A 3-year-old boy presented to the pediatric emergency department with a 4-day history of a progressive papulovesicular rash that started on his buttock and involved his legs, hands, feet, axilla and oropharynx ( Figure 1). Ten days earlier, he had been diagnosed with pharyngitis and prescribed amoxicillin. The patient had been in contact with other children with pharyngitis at day care. In the emergency department, he was febrile, but appeared clinically well. Because of the concern about eczema herpeticum, he was admitted and given intravenous acyclovir. A lesional polymerase chain reaction (PCR) swab was positive for enterovirus, and negative for herpes simplex virus and varicella-zoster virus. Acyclovir was discontinued, and the patient was discharged home with follow-up in pediatric dermatology. The patient's sister subsequently developed a sore throat and intraoral lesions.We diagnosed this patient with atypical hand-foot-and-mouth disease, a manifestation of enterovirus infection that is becoming more widely recognized.
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