Guidelines for the diagnosis and treatment of hand, foot and mouth disease

Hand, foot and mouth disease is a disease that mostly occurs in children under five years old and is contagious. Therefore, many parents will pay special attention to it, especially children in kindergarten. They do not know how to be careful when playing and are prone to cross infection, so parents are even more worried. Because many parents do not know the specific symptoms and coping measures of this disease, we need to understand it well.

In fact, the country has already had guidelines for the diagnosis and treatment of hand, foot and mouth disease a few years ago. It introduces the symptoms, cases, treatments, etc. of this disease in great detail. If a child is not as lively as before after returning from kindergarten, and has fever, ulcers on the hands, feet or mouth, then parents must pay great attention to it and take the child to the doctor in time. Let us learn about the diagnosis and treatment guidelines for hand, foot and mouth disease.

Guidelines for the diagnosis and treatment of hand, foot and mouth disease (2008 edition)

Hand, foot and mouth disease is an acute infectious disease caused by enterovirus (most commonly Coxsackie A16 (CoxA16) and enterovirus 71 (EV71)). It often occurs in preschool children, especially in the age group under 3 years old. The main symptoms are maculopapular rashes and herpes on the hands, feet, mouth and other parts of the body. A few severe cases may develop meningitis, encephalitis, encephalomyelitis, pulmonary edema, circulatory disorders, etc., which are mostly caused by EV71 infection. The main cause of death is severe brainstem encephalitis and neurogenic pulmonary edema. Both patients and asymptomatic carriers are sources of infection, and the disease is mainly transmitted through the digestive tract, respiratory tract and close contact.

1. Clinical manifestations

(I) Common symptoms

Acute onset, fever, scattered blisters on the oral mucosa, maculopapular rashes and blisters on the hands, feet and buttocks, with inflammatory red halos around the blisters and less fluid in the blisters. May be accompanied by symptoms such as cough, runny nose, and loss of appetite. Some cases only present as rash or herpangina. The prognosis is good.

(II) Symptoms of severe cases

A small number of cases (especially those under 3 years old) may develop meningitis, encephalitis, encephalomyelitis, pulmonary edema, circulatory disorders, etc. The condition is serious and may cause death or leave sequelae.

1. Nervous system: poor spirit, drowsiness, easy to be frightened; headache, vomiting; limb myoclonus, nystagmus, ataxia, eye movement disorder; weakness or acute flaccid paralysis; convulsions. Physical examination may reveal signs of meningeal irritation and weakened or absent tendon reflexes; critical cases may present with coma, cerebral edema, and brain herniation.

2. Respiratory system: shallow and rapid breathing, difficulty breathing or changes in rhythm, cyanosis of the lips, white, pink or bloody foamy fluid (sputum) in the mouth; moist rales or sputum sounds can be heard in the lungs.

3. Circulatory system: Pale complexion, pale skin, cold limbs, cyanosis of fingers and toes; cold sweat; faster or slower heart rate, shallow or weak pulse or even disappearance; higher or lower blood pressure. 2. Laboratory examination (I) Routine blood test

The white blood cell count is normal in common cases, but may be significantly elevated in severe cases.

(II) Blood biochemical examination

Some cases may have mild elevations in ALT, AST, and CK-MB, while severe cases may have elevated troponin (cTnI) and blood sugar. CRP is generally not elevated.

(III) Cerebrospinal fluid examination

When the nervous system is affected, the following abnormalities may occur: clear appearance, increased pressure, leukocytosis, normal or slightly increased protein, and normal sugar and chloride.

(IV) Etiological examination

Enterovirus (CoxA16, EV71, etc.) specific nucleic acid is positive or enterovirus is isolated. The positive rates of pharyngeal and airway secretions, herpes fluid, and feces are higher. Specimens should be collected in a timely and standardized manner and sent for examination as soon as possible.

(V) Serological examination

Serum neutralizing antibodies to EV71, CoxA16 or other enteroviruses increased more than 4 times between the acute and recovery phases. 3. Physical examination (I) Chest X-ray

It may manifest as increased texture in both lungs, grid-like and patchy shadows, and severe cases may show signs of pulmonary edema and pulmonary hemorrhage, which may be unilateral in some cases.

(ii) Magnetic resonance

Those with nervous system involvement may have abnormal changes, mainly damage to the brainstem and gray matter of the spinal cord.

(III) Electroencephalogram

Some cases may present as diffuse slow waves, and a few may present as spike (point) slow waves.

(IV) Echocardiography

Decreased left ventricular ejection fraction, weakened left ventricular contraction, and mitral or tricuspid valve regurgitation.

(V) Electrocardiogram

No specific changes. Sinus tachycardia or bradycardia, QT interval prolongation, and ST-T changes may be seen. IV. Diagnostic Criteria (I) Clinical diagnosis Cases occur during the epidemic season and are common in preschool children and infants.

1. Common cases: fever accompanied by rash on the hands, feet, mouth, and buttocks; some cases may be without fever.

2. Severe cases: Symptoms include involvement of the nervous system, respiratory and circulatory dysfunction, etc. Laboratory tests may show increased peripheral blood leukocytes, abnormal cerebrospinal fluid, increased blood sugar, and abnormalities in electroencephalogram, brain and spinal magnetic resonance imaging, chest X-ray, and echocardiography.

In very rare severe cases, the rash is atypical, making clinical diagnosis difficult and requiring diagnosis in combination with etiological or serological tests.

If there is no rash, it is not appropriate to diagnose hand, foot and mouth disease clinically.

2. Confirmed cases

Clinical diagnosis cases can be confirmed if one of the following is present.

1. Enterovirus (CoxA16, EV71, etc.) specific nucleic acid test is positive.

2. Isolate the enterovirus and identify it as EV71, CoxA16 or other enterovirus that can cause hand, foot and mouth disease.

3. The neutralizing antibodies against EV71, CoxA16 or other enteroviruses that can cause hand, foot and mouth disease in serum increased by more than 4 times between the acute and recovery phases.

5. Differential Diagnosis

(I) Common cases: need to be differentiated from other childhood eruptive diseases, such as herpetic urticaria, varicella, atypical measles, roseola infantum and rubella. Epidemiological characteristics, rash morphology, location, time of rash onset, and the presence or absence of lymph node enlargement can be used for identification, among which the rash morphology and location are the most important.

(II) Severe cases:

1. Differentiation from other central nervous system infections

(1) The manifestations of central nervous system infections caused by other viruses may be similar to those of severe hand, foot and mouth disease. For those with atypical rashes, specimens should be collected as soon as possible for virological examination of enterovirus, especially EV71, combined with etiological or serological examinations to make a diagnosis. At the same time, diagnosis and treatment should be carried out according to the handling procedures for severe cases of hand, foot and mouth disease.

(2) Patients with flaccid paralysis as the main symptom should be differentiated from poliomyelitis. 2. Differentiation from severe pneumonia Severe hand, foot and mouth disease may cause neurogenic pulmonary edema, which should be differentiated from severe pneumonia. The former has relatively mild cough symptoms and the condition changes rapidly, with shallow and rapid breathing in the early stage and difficulty breathing in the late stage. White, pink or bloody foamy sputum may appear, and chest X-rays show pulmonary edema.

3. Patients with circulatory disorders as the main manifestation should be differentiated from fulminant myocarditis, septic shock, etc.

6. Early identification of severe cases

Patients with the following characteristics, especially those under 3 years old, may develop into critical cases in a short period of time. They should be closely monitored for changes in their condition, undergo necessary auxiliary examinations, and receive targeted treatment.

(1) Persistent high fever.

(ii) Poor spirit, vomiting, limb myoclonus, limb weakness, and convulsions.

(3) Increased breathing and heart rate.

(iv) Cold sweat and poor peripheral circulation.

(V) Hypertension or hypotension.

(VI) The peripheral blood leukocyte count increased significantly.

(VII) Hyperglycemia.

VII. Disposal Process

During the consultation, outpatient physicians should carefully inquire about the medical history, focusing on whether there are similar cases around, as well as the contact history and treatment process; during the physical examination, pay attention to the rash, vital signs, nervous system and lung signs.

(1) Clinically diagnosed cases and confirmed cases shall be reported in accordance with the requirements for Class C infectious diseases in the Law on the Prevention and Control of Infectious Diseases.

(ii) Ordinary cases can be treated on an outpatient basis, and patients and their families should be informed to follow up if their condition changes.

(III) Children under 3 years old with persistent fever, poor spirits, vomiting and a course of illness within 5 days should be kept under observation. During the observation period, closely monitor changes in the patient's condition, especially the functions of important organs such as the heart, lungs, and brain, and provide targeted treatment based on the condition.

If the conditions for hospitalization are met during the observation period, the patient should be hospitalized immediately for treatment. If the condition improves within 48 hours, the patient can be released from observation.

(IV) Those who meet any of the following conditions should be hospitalized for treatment

1. Drowsiness, easy to be startled, irritability, and convulsions.

2. Limb myoclonus, weakness or paralysis.

3. Shallow and difficult breathing.

4. Pale complexion, cold sweat, increased or decreased heart rate (disproportionate to the degree of fever), and poor peripheral circulation.

Those who meet any of the above 3 or 4 conditions should be admitted to the ICU for treatment.

8. Treatment

(I) Common cases

1. General treatment: pay attention to isolation to avoid cross infection. Get adequate rest, eat a light diet, and take good care of your oral and skin.

2. Symptomatic treatment: Fever and other symptoms are treated with a combination of Chinese and Western medicine.

(II) Severe cases

1. Treatment of nervous system involvement (1) Control intracranial hypertension: limit the intake and give mannitol 0.5-1.0 g/kg per time, once every 4-8 hours, 20-30 minutes intravenous injection, and adjust the dosing interval and dosage according to the condition. Add furosemide if necessary. (2) Intravenous immunoglobulin, total amount 2g/kg, given over 2 to 5 days. (3) Glucocorticoids should be used as appropriate. The reference doses are: methylprednisolone 1-2 mg/(kg·d); hydrocortisone 3-5 mg/(kg·d); dexamethasone 0.2-0.5 mg/(kg·d). Once the patient’s condition stabilizes, the dose should be reduced or discontinued as soon as possible. In some cases where the disease progresses rapidly and is severe, the dosage may be increased, such as giving methylprednisolone 10-20 mg/kg·d (the maximum single dose should not exceed 1 g) or dexamethasone 0.5-1.0 mg/(kg·d) within 2-3 days. (4) Other symptomatic treatments: cooling down, calming, and stopping shock. (5) Closely observe changes in the patient's condition and provide close monitoring. 2. Treatment of respiratory and circulatory failure (1) Keep the airway open and administer oxygen. (2) Ensure that both venous channels are open and monitor respiration, heart rate, blood pressure, and blood oxygen saturation. (3) In case of respiratory dysfunction, timely endotracheal intubation and positive pressure mechanical ventilation are recommended. The recommended initial adjustment parameters of the ventilator are: inspired oxygen concentration 80% to 100%, PIP 20 to 30 cmH2O, PEEP 4 to 8 cmH2O, f 20 to 40 times/min, and tidal volume 6 to 8 ml/kg. Adjust the ventilator parameters at any time according to the results of blood gas and chest X-ray. (4) While maintaining stable blood pressure, limit fluid intake (if conditions permit, adjust fluid volume based on central venous pressure measurement). (5) Raise the head and shoulders 15-30 degrees and maintain a neutral position; place a gastric tube and a urinary catheter. (6) Drug application: Milrinone, dopamine, dobutamine and other drugs can be used according to changes in blood pressure and circulation; diuretics can be used as appropriate. (7) Protect the functions of important organs and maintain the stability of the internal environment. (8) Monitor blood sugar changes and use insulin when severe hyperglycemia occurs. (9) Inhibit gastric acid secretion: cimetidine, omeprazole, etc. can be used. (10) Effective antibiotics to prevent and treat secondary bacterial lung infections. 3. Recovery period treatment

(1) Avoid secondary respiratory tract infections.

(2) Promote the recovery of organ functions.

(3) Functional rehabilitation therapy or integrated Chinese and Western medicine treatment.

After understanding the diagnosis and treatment guidelines for hand, foot and mouth disease, everyone should take better care of their children in life, maintain personal hygiene, provide children with more nutrition, and improve their body's resistance. Children with high immunity will not be easily infected by this virus. If unfortunately infected, don't panic, just go to a regular hospital for timely medical treatment.