"Eczema Coxsackium" and Unusual Cutaneous Findings in an Enterovirus Outbreak

Eczema Coxsackium" and Unusual Cutaneous Findings in an Enterovirus Outbreak WHAT'S KNOWN ON THIS SUBJECT: Coxsackievirus A6 (CVA6) was identified as an important cause of "severe" hand, foot, and mouth disease (HFMD) during the 2011-2012 outbreak in North America.The atypical cutaneous features in this outbreak have not been well documented.WHAT THIS STUDY ADDS: The cutaneous manifestations of CVA6associated HFMD may be more extensive and variable than classic HFMD.Four distinct morphologies characterize this exanthem:(1) widespread vesiculobullous and erosive lesions, (2) "eczema coxsackium," (3) an eruption similar to Gianotti-Crosti, and (4) purpuric lesions.abstract OBJECTIVE: To characterize the atypical cutaneous presentations in the coxsackievirus A6 (CVA6)-associated North American enterovirus outbreak of 2011-2012. METHODS:We performed a retrospective case series of pediatric patients who presented with atypical cases of hand, foot, and mouth disease (HFMD) from July 2011 to June 2012 at 7 academic pediatric dermatology centers.Patients were included if they tested positive for CVA6 or if they met clinical criteria for atypical HFMD (an enanthem or exanthem characteristic of HFMD with unusual morphology or extent of cutaneous findings).We collected demographic, epidemiologic, and clinical data including history of skin conditions, morphology and extent of exanthem, systemic symptoms, and diagnostic test results.RESULTS: Eighty patients were included in this study (median age 1.5 years, range 4 months-16 years).Seventeen patients were CVA6positive, and 63 met clinical inclusion criteria.Ninety-nine percent of patients exhibited a vesiculobullous and erosive eruption; 61% of patients had rash involving .10%body surface area.The exanthem had a perioral, extremity, and truncal distribution in addition to involving classic HFMD areas such as palms, soles, and buttocks.In 55% of patients, the eruption was accentuated in areas of eczematous dermatitis, termed "eczema coxsackium."Other morphologies included Gianotti-Crosti-like (37%), petechial/purpuric (17%) eruptions, and delayed onychomadesis and palm and sole desquamation.There were no patients with serious systemic complications. CONCLUSIONS:The CVA6-associated enterovirus outbreak was responsible for an exanthem potentially more widespread, severe, and varied than classic HFMD that could be confused with bullous impetigo, eczema herpeticum, vasculitis, and primary immunobullous disease.