A 21 y.o. male presents with a sore throat and a rash on his palms. What does he have?


Our patient had an enterovirus causing hand/foot/mouth disease.  This was cultured from his throat swab.

This a common viral illness of infants and children less than five years of age but can also occur in adults.  Typical symptoms include fever, mouth sores and a skin rash.  It can be accompanied by viral meningitis.  Rare complications include a polio-like paralysis or encephalitis which can be fatal. Coxsackievirus A 16 is the most common cause of hand,foot and mouth disease in the US.

From Aug 2014 to Jan 2015,  1,153 pople had confirmed enterovirus D68 infection.The virus  was thought to be causing a polio-like paralysis in children. The first facility to report enterovirus D68 was Mercy Children’s Hospital in Kansas City , Missouri.  They reported six children on one shift in the ED with severe respiratory symptoms. Several children in various sites across the country developed limb weakness or transverse myelitis prompting a CDC investigation.

A child with hand/foot/mouth disease

A child with hand/foot/mouth disease

The differential for rashes of the hands and feet includes:

1.       Enterovirus- as in our patient usually benign and gone in 7 days

2.       Syphilis- In secondary syphilis the reddish or brownish spots can occur on palms and soles. The lesions of disseminated GC tend to be pustules occurring on the distal extremities. 

3.       Rocky Mountain Spotted Fever- Rash begins as small macules on the wrists, forearms and ankles

On the sixth day petechiae deveop with a rash on the palms and soles in 80% of patients.

4.       Janeway lesions of endocarditis- These are indications of septic emboli

5.       Kawasaki disease-In Kawasaki erythema of palms and soles often occurs first accompanied by pain . Children often refuse to hold objects in their hands.

6.       Measles-This rash start of the face and then progresses to the palms and soles.

7.       Toxic Shock Syndrome- is more likely to desquamate than cause a papular rash

8.       Reactive arthritis- Causes small hard nodules called keratoderma blennorrhagicum usually on the soles.

9.       Meningococcemia- causes a petechial rash in 50-75% of cases. They do not blanch.


Janeway lesions in an IV drug user with endocarditis of the aortic valve.

Janeway lesions in an IV drug user with endocarditis of the aortic valve.


Our patient recovered without incident.


Schwartz, R.  Enteroviruses treatment &Management May 2, 2014 http://emedicine. medscape.com/article217146-treatment

United States. Centers for disease Control and Prevention”Severe Respiratory Illness Associated with Enterovirus D68-Missouri and Illinois, 2014.  MMWR 63:36 Sept 12, 2014. 798-99 http//www.cdc.gov/mmwr/preview/mmwrhtml/mm63e0908a1.htm