Enterovirus Co-infections and Onychomadesis after Hand, Foot, and Mouth Disease, Spain, 2008

Maria A Bracho,Fernando González-Candelas,Antonio Salazar,Juan Córdoba,Ana Valero

doi:10.3201/eid1712.110395

Abstract

Hand, foot, and mouth disease (HFMD), a common disease caused by enteroviruses (EVs), usually affects children. Clustered and sporadic HFMD cases, followed by onychomadesis (nail shedding), occurred during summer and fall 2008 in Valencia, Spain. Fecal samples from onychomadesis patients, who did or did not have previous HFMD, and from healthy children exposed to onychomadesis patients tested positive for EV. The complete viral protein 1 capsid gene sequence was obtained for typing and phylogenetic analysis. Two EV serotypes, coxsackievirus A10 and coxsackievirus B1 (CVB1), were mainly detected as a monoinfection or co-infection in a childcare center where an onychomadesis outbreak occurred. On the basis of our results, and detection of CVB1 in 2 other contemporary onychomadesis outbreaks in childcare centers in Spain, we propose that mixed infection of an EV serotype that causes HFMD, plus the serotype CVB1, could explain the emergence after HFMD of onychomadesis, a rare and late complication.

Highlights

Hand, foot, and mouth disease (HFMD), a common disease caused by enteroviruses (EVs), usually affects children
The main EVs detected in the HFMD–onychomadesis outbreak in Valencia in 2008 included human enteroviruses (HEVs)-A serotypes that caused HFMD (CVA6 and CVA10) and an HEV-B serotype (CVB1), currently associated with meningitis and myocarditis and detected recently in clusters of severe systemic neonatal illness [25] and onychomadesis outbreaks [14,15]
The other EVs detected in our survey (CVA5, EV71, coxsackievirus A16 (CVA16), and echovirus 9 (E9)) could be incidental to the outbreak because they were found rarely and, except for CVA16, were identified from fecal samples collected long after HFMD onset [26]

Summary

Introduction

Foot, and mouth disease (HFMD), a common disease caused by enteroviruses (EVs), usually affects children. Serotypes CVA10 and CVB1 were prevalent in the preliminary reports of the 2008 onychomadesis outbreak in Valencia [17]. All 3 mixed infections CVB1/CVA10 occurred in childcare center 1 and were found in 2 symptomatic children (with both HFMD and onychomadesis) and 1 healthy child.

Results

Conclusion