Teaching file 5

Sharing thoughts about few cases we encountered this week.
First one is a case of Hand foot mouth disease.
Just to highlight few atypical features.
This entity was not a common before 2000.
when we encounter fever with vesicles. most common possibility we considered was varicella (chicken pox).
Even though we studied theoretical details of smallpox,and how to differentiate this from chickenpox it was not of much practical use as it was declared eradicated in 1980.
This new entity of HFMD appeared once in a while in the beginning of this century but last ten years this became more common than chickenpox .
If we examine the data in IDSP Kerala,last year we ll see the number of chicken pox cases in thousands.
Most of this must be wrongly reported HFMD, some times if we are not careful it is very likely that Hand foot mouth disease is mistaken for varicella and many cases put on anti viral drugs and contacts vaccinated against varicella.
In a way it is good.

One interesting thing noticed over years is the change in the pattern of clinical features over time. 

All of us know the typical features of varicella, and modified features of varicella when it  occurs in breakthrough cases ,partially immunized cases or immuno- compromised cases.

• Typical features of HFMD which we all observed were ,
•  low grade fever. 
• irritability ,
• drooling of saliva and feeding problem in the first one or two days. Most of the cases involved younger ones less than five years.
• Few papular lesions seen initially changed to vesicles.
• The lesions were more on knee, buttocks and elbows. Lesions in the mouth, gingivi,palate , soles and feet.

The typical lesions of varicella "dew drops on rose petals"predominant on the trunks were not seen in HFMD.

Following  years , 

1. there were many cases with no involvement of oral mucosa.
2. Few lesions dark verrucas type remained for few more days
3. There were cases in older age group.Last year one of our house surgeon had same lesions

Even though neurological problems like encephalitis and aseptic meningitis reported we did nt have cases , But last year a case of encephalitis gave history of HFMD. we could nt get a virologial proof as CSF could nt be sent

Atypical features we observed in this case are

• Look at the large confluent lesion on the knees ,legs and foot
• Look at the lesion on face, which is bit unusual
• Look the buttocks, and elbows ,no lesions

He was treated symptomatically with paracetamol,
He was not sick, and was discharged without any sequel e

Second case

3 yr old previously normal girl had sudden onset of focal seizures involving face and limbs. No fever. Vomited twice. She was Investigated and managed outside and referred to our hospital.
CT taken outside hypodense lesion in left tempero parietal region.





She had minimal weakness on right side which recovered within days.
At the time of reaching here fully conscious oriented, general examination was normal , no neurocutaneous markers.
Here Neurological examination was normal.
MRI taken here showed acute infarct involving left MCA territory.











Cardio vascular examination normal.
No bruit carotid.
Thrombotic work up (basic ones ) done from here normal
Peripheral smear showed iron deficiency anemia.
She was sent back

Two months later,

She presented to local hospital with status- epilepticus. She was managed as usual.As she was deteriorating referred to us
By the time she reached here no breathing, pupils asymmetrical dilated non reacting on one side.

CT was taken

It was a huge tumor , mid line shift lead to coning
She was on kept with supportive measures waiting for recovery.
She succumbed after 72 hours
Most probably Primary intracranial atypical teratoid tumor of infancy and childhood was considered.
we could nt do repeat MRI or other work up.