Loss of Nails Following Hand Foot and Mouth Disease Infection in 2 Children

I present an unusual case of 2 unrelated children who coincidentally presented to me on the same day with Hand, Foot, and Mouth Disease and then returned 7 and 8 weeks later with the same uncommon complication of this disease.

The first was an otherwise healthy 3 year old boy whose symptoms at presentation were a 2 day history of fever up to 102 degrees, and a vesicular rash on the hands, feet, buttocks and around the mouth.  A diagnosis of hand, foot and mouth disease was made, he and mom were sent home with reassurance.  No further contact was made until he presented 7 weeks later with his mother who was complaining that his nails were peeling off.  He had no other symptoms.  I had no specific explanation for this, so I inquired about any recent systemic illnesses.  She reminded me of the recent HFM infection so I did some quick research - Google Search:  "hand foot mouth disease onycholysis" and I found this article.  It describes 4 cases of onycholysis and/or onychomadesis following HFM infection.

 

 The second case involved a 20 month old girl who had initally presented with 2 day history of temp. up to 99.8 and vesicular rash on hands, feet and groin area.  The diagnosis of hand, foot and mouth disease was made and reassurance was given.  A few days later she returned with worsening of the rash but had no significant feeding problems.  There were no signs of dehydration or fever at that time, but the child now was extensively covered with the vesicular rash over all extremities, trunk and external lips.  No further treatment was recommended at that time and f/u by telephone a few days later revealed that she was finally improving and further follow up for this was planned on an as needed basis.  Our next encounter was just under 8 weeks later for an unrelated minor problem.  As we were finishing the visit, the mom said "All her fingernails and toenails fell off after she had that hand foot and mouth disease".  Indeed, on her exam, all of her fingernails had shed and were growing back with some small irregularities and indentations and the same was true for her toenails except the nail of each great toe which had not completely lost the older portions of the nails.

 

Wikipedia - Onychomadesis





Hand, Foot and Mouth Disease

This is a 6 year old girl who presented with a 3-4 day history of sores on the hands feet and mouth.  The child was otherwise acting well.  She had no fever or really any other symptoms.  The mother stated that the child had been exposed to another child at the school with Hand, Foot and Mouth Disease.  This is probably the most demonstrative case I have seen.  The lower pic is of the lower lip and chin of the child; the upper lip looks the same.  There were no mucosal lesions identified in this case but they are very commonly present.  Treatment is usually supportive.  Here is an entry on HFM disease from Mayo Clinic.

Photo Quiz: A Human Parasite

Here is an easy one for you. This is a picture of a small part of a human parasite I took with a Celestron LCD Digital Microscope.
What is it?

Derm Photo Quiz: An Interesting Rash

This case involves a 67 year old, diabetic man who has taken no medications for the last 4 years except for a daily aspirin. He presented to my clinic for the first time in over four years with a 2 week history of a rash that started on his right arm as seen below. His left arm had a similar appearance.
The rash then spread to the rest of the right arm and all extremities. The rash was initially pruritic but by the time of the visit the itching had resolved. He denied any recent OTC medication use except for the daily aspirin. He denied any new or unusual foods or contacts. He was feeling well. He denied fever, nausea, vomiting, diarrhea, abdominal pain or headache. He denied any recent tick bites or possible exposure to ticks. His trunk showed no lesions but his legs were affected as seen below.



Lab work revealed: glucose 281, creatinine 0.9, sodium 134, total bilirubin 1.50, direct bilirubin 0.30 (both slightly elevated), AST 42, ALT 72, CRP 0.2, WBC 4,800 a with normal differential, platlets 92,000. He was seen by a dermatologist that day, and given a provisional diagnosis. A biopsy was done which confirmed the diagnosis. What was the diagnosis?

Skin Hyperpigmentation after Cryotherapy for Wart Removal

A few years ago I performed cryotherapy on a teenager to remove some warts on his knees and elbows. A several days later I got a call from his mother because of darkening of the skin around the areas that I froze.

There were even some patches near but not connected to the areas that I froze.

This was the first time I had seen this complication, but I explained to the mother that this is something that can happen with cryotherapy. It usually only lasts a few months but can last longer. I am not exactly sure how long it lasted in this case but it wasn't very long. I have seen this young man many times since then and it was never an issue again. I spoke with my fellow blogger Joe about this and he told me to have the patient use sunscreen over the areas (right Joe?) when out it the sun, which I did do. I haven't really been able to find any literature that supports that practice but it is something to try.