Dermatologic Manifestations of Enteroviral Infections Clinical Presentation

Updated: May 21, 2018
  • Author: Mercè Alsina-Gibert, MD; Chief Editor: Dirk M Elston, MD  more...
  • Print

Physical Examination


The enanthem is characterized by the presence of gray-white small papulovesicles of approximately 1-2 mm in diameter and are most frequently found on the tonsils, uvula, soft palate, and anterior pillars of the tonsillar fauces.

The lesions are surrounded by an erythematous halo, which progresses to a shallow ulcer covered by fibrin.

The lesions are self-limiting, resolving over 5-10 days.

The most important differential diagnosis to be considered is acute herpetic gingivostomatitis. However, acute gingivitis is not present in herpangina. Furthermore, herpetic gingivostomatitis is characterized by longer duration and more severe pain.

Hand-foot-and-mouth disease (HFMD)

Oral lesions begin as erythematous macules and papules that are 2-8 mm in diameter; these progress to form thin-walled vesicles. The vesicles rapidly ulcerate, remaining as shallow painful ulcers surrounded by an erythematous halo. The lesions may be found anywhere in the oral cavity, but they most frequently appear on the hard palate, tongue, buccal mucosa, and gums. The tongue may be erythematous and edematous, and pain may interfere with adequate oral intake. Scalp involvement with papules, crusts, and vesicles may also be present. [38, 39] Lesions heal without treatment over 5-10 days.

Skin lesions are variably present, but they are characteristic when they occur. They appear along with or shortly after the oral lesions, and they vary in number from a few to more than 100. They begin as erythematous macules or papules, which quickly become small (up to 5 mm in diameter), gray, oval or linear vesicles surrounded by a red halo. The hands are more commonly involved than the feet. Lesions usually occur on the lateral aspects of the fingers and toes, especially around the nails, but they may be seen in the digital flexures and on the palms and soles. The lesions gradually disappear over 7-10 days, without scarring.

Atypical HFMD due to Coxsackie A virus (CVA) 16 and 6 has been described in both children and adults. [40, 41] In these cases, maculopapular rashes presenting on the hands, buttocks, or facial areas, with or without vesicles or bullae on any sites of the body, can occur. [36, 42] Oral involvement includes petechiae, strawberry tongue, and enanthem, but in about 40% of cases there are no mucosal lesions. [43]

In some patients, especially infants, a more widespread papular or vesicular exanthem appears principally on the buttocks, although it may occasionally generalize.

In Asia, some epidemics of HFMD have been associated with severe refractory left ventricular failure, cardiogenic shock, CNS disorders, and death. These cases have generally been linked to EV71.

Boston exanthem disease (BED)

After a brief febrile illness, pink macules and papules abruptly erupt on the face, upper trunk, and, less commonly, on the extremities.

Small ulcerations may be seen on the soft palate and tonsils.

Eruptive pseudoangiomatosis (EP)

After the prodromal period, 2-4 mm blanchable, red papules resembling cherry angiomas appear.

The lesions usually number no more than 10, and they resolve spontaneously within a few weeks.

They are distributed on the face, trunk, and extremities.



Enteroviruses can cause severe complications, especially cardiac and neurologic complications. These include the following:

  • Myocarditis
  • Aseptic meningitis: Nonpolio human enteroviruses are the leading recognizable causes of aseptic meningitis, accounting for 80-92% of all cases in which a pathogen is identified. Certain enteroviruses (eg, coxsackie B virus [CVB] 5; echoviruses 6, 9, and 30) are more likely to cause meningitis outbreaks, while others (coxsackie A virus [CVA] 9, CVBs 3 and 4) are the cause of endemic aseptic meningitis. [44]
  • Meningoencephalitis, which can be chronic in immunocompromised patients.
  • Sepsis [45]
  • Hepatitis
  • Disseminated intravascular coagulation
  • Pancreatitis [46]
  • Acute flaccid myelitis linked to enterovirus D68 [47]
  • Debut of type 1 diabetes mellitus reported after enteroviral infection [48]

A case-control study of 553 cases of severe hand-foot-mouth disease (HFMD) identified enterovirus 71 (EV71), convulsion, dyspnea, and vomiting as risk factors for death. [49]

Coxsackievirus infections in pregnancy have been associated in several studies with increased rates of type 1 diabetes mellitus in the offspring. Additionally, maternal CVB infection during pregnancy may increase the rate of cardiac anomalies, [50] while enteroviral infection acquired during the first trimester of pregnancy may result in spontaneous abortion.