Hand, Foot, and Mouth Disease Caused by Coxsackievirus A6: To The Editor: Coxsackievirus
Hand, Foot, and Mouth Disease Caused by Coxsackievirus A6: To The Editor: Coxsackievirus
Hand, Foot, and Mouth Disease Caused by Coxsackievirus A6: To The Editor: Coxsackievirus
1702 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 18, No. 10, October 2012
LETTERS
Figure. Manifestations of hand, foot, and mouth disease in patients, Boston, Massachusetts, USA, 2012. Discrete superficial crusted
erosions and vesicles symmetrically distributed in the perioral region (A), in the perianal region (B), and on the dorsum of the hands (C).
A color version of this figure is available online (wwwnc.cdc.gov/EID/article/18/10/12-0813-F1.htm).
HFMD in Taiwan in 2010, patients Because of the atypical presentation DOI: http://dx.doi.org/10.3201/eid1810.120813
with CVA6 had perioral lesions in of CVA6-associated HFMD, clinical References
addition to an enanthem (3). vigilance is needed to recognize
Outbreaks of CVA6-associated emerging regional outbreaks. More 1. Nix WA, Oberste MS, Pallansch MA.
HFMD in Finland, Taiwan, and Japan detailed epidemiologic and genetic Sensitive, seminested PCR amplification
of VP1 sequences for direct identification
were associated with onychomadesis, analyses will be required to of all enterovirus serotypes from original
with the loss of nails occurring 1–2 characterize the role of CVA6 in US clinical specimens. J Clin Microbiol.
months after initial symptoms (3,4,6). outbreaks of HFMD. 2006;44:2698–704. http://dx.doi.org/10.
The association between more typical 1128/JCM.00542-06
2. Lo SH, Huang YC, Huang CG, Tsao KC,
HFMD and onychomadesis has Acknowledgments Li WC, Hsieh YC, et al. Clinical and
additionally been described in the We thank Richard Rossi and Renee epidemiologic features of coxsackievirus
United States and Europe but without Roy for clinical sample preparation and A6 infection in children in northern Taiwan
a link to specific serotype or with a between 2004 and 2009. J Microbiol
processing and Kenneth McIntosh for Immunol Infect. 2011;44:252–7. http://
small percentage of CVA6-associated critical review of this manuscript. dx.doi.org/10.1016/j.jmii.2011.01.031
cases (9). Cases from the Boston 3. Wei SH, Huang YP, Liu MC, Tsou TP,
A.A.A. is supported by National
epidemic may fit into an emerging Lin HC, Lin TL, et al. An outbreak
Institutes of Health grant no. 5 K08 of coxsackievirus A6 hand, foot,
clinical phenotype of CVA6, and it
AI093676-02. and mouth disease associated with
will be interesting to see whether nail onychomadesis in Taiwan, 2010. BMC
loss develops in those patients. Infect Dis. 2011;11:346. http://dx.doi.
Kelly Flett,1 Ilan Youngster,1
Given the numerous CVA6 org/10.1186/1471-2334-11-346
Jennifer Huang, 4. Fujimoto T, Iizuka S, Enomoto M,
outbreaks in multiple countries in
Alexander McAdam, Abe K, Yamashita K, Hanaoka N, et al.
2008 and a US population that may be Hand, foot, and mouth disease caused by
Thomas J. Sandora,
relatively naïve to this serotype, CVA6 coxsackievirus A6, Japan, 2011. Emerg
Marcus Rennick,
is likely to spread throughout North Infect Dis. 2012;18:337–9. http://dx.doi.
Sandra Smole, org/10.3201/eid1802.111147
America. Clinicians should be aware
Shannon L. Rogers, 5. Blomqvist S, Klemola P, Kaijalainen S,
that, although standard precautions Paananen A, Simonen ML, Vuorinen T,
W. Allan Nix, M. Steven Oberste,
are routinely recommended for et al. Co-circulation of coxsackieviruses
Stephen Gellis, and Asim A. Ahmed
managing enteroviral infections A6 and A10 in hand, foot and mouth
Author affiliations: Children’s Hospital disease outbreak in Finland. J Clin
in health care settings, contact
Boston, Boston, Massachusetts, USA (K. Virol. 2010;48:49–54. http://dx.doi.
precautions are indicated for children org/10.1016/j.jcv.2010.02.002
Flett, I. Youngster, J. Huang, A. McAdam,
in diapers to control institutional 6. Osterback R, Vuorinen T, Linna M, Susi
T.J. Sandora, S. Gellis, A.A. Ahmed);
outbreaks (10). In addition, the P, Hyypia T, Waris M. Coxsackievirus A6
Boston Public Health Commission, and hand, foot, and mouth disease, Finland.
presence of perioral lesions and
Boston (M. Rennick); Massachusetts Emerg Infect Dis. 2009;15:1485–8. http://
peripheral vesicles on the dorsum dx.doi.org/10.3201/eid1509.090438
Department of Public Health, Jamaica
rather than palmar/plantar surface of
Plain, Massachusetts, USA (S. Smole);
the hands and feet represents a unique
and Centers for Disease Control and
phenotype of HFMD that could be
Prevention, Atlanta, Georgia, USA (S.L.
confused with herpes simplex or 1
These authors contributed equally to this
Rogers, W.A. Nix, M.S. Oberste)
varicella-zoster virus infections. article.
Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 18, No. 10, October 2012 1703
LETTERS
7. Centers for Disease Control and the presence of the parasite in these gorillas (i.e., Democratic Republic
Prevention. Notes from the field: severe regions, the most convincing of of the Congo [3], Uganda [4], and
hand, foot, and mouth disease associated
with coxsackievirus A6—Alabama, which were the steady and consistent Equatorial Guinea [5]). During our
Connecticut, California, and Nevada, numbers of non-African travelers who seroepidemiologic study from the
November 2011–February 2012. MMWR returned to their countries of origin Democratic Republic of the Congo,
Morb Mortal Wkly Rep. 2012;61:213–4. infected with malarial parasites that in which P. vivax sporozoite–specific
8. Wu Y, Yeo A, Phoon MC, Tan EL, Poh CL,
Quak SH, et al. The largest outbreak of were subsequently identified as P. antibodies were detected in ≈10% of
hand; foot and mouth disease in Singapore vivax (2). the population, we found that women
in 2008: the role of enterovirus 71 and More recently, evidence has were significantly more likely than
coxsackievirus A strains. Int J Infect emerged regarding the transmission men to have been exposed to P. vivax
Dis. 2010;14:e1076–81. http://dx.doi.
org/10.1016/j.ijid.2010.07.006 of P. vivax in regions of Africa sporozoites (3). Women in this region
9. Bracho MA, Gonzalez-Candelas F, Valero where the local human population is typically spend more time than men
A, Cordoba J, Salazar A. Enterovirus co- predominantly Duffy negative (3–6). near the forest fringe, where they work
infections and onychomadesis after hand, In 4 (3.5%) of 155 patients from in crop fields. This forest is within the
foot, and mouth disease, Spain, 2008.
Emerg Infect Dis. 2011;17:2223–31. western Kenya (6), 7 (0.8%) of 898 known habitat range of the chimpanzee
http://dx.doi.org/10.3201/eid1712.110395 persons from Angola (4), and 8 (8.2%) Pan troglodytes and the gorilla, Gorilla
10. Siegel JD, Rhinehart E, Jackson M, of 97 persons from Equatorial Guinea gorilla gorilla, both of which have
Chiarello L. 2007 Guideline for isolation (4), P. vivax parasites were detected been reported to be natural hosts of the
precautions: preventing transmission of
infectious agents in health care settings. in the blood of apparently Duffy- malaria parasite P. schwetzi, which is a
Am J Infect Control. 2007;35(Suppl negative persons, suggesting that the P. vivax–like or P. ovale–like parasite
2):S65–164. http://dx.doi.org/10.1016/j. parasite might not be as absolutely that might also be unable to invade
ajic.2007.10.007 dependent on the Duffy receptor for the erythrocytes of persons who are
erythrocyte invasion as previously Duffy negative (8). These animals have
Address for correspondence: Asim A. Ahmed,
thought. These findings are supported recently been shown to be infected
Children’s Hospital Boston–Infectious
by a report from Madagascar (where occasionally with parasites that have
Diseases, 300 Longwood Ave, Boston, MA
the human population is composed mitochondrial genomes closely
02115, USA; email: asim.ahmed@childrens.
of a mixture of Duffy-positive and resembling those of P. vivax (9,10).
harvard.edu
Duffy-negative persons), in which 42 We have argued that, given the
(8.8%) of 476 Duffy-negative persons high malaria transmission rates in sub-
who had symptoms of malaria were Saharan Africa, it is plausible that the
reported to be positive for P. vivax 1%–5% of the human population who
by both microscopy and PCR (7). are Duffy positive might maintain
The prevalence of P. vivax in Duffy- the transmission of the parasite (2).
negative persons was significantly The discovery of P. vivax parasites
Duffy Phenotype lower than its prevalence in Duffy- (or P. vivax–like parasites) in the
and Plasmodium positive persons residing in the same
area, suggesting that Duffy negativity
blood of African great apes leads to
a question: could nonhuman primates
vivax infections in is a barrier to the parasite to some in Africa be acting as Duffy-positive
Humans and Apes, degree. Given the extremely high rates reservoirs of P. vivax in regions
Africa of malaria transmission in western and
central Africa, a P. vivax parasite that
where the human population is almost
entirely insusceptible? This possibility
To the Editor: Benign tertian could efficiently invade Duffy-negative warrants further investigation. Given
malaria, caused by Plasmodium vivax, erythrocytes would, presumably, the increasing rarity of the great
has long been considered absent, or become highly prevalent very rapidly. apes, however, their capacity to act as
at least extremely rare, in western With the exception of the cases zoonotic reservoirs could be limited.
and central Africa. In these regions, reported from Angola and Kenya, It would be informative, in any case,
95%–99% of humans are of the Duffy which lie outside the area where to determine how the regions that P.
negative phenotype, a condition that is the proportion of the population vivax–positive travelers visit during
thought to confer complete protection with Duffy negativity is highest, their stay in Africa correspond with the
against the parasite during the blood the reports of the transmission of P. ranges of chimpanzees and gorillas.
stages of its life cycle (1,2). Sporadic vivax within predominantly Duffy- If African great apes do, indeed,
reports throughout the latter half of the negative populations all come from constitute a zoonotic reservoir of
20th century, however, have hinted at regions inhabited by chimpanzees and P. vivax parasites, what are the
1704 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 18, No. 10, October 2012