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Conference summaries

Important viral diseases

Viral Disease Update: Coxsackie, Zika, and Varicella-Zoster

Presented by: Ilona J. Frieden, MD
Dermatology and Pediatrics
University of California, San Francisco

Coxsackie virus falls under the broader set of viruses referred to as enteroviruses. In the winter of 2011-2012, unusual cases of hand-foot mouth disease were surfacing in older children with perioral and perirectal involvement (50% intraoral). Patients had a characteristic papulovesicular dorsum rash on the hands and feet as opposed to only the palms and the soles.1 Unusual cases were also reported in Singapore, Taiwan, and Finland.2

This Coxsackie virus A6 (CVA6) outbreak and related cutaneous findings were documented in more detail.1 Mathes et al. noted that while most patients were outpatients, some patients were admitted to the hospital because of vasculitis and symptoms mimicking eczema herpeticum. The four distinct morphologies that surfaced included:1

  • Widespread vesiculobullous and erosive lesions
  • “Eczema coxsackium”
  • Gianotti-Crosti-like lesions
  • Purpuric lesions.

Both children and adults presented with severe Coxsackie infections. Parents of infected children have presented with onychomadesis (~2 months later), a well-recognized complication.3 Caregivers and playground equipment are known reservoirs.

Hubiche et al. demonstrated that 88% of patients had greater involvement than just the hand, foot, and mouth with almost 50% having 5 or more sites of involvement.4 A major clue to this diagnosis is the perioral involvement.4

Diagnosis of CVA6 may be completed via PCR of blister fluid, pharyngeal or rectal swab (for enterovirus). Onychomadesis in patients and seemingly unaffected family members is also an important clue to diagnosis.

Zika virus is becoming more prevalent with Zika hotspots in central/south America, and parts of Africa. Areas next to these known hotspots have also seen an increase in Zika virus transmission.5 Zika rashes are characterized as rubelliform eruptions (versus morbilliform in Dengue).5,6 It may be accompanied by fever, arthralgias, conjunctivitis, myalgia, and headache. Symptoms may last from several days to a week.

Diagnosis can be made on whole blood, serum, or plasma to detect the virus, viral nucleic acid, or virus-specific immunoglobulin M and neutralizing antibodies. Review the CDC website for up-to-date and worldwide information.6

There has been a steady decline in outpatient visits (84%) and hospitalizations (93%) in 2012 compared to 1994-1995.7 Mortality rates have also declined 87% for all ages and 99% for people less than 20 years old from 2008-2011 compared to pre-vaccination years 1990-1994.7 Currently, varicella often arises among older children, adolescents, and adults, and the majority of cases occurs among people that have been vaccinated. Vaccinated patients usually present a milder form with a shorter duration illness and with fewer than 50 lesions/vesicles compared with 300 or more lesions in unvaccinated people.7 The modified clinical presentation of varicella can be challenging for practitioners and parents to recognize.

The rates of herpes zoster have remained relatively steady.

The biggest risk factors for herpes zoster include:8

  • In utero exposure from a mother with primary varicella
  • Exposure early in life to primary varicella
  • Delayed age of vaccination, severe asthma, and developmental disorders.

It is important to note that there are multiple conditions that may cause an acral rash in infants and the main ones include:

  • Kawasaki disease
  • Contact dermatitis
  • Pseudomonas hand-foot syndrome
  • Parvovirus exanthem
  • Enteroviral exanthems.
  • Unusual cases of hand-foot mouth disease due to CVA6 have surfaced in older children with perioral and perirectal involvement.
  • CVA6 presents with four distinct morphologies: widespread vesiculobullous and erosive lesions, “eczema coxsackium”, Gianotti-Crosti-like lesions, purpuric lesions.
  • Both children and adults still present with severe coxsackie infections.
  • Parents of infected children often presented with onychomadesis ~2 months later.
  • Zika virus is becoming more prevalent with Zika hotspots in central/south America and parts of Africa.
  • Zika rashes are characterized as rubelliform eruptions.
  • Varicella often arises among older children, adolescents, and adults, and the majority of cases occurs among people that have been vaccinated.
  • Vaccinated patients usually present a milder form with a shorter duration illness and with fewer than 50 lesions/vesicles.

There has been a steady decline in outpatient visits (84%) and hospitalizations (93%) in 2012 compared to 1994-1995.7 Mortality rates have also declined 87% for all ages and 99% for people less than 20 years old from 2008-2011 compared to pre-vaccination years 1990-1994.7 Currently, varicella often arises among older children, adolescents, and adults, and the majority of cases occurs among people that have been vaccinated. Vaccinated patients usually present a milder form with a shorter duration illness and with fewer than 50 lesions/vesicles compared with 300 or more lesions in unvaccinated people.7 The modified clinical presentation of varicella can be challenging for practitioners and parents to recognize.

The rates of herpes zoster have remained relatively steady.

The biggest risk factors for herpes zoster include:8

  • In utero exposure from a mother with primary varicella
  • Exposure early in life to primary varicella
  • Delayed age of vaccination, severe asthma, and developmental disorders.

It is important to note that there are multiple conditions that may cause an acral rash in infants and the main ones include:

  • Kawasaki disease
  • Contact dermatitis
  • Pseudomonas hand-foot syndrome
  • Parvovirus exanthem
  • Enteroviral exanthems.
  • Unusual cases of hand-foot mouth disease due to CVA6 have surfaced in older children with perioral and perirectal involvement.
  • CVA6 presents with four distinct morphologies: widespread vesiculobullous and erosive lesions, “eczema coxsackium”, Gianotti-Crosti-like lesions, purpuric lesions.
  • Both children and adults still present with severe coxsackie infections.
  • Parents of infected children often presented with onychomadesis ~2 months later.
  • Zika virus is becoming more prevalent with Zika hotspots in central/south America and parts of Africa.
  • Zika rashes are characterized as rubelliform eruptions.
  • Varicella often arises among older children, adolescents, and adults, and the majority of cases occurs among people that have been vaccinated.
  • Vaccinated patients usually present a milder form with a shorter duration illness and with fewer than 50 lesions/vesicles.

There has been a steady decline in outpatient visits (84%) and hospitalizations (93%) in 2012 compared to 1994-1995.7 Mortality rates have also declined 87% for all ages and 99% for people less than 20 years old from 2008-2011 compared to pre-vaccination years 1990-1994.7 Currently, varicella often arises among older children, adolescents, and adults, and the majority of cases occurs among people that have been vaccinated. Vaccinated patients usually present a milder form with a shorter duration illness and with fewer than 50 lesions/vesicles compared with 300 or more lesions in unvaccinated people.7 The modified clinical presentation of varicella can be challenging for practitioners and parents to recognize.

The rates of herpes zoster have remained relatively steady.

The biggest risk factors for herpes zoster include:8

  • In utero exposure from a mother with primary varicella
  • Exposure early in life to primary varicella
  • Delayed age of vaccination, severe asthma, and developmental disorders.

It is important to note that there are multiple conditions that may cause an acral rash in infants and the main ones include:

  • Kawasaki disease
  • Contact dermatitis
  • Pseudomonas hand-foot syndrome
  • Parvovirus exanthem
  • Enteroviral exanthems.

Key messages

  • Unusual cases of hand-foot mouth disease due to CVA6 have surfaced in older children with perioral and perirectal involvement.
  • CVA6 presents with four distinct morphologies: widespread vesiculobullous and erosive lesions, “eczema coxsackium”, Gianotti-Crosti-like lesions, purpuric lesions.
  • Both children and adults still present with severe coxsackie infections.
  • Parents of infected children often presented with onychomadesis ~2 months later.
  • Zika virus is becoming more prevalent with Zika hotspots in central/south America and parts of Africa.
  • Zika rashes are characterized as rubelliform eruptions.
  • Varicella often arises among older children, adolescents, and adults, and the majority of cases occurs among people that have been vaccinated.
  • Vaccinated patients usually present a milder form with a shorter duration illness and with fewer than 50 lesions/vesicles.


REFERENCES

Present disclosure: The presenter disclosed that she was a consultant for Bridgebio and Venthera and was on the drug safety monitor board for Pfizer.

Written by: Debbie Anderson, PhD

Reviewed by: Victor Desmond Mandel, MD



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Viral Disease Update: Coxsackie, Zika, and Varicella-Zoster

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