leading to drooling of saliva, refusal to feed, and anorexia. The disease was preceded or accompanied by a prodrome of systemic features in 25 patients (65.78%). The most common complaints were fever in 18 (47.3%) and sore throat in 12 (31.5%) patients. There was associated family history in 11 (28.9%) patients. The results of hematological investigations were normal and Tzanck smears showed nonspecific inflammatory cells. Twenty patients were followed up till recovery. The duration of disease in these patients varied from 8 to 12 days. None of our patients developed any complications.

Figure 1

Oval vesicular lesions on palm

Figure 2

Papulovesicular lesions on dorsum of hands

Figure 3

Lesions on buttocks

Figure 4

Vesicular lesions on tongue

HFMD was first reported in India from Calicut, Kerala, in 2003. In barely a decade, there has been a rapid spread of the disease with reports of epidemics from Eastern, Southern, and Central regions of the country. HFMD patients have been presenting to us for the past few years. The steady and significant rise in their number over the years prompted us to undertake the study for greater awareness among pediatricians, dermatologists, and general physicians. Apart from the cases mentioned above, there were a significantly greater number of HFMD patients diagnosed and managed by other dermatologists and pediatricians in the region. As is the case with other enteroviral diseases, the clinical disease presents just the tip of the iceberg as far as the disease prevalence in community is concerned. Since the disease is self-limiting, majority of patients do not reach the health professionals and a greater number serve as carriers of the disease. To the best of our knowledge, this is the first reported outbreak of HFMD from Western India. Given the history of HFMD in South East Asia, many more outbreaks possibly with severe disease may be expected in India in the near future.[8] It is important for health professionals across the country to have a high index of suspicion for HFMD. Prompt identification and management will help reduce morbidity due to the disease.