Surveillance for Enteroviruses Associated with Hand, Foot, and Mouth Disease, and Other Mucocutaneous Symptoms in Spain, 2006–2020

Nieves Martínez-López,María Cabrerizo,María Pilar Romero,Carmen Muñoz-Almagro,Manuel Imaz-Pérez,Cristian Launes,Gregoria Megias,Juan Valencia-Ramos,Ana Navascués,Jordi Reina,Almudena Otero,Cristina Calvo,Montserrat Ruiz-García

doi:10.3390/v13050781

Abstract

Hand, foot, and mouth disease (HFMD) is a mild illness caused by enteroviruses (EV), although in some Asian countries, large outbreaks have been reported in the last 25 years, with a considerable incidence of neurological complications. This study describes epidemiological and clinical characteristics of EV infections involved in HFMD and other mucocutaneous symptoms from 2006 to 2020 in Spain. EV-positive samples from 368 patients were included. EV species A were identified in 85.1% of those typed EV. Coxsackievirus (CV) A6 was the prevalent serotype (60.9%), followed by EV-A71 (9.9%) and CVA16 (7.7%). Infections affected children (1–6 years old) mainly, and show seasonality with peaks in spring–summer and autumn. Clinical data indicated few cases of atypical HFMD as well as those with neurological complications (associated with the 2016 EV-A71 outbreak). Phylogenetic analysis of CVA6 VP1 sequences showed different sub-clusters circulating from 2010 to present. In conclusion, HFMD or exanthemas case reporting has increased in Spain in recent years, probably associated with an increase in circulation of CVA6, although they did not seem to show greater severity. However, EV surveillance in mucocutaneous manifestations should be improved to identify the emergence of new types or variants causing outbreaks and more severe pathologies.

Highlights

Hand, foot, and mouth disease (HFMD) is a limited acute infection produced by enteroviruses (EV), principally from species A (EV-A)
Typical HFMD was defined by blisters on the palms, soles, buttocks, knees, or elbows [29]; atypical HFMD was diagnosed when the patients presented with a vesiculobullous and erosive eruption involving more than 10% of the body, including the perioral, extremity, or truncal areas; herpangina was characterised by vesicular eruptions only in the mouth or throat; non-specific exanthema was a widespread rash or area of irritated or swollen skin; petechiae were defined by tiny red, flat spots on skin; and, onychomadesis was loosening and shedding of the nails
Taking into account infections in which EV type was identified (N = 323), the most frequent EV detected was CVA6 accounting for 60.9% of the cases (N = 197), followed by EV-A71 (N = 32, 9.9%), CVA16 (N = 25, 7.7%), and CVA10 (N = 9, 2.8%)

Summary

Introduction

Foot, and mouth disease (HFMD) is a limited acute infection produced by enteroviruses (EV), principally from species A (EV-A). Transmission is faecal–oral or through respiratory secretions and contact with cutaneous lesions, and infections are prevalent in children younger than 5 years old [1,2,3]. Typical clinical manifestations are vesicular lesions in the palm of the hands, feet, and in the oral mucosa. HFMD can lead to fever, but subsequent neurological complications are infrequent, except for the large outbreaks occurring every 2–3 years in countries from the Asia-Pacific region since 1997, where there is a considerable incidence of neurological and cardiopulmonary cases [4,5,6]. Other frequent mucocutaneous manifestations caused by EV are herpangina and nonspecific exanthemas [1,6].

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Discussion

Conclusion