The first case of HFMD was found on 19.08.07, in Bally (an area located at the north end of Howrah district), in a one and a half-year-old female child, who presented with multiple papulo-vesicular lesions over the buttocks, knees, hands and feet and oral mucosa for two days along with mild fever of same duration.
A total of 38 cases of HFMD were reported till 08.10.07. The last one reported onset of disease on 6th October. Most of the cases were preschool or early school going children, from the medium socio-economic section. The age group ranged from 12 months to 12 years (mean 40.76 months, SD 29.49). Males were slightly higher in number than females (M:F - 21:17) . Date and district-wise incidence of cases, as reported to our centers, is presented in . The contribution of different districts is presented in .
Date and district-wise incidence of cases
Contribution of different districts in the total cases of HFMD
The disease started as small (1-5mm) erythematosus maculo-papular lesions that rapidly enlarged (3-15mm) and progressed to vesicular eruption with a prominent erythematous halo . Many of these transformed into gray vesicles. The vesicles were round, elongated or oval. Not all erythematous papules progressed to well-defined vesicles. Frequently, the vesicle formed was smaller than the papule.
A well formed vesicle with marked erythematous halo in a child in HFMD
The distribution of lesions was very characteristic and involved the buttocks, knees, hands, feet - both dorsum and palmar, or the plantar surface, and the oral mucosa. However, the severity of the disease was the highest over the buttocks and the knee in most cases . Infrequently, the adjoining areas like the wrist and the lower leg were involved. The involvement of the trunk was mild and rare in most. Extensive papulo-vesicular eruptions involving the trunk and even the axilla were noted in three patients.
Multiple papulo-vesicular eruptions over the knee and the hand
The vesicles developed poorly over the palms and the soles, and, frequently, presented as slightly elevated erythematous papules , unlike the dorsal surface where fluid collected early in the papule [Figures and ]. Also, the lesions were more common over the margins, thenar and hypothenar eminence and dorsal surfaces, than on the volar surfaces .
Erythematous papules without any vesicles over the margin of the foot
Severe involvement of the dorsum foot with multiple vesicles
Erythematous papules with mild vesiculation over thenar eminence and margin of the hand
The vesicles often mimicked vesicles of chicken pox and initial maculo-papular lesions simulated lesions of mosquito bites. Most cases also mimicked papular urticaria.
Secondary infection of the skin lesions was observed in three patients. Mild to moderate itching was observed in 17, mostly during healing.
Among 22 patients who completed follow-up, healing time for skin lesions was 6-13 days (mean 9.13 days, SD 1.93), with prominent scaling and slight hypo-pigmentation that persisted even four weeks in at least two cases.
Oral lesions were found in 33 (86.8%) cases, but they were symptomatic only in 11 (29%). Sites of involvement were the inner side of the lips, gums, buccal mucosa, tongue, and the hard palate. Usually, one to three small erythematous erosions of 3-5 mm size were noted. Occasional cases had diffuse inflammation over the larger areas of gum .
Diffuse erythema over the lower gum, along with erosion from ruptured vesicle over the inner side of lip
A history of mild fever, mostly preceding, sometimes simultaneously (as told by parents), with skin lesions was found in 12 cases. Two most common systemic symptoms were fever and anorexia . Systemic symptoms were difficult to be elicited, due to the small age of patients. Doctor consultation for nondermatological symptoms was required only for abdominal pain and fever in two cases each. In most of these, systemic symptoms preceded skin eruption by one to four days and were milder at the time of presentation at skin OPD.
Systemic symptoms observed in patients with hand, foot and mouth disease
In none of the cases we could identify the source case or a secondary case, either from history or during home visit. All the suspected household cases, in home visits, turned out to be non-HFMD disease.
Mild neutrophillia and eosinophillia were noted in one case each. Serum IgE and routine examination of the urine and stool did not reveal abnormality in any of the cases.
Topical antibiotics were given in all the cases. Oral antibiotic and antihistamines were used in four patients.