Recurrent Hand, Foot, and Mouth Disease in a Saudi Girl

Hand, foot, and mouth disease (HFMD) is a viral illness that predominantly affects infants and children, causing blisters and sores on the hands, feet, and mouth. Recurrence is rare, but a case in a six-year-old girl in Saudi Arabia was reported. A six-year-old girl presented with a rash on her palms and soles, which was preceded by a mild sore throat and low-grade fever. She had been in contact with her two-year-old sister, who had similar symptoms but a different rash pattern.  During clinical examination, multiple erythematous deep-seated vesicles and papules were noted on the patient's palms and soles, with no involvement of mucous membranes or nails. The diagnosis of hand, foot, and mouth disease (HFMD) was made based on the characteristic clinical presentation, and the rash resolved within seven days without treatment or complications.  The patient had experienced a similar presentation six months ago, which was also diagnosed as HFMD, and the rash had resolved spontaneously within one week. In her second episode, the rash was less severe, with milder prodromal symptoms. In both episodes, the lesions were asymptomatic and had no mucosal involvement. The patient had experienced onychomadesis after her first episode, but no nail abnormalities were seen after her second episode. Although HFMD is rare to recur in children, outbreaks can lead to another episode. HFMD prevalence is underestimated in Saudi Arabia due to missed mild cases. Pediatricians and dermatologists should be aware of HFMD incidence and its complications, as early detection is vital in preventing outbreaks and transmission.

Atypical cutaneous findings of hand-foot-mouth disease in children: A systematic review

INTRODUCTION

Hand-foot-mouth disease (HFMD) is a common childhood infectious disease. Atypical skin findings of HFMD, often associated with coxsackievirus A6 (CVA6), were first reported in 2008, with increasing reports worldwide since. Atypical lesions of HFMD often involve sites beyond the palms and soles and tend to have unusual, polymorphic morphology.

METHODS

A systematic review was conducted on clinical features and outcomes of pediatric HFMD with atypical cutaneous manifestations.

RESULTS

Eighty-five studies were included, representing 1359 cases with mean age 2.4 years and a male predominance of 61%. The most reported morphologies were vesicles (53%), papules (49%), and bullae (36%). Other morphologies included eczema herpeticum-like (19%), purpuric/petechial (7%), and Gianotti Crosti-like (4%). Common atypical sites included the arms and/or legs (47%), face (45%), and trunk (27%). CVA6 was identified in 63% of cases. Symptoms resolved in a mean of 10 days. Overall, 16% of cases received treatment, most commonly with acyclovir, intravenous antibiotics, or topical steroids. The most common complications were nail changes (21%) and desquamation (4%) which occurred a mean of 3 and 2 weeks after symptoms, respectively.

CONCLUSION

Due to unusual morphologies resembling other conditions, HFMD with atypical cutaneous findings may be misdiagnosed, leading to inappropriate and unnecessary investigations, hospitalization, and treatment. Greater awareness of atypical presentations of HFMD is warranted to improve patient care and counseling on infection control precautions.

Establishment of the 1st Chinese national standard for CA6 neutralizing antibody

Coxsackievirus A6 (CA6) is one of the major causative agents of herpangina and hand-foot-mouth disease (HFMD). Since 2008, CA6 has circulated widely around the world. Especially in Asia-Pacific region CA6 had even replaced enterovirus A71 (EV71) and coxsackievirus A16 (CA16) as the main prevalent strain of HFMD. In the recent 10 years, monovalent and multivalent vaccines against CA6 have been researched and developed by manufacturers from China, Korea, and the USA. The neutralizing antibody titer is a key indicator for accurately evaluating immunogenicity of vaccine. However, so far, the World Health Organization international standard for CA6 neutralizing antibody has not been available. In order to meet the needs of evaluating the immunogenicity of vaccines against CA6, the first Chinese national standard for CA6 neutralizing antibody was established, which was conducted to ensure that methods used to measure the neutralizing antibody titers against CA6 are accurate, reliable, and comparable. Three lyophilized candidate standards (29#, 39# and 44#) were produced with 0.40 ml/vial from plasma samples donated by healthy individuals. The collaborative study showed that the 29# candidate standard could effectively minimize the variability in neutralization titers between labs and across challenging viruses of different genotypes (A, D1, and D3). Therefore, the 29# candidate sample was established as the first Chinese national standard for CA6 neutralizing antibody test. This standard has good long-term stability and was assigned a potency of 150 units per milliliter (U/ml) of CA6 neutralizing antibody. It will contribute to ensure uniformity of potency or activity of vaccines and potentially therapeutic antibody preparations.

Guillain-Barré Syndrome Following Hand, Foot, and Mouth Disease in an Adult Patient

Guillain-Barré syndrome (GBS) stands as one of the primary causes of acute flaccid paralysis. It includes acute-onset peripheral nerve lesions and typically follows a monophasic course. Its etiopathogenesis is linked to an immune-mediated response to a prior infection, often respiratory or intestinal. The main variants of GBS are acute inflammatory demyelinating polyneuropathy, which accounts for approximately 90% of cases in the USA and Europe, and acute motor axonal neuropathy, responsible for about 10% of cases in the USA and Europe. From the literature review, only one case of GBS preceded by hand, foot, and mouth disease (HFMD) has been described. The authors report a rare clinical case of typical GBS after HFMD. Recognizing this adult-onset disease as a potential preceding infection of GBS is crucial for early diagnosis and treatment. Additionally, the integration into a rehabilitation program adjusted to the deficits plays an important role in motor and functional recovery.

Disease trend assessment via Google and Wikipedia

BACKGROUND AND AIM

The study aimed to evaluate the epidemiological trend of hand, foot and mouth disease (HFMD) in Italy using data on Internet search volume.

METHODS

A cross-sectional study design was used. Data on Internet searches were obtained from Google Trends (GT) and Wikipedia. We used the following Italian search term: "Malattia mano-piede-bocca" (Hand-foot-mouth disease, in English). A monthly time-frame was extracted, partly overlapping, from July 2015 to December 2022. GT and Wikipedia were overlapped to perform a linear regression and correlation analyses. Statistical analyses were performed using the Spearman's rank correlation coefficient (rho). A linear regression analysis was performed considering Wikipedia and GT.

RESULTS

Search peaks for both Wikipedia and GT occurred in the months November-December during the autumn-winter season and in June during the spring-summer season, except for the period from June 2020 to June 2021, probably due to the restrictions of the COVID19 pandemic. A temporal correlation was observed between GT and Wikipedia search trends.

CONCLUSIONS

This is the first study in Italy that attempts to clarify the epidemiology of HFMD. Google search and Wikipedia can be valuable for public health surveillance; however, to date, digital epidemiology cannot replace the traditional surveillance system.

SHFL inhibits enterovirus A71 infection by triggering degradation of viral 3Dpol protein via the ubiquitin-proteasome pathway

Enterovirus A71 (EV-A71) is a highly contagious virus that poses a major threat to global health, representing the primary etiological agent for hand-foot and mouth disease (HFMD) and neurological complications. It has been established that interferon signaling is critical to establishing a robust antiviral state in host cells, mainly mediated through the antiviral effects of numerous interferon-stimulated genes (ISGs). The host restriction factor SHFL is a novel ISG with broad antiviral activity against various viruses through diverse underlying molecular mechanisms. Although SHFL is widely acknowledged for its broad-spectrum antiviral activity, it remains elusive whether SHFL inhibits EV-A71. In this work, we validated that EV-A71 triggers the upregulation of SHFL both in cell lines and in a mouse model. Knockdown and overexpression of SHFL in EVA71-infected cells suggested that this factor could markedly suppress EV-A71 replication. Our findings further revealed an intriguing mechanism of SHFL that it could interact with the nonstructural proteins 3Dpol of EV-A71 and promoted the degradation of 3Dpol through the ubiquitin-proteasome pathway. Furthermore, the zinc-finger domain and the 36 amino acids (164-199) of SHFL were crucial to the interaction between SHFL and EV-A71 3Dpol . Overall, these findings broadened our understanding of the pivotal roles of SHFL in the interaction between the host and EV-A71.

A Case of Hand-Foot-and-Mouth Disease in an Adult Male

Hand-foot-and-mouth disease (HFMD) is commonly seen in infants and children; less frequently, it may be seen in adults as well. The disease is usually associated with viral infections, including many variants of enteroviruses and coxsackieviruses. We discuss the case of a 39-year-old male who presented with constitutional symptoms, fever, and lesions on his hands, feet, and mouth. His children, who had been recently diagnosed with HFMD, were likely the source of his infection. A comprehensive history and physical examination enabled us to identify the lesions, some of which were faint and difficult to visualize. Viral panel testing indicated positive results for human rhinovirus/enterovirus. Treatment and testing associated with the patient's condition were supportive, largely based on the history and physical findings which helped us narrow down our differential diagnoses. Complete resolution of the symptoms within one to two weeks is generally expected in these patients.

Isolation and Characterization of scFv Antibody against Internal Ribosomal Entry Site of Enterovirus A71

Enterovirus A71 (EV-A71) is one of the causative agents of hand-foot-mouth disease, which can be associated with neurocomplications of the central nervous system. A limited understanding of the virus's biology and pathogenesis has led to the unavailability of effective anti-viral treatments. The EV-A71 RNA genome carries type I internal ribosomal entry site (IRES) at 5' UTR that plays an essential role in the viral genomic translation. However, the detailed mechanism of IRES-mediated translation has not been elucidated. In this study, sequence analysis revealed that the domains IV, V, and VI of EV-A71 IRES contained the structurally conserved regions. The selected region was transcribed in vitro and labeled with biotin to use as an antigen for selecting the single-chain variable fragment (scFv) antibody from the naïve phage display library. The so-obtained scFv, namely, scFv #16-3, binds specifically to EV-A71 IRES. The molecular docking showed that the interaction between scFv #16-3 and EV-A71 IRES was mediated by the preferences of amino acid residues, including serine, tyrosine, glycine, lysine, and arginine on the antigen-binding sites contacted the nucleotides on the IRES domains IV and V. The so-produced scFv has the potential to develop as a structural biology tool to study the biology of the EV-A71 RNA genome.

Hand-Foot-Mouth Disease in an Adult

Hand-foot-mouth syndrome is a common childhood illness. Although occurrence in adults is rare, its incidence has been increasing. In such cases, it usually presents with atypical symptoms. The authors present the case of a 33-year-old male patient who presented with constitutional symptoms, feverish sensation, and macular palmoplantar rash associated with oral and oropharynx ulcers. The epidemiological history revealed exposure to two cohabitants (children) with a recent diagnosis of hand-foot-mouth disease (HFMD).

Hand, Foot, and Mouth Disease: A Narrative Review

BACKGROUND

Hand, foot, and mouth disease is a common viral disease in childhood. Because the disease has the potential to reach epidemic levels and mortality is high in some countries, early recognition of this disease is of paramount importance.

OBJECTIVE

This purpose of this article is to familiarize pediatricians with the clinical manifestations and management of hand, foot, and mouth disease.

METHODS

A search was conducted in February 2022 in PubMed Clinical Queries using the key term "hand, foot, and mouth disease". The search strategy included all clinical trials, observational studies, and reviews published within the past 10 years. Only papers published in English were included in this review.

RESULTS

Hand, foot, and mouth disease is characterized by a painful oral enanthem and asymptomatic exanthem on the palms and soles. Children younger than 5 years are most commonly affected. Hand, foot, and mouth disease caused by enterovirus A71 is more severe and has a higher rate of complications than that attributed to other viruses such as coxsackievirus A16. Circulatory failure secondary to myocardial impairment and neurogenic pulmonary edema secondary to brainstem damage are the main causes of death. Fortunately, the disease is usually benign and resolves in 7 to10 days without sequelae. Given the self-limited nature of most cases, treatment is mainly symptomatic and supportive. Intravenous immunoglobulin should be considered for the treatment of severe/complicated hand, foot, and mouth disease and has been recommended by several national and international guideline committees. Currently, there are no specific antiviral agents approved for the treatment of the disease. Drugs such as ribavirin, suramin, mulberroside C, aminothiazole analogs, and sertraline have emerged as potential candidates for the treatment of hand, foot, and mouth disease. Vaccination of susceptible individuals in high-risk areas and good personal hygiene are important preventative measures to combat the disease.

CONCLUSION

Familiarity of the disease including its atypical manifestations is crucial so that a correct diagnosis can be made, and appropriate treatment initiated. A timely diagnosis can help avoid contact with the affected individual and decrease the risk of an outbreak.

Network meta-analysis of heat-clearing and detoxifying oral liquid of Chinese medicines in treatment of children's hand-foot-mouth disease: A protocol for systematic review and meta-analysis

BACKGROUND

Hand-foot-mouth is a viral infectious disease characterized by fever, hand foot rash and oral mucosal herpes caused by a variety of enteroviruses. It is often found in preschool children, and its immune system is not well developed, so it is very susceptible to infection by pathogens and epidemics, resulting in rapid progress of the disease. At present, the commonly used Chinese patent medicine oral liquid in our country has good clinical efficacy of antiviral, antibacterial, antiphlogistic and improving immunity, but there is no evidence to compare the clinical efficacy and safety of a variety of oral liquid of Chinese patent medicine. Therefore, this study is aim to use the network meta-analysis to integrate the clinical relevant evidence of direct and indirect comparative relationship, and to conduct quantitative comprehensive statistical analysis and sequencing after the aggregation of different Chinese patent medicine oral liquid with the same evidence body, and then the best clinical medication scheme is selected, which can provide reference value and evidence-based theoretical evidence for clinical optimization of drug selection.

METHODS

Comprehensive retrieval of CNKI, VIP, CBM, and WANFANG database and the Cochrane Library, PubMed, Web of Science and EMBASE database. Search and publish the clinical RCT of these 7 kinds of oral liquid of Chinese patent medicine compared with ribavirin or oral liquid of Chinese patent medicine. The retrieval time is from the establishment of the database to October 31st, 2021. The 2 first authors will screen the literatures that meets the inclusion criteria, extract the data independently according to the predesigned rules, and evaluate the literature quality and bias risk of the included research according to the Cochrane manual standard. Data merging and network meta-analysis were carried out with R programming software to evaluate the ranking probability of all interventions.

RESULTS

This network meta-analysis and probability ranking will identify the best Chinese patent medicine oral liquid treatment for Hand-foot-mouth.

CONCLUSION

This study will provide systematic evidence-based medicine evidence for Chinese patent medicine oral liquid treatment for Hand-foot-mouth, and help clinicians, patients with poststroke depression and decision-makers to make more effective, safer and economic optimal treatment plan in the decision-making process.

REGISTRATION NUMBER

INPLASY202210032. The protocol for this systematic review was registered on INPLASY and is available in full on the inplasy.com (https://inplasy.com/inplasy-2022-1-0032/).

Metabolomic characteristics of hand-foot-mouth disease facilitate discovery and diagnosis of pathogeny

BACKGROUND

Hand-foot-mouth disease (HFMD) is a significant public health concern, especially in Asia-Pacific countries. Its diagnosis mainly depends on clinical symptoms. It is easy to miss the source of infection and best treatment period. This research aims to provide a tool for its early clinical diagnosis and for predicting the possibility of complications.

METHODS

The serum samples of 39 HFMD children and 36 healthy children were collected for clinical testing and ¹ H-NMR spectroscopy. Metabolomic analyses were performed to obtain the metabolic differences between the HFMD and healthy children and to speculate on the pathogenesis of HFMD.

RESULTS

Thirty-nine children were divided into severe cases and mild cases. Severe cases demonstrated more obvious inflammatory responses, but no metabolic difference was observed between the severe and mild cases. The metabolic differences between HFMD and healthy children were noticeable. Ten differential metabolites were screened out as the potential biomarkers for HFMD, and seven disturbed metabolic pathways responsible for HFMD were affected by inflammation, impaired intestinal absorptive function, and immune response.

CONCLUSIONS

Our results will provide a complementary tool for the early diagnosis of HFMD and potential ideas for later treatment.

Risk Factors for Severe Hand-Foot-Mouth Disease in China: A Systematic Review and Meta-Analysis

Background: This study aimed to identify potential risk factors for severe hand-foot-mouth disease (HFMD). Methods: The PubMed, Embase, the Cochrane Library, Sinomed, WanFang, CNKI, and VIP databases were searched (up to August 2021). Results: Twenty-nine studies (9,241 and 927,355 patients with severe HFMD and controls, respectively; all from China) were included. EV71 was associated with higher odds of severe HFMD compared with other agents (OR = 4.44, 95%CI: 3.12-6.33, p < 0.001). Being home-raised (OR = 1.99, 95%CI: 1.59-2.50, p < 0.001), higher number of children in the family (OR = 2.09, 95%CI: 1.93-2.27, p < 0.001), poor hand hygiene (OR = 2.74, 95%CI: 1.78-4.23, p < 0.001), and no breastfeeding (OR = 2.01, 95%CI: 1.45-2.79, p < 0.001) were risk factors for severe HFMD. First consulting to a district-level or above hospital (OR = 0.34, 95%CI: 0.25-0.45, p < 0.001) and diagnosis of HFMD at baseline (OR = 0.17, 95%CI: 0.13-0.24, p < 0.001) were protective factors against severe HFMD. Fever, long fever duration, vomiting, lethargy, leukocytosis, tic, and convulsions were each associated with severe HFMD (all p < 0.05), while rash was not. Conclusions: EV71, lifestyle habits, frequent hospital visits, and symptoms are risk factors for severe HFMD in children in China, while early diagnosis and admission to higher-level hospitals are protective factors.

Epidemiological characteristics of hand, foot, and mouth disease in China: A meta-analysis

BACKGROUND

To study the epidemic features of hand-foot-mouth disease (HFMD) in mainland China through systematic review and meta-analysis so as to provide evidence for the future prevention and control of HFMD.

METHODS

Articles on the epidemic features of HFMD in mainland China, written in English or Chinese and released between January 1, 2015 and January 1, 2020, were searched from English literature databases including Embase, Web of Science, PubMed, Cochrane library, Google academic, and Chinese literature databases including China national knowledge infrastructure (CNKI), Wanfang, and China Biology Medicine (CBM). Papers were selected according to the inclusion and exclusion criteria, and quality scoring was performed. Meta-analysis, sensitivity analysis, and identification of publication bias were finished through STATA version 12.0 software.

RESULTS

A total of 23 articles were included in this study, the total number of cases was 377,083, of which the total number of male cases was 231,798 and the total number of female cases was 145,285, the sex ratio was about 1.6:1, and the incidence of HFMD in China was 1.61‰ (95% confidence interval [CI]: 1.21‰-1.94‰). The results of the subgroup analysis showed that the incidence of HFMD in mainland China was the highest in South China, in 2014, in 1-year-old group and in other types of enteroviruses, respectively, with the rate of 3.48‰ (95% CI: 1.22‰-5.73‰), 1.81‰ (95% CI: 1.06‰-2.57‰), 15.20‰ (95% CI: 5.00‰-25.30‰), and 1.83‰ (95% CI: 1.32‰-2.33‰), respectively. The differences among the above 4 subgroups were statistically significant (P < .05). There were no publication bias in this study, and the sensitivity analysis results suggested that the meta-analysis results were robust.

CONCLUSION

There were differences in the distribution of region, time, population, and etiology of HFMD in mainland China. Health departments should adopt key strategies and measures for key populations in key areas to prevent and control the development of HFMD, and improve the ability of pathogen detection and typing in laboratories.

The use of respiratory pathogen panel nasal polymerase chain reaction testing in predicting cutaneous enteroviral infections in the pediatric population

BACKGROUND/OBJECTIVE

To characterize the relationship between the presence of enteroviral skin infection, defined as a positive skin polymerase chain reaction (PCR) test, and the nasopharyngeal (NP) respiratory pathogen panel (RPP) PCR test which includes enterovirus/rhinovirus as an analyte.

METHODS

A retrospective chart review was performed on 543 subjects, age 18 years or younger, who had enterovirus (EV) skin swabs performed at an academic medical center in New York City between September 2014 and November 2019. Those patients with positive EV skin PCR were considered to have an enteroviral skin infection, and those with a negative EV skin PCR were considered not to have an enteroviral skin infection. Of those 543 children who had EV skin PCR, 170 also had an NP swab RPP performed. These NP swab RPP results were characterized as positive or negative, and if positive, it was noted if the patient was positive or negative for enterovirus/rhinovirus. The positive predictive value (PPV), negative predictive value (NPV), specificity, and sensitivity of a NP swab RPP for enteroviral skin infection were then calculated.

RESULTS

An enterovirus/rhinovirus NP swab RPP had a NPV of 95%, PPV of 43%, sensitivity of 90%, and specificity of 62% for cutaneous enterovirus infection.

CONCLUSION

The enteroviral skin PCR test is an assay that was validated at this institution. In clinically suspicious cases of EV, a positive NP swab RPP for enterovirus/rhinovirus is a sensitive test. A negative test is highly predictive of not having EV on the skin. Although further data are needed, given that NP swab RPP is readily available, these data may suggest that an NP swab RPP, when appropriately utilized, can support or exclude a clinical diagnosis of cutaneous enterovirus in the pediatric population.

Nonlinear effect of temperature on hand, foot, and mouth disease in Lanzhou, China

To examine the effects of temperature on the daily cases of hand, foot, and mouth disease (HFMD).Data on the daily cases of HFMD in Lanzhou from 2008 to 2015 were obtained, and meteorological data from the same period were collected. A distributed lag nonlinear model was fitted to reveal the relationship between the daily mean temperature and the daily cases of HFMD.From 2008 to 2015, 25,644 cases were reported, of which children under 5 years of age accounted for 78.68% of cases. The highest peak of HFMD cases was usually reported between April to July each year. An inverse V-shaped relationship was observed between daily mean temperature and HFMD cases; a temperature of 18°C was associated with a maximum risk of HFMD. The relative risk (RR) was 1.57 (95% confidence interval: 1.23-1.23), and boys and children aged 3 to 5 years were populations with the highest risk. The cumulative risks of high temperature (20.2°C and 25.2°C) in the total, age-specific, and gender-specific groups peaked on lag 14 days; RR was higher in girls than in boys and in children aged 1 to 2 years than in other age groups. However, the effects of low temperature (-5.3°C, 2.0°C, and 12.8°C) were not significant for both gender-specific and age-specific patients.High temperature may increase the risk of HFMD, and boys and children aged 3 to 5 years were at higher risks on lag 0 day; however, the cumulative risks in girls and children aged 1 to 2 years increased with the increasing number of lag days.

[Effect of vasoactive agents on the prognosis of children in the third stage of hand-foot-mouth disease]

OBJECTIVE

To study the effect of the application timing of vasoactive agents on the prognosis of children in the third stage of hand-foot-mouth disease (HFMD).

METHODS

A retrospective analysis was performed on the medical data of children in the third stage of HFMD between April 2012 and September 2016. According to the application time of vasoactive agents (milrinone combined with phentolamine) after admission, the children were divided into an early stage (within 2 hours after admission) group with 32 children, a middle stage (within 2-6 hours after admission) group with 28 children, and a late stage (more than 6 hours after admission) group with 26 children. Venous blood samples were collected before vasoactive agent treatment and after 24 hours of vasoactive agent treatment to measure the levels of creatine kinase-MB (CK-MB), troponin (TnI), and brain natriuretic peptide (BNP). The recovery time of left ventricular ejection fraction (LVEF), respiratory rate, blood pressure, and heart rate were recorded. The response rate to the treatment within 72 hours of treatment was evaluated.

RESULTS

The early stage group had a significantly higher overall response rate to the treatment than the middle stage and late stage groups (P<0.0167). After 24 hours of treatment, there were significant differences in heart rate, blood pressure, respiratory rate, and LVEF among the three groups (P<0.05). The early stage group showed the most significant improvement in these parameters (P<0.0167). Compared with the middle stage and late stage groups, the early stage group had significantly shorter recovery time of LVEF, respiratory rate, heart rate, and blood pressure (P<0.0167). After 24 hours of treatment, the early stage group had a significantly lower level of BNP than the middle stage and late stage groups (P<0.05).

CONCLUSIONS

Vasoactive agents should be given to children with critical HFMD as early as possible to improve cardiovascular function, reduce the risk of disease progression, and improve prognosis.

[Effect of vasoactive agents on the prognosis of children in the third stage of hand-foot-mouth disease]

OBJECTIVE

To study the effect of the application timing of vasoactive agents on the prognosis of children in the third stage of hand-foot-mouth disease (HFMD).

METHODS

A retrospective analysis was performed on the medical data of children in the third stage of HFMD between April 2012 and September 2016. According to the application time of vasoactive agents (milrinone combined with phentolamine) after admission, the children were divided into an early stage (within 2 hours after admission) group with 32 children, a middle stage (within 2-6 hours after admission) group with 28 children, and a late stage (more than 6 hours after admission) group with 26 children. Venous blood samples were collected before vasoactive agent treatment and after 24 hours of vasoactive agent treatment to measure the levels of creatine kinase-MB (CK-MB), troponin (TnI), and brain natriuretic peptide (BNP). The recovery time of left ventricular ejection fraction (LVEF), respiratory rate, blood pressure, and heart rate were recorded. The response rate to the treatment within 72 hours of treatment was evaluated.

RESULTS

The early stage group had a significantly higher overall response rate to the treatment than the middle stage and late stage groups (P<0.0167). After 24 hours of treatment, there were significant differences in heart rate, blood pressure, respiratory rate, and LVEF among the three groups (P<0.05). The early stage group showed the most significant improvement in these parameters (P<0.0167). Compared with the middle stage and late stage groups, the early stage group had significantly shorter recovery time of LVEF, respiratory rate, heart rate, and blood pressure (P<0.0167). After 24 hours of treatment, the early stage group had a significantly lower level of BNP than the middle stage and late stage groups (P<0.05).

CONCLUSIONS

Vasoactive agents should be given to children with critical HFMD as early as possible to improve cardiovascular function, reduce the risk of disease progression, and improve prognosis.

Salvianolic Acid B Inhibits Hand-Foot-Mouth Disease Enterovirus 71 Replication through Enhancement of AKT Signaling Pathway

Hand, foot, and mouth disease (HFMD) is caused by enterovirus 71 (EV71) in infants and children under six years of age. HFMD is characterized by fever, mouth ulcers, and vesicular rashes on the palms and feet. EV71 also causes severe neurological manifestations, such as brainstem encephalitis and aseptic meningitis. Recently, frequent outbreaks of EV71 have occurred in the Asia-Pacific region, but currently, no effective antiviral drugs have been developed to treat the disease. In this study, we investigated the antiviral effect of salvianolic acid B (SalB) on EV71. SalB is a major component of the Salvia miltiorrhiza root and has been shown to be an effective treatment for subarachnoid hemorrhages and myocardial infarctions. HeLa cells were cultured in 12-well plates and treated with SalB (100 or 10 µg/ml) and 10⁶ PFU/ml of EV71. SalB treatment (100 µg/ml) significantly decreased the cleavage of the eukaryotic eIF4G1 protein and reduced the expression of the EV71 capsid protein VP1. In addition, SalB treatment showed a dramatic decrease in viral infection, measured by immunofluorescence staining. The Akt signaling pathway, a key component of cell survival and proliferation, was significantly increased in EV71-infected HeLa cells treated with 100 µg/ml SalB. RT-PCR results showed that the mRNA for anti-apoptotic protein Bcl-2 and the cell cycle regulator Cyclin-D1 were significantly increased by SalB treatment. These results indicate that SalB activates Akt/PKB signaling and inhibits apoptosis in infected HeLa cells. Taken together, these results suggest that SalB could be used to develop a new therapeutic drug for EV71-induced HFMD.

A review and meta-analysis of the epidemiology and clinical presentation of coxsackievirus A6 causing hand-foot-mouth disease in China and global implications

Coxsackievirus A6 (CV-A6) has been associated with increasingly occurred sporadic hand-foot-mouth disease (HFMD) cases and outbreak events in many countries. In order to understand epidemiological characteristics of CV-A6, we collected the information describing HFMD caused by CV-A6 to describe the detection rate, severe rate and onychomadesis rate, which is defined as one or more nails defluvium, caused by CV-A6 from 2007 to 2017. The results showed that there was an outbreak of CV-A6 every other year, and overall trend of the epidemic of CA6-associated HFMD was increasing in China. The detection rate of CV-A6 in other countries was 32.0% (95% CI: 25.0%~40.0%) before 2013 and 28.0% (95% CI: 20.0%~36.0%) after 2013, respectively. Although the severe rate of HFMD caused by CV-A6 was low (0.10%, 95% CI: 0.01%~0.20%), CV-A6 can cause a high incidence of onychomadesis (28.0%, 95%CI: 21.9%-34.3%). Thus, it would be worthwhile to research and develop an effective multivalent vaccine for CV-A6 to achieve a more powerful prevention of HMFD.

Plant-Produced Anti-Enterovirus 71 (EV71) Monoclonal Antibody Efficiently Protects Mice Against EV71 Infection

Enterovirus 71 (EV71) is the main causative agent of severe hand-foot-mouth disease. EV71 affects countries mainly in the Asia-Pacific region, which makes it unattractive for pharmaceutical companies to develop drugs or vaccine to combat EV71 infection. However, development of these drugs and vaccines is vital to protect younger generations. This study aims to develop a specific monoclonal antibody (mAb) to EV71 using a plant platform, which is a cost-effective and scalable production technology. A previous report showed that D5, a murine anti-EV71 mAb, binds to VP1 protein of EV71, potently neutralizes EV71 in vitro, and effectively protects mice against EV71 infection. Herein, plant-produced chimeric D5 (cD5) mAb, variable regions of murine D5 antibody linked with constant regions of human IgG1, was transiently expressed in Nicotiana benthamiana using geminiviral vectors. The antibody was expressed at high levels within six days of infiltration. Plant-produced cD5 retained its in vitro high-affinity binding and neutralizing activity against EV71. Furthermore, a single dose (10 µg/g body weight) of plant-produced cD5 mAb offered 100% protection against infection in mice after a lethal EV71 challenge. Therefore, our results showed that plant-produced anti-EV71 mAb is an effective, safe, and affordable therapeutic option against EV71 infection.

[Clinical effect of carvedilol in treatment of children with severe hand-foot-mouth disease caused by enterovirus 71 infection]

OBJECTIVE

To study the clinical effect of carvedilol in the treatment of children with severe hand-foot-mouth disease (HFMD) caused by enterovirus 71 (EV71) infection.

METHODS

A retrospective analysis was performed for the clinical data of 86 children with severe HFMD caused by EV71 infection who were admitted to the hospital from April 2016 to August 2017. According to whether carvedilol was used, the children were divided into conventional treatment group with 51 children and carvedilol treatment group with 35 children. A total of 56 healthy children who underwent physical examination at the outpatient service during the same period were enrolled as the control group. The two treatment groups were compared in terms of clinical features and levels of catecholamines (norepinephrine, adrenaline and dopamine), and the levels of catecholamines were compared between these two treatment groups and the control group.

RESULTS

Before treatment, the conventional treatment group and the carvedilol treatment group had significantly higher levels of norepinephrine and adrenaline than the control group (P<0.05). After treatment, both the conventional treatment group and the carvedilol treatment group had significant reductions in norepinephrine, adrenaline, blood glucose, systolic pressure, diastolic pressure, heart rate, body temperature and leukocyte count (P<0.05). Compared with the conventional treatment group, the carvedilol treatment group had significantly lower dopamine level, blood glucose, heart rate and respiratory rate after treatment (P<0.05).

CONCLUSIONS

Changes in norepinephrine and adrenaline might be involved in the pathogenesis of severe HFMD caused by EV71 infection. Carvedilol, in addition to the conventional treatment, can improve respiration, heart rate and blood glucose in children with severe HFMD caused by EV71 infection.

[Clinical effect of carvedilol in treatment of children with severe hand-foot-mouth disease caused by enterovirus 71 infection]

OBJECTIVE

To study the clinical effect of carvedilol in the treatment of children with severe hand-foot-mouth disease (HFMD) caused by enterovirus 71 (EV71) infection.

METHODS

A retrospective analysis was performed for the clinical data of 86 children with severe HFMD caused by EV71 infection who were admitted to the hospital from April 2016 to August 2017. According to whether carvedilol was used, the children were divided into conventional treatment group with 51 children and carvedilol treatment group with 35 children. A total of 56 healthy children who underwent physical examination at the outpatient service during the same period were enrolled as the control group. The two treatment groups were compared in terms of clinical features and levels of catecholamines (norepinephrine, adrenaline and dopamine), and the levels of catecholamines were compared between these two treatment groups and the control group.

RESULTS

Before treatment, the conventional treatment group and the carvedilol treatment group had significantly higher levels of norepinephrine and adrenaline than the control group (P<0.05). After treatment, both the conventional treatment group and the carvedilol treatment group had significant reductions in norepinephrine, adrenaline, blood glucose, systolic pressure, diastolic pressure, heart rate, body temperature and leukocyte count (P<0.05). Compared with the conventional treatment group, the carvedilol treatment group had significantly lower dopamine level, blood glucose, heart rate and respiratory rate after treatment (P<0.05).

CONCLUSIONS

Changes in norepinephrine and adrenaline might be involved in the pathogenesis of severe HFMD caused by EV71 infection. Carvedilol, in addition to the conventional treatment, can improve respiration, heart rate and blood glucose in children with severe HFMD caused by EV71 infection.

The Mechanism of Onychomadesis (Nail Shedding) and Beau's Lines Following Hand-Foot-Mouth Disease

Background: Nail changes, including onychomadesis (nail shedding) and Beau’s line, following hand-foot-mouth disease (HFMD) are a common emergence at the stage of late complications of HFMD. However, the exact mechanism is still unknown. Therefore, we conducted this study to elucidate the mechanism of nail changes following HFMD. Methods: We collected 11 patients suffering from onychomadesis following HFMD. Nail samples from all of them were collected. Real time reverse transcription polymerase chain reaction (RT-PCR) and sequencing for human enteroviruses (HEV) were performed. Throat swabs for RT-PCR and sequencing for HEV were performed for three cases. Results: RT-PCR demonstrated the presence of Coxackievirus A6 (CVA6) in nail samples from three patients and one with Echovirus. Conclusion: In conclusion, we believe that the major cause of onychomadesis following HFMD is that certain novel viruses, mostly CVA6, are virulent and may damage nail matrix. Direct injury caused by cutaneous lesions of HFMD around nail matrix is a minor cause. There are still other virulent HEV which may result in onychomadesis. In addition, the novel strain of CVA6 also causes atypical clinical presentations, such as adult involvement and delayed-onset palmar and plantar desquamation. Physicians should be familiar with atypical presentations caused by novel viruses to avoid misdiagnosis and even inform patients of the possibility of onychomadesis that may take place weeks later to reassure patients.

Application of a combined model with seasonal autoregressive integrated moving average and support vector regression in forecasting hand-foot-mouth disease incidence in Wuhan, China

Hand-foot-mouth disease (HFMD) is a serious public health problem with increasing cases and substantial financial burden in China, especially in Wuhan city. Hence, there is an urgent need to construct a model to predict the incidence of HFMD that could make the prevention and control of this disease more effective.The incidence data of HFMD of Wuhan city from January 2009 to December 2016 were used to fit a combined model with seasonal autoregressive integrated moving average (SARIMA) model and support vector regression (SVR) model. Then, the SARIMA-SVR hybrid model was constructed. Subsequently, the fitted SARIMA-SVR hybrid model was applied to obtain the fitted HFMD incidence from 2009 to 2016. Finally, the fitted SARIMA-SVR hybrid model was used to forecast the incidence of HFMD of the year 2017. To assess the validity of the model, the mean square error (MSE) and mean absolute percentage error (MAPE) between the actual values and predicted values of HFMD incidence (2017) were calculated.From 2009 to 2017, a total of 107636 HFMD cases were reported in Wuhan City, Hubei Province, and the male-to-female ratio is 1.60:1. The age group of 0 to 5 years old accounts for 95.06% of all reported cases and scattered children made up the large proportion (accounted for 56.65%). There were 2 epidemic peaks, from April to July and September to December, respectively, with an emphasis on the former. High-prevalence areas mainly emerge in Dongxihu District, Jiangxia District, and Hongshan District. SARIMA (1,0,1)(0,0,2)[12] is the optimal model given with a minimum Akaike information criterion (AIC) (700.71), then SVR model was constructed by using the optimum parameter (C = 100000, =0.00001, =0.01). The forecasted incidences of single SARIMA model and SARIMA-SVR hybrid model from January to December 2017 match the actual data well. The single SARIMA model shows poor performance with large MSE and MAPE values in comparison to SARIMA-SVR hybrid model.The SARIMA-SVR hybrid model in this study showed that accurate forecasting of the HFMD incidence is possible. It is a potential decision supportive tool for controlling HFMD in Wuhan, China.

Characterization of Critical Functions of Long Non-Coding RNAs and mRNAs in Rhabdomyosarcoma Cells and Mouse Skeletal Muscle Infected by Enterovirus 71 Using RNA-Seq

Enterovirus 71 (EV71) is the main pathogen of severe hand-foot-mouth disease (HFMD). Long non-coding RNAs (lncRNAs) are recognized as pivotal factors during the pathogenesis of viral infection. However, the critical functions of lncRNAs in EV71–host interactions have not been characterized. Here, for the first time, we performed global transcriptome analysis of lncRNA and mRNA expression profiles in EV71-infected human rhabdomyosarcoma (RD) cells and skeletal muscle of mice using second-generation sequencing. In our study, a total of 3801 novel lncRNAs were identified. In addition, 23 lncRNAs and 372 mRNAs exhibited remarkable differences in expression levels between infected and uninfected RD cells, while 104 lncRNAs and 2647 mRNAs were differentially expressed in infected skeletal muscle from neonatal mice. Comprehensive bioinformatics analysis included target gene prediction, lncRNA-mRNA co-expression network construction, as well as gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis mainly focused on differentially-expressed genes (DEGs). Our results suggest that lncRNAs may participate in EV71 infection-induced pathogenesis through regulating immune responses, protein binding, cellular component biogenesis and metabolism. The present study provides novel insights into the functions of lncRNAs and the possible pathogenic mechanism following EV71 infection.

Innate Immunity Evasion by Enteroviruses Linked to Epidemic Hand-Foot-Mouth Disease

Enterovirus (EV) infections are a major threat to global public health, and are responsible for mild respiratory illness, hand, foot, and mouth disease (HFMD), acute hemorrhagic conjunctivitis, aseptic meningitis, myocarditis, severe neonatal sepsis-like disease, and acute flaccid paralysis epidemic. Among them, HFMD is a common pediatric infectious disease caused by EVs of the family Picornaviridae including EV-A71, coxsackieviruses (CV)-A2, CV-A6, CV-A10, and CV-A16. Due to lack of vaccines and specific antiviral therapeutics, millions of children still suffer from HFMD. Innate immune system detects foreign invaders by means of a relatively limited number of sensors, such as pattern recognition receptors (PRRs) [e.g., retinoic acid-inducible gene I (RIG-I)-like receptors (RLRs), Toll-like receptors (TLRs), and NOD-like receptors (NLRs)] and even some secreted functional proteins. However, a range of research, highlighted in this review, suggest that EV-associated with HFMD have evolved different strategies to avoid detection by innate immunity via different proteases (e.g., 2A, 3C, 2C, and 3D). Ongoing efforts to better understand virus-host interactions that control innate immunity and then distill how that influences HFMD development promises to have real-world significance. In this review, we address this complex topic in nine sections including multiple proteins associated with PRR and type I interferon (IFN) signaling. Recognizing how EVs linked to HFMD evade host innate immune system, we also describe the interactions between them and, finally, suggest future directions to better inform drug development and public health.

[Effects of L-carnitine on serum levels of brain natriuretic peptide and N-terminal pro-brain natriuretic peptide and cardiac function in children with severe hand-foot-mouth disease]

OBJECTIVE

To observe the effects of L-carnitine treatment on serum levels of brain natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) and cardiac function in children with heart dysfunction and severe hand-foot-mouth disease (HFMD).

METHODS

A total of 120 children with severe HFMD were enrolled and randomly and equally divided into routine treatment group and L-carnitine treatment group. Thirty healthy children served as the control group. HFMD patients were given anti-fever and antiviral treatment as the basic treatment, while the patients in the L-carnitine treatment group were given L-carnitine as an adjuvant treatment to the basic treatment. Treatment outcomes were observed in the two groups. For all the subjects, serum levels of BNP and NT-proBNP and cardiac function parameters including left ventricular ejection fraction (LVEF), fractional shortening (FS), and cardiac index (CI) were measured at different time points before and after treatment.

RESULTS

Before treatment, HFMD patients had significantly higher serum levels of BNP and NT-proBNP and heart rate but significantly lower LVEF, FS, and CI compared with the control group (P<0.05). After treatment, the L-carnitine treatment group had a significantly higher response rate than the routine treatment group (P<0.05). After 3 days of treatment, the serum levels of BNP and NT-proBNP, LVEF, FS, and CI were significantly reduced in the L-carnitine group (P<0.05); the L-carnitine group had significantly lower serum levels of BNP and NT-proBNP, LVEF, FS, and CI than the routine treatment group (P<0.05); there were no significant differences in the serum levels of BNP and NT-proBNP, LVEF, FS, or CI between the L-carnitine treatment and control groups (P>0.05). After 5 days of treatment, there were no significant differences in the serum levels of BNP and NT-proBNP, LVEF, FS, or CI between the L-carnitine treatment and routine treatment groups (P>0.05). Heart rate recovery was significantly slower in the routine treatment group than in the L-carnitine treatment group (P<0.05).

CONCLUSIONS

As an adjuvant therapy for severe HFMD, L-carnitine treatment has satisfactory short-term efficacy in reducing the serum levels of BNP and NT-proBNP and improving cardiac function, thus improving clinical outcomes.

[Effects of L-carnitine on serum levels of brain natriuretic peptide and N-terminal pro-brain natriuretic peptide and cardiac function in children with severe hand-foot-mouth disease]

OBJECTIVE

To observe the effects of L-carnitine treatment on serum levels of brain natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) and cardiac function in children with heart dysfunction and severe hand-foot-mouth disease (HFMD).

METHODS

A total of 120 children with severe HFMD were enrolled and randomly and equally divided into routine treatment group and L-carnitine treatment group. Thirty healthy children served as the control group. HFMD patients were given anti-fever and antiviral treatment as the basic treatment, while the patients in the L-carnitine treatment group were given L-carnitine as an adjuvant treatment to the basic treatment. Treatment outcomes were observed in the two groups. For all the subjects, serum levels of BNP and NT-proBNP and cardiac function parameters including left ventricular ejection fraction (LVEF), fractional shortening (FS), and cardiac index (CI) were measured at different time points before and after treatment.

RESULTS

Before treatment, HFMD patients had significantly higher serum levels of BNP and NT-proBNP and heart rate but significantly lower LVEF, FS, and CI compared with the control group (P<0.05). After treatment, the L-carnitine treatment group had a significantly higher response rate than the routine treatment group (P<0.05). After 3 days of treatment, the serum levels of BNP and NT-proBNP, LVEF, FS, and CI were significantly reduced in the L-carnitine group (P<0.05); the L-carnitine group had significantly lower serum levels of BNP and NT-proBNP, LVEF, FS, and CI than the routine treatment group (P<0.05); there were no significant differences in the serum levels of BNP and NT-proBNP, LVEF, FS, or CI between the L-carnitine treatment and control groups (P>0.05). After 5 days of treatment, there were no significant differences in the serum levels of BNP and NT-proBNP, LVEF, FS, or CI between the L-carnitine treatment and routine treatment groups (P>0.05). Heart rate recovery was significantly slower in the routine treatment group than in the L-carnitine treatment group (P<0.05).

CONCLUSIONS

As an adjuvant therapy for severe HFMD, L-carnitine treatment has satisfactory short-term efficacy in reducing the serum levels of BNP and NT-proBNP and improving cardiac function, thus improving clinical outcomes.

Application of seasonal auto-regressive integrated moving average model in forecasting the incidence of hand-foot-mouth disease in Wuhan, China

Outbreaks of hand-foot-mouth disease (HFMD) have occurred many times and caused serious health burden in China since 2008. Application of modern information technology to prediction and early response can be helpful for efficient HFMD prevention and control. A seasonal auto-regressive integrated moving average (ARIMA) model for time series analysis was designed in this study. Eighty-four-month (from January 2009 to December 2015) retrospective data obtained from the Chinese Information System for Disease Prevention and Control were subjected to ARIMA modeling. The coefficient of determination (R ²), normalized Bayesian Information Criterion (BIC) and Q-test P value were used to evaluate the goodness-of-fit of constructed models. Subsequently, the best-fitted ARIMA model was applied to predict the expected incidence of HFMD from January 2016 to December 2016. The best-fitted seasonal ARIMA model was identified as (1,0,1)(0,1,1)₁₂, with the largest coefficient of determination (R ²=0.743) and lowest normalized BIC (BIC=3.645) value. The residuals of the model also showed non-significant autocorrelations (P _{Box-Ljung (Q)}=0.299). The predictions by the optimum ARIMA model adequately captured the pattern in the data and exhibited two peaks of activity over the forecast interval, including a major peak during April to June, and again a light peak for September to November. The ARIMA model proposed in this study can forecast HFMD incidence trend effectively, which could provide useful support for future HFMD prevention and control in the study area. Besides, further observations should be added continually into the modeling data set, and parameters of the models should be adjusted accordingly.

[Real world analysis to explore Xiyanping injection combined with other drugs for hand-foot-mouth disease]

Integrated network analysis was used in this paper to analyze Xiyanping injection combined therapy for hand-foot-mouth disease based on the registered research data of 3 204 cases. It was found that the drug combination therapy was almost consistent with the guidelines for the diagnosis and treatment of hand foot mouth disease, but there were some problems to be noticed: there were too many applications of antibiotics, more than the need in preventing secondary infection; and ribavirin was not necessary for use. This article showed that the clinical antibacterial and antiviral values of Xiyanping injection has not been well recognized for hand-foot-mouth disease.

Spatial Clustering of Severe Hand-Foot-Mouth Disease Cases on Hainan Island, China

The incidence of severe hand-foot-mouth disease (HFMD) in Southeast and East Asia has increased in recent years. This study explored spatial clusters of the incidence and proportion of severe HFMD cases on Hainan Island, where the prevalence and mortality of HFMD were the highest in China during 2011. A spatial autocorrelation statistic (Anselin's Local Moran I) was calculated for the Empirical Bayesian (EB)-smoothed dataset of severe HFMD cases. Significant spatial clusters were detected for both the incidence and proportion of severe HFMD cases. Population density was higher in spatial clusters with a high proportion of severe HFMD cases among total HFMD cases. We speculate that a higher proportion of severe HFMD cases were diagnosed in densely populated townships. This should be considered when analyzing the HFMD database of Hainan Island.

Placental Massive Perivillous Fibrinoid Deposition Associated with Coxsackievirus A16-Report of a Case, and Review of the Literature

Massive placental perivillous fibrinoid deposition in the placenta is thought to be an immune-related condition associated with poor perinatal outcomes, including growth restriction and intrauterine fetal demise, with a high risk of recurrence. Rare cases have been associated with Coxsackievirus infection. We present such a case and review the literature.

Epidemiological and genetic analysis concerning the non-enterovirus 71 and non-coxsackievirus A16 causative agents related to hand, foot and mouth disease in Anyang city, Henan Province, China, from 2011 to 2015

Enterovirus 71 (EV-A71) and coxsackievirus A16 (CV-A16) are major pathogens of hand, foot, and mouth disease (HFMD) and have been associated with consecutive outbreaks of HFMD in China over the past years. Although several other human enteroviruses (HEVs) have also acted as causative agents of HFMD, published information on their roles in the prevalence of HFMD is limited. This study was conducted to reveal the characteristics of the pathogenic spectrum and molecular epidemiology of the non-EV-71 and -CV-A16 HEVs in Anyang City, which is located in north-central China and has a population of five million. From 2011 to 2015, 2270 samples were collected from HFMD patients (3.89 ± 1.06 years of age), and 1863 HEV-positive samples, including 524 samples with 23 non-EV-71 and non-CV-A16 serotypes, were identified. Based on the nucleotide sequence of the VP1 gene, 6 common non-EV-71 and non-CV-A16 HEVs, including coxsackievirus A2, A6, A10, A14, B2, and B5, were studied to determine their phylogenies and selective pressures. Phylogenetic analyses revealed a high level of genetic divergence and a pattern of lineage replacement over time in Mainland China. Selective pressure analyses showed that purifying selection was predominant in the evolution of the VP1 gene, whereas positive selection acted on individual codons. Overall, non-EV-71 and non-CV-A16 HEVs were important constituents of the pathogenic spectrum of HFMD in Anyang City during 2011-2015. Some of these HEVs with complex and active phylogenies represent a potential threat to public health, suggesting that long-term monitoring of these pathogens should be implemented to prevent HFMD outbreaks.

Enterovirus 71 Neutralizing Antibodies Seroepidemiological Research among Children in Guangzhou, China between 2014 and 2015: A Cross-Sectional Study

A hand-foot-mouth disease outbreak occurred in 2014 around Guangdong. The purpose of this study was investigating the status and susceptibility of infectious neutralizing antibodies to enterovirus 71 among children so as to provide scientific evidence for the population immunity level of hand-foot-mouth disease and prepare for enterovirus 71 vaccination implementation. Serum specimens were collected from children in communities from January 2014 to March 2015 in Guangzhou. A total of 197 serum samples from children 1–5 years old were collected for this cross-sectional study via non-probabilistic sampling from the database of Chinese National Science and Technique Major Project. Neutralization activity was measured via micro neutralization test in vitro. The positive rate of enterovirus 71 neutralizing antibodies was 59.4%, whereas the geometric mean titre was 1:12.7. A statistically significant difference in true positive rates was found between different age groups but not between different genders. Being the most susceptible population of hand–foot–mouth disease, children under 3 years of age are more likely to be infected with enterovirus 71, and the immunity of children increases with increasing age. Further cohort studies should be conducted, and measures for prevention and vaccination should be taken.

Short-term impacts of floods on enteric infectious disease in Qingdao, China, 2005-2011

The current study aimed to examine the relationship between floods and the three enteric infectious diseases, namely bacillary dysentery (BD), hand-foot-mouth disease (HFMD) and other infectious diarrhoea (OID) in Qingdao, China. Relative risks (RRs) and 95% confidence intervals (CIs) of floods on BD, HFMD and OID were calculated using a quasi-Poisson generalized linear model, adjusting for daily average temperature, daily average relative humidity, and seasonal and long-term temporal trends. Two separate models within two different periods were designed. Model 1 for the summer period showed that floods were positively associated with BD for 4- to 12-day lags, with the greatest effects for 7-day (RR 1·41, 95% CI 1·22-1·62) and 11-day (RR 1·42, 95% CI 1·22-1·64) lags. Similar findings were found in model 2 for the whole study period for 5- to 12-day lags. However, HFMD and OID were not significantly associated with floods in both models. Results from this study will provide insight into the health risks associated with floods and may help inform public health precautionary measures for such disasters.

The Current Status of the Disease Caused by Enterovirus 71 Infections: Epidemiology, Pathogenesis, Molecular Epidemiology, and Vaccine Development

Enterovirus 71 (EV71) infections have a major public health impact in the Asia-Pacific region. We reviewed the epidemiology, pathogenesis, and molecular epidemiology of EV71 infection as well as EV71 vaccine development. Previous studies were found using the search terms “enterovirus 71” and “epidemiology” or “pathogenesis” or “molecular epidemiology” or “vaccine” in Medline and PubMed. Articles that were not published in the English language, manuscripts without an abstract, and opinion articles were excluded from the review. The reported epidemiology of cases caused by EV71 infection varied from country to country; seasonal variations in incidence were observed. Most cases of EV71 infection that resulted in hospitalization for complications occurred in children less than five years old. The brainstem was the most likely major target of EV71 infection. The emergence of the EV71 epidemic in the Asia-Pacific region has been associated with the circulation of different genetic lineages (genotypes B3, B4, C1, C2, and C4) that appear to be undergoing rapid evolutionary changes. The relationship between the gene structure of the EV71 virus and the factors that ensure its survival, circulation, and evasion of immunity is still unknown. EV71 infection has emerged as an important global public health problem. Vaccine development, including the development of inactivated whole-virus live attenuated, subviral particles, and DNA vaccines, has been progressing.

Epidemiological features and spatio-temporal clusters of hand-foot-mouth disease at town level in Fuyang, Anhui Province, China (2008-2013)

Hand-foot-mouth disease (HFMD) is a frequently occurring epidemic and has been an important cause of childhood mortality in China. Given the disease's significant impact nationwide, the epidemiological characteristics and spatio-temporal clusters in Fuyang from 2008 to 2013 were analysed in this study. The disease exhibits strong seasonality with a rising incidence. Of the reported HFMD cases, 63·7% were male and 95·2% were preschool children living at home. The onset of HFMD is age-dependent and exhibits a 12-month periodicity, with 12-, 24- and 36-month-old children being the most frequently affected groups. Across the first 60 months of life, children born in April [relative risk (RR) 8·18], May (RR 9·79) and June (RR 8·21) exhibited an elevated infection risk of HFMD relative to January-born children; the relative risk compared with the reference (January-born) group was highest for children aged 24 months born in May (RR 34·85). Of laboratory-confirmed cases, enterovirus 71 (EV71), coxsackie A16 (Cox A16) and other enteroviruses accounted for 60·1%, 7·1% and 32·8%, respectively. Spatio-temporal analysis identified one most likely cluster and several secondary clusters each year. The centre of the most likely cluster was found in different regions in Fuyang. Implications of our findings for current and future public health interventions are discussed.

Comprehensive safety assessment of a human inactivated diploid enterovirus 71 vaccine based on a phase III clinical trial

Human enterovirus 71 (EV71) is a causative agent of hand, foot, and mouth disease (HFMD). In a previous phase III trial in children, a human diploid cell-based inactivated EV71 vaccine elicited EV71 specific immune responses and protection against EV71 associated HFMD. This study aimed to assess the factors influencing the severity of adverse events observed in this previous trial. This was a randomized, double-blinded, placebo-controlled, phase III clinical trial of a human diploid vaccine carried out in 12,000 children in Guangxi Zhuang Autonomous Region, China (ClinicalTrials.gov: NCT01569581). Solicited events were recorded for 7 days and unsolicited events were reported for 28 days after each injection. Age trend analysis of adverse reaction was conducted in each treatment group. Multiple logistic regression models were built to identify factors influencing the severity of adverse reactions. Fewer solicited adverse reactions were observed in older participants within the first 7 days after vaccination (P < 0.0001), except local pain and pruritus. More severe adverse reactions were observed after the initial injection than after the booster injection. Serious cold or respiratory tract infections (RTI) were observed more often in children aged 6-36 months than in older children. Only the severity of local swelling was associated with body mass index. Children with throat discomfort before injection had a higher risk of serious cold or RTI. These results indicated that the human diploid cell-based vaccine achieved a satisfactory safety profile.

Coxsackie Virus A16 Infection of Placenta with Massive Perivillous Fibrin Deposition Leading to Intrauterine Fetal Demise at 36 Weeks Gestation

Massive perivillous fibrin deposition (MPFD) is an uncommon placental disorder, associated with significant fetal morbidity, mortality, and recurrence; its etiology is unknown. We describe a 31-year-old mother, diagnosed with Coxsackievirus infection and hand-foot-and-mouth disease at 35 weeks gestation. Ultrasound at 35 weeks revealed a normal fetus and placenta. One week later, the mother experienced decreased fetal movement and ultrasound demonstrated intrauterine demise. The autopsy showed mild, acute pericarditis and hypoxic-ischemic encephalopathy. Placenta examination showed MPFD involving 80% of the parenchyma. Molecular viral analysis and serotyping showed Coxsackie A16 virus. The mother had an uneventful pregnancy 15 months later. Coxsackievirus infections in pregnant mothers are often asymptomatic. Transplacental Coxsackievirus infection is very rare but is associated with spontaneous abortion, intrauterine demise, or serious neonatal morbidity. Mild, nonspecific histologic changes have been reported in the placenta. To our knowledge, this is the first report of MPFD associated with Coxsackievirus infection.

Risk Factors for Severe Hand-Foot-Mouth Disease in Children in Hainan, China, 2011-2012

The incidence of severe/fatal cases of hand-foot-mouth disease (HFMD) has increased in South Asia. In China, Hainan Province had the highest incidence of mortality associated with HFMD in 2011. This study investigated the risk factors for severe HFMD in Hainan. The HFMD survey database for Hainan Province for 2011 and 2012 was analyzed, and the biological and behavioral characteristics of severe (n = 980) and nonsevere (n = 1679) HFMD were compared. The association between each explanatory variable and the severity of HFMD was investigated using a logistic regression model after adjusting for confounders. Human enterovirus 71 infection, a peak body temperature >39°C, living outside urban areas, visiting a village clinic, low birth weight, never breastfed, cared for by grandparents, and caregiver with <6 years of education were associated with severe HFMD. Individual characteristics that are generally shared by children in households of low socioeconomic status tended to increase the risk of severe HFMD.

Epidemiological and etiological characteristics of hand, foot, and mouth disease in Wuhan, China from 2012 to 2013: outbreaks of coxsackieviruses A10

Hand-foot-mouth disease (HFMD) is a common infectious disease which often occurs in young children. It is caused by enteroviruses, most commonly enterovirus71 (EV71) and Coxsackievirus A16 (CVA16). The present study focuses on the molecular epidemiology of the pathogen of HFMD in the Wuhan region of China during the period 2012 to 2013. A total of 463 viruses were isolated from throat swab of 3,208 HFMD patients and analyzed by quantitative RT-PCR with all sets of specific primers for EV71, CVA16, and pan-enterovirus. Of the 463 viruses, 111 (21.2%) were EV71, 52 (9.6%) were CVA16, and 300 (69.2%) were pan-enterovirus. In pan-enterovirus isolations 190 (52.8%) were CVA10, 50 (13.9%) were CVA4, 30 were CB2, 17 were CB3, 13 were CB5 identified by VP4 gene sequencing. Eleven EV71 isolates were complete genome sequenced and phylogenetic analysis revealed that the EV71 strains that circulated in Wuhan belonged to the C4 subgenotype. Among the 190 CVA10 isolations, 187 CVA10 strains have the same nucleotide sequence, the other three CVA10 strains belongs to another type of nucleotide sequence. Phylogenetic analysis based on 19 CVA10 isolations suggested that they belonged to the clade of Chinese strains, but form different clusters isolated from Japan, Europe. This study showed that EVA71 and CVA16 were detected as the predominant viruses (>60%) in 2012 and the total reported HFMD cases attained a peak in June and July. In contrast, CVA10 was also detected during April 2012 and replaced EVA71 and CVA16 as the major HFMD-associated pathogen from May 2013.

Emerging and reemerging enterovirus diseases: From poliomyelitis to hand, foot and mouth disease

Several picornaviruses (Picornaviridae) are currently attracting interest without the need of being "emergent". The Parechovirus genus, validated 40 years after the discovery of the first two members ("echoviruses 22 and 23") includes neurotropic viruses whose molecular diagnosis demonstrated the involvement in infant meningitis and newborn sepsis, in particular type 3. Improvements in multiplex molecular diagnosis of respiratory infections - thanks to the Influenza AH1N1pdm2009 pandemy - showed that rhinoviruses may be involved in severe forms. The risk of the re-emergence of poliomyelitis in Europe, after an 11-year period of elimination, is a serious threat, owing to the circulation of the wild-type poliovirus in the Middle East and Africa because of conflicts, population displacements and poverty. The current widespread epidemics of hand-foot-mouth disease and/or meningitis infections due to enterovirus 71, with fatal encephalitis and cardio-pulmonary failure, are clear evidence of its emergence in South-East Asia. Although uncommon in Europe and less frequently incriminated than coxsackieviruses A6 and A10 in hand-foot-mouth disease, EV71 represents a real risk for the future. Extensive genotyping of the enteroviruses by the Enterovirus Surveillance Network should ward off these two potential risks of emergence/reemergence.

Clinicopathologic analysis of coxsackievirus a6 new variant induced widespread mucocutaneous bullous reactions mimicking severe cutaneous adverse reactions

BACKGROUND

The cutaneous manifestations of human enterovirus (HEV) infection are usually limited, such as hand-foot-mouth disease. By comparison, Stevens-Johnson syndrome (SJS) is a life-threatening severe cutaneous adverse reaction (SCAR), mainly caused by drugs. During the HEV outbreaks in 2010-2012 in Taiwan, we identified 21 patients who developed widespread blistering mucocutaneous reactions without any suspected drug causality.

METHODS

We screened possible pathogen(s) for detecting human herpes virus (HHV1-HHV7), HEV, or Mycoplasma pneumoniae infections using throat swab virus cultures, real-time PCR, DNA sequencing, immunochemistry and electron microscopy analyses.

RESULTS

Coxsackievirus A6 (CVA6) DNA was identified in the blistering skin lesions in 6 of 21 patients. Cytotoxic T lymphocytes and natural killer cells expressing granulysin predominantly infiltrated into the skin lesions, sharing the histopathological features with SJS. Intact CVA6 viral particles were identified in the blister fluids and skin lesions by electron microscopy. The phylogenetic analysis of the viral genome showed the CVA6 DNA sequence sharing higher similarity (97.6%-98.1%) to CVA6 strains reported from Finland at 2008.

CONCLUSIONS

This study identifies a new variant of CVA6 as the causative agent for severe mucocutaneous blistering reactions mimicking SCAR. An awareness of this unusual presentation of HEV infection is needed in the epidemic area.

Co-detection in the pathogenesis of severe hand-foot-mouth disease

It still needs to be elucidated whether co-detection of EV71 with other intestinal tract viruses plays a role in the pathogenesis of severe hand-foot-mouth disease (HFMD). A total of 680 stool specimens collected from clinically diagnosed mild and severe-HFMD patients were tested for EV71, CA16, norovirus, bocavirus and rotavirus. The results showed that EV71 was significantly associated with severe-HFMD patients. Co-detection of EV71 with norovirus and rotavirus was also significantly associated with severe-HFMD patients: The OR (95 % CI) value was 6.466 (2.735, 15.283) and 7.561 (3.560, 16.057), p < 0.001, respectively. Co-detection of EV71 with rotavirus or norovirus is probably associated with severe HFMD.