Hand foot and mouth disease in children caused by coxsackievirus

Coxsackievirus is the main cause of Hand, Foot, and Mouth Disease (HFMD) in children. It is a common and highly contagious illness, especially among children under five years old. Symptoms include fever, a skin rash, and blisters on the hands, feet, and inside the mouth, which can make eating and drinking difficult. Although most cases are mild and resolve within a few days, certain strains of the virus can cause rare but serious complications. In this Daleely Medical article, we will explore the symptoms of Coxsackievirus, how it spreads, home treatment options, and effective prevention measures to safely protect your child.

What is Hand, Foot, and Mouth Disease (HFMD)?

Hand, Foot, and Mouth Disease (HFMD) is a common viral infection in children, caused by a strain of Coxsackievirus. The disease is characterized by a blister-like rash that usually appears on the hands, feet, and inside the mouth.

Important Note: HFMD is completely different from foot-and-mouth disease, which affects cows, pigs, goats, and deer and is caused by a different virus.

Who gets HFMD?

Most cases occur in children under 10 years old.
Sometimes, young adults may get infected, but it is much less common.

How does HFMD spread?

Direct contact with nasal or throat secretions from an infected person.
Contact with blisters or feces of infected individuals.
The disease spreads rapidly, especially in nurseries and schools.

What is Coxsackievirus infection?

Coxsackievirus is part of the enterovirus family, which also includes poliovirus and hepatitis A virus.

It can live in the digestive system and spreads through unwashed hands or surfaces contaminated with feces, where it can survive for several days.
Most infections cause mild flu-like symptoms and resolve without treatment, but some cases may lead to serious infections requiring medical attention.

Is Coxsackievirus infection contagious?

Yes, Coxsackievirus is highly contagious and can spread easily:

Through unwashed hands or contaminated surfaces.
Through droplets from sneezing or coughing.
Infants and children under five are most at risk, especially in schools, daycare centers, and summer camps.
The risk of infection is highest during the first week of illness.
In colder climates, outbreaks are more common in summer and fall, while in tropical areas, cases can occur year-round.

How long does Coxsackievirus infection last?

Fever usually lasts 1–3 days.
HFMD generally lasts 2–7 days.
Viral meningitis may take 3–7 days to recover.

Can adults get HFMD?

Yes, adults and older children can get HFMD, but it is less common.

Most adults show no symptoms.
When symptoms appear, they are similar to those in children.

HFMD vs Other Diseases

Disease	Cause	Who it affects	Notes
Foot-and-Mouth Disease	Different virus	Cows, pigs, goats, deer	Humans do not get it
Monkeypox	Orthopoxvirus	Humans	Causes rash and flu-like symptoms
Herpangina	Coxsackievirus	Children	Blisters only in mouth and throat, not hands or feet

Vaccines for HFMD and Coxsackievirus

1️⃣ HFMD Vaccine

Type: Enterovirus 71 (EV71), associated with severe cases.
Target Age: Children 6 months to 5 years.
Administration: Intramuscular or subcutaneous, usually 2–3 doses.
Benefits: Protects against severe cases and reduces hospitalization risk.
Notes:
- Does not cover all Coxsackievirus types (e.g., A16).
- Mild side effects: redness at injection site, mild fever.
- Personal hygiene, handwashing, and surface disinfection remain crucial.

2️⃣ Coxsackievirus Vaccine

Current Status: No universal vaccine for all types (A & B), only available against EV71.
Benefits: Protects against severe cases, not all infections.
Notes: Children remain at risk of other types like Coxsackievirus A16 & B. Hygiene and preventive measures are very important.

Is Coxsackievirus more dangerous for adults?

In most cases, Coxsackievirus infections are mild in children and resolve on their own.
Some strains, such as Coxsackievirus A6, can cause more severe illness in both children and adults.
In adults, severe cases may require hospitalization and present with:
- Fever
- Joint pain
- Painful rash
Although HFMD is rare in adults, infection rates may increase due to climate changes and viral evolution.

Stages of Hand, Foot, and Mouth Disease (HFMD)

Stage	Duration	Symptoms & Notes
Incubation Period	3–6 days	No symptoms appear, but the child is contagious.
Early Stage	1–2 days	Mild fever, fatigue, loss of appetite, headache, mild muscle aches.
Rash & Lesion Stage	1–2 days	Red blisters on hands, feet, mouth, sometimes on buttocks or legs. Painful mouth sores make eating and drinking difficult.
Peak Stage	3–5 days	Fever may rise, rash and blisters become widespread.
Recovery	~1 week	Gradual disappearance of rash and fever; most children return to normal activity within 7–10 days.
Rare Complications	Varies	Meningitis, encephalitis, myocarditis, temporary or permanent paralysis (often associated with EV71 virus).

Stages of Coxsackievirus Infection

Stage	Duration	Symptoms & Notes
Incubation Period	3–6 days	No symptoms, virus is contagious even without signs.
Early Infection	1–2 days	Fever, fatigue, headache, loss of appetite, sometimes nausea or vomiting.
Specific Symptom Stage	Varies	Depends on disease type: - HFMD: blisters and rash on hands, feet, mouth. - Herpangina: sores in throat and tonsils. - General rash: small red spots on body. - Meningitis or encephalitis: severe headache, neck stiffness, seizures. - Myocarditis: severe fatigue, shortness of breath, weak heart.
Peak Stage	Varies	Symptoms reach their maximum: high fever, widespread rash or blisters, possible rare complications.
Recovery / Complications	~1 week	Most mild cases recover within a week; some may develop serious complications affecting the brain, heart, or nerves.

Causes of HFMD and Coxsackievirus

1️⃣ Coxsackievirus Causes

Belongs to the Enterovirus family; main types: A and B.
Transmission:
Contact with secretions: saliva or mucus.
Direct contact with feces, especially if hand hygiene is poor.
Contaminated surfaces or toys, particularly in schools or daycare.
Virus can spread even if the child shows no symptoms.

2️⃣ HFMD Causes

Usually caused by Coxsackievirus A16 or Enterovirus 71 (EV71).
Transmission:
Direct contact with an infected child (skin or shared toys).
Contact with body fluids: saliva, mucus, feces.
Environmental surfaces: contaminated toys, towels, eating utensils.
Children under 5 are more susceptible due to weaker immunity.

Symptoms of Coxsackievirus and HFMD

1️⃣ General Coxsackievirus Symptoms

Fever (mild to moderate)
Fatigue
Headache and mild muscle aches
Nausea or vomiting (sometimes)
Rash or small blisters (in some cases)
Mouth or throat sores (in some infections)
Rare complications: viral meningitis, encephalitis, myocarditis, temporary or permanent paralysis

2️⃣ HFMD Symptoms

Sudden fever before rash appears
Small mouth blisters causing difficulty eating or drinking
Red rash or small blisters on hands, feet, sometimes buttocks or legs
Loss of appetite due to mouth pain
General fatigue
Occasionally: headache, abdominal pain, nausea

How Coxsackievirus Spreads

Direct contact with contaminated surfaces (e.g., changing tables).
Inhalation of droplets from coughs or sneezes of an infected person.
During pregnancy or childbirth, virus can pass from mother to child.
⚠️ Highest risk during the first week of illness.
Spreads easily among children under 5, especially in daycare, schools, or crowded places.

Risks of Coxsackievirus and HFMD

1️⃣ General Coxsackievirus Risks

Viral meningitis: severe headache, neck stiffness, nausea, vomiting
Encephalitis: seizures, loss of consciousness, behavioral changes
Myocarditis: severe fatigue, shortness of breath, weak heartbeats
Rare paralysis: extremely rare with some Coxsackievirus types
Rare liver or lung complications: e.g., viral hepatitis, severe respiratory issues

2️⃣ HFMD Risks

Dehydration due to painful mouth sores
Rare neurological complications: meningitis or encephalitis
Rare heart complications: myocarditis or temporary heart weakness
High contagiousness especially in schools and daycare
Reinfection possible as different virus types exist

Diagnosis of HFMD

1️⃣ Clinical Examination

Most HFMD cases are diagnosed by observing external symptoms:
- Small blisters on hands, feet, mouth, sometimes buttocks or legs
- Mouth sores causing difficulty eating or drinking
- Fever and general fatigue
A history of similar cases in school or daycare helps confirm diagnosis

2️⃣ Laboratory Tests (rare for mild cases)

Throat or mouth swab to confirm Coxsackievirus
Blood or urine tests to identify virus type or rule out other illnesses

Diagnosis of Coxsackievirus Infection

1️⃣ Clinical Examination

Depends on disease type caused by the virus:
- Herpangina: throat sores with fever
- HFMD or rash: blisters on hands, feet, mouth, or other areas
- Meningitis or encephalitis: headache, neck stiffness, nausea, seizures
- Myocarditis: severe fatigue, shortness of breath, weak heartbeats

2️⃣ Laboratory Tests

PCR (Polymerase Chain Reaction) to detect virus in saliva, blood, or stool
Blood tests to check for complications (e.g., heart inflammation, electrolyte imbalance)
Heart or brain imaging if serious complications appear

Health Issues Caused by Coxsackievirus

1️⃣ Mild / Non-serious

Conjunctivitis (pink eye): redness, itching, eye discharge
Herpangina: throat inflammation, fever, small blisters or sores in mouth

Hand, Foot, and Mouth Disease (HFMD)

Symptoms and Health Issues

Mild Symptoms:
- Blisters and rash on hands, feet, and mouth.
- May cause difficulty eating or breastfeeding in children.
More Serious Health Issues:
- Encephalitis (Brain Inflammation): Rare cases can cause brain damage and even death.
- Hepatitis (Liver Inflammation): Swelling of the liver, impaired liver function, possible liver failure.
- Myocarditis (Heart Muscle Inflammation): Swelling around the heart, potentially leading to serious complications or death, especially in children.
- Other Rare Conditions: Viral meningitis, temporary or permanent paralysis, neurological or cardiac complications.

Types of HFMD and Coxsackievirus-related Illnesses

1️⃣ HFMD Types

Type	Cause	Symptoms
Classic HFMD	Coxsackievirus A16	Rash on hands, feet, and mouth; mild fever; mouth sores
Severe HFMD	Enterovirus 71 (EV71)	Typical HFMD symptoms; high fever; widespread rash; rare neurological or cardiac complications
Atypical HFMD	Any Coxsackievirus type	Rash in unusual areas such as buttocks or legs

2️⃣ Other Coxsackievirus-related Illnesses (Non-HFMD)

Herpangina: Small sores or blisters in the throat, tonsils, or uvula; accompanied by fever, headache, and loss of appetite.
Maculopapular Rash: Small red rash in various areas of the body.
Viral Meningitis: Rare; severe headache, neck stiffness, nausea.
Encephalitis: Very rare; seizures, loss of consciousness, behavioral disturbances.
Myocarditis: Rare; weak heart, shortness of breath, severe fatigue.
Rare Paralysis: Extremely rare; associated with certain Coxsackievirus types.

Difference Between Coxsackievirus and HFMD

Aspect	Coxsackievirus	HFMD
Definition	Virus from the Enterovirus family; can cause various illnesses	Disease mainly affecting children, usually caused by Coxsackievirus
Cause	Infection with Coxsackievirus A or B	Usually caused by Coxsackievirus A16 or EV71
Transmission	Contact with secretions (saliva, mucus, feces) or contaminated surfaces	Same as virus transmission
Main Symptoms	Vary by illness: sore throat, rash, fever, sometimes neurological or cardiac complications	Rash on hands, feet, and mouth; fever; loss of appetite; mouth sores
Most Affected Group	Children under 10 years; adults can be affected	Young children (usually under 5 years)
Complications	Rare; may include meningitis, encephalitis, myocarditis, paralysis	Rare; usually mild, may cause dehydration or difficulty eating due to mouth sores
Treatment	Supportive: rest, hydration, pain relief, monitor for complications	Supportive: pain relief, hydration, soft foods, monitor for complications
Prevention	Wash hands thoroughly, avoid contact with infected persons, maintain clean environment	Same as virus prevention

Prevention of Coxsackievirus and HFMD

1️⃣ Coxsackievirus Prevention

Wash hands frequently, especially after using the toilet or changing diapers.
Avoid contact with secretions of infected individuals (saliva, mucus, feces).
Clean and disinfect surfaces and toys that children often touch.
Avoid sharing food or eating utensils with infected children.
Avoid direct contact with infected children in schools or daycare until symptoms improve.

2️⃣ HFMD Prevention

Same as Coxsackievirus prevention since it is the main cause of HFMD.
Isolate the infected child from other children during the infectious period (usually 7–10 days).
Encourage children to wash hands after playing or before meals.
Keep the environment and toys clean, especially in schools and daycare.
Monitor for early symptoms and treat promptly to prevent spread.

Dietary Guidelines for Children with HFMD or Coxsackievirus

Type	Allowed	Not Allowed	Notes
Drinks	Water, diluted natural juices (apple, grape), warm soup or broth, milk or liquid yogurt, cold or iced juices	Soda, very sugary juices, very hot drinks	Cold drinks help soothe mouth sores; avoid sugar to reduce irritation and tooth decay
Fruits	Banana, pear, mashed apple, soft mashed fruits	Citrus fruits (orange, lemon, grapefruit), very acidic fruits	Soft fruits are easy to swallow and gentle on mouth sores
Vegetables	Cooked mashed vegetables, mashed potatoes, boiled zucchini	Hard or crunchy vegetables (raw carrots, tough lettuce)	Avoid rough textures to reduce pain while chewing
Grains & Starches	Boiled rice, soft pasta, soft bread (without hard crust)	Toasted bread, hard cereal flakes	Choose soft foods for easy swallowing and minimal mouth irritation
Proteins	Boiled eggs, soft boiled or grilled chicken, cooked or boiled fish	Tough or fried meats, hard nuts	Cooked soft foods are easier to eat without pain
Cold or Frozen Foods	Pudding, light ice cream, iced juices	Spicy, salty, or very acidic foods	Help soothe mouth sores and reduce pain
Other Foods	Small, frequent meals; easily digestible foods	Large, heavy meals	Dividing meals helps maintain nutrition and compensate for loss of appetite

Additional Tips:

Encourage the child to drink water between meals to stay hydrated.
Maintain hand hygiene before and after eating to prevent infection spread.
Use soft or plastic utensils to make eating easier and prevent mouth irritation.

Caring for a Child with HFMD or Coxsackievirus

1️⃣ Caring for a Child with HFMD

A) Symptom Relief

Fever & Pain: Safe children’s medications such as paracetamol or ibuprofen, according to age and weight, under doctor guidance.
Mouth Sores: Soft, cold foods to reduce pain (yogurt, pudding, diluted juices); avoid spicy or salty foods.
Skin Itching: Apply soothing creams or moisturizers if blisters or rash are severe.

B) Hydration & Nutrition

Ensure adequate water intake to replace lost fluids.
Offer small, soft, easy-to-swallow meals to prevent loss of appetite.

C) Isolation & Prevention

Keep the child at home until fever subsides and blisters heal (usually 7–10 days).
Ensure good hand hygiene for both child and caregivers.
Clean and disinfect surfaces and toys.

Caring for a Child with Coxsackievirus Infection (Non-HFMD)

A) Monitoring General Symptoms

Fever, fatigue, headache, nausea, or vomiting.
Any appearance of rash or mouth sores.

B) Medical Intervention When Needed

Sore throat or Herpangina: Provide pain relief and ensure proper hydration.
Severe cases or rare complications (meningitis, encephalitis, myocarditis): Seek medical attention immediately.

C) Preventing Transmission to Others

Wash hands thoroughly and frequently.
Keep the child isolated from other children at school or daycare until symptoms improve.
Clean and disinfect toys and surfaces regularly.

Medication Treatment for Coxsackievirus Infection

⚠️ There is no antiviral medication that kills Coxsackievirus. Treatment is supportive, focusing on relieving symptoms and preventing complications.

1️⃣ Fever and Pain Relief

Paracetamol (Acetaminophen):
- Suitable for children according to age and weight.
- Reduces fever and relieves muscle pain or headache.
Ibuprofen:
- Safe alternative for children over 6 months.
- Reduces fever, inflammation, and pain.
❌ Avoid aspirin in children due to the risk of Reye’s syndrome.

2️⃣ Anti-Nausea Medications

Given only if the child experiences severe vomiting or difficulty drinking fluids, and under doctor supervision.

3️⃣ Anti-Itch or Skin Irritation Treatments

Soothing creams or ointments can be applied if a rash causes itching or irritation.

4️⃣ Treatment for Rare Complications

Meningitis or Encephalitis: Supportive medications in the hospital.
Myocarditis: Cardiac medications according to the condition.
⚠️ These treatments are administered only under direct medical supervision.