Hand-foot-and-mouth disease caused by coxsackievirus A6 in a patient infected with HIV

Abstract

Case studyIn August 2013, a 12-year-old boy infected with human immunodeficiency virus (HIV), who has been on antiretroviral therapy for more than two years, presented to the Tshwane District Hospital HIV clinic with fever and a rash. His symptoms had started two days ago. The rash was mainly on the palms and soles, and was sometimes itchy. His antiretroviral (ARV) drug regimen consisted of zidovudine, lamivudine and nevirapine. He was no longer receiving prophylaxis for pneumocystis pneumonia at the time of consultation.On examination, he was clinically stable and pyrexial (37.6 °C). The boy had a macular rash on his palms and soles (Figure 1), and a vesicular rash at the right corner of his mouth. There were dark streaks on his palate, and no other lesions. In addition to his ARV drugs, he was also prescribed mupirocin ointment and oral acyclovir. A blood sample for syphilis tests was taken on the day of consultation, and a stool sample was submitted a day later for enterovirus testing.Blood taken a month before this consultation revealed that the patient's HIV viral load was undetectable, and the CD4 count was 929 cells/µl (30.9%). The syphilis tests, rapid plasma reagin and the Treponema pallidum haemagglutination assay were all negative. Enterovirus realtime reverse transcription polymerase chain reaction (RT-PCR), carried out on a stool sample, tested positive. A leftover serum sample (after the syphilis testing) tested negative on enterovirus real-time RT-PCR.However, this sample was slightly haemolysed and was tested five days after collection. Nucleotide sequence analysis of the nested enterovirus RT-PCR products from the stool sample showed that the patient was infected with the coxsackievirus A6 (CVA6) strain. At the follow-up visit, the patient and his guardian reported that the rash had disappeared completely without any complications, roughly a week after the consultation. MethodEthical approval for this investigation was obtained from the University A 12-year-old boy on treatment for human immunodeficiency virus (HIV) presented to an HIV clinic with fever and a rash on the palms and soles. The syphilis test were negative. Enterovirus was identified from a stool sample by PCR and characterised as as coxsackievirus A6(CVA6). The patient completely recovered a week later. CVA6 has recently been associated with HFMD. This case highlights the significance of the laboratory confirmation of suspected HFMD cases aand phylogenetic analysis of the identified virus.Peer reviewed.