Onychomadesis (Nails Shedding) Secondary to Enterovirus Herpangina Like Infection and Without the Skin Manifestations of Hand Foot Mouth Disease

Abstract

Onychomadesis or onycholysis is a newly recognized complication in the course of viral infections particularly the Hand Foot Mouth Disease (HFMD) in children and adults. Onychomadesis is characterized by proximal separation of the nail plate from the nail matrix due to temporary cessation of growth of the nail matrix. The etiology of onychomadesis is including infections, trauma, medications side effects, systemic diseases and idiopathic. The association of the HFMD and the onychomadesis first reported in the year 2000. Since then, few studies and case reports published illustrating the relationship of the HFMD and the resultant onychomadesis 4 to 8 weeks after the resolution of the HFMD. HFMD is a relatively common viral infection, especially in children of preschool age. It is usually presented with characteristic eruption on hands, feet and mouth. Out breaks may happen in nurseries and schools. HFMD usually caused by enteroviruses, most commonly, Coxsackie virus A (CVA) and enterovirus 71 (EV71). It is usually self-limiting disease however; serious neurological complications have been reported with EV71. The enteroviruses that cause HFMD and nail changes may cause herpangina which is unlike the HFMD, usually characterized by mouth spots on the soft palate without the skin manifestations, however onychomadesis was not reported before with herpangina. This case presented with no HFMD eruption but small red spots on the soft palate consistent with herpangina. Enterovirus was isolated from throat swab and the onychomadesis occurred 1 month after the resolution of the soft palate spots. It is the first case report about nail changes occurring after herpangina presentation. It is therefore important that in patients presented with onychomadesis to consider the review of the patient's history not only for HFMD but herpangina and possible other EV infections, 8 weeks before the nail changes, to avoid unnecessary referrals, concerns and over investigations. The exact mechanism of the nail changes is not yet known and a review of theories behind the nail damage will be considered in this report.