Hand Foot Mouth Disease versus Herpangina

My daughter goes to daycare where several other kids were told they have Hand Foot Mouth Disease (HFMD) and within few days my daughter has got this oral enanthem

Hand Foot Mouth Disease

We can see there is a big ulcer on the side of the tongue but also several white coated flat vesicles on the hard and soft palate posteriorly. The image does not show the uvula and posterior pharygneal wall but there were lesions there too.

Why we looked into the mouth? she was pointing to mouth hurting. This is the typical presentation in verbal children but in non-verbal children the presentation is typically refusal to eat and drink.

At the time of the picture there was no skin rash (no exanthem) and therefore I was thinking she most likely having herpangina. But within few hours she started to have tiny red pink papules on the dorsum of her feet which later evolved to more vesicular and at that point we realized that just like the other children in daycare she has HFMD.

But I was asking myself. Does it really matter clinically to differentiate HFMD from herpangina? They are both caused by Coxsackievirus Type A and sometimes Type B or echo virus. They both have similar rate of complications (HFMD little higher rate). They are both managed with supportive treatment and there is no specific antiviral treatment in either case.

The lesson for pediatricians here is that we tend to think herpangina when we see only enanthem but here is a proof that HFMD can start with the oral enanthem and then after a day or two you will see the hands and feet rash, in fact in some cases it’s only the oral lesions and there won’t be any exanthem and in other cases you will see only exanthem with no enanthem.

One of the parents told me (Hand Foot Mouth Disease! The name is kind of scary name of a disease in cattle, can you guys please change the name?) Since then I started telling my patients and families it’s a Coxsackievirus infection and this would serve two benefits (avoid labeling herpangina versus HFMD and avoiding the scary name) 😉

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