Aims Coxsackie virus A6 has been documented as a rare cause of hand, foot and mouth disease and, in cases where the infection is more dramatic in eczematous areas, it has been termed ‘eczema coxsackium’. It can be a challenging diagnosis due to similarity with other common infections and lack of routine testing. We describe a familial trio who presented a diagnostic dilemma, to illustrate the importance of considering enterovirus infection in atypical cases.
Methods The index case was a 28 week old female, with a background of eczema, admitted with a one day history of maculopapular, vesicular rash on forehead and face spreading to her body. Some areas of skin appeared scalded. She was pyrexial. Treatment was initiated for eczema herpeticum with superadded bacterial infection with intravenous antibiotics and aciclovir. Treatment was complicated by swelling due to coalesced blisters. Swabs were negative for bacterial pathogens, herpes simplex virus (HSV) and varicella zoster virus (VZV). Three days after visiting his niece, her 21 year old uncle, with known flexural eczema, developed left antecubital fossa vesicles spreading to face, trunk, and palms with a predilection for eczematous areas. These evolved from vesicular to purpuric with haemorrhagic centres. Skin swabs were negative. He also had intravenous therapy. After visiting the index case, another 21 year old uncle presented to the emergency department with pharyngitis, vesicular stomatitis and oral ulceration. He subsequently developed vesicular eruption of the face, spreading to trunk and extremities, treated as an outpatient with oral aciclovir.
Results The three cases were identified to be related and suffering with similar unusual features. All were negative for routine bacterial and viral swabs. In view of this their swabs were subsequently tested for enterovirus RNA. All were positive for Coxsackie A6. They all made a complete recovery.
Conclusions This diagnosis of eczema cocksackium requires a high index of suspicion as testing for vesicular eruptions is often limited to HSV and VZV; it should be considered where features are atypical and first line investigations are negative. Early identification can avoid unnecessary treatment and potential side effects of intravenous aciclovir.
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