2 Hand Foot and Mouth Disease (HFMD) Viral illness Caused by non-poliolo enterovirus: Coxsackies A & B, Echovirus, Enterovirus Manifestation: Fever and vesicular lesions (Hands, Feet, Oral mucosa) Mode of transmission: oral-fecal and respiratory droplet Case fatality rates were usually low (< 1 %)
3 Large Outbreaks of HFMD in Asia Japan ,301/ ? Taiwan ,106/ 78 Malaysia ,999/ 31 Singapore 2000 > 4,000/ 7 Thailand ,646/ 0 Malaysia ,253/ ?
9 Age distribution of reported HFMD cases, Thailand, 2006
10 HFMD Fatal Cases by Date of Onset, Thailand, 2006
11 Location of Fatal HFMD Cases by Chronological Date BKK/June BKK/July Phrae/August Petchabun/October Kumphang/September Khonkhan/August Nakhorn Sawan/November
12 Characteristics of Fatal HFMD Cases ( N=7 ) Median age (months) 11 ( 7-19 ) Age < 12 months 71% Male71% Hospitalized case 100% Median length of illness* (days) 6 (4–20) Attending school/day care 14 % * During from date of onset to dead
15 Laboratory Results Enterovirus isolation: Fatal Case Enterovirus isolation: Fatal Case SpecimenNumber Test Result Stool 2 Viral isolation Negative Nasopharyngeal swab 1 Viral isolation EV71 Tracheal suction 6 Viral isolation Negative
16 Laboratory Results Enterovirus Isolation: Contact tracing Enterovirus Isolation: Contact tracing SpecimenNumber Test Result Stool 2 Viral isolation EV71 Demonstrate evidence of epidemiological linkage
17 Discussion A cause of fatal HFMD reported during the Taiwanese outbreaks was brainstem infection resulting in cardiopulmonary failure And 7 cases of fatal HFMD in Thailand showed evidence of brainstem infection including –Pulmonary edema/hemorrhage –Hyperglycemia –Tachycardia –Leukocytosis
18 Reticular formation involvement autonomic dysfunction Damage of some area of brain stem esp. medullary vasomotor center Sympathetic over-stimulation Excessive release of cathecolamine & cortisol HT,Tachycardia,Sweating Hyperglycemia Pulmonary veins constriction Inc. pulmonary capillary hydrostatic pressure Pulmonary edema Pathogenesis : 12 3
When to think about EV71 infection? 1. Age < 5 years ( < 15 years possible) 2. High grade fever ( > 39 degree celsius) 3. Abrupt onset of fever and dyspnea 4. Rapidly progression until death or coma 5. Evidence of Brainstem Infection 5.1 Pulmonary edema/hemorrhage 5.2 Extreme tachycardia 5.3 Abnormal pattern of EKG 5.4 Hyperglycemia 5.5 Hypertension
6. Evidence of Myocarditis/Pericarditis 6.1 Increased cardiac enzyme 6.2 Extreme tachycardia 6.3 Abnormal pattern of EKG When to think about EV71 infection?