“Eczema Coxsackium” and Unusual Cutaneous Findings in an Enterovirus Outbreak

Abstract

OBJECTIVE: To characterize the atypical cutaneous presentations in the coxsackievirus A6 (CVA6)–associated North American enterovirus outbreak of 2011–2012. METHODS: We performed a retrospective case series of pediatric patients who presented with atypical cases of hand, foot, and mouth disease (HFMD) from July 2011 to June 2012 at 7 academic pediatric dermatology centers. Patients were included if they tested positive for CVA6 or if they met clinical criteria for atypical HFMD (an enanthem or exanthem characteristic of HFMD with unusual morphology or extent of cutaneous findings). We collected demographic, epidemiologic, and clinical data including history of skin conditions, morphology and extent of exanthem, systemic symptoms, and diagnostic test results. RESULTS: Eighty patients were included in this study (median age 1.5 years, range 4 months–16 years). Seventeen patients were CVA6-positive, and 63 met clinical inclusion criteria. Ninety-nine percent of patients exhibited a vesiculobullous and erosive eruption; 61% of patients had rash involving >10% body surface area. The exanthem had a perioral, extremity, and truncal distribution in addition to involving classic HFMD areas such as palms, soles, and buttocks. In 55% of patients, the eruption was accentuated in areas of eczematous dermatitis, termed “eczema coxsackium.” Other morphologies included Gianotti-Crosti–like (37%), petechial/purpuric (17%) eruptions, and delayed onychomadesis and palm and sole desquamation. There were no patients with serious systemic complications. CONCLUSIONS: The CVA6-associated enterovirus outbreak was responsible for an exanthem potentially more widespread, severe, and varied than classic HFMD that could be confused with bullous impetigo, eczema herpeticum, vasculitis, and primary immunobullous disease.

Eczema exacerbation caused by Coxsackie virus A6

“…While hand, foot and mouth disease has traditionally been attributed to Coxsackie virus A16, 1 Coxsackie virus type A6 has been implicated in severe cutaneous eruptions, with outbreaks in Asia, Europe, America and New Zealand. [2][3][4] This study confirms the presence of The anaplastic variant of CD30-positive diffuse large B-cell lymphoma is a rare type of B-cell lymphoma which is characterised by the presence of large pleomorphic lymphoid cells and the exprerssion of CD 30. 1 The cutaneous involvement of CD30-positive B-cell lymphoma is very rare.…”

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“…In children, this severe form has a spectrum of manifestations including widespread distribution, petechial eruption, and "eczema coxsackium", which is the predilection of the HFMD vesicles for areas of eczema. This phenomenon is similar to eczema herpeticum, and among enteroviruses, only Coxsackie A16 is also known to cause it [4]. The presentation of Cocksackie A6 HFMD described in our four patients is atypical given the adult age predilection and a more generalized distribution involving the face and forehead as well as the dorsum of the hands and feet.…”

Atopic Dermatitis: Skin-Directed Management

“…These include molluscum contagiosum, eczema herpeticum, the recently described atypical enteroviral infection attributable to Coxsackie virus A6 (the socalled "eczema coxsackieum"), 59 and vaccinia virus (the virus used in smallpox vaccine). Patients with eczema herpeticum present with shallow, "punched-out" erosions in areas of skin affected with or prone to AD.…”