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Sunday, October 2, 2011

Hand, Foot and Mouth - A Case Report

Working with sick patients means that one way or another, you're going to get sick yourself. This is one of the risks of the job. It is one that many, myself included, are happy to take. Nobody likes to become ill, me least of all, but in a way, I think it's healthy for a physicians and physicians-in-training to get sick because it helps us understand what a patient goes through and how he feels. It's easy to think yourself immune to the very conditions you're trying to treat. Getting sick is humbling and reminds me that all of us are cut from the same cloth and must confront the same fundamental challenges.Anyway, that's a lot of talk to lead up to what is a minor yet annoying (and kind of interesting) problem.

So here we go... 9/14/11: I was doing my pediatrics endocrinology rotation in the diabetes clinic. Right at lunch time, I started feeling very lightheaded, so much so that I had to sit down for fear of fainting. I got very sweaty all of a sudden and had to mop my brow. I ate my lunch, thinking that maybe I was not nourished enough or I hadn't drunk enough water. No luck. I had to just sit down. The lightheadedness didn't let up all afternoon. I began to feel sleepy as well. I couldn't concentrate. When I came home, I had some dinner and had to just go to sleep.

When I woke up the next day the lightheadedness resolved.

Over the next week, I only experienced the lightheadedness a few more times, and it wasn't intense like before.

Then last Saturday (9/22) I started feeling lightheaded constantly. I didn't have a thermometer, so I don't know if I had a fever or not, but I didn't feel particularly hot. I was getting a bit sweaty. The lightheadedness was resolved by lying down.

These near-fainting spells came on in the morning, and I hypothesized that maybe they were somehow connected to my coffee drinking. I drink quite a bit of coffee, and it's never bothered me before, but perhaps I had reached my limit, I thought.

So starting last Sunday, I cut out of the coffee. I started to feel lightheaded again, constantly, but now I just chalked it up to caffeine withdrawal.

The next day, Monday (9/26) I was to begin my anesthesia rotation. I was having a splitting headache and still feeling lightheaded as I drove into work. It got worse throughout the day. When I came home, I took some aspirin, and that helped with the headache, but the lightheadedness didn't got away. I was feeling very sweaty too. I imagine at this time I was febrile, but I can't be sure.

I didn't have any coughing or congestion. No abdominal pain, nausea, vomiting or diarrhea. I didn't feel achy, but I did feel fatigued.

On Tuesday I woke up with really deep pain in my calves. When I stretched them it, it really hurt. I figured that maybe the calf pain was from being on my feet for so many hours the day before in the OR. This explanation wasn't particularly convincing, however, since I had been on my feet for hours at a time over the last 6 weeks during Pediatrics. But, I just put it aside and got on with my day.

On Wednesday, not only was I feeling lightheaded still, but the pain had extended up to my thighs and pelvis. Now I was beginning to get worried. I went to the Student Health Clinic and saw a doctor there. They did the usual work up. They checked my BP and did a neuro exam. All normal. My pressure was perfectly normal at 120/70. Hypotension is high on the differential whenever someone complains of lightheadedness, but hypotensive I was not. The doc said to go home and come back if my problems persisted.

Fast forward to Friday. The pain in my legs was still there. I'd been 5 days out since giving up coffee and so any withdrawal symptoms like headache or lightheadedness should have subsided. When I got to work, I noticed some small reds vesicular lesions on my palms. I noticed them because I was having slight pain in my hand as I touched things. I noticed that my feet were hurting too. The feeling was like there were little sores on the bottom of my toes. Then I noticed I had some raw spots in my mouth. I went to the bathroom and pulled out my lip in the mirror and I saw little vesicles with white centers and erythematous borders that looked very similar to the ones on my hands.

Hmmm... lesions on my hands, feet and mouth. I got suspicious, and nervous.

So I went to the doctor yesterday morning and he suggested........
Hand Foot and Mouth Disease. (HFMD)


"But isn't that a little kid's disease," I replied. "It does primarily occur in children, but adults can get it too. I think there is something going around because I've seen other cases recently of Hand Foot and Mouth."

The diagnosis seemed reasonable. I thanked the doc for his help. I felt relieved. It's so nice to get some closure. I can deal with sick if I know what the problem is since I can rest assured that it will go away. Constant lightheadedness is a vague symptom with a plethora of causes, some of them quite ominous. You can bet your bottom dollar that for the last week, I've been conjuring up every thing I could think of to explain lightheadedness and headache. Hypotension, vasovagal syndrome, some weird viral illness, maybe some kind of vascular disease causing some ischemia to my head. You name it, I thunk it, no matter how outlandish. The fear of not knowing is the worst.

As I got out of the doctor's office, I quickly looked up HFMD on my iPad. Here is what I found:

Hand-foot-and-mouth disease (HFMD) is a viral illness with a distinct clinical presentation of oral and characteristic distal extremity lesions. Most commonly, the etiologic agents are coxsackieviruses, members of the Picornaviridae family 
A brief prodrome of 12-36 hours duration is part of the usual presentation of hand-foot-and-mouth disease (HFMD), which consists of the following:

  • Low-grade fever with an average temperature of 38.3°C and duration of 2-3 days 
  • Anorexia Malaise 
  • Abdominal pain 
  • Sore mouth 
  • Cough 
In one study, 80% of the children presented with anorexia and mouth soreness. The enanthem usually precedes the exanthem that is asymptomatic, but both may occur simultaneously. The lesions on the hands and feet are present for 5-10 days. The mucosal and cutaneous lesions heal spontaneously in 5-7 days. Hand-foot-and-mouth disease (HFMD) is more severe in infants and children than adults, but generally, the disease has a mild course. 
Symptoms such as malaise, low-grade fever, and anorexia are often present. Occasionally, patients have high fever, marked malaise, diarrhea, and arthralgias. Enteroviral infections may also cause myocarditis, pneumonia, meningoencephalitis, and even death. Infection in the first trimester may lead to spontaneous abortion or intrauterine growth retardation.




This one is my own (sorry for the low quality - it's from my iPad)


Source: eMedicine

So that's what I've got. Nothing life-threatening, but a nuisance nonetheless. My wife woke up feeling fatigued and feverish with some lesions in her mouth, so now I fear I've spread it to her. That makes me feel most bad about all this. Hopefully this mess goes away pretty quickly. I'm not feeling horrible but the lesions are painful and I'm still feeling lightheaded. I also don't want to get anyone else sick.

If nothing else, these past two weeks have helped me reflect on how it feels to have something wrong with you and not know the cause. It makes me more empathetic to the patients who come in in exactly that state of mind. And, I've learned about another disease that I won't miss if it's ever presented to me. I won't just assume it's for little kids.



6 comments:

  1. Wow, I'm glad you got a diagnosis! Are you starting to feel better. Do you get (or have) to take any time off from your rotation to recover? Any meds, or do you just have to wait it out?

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  2. My kids came down sick, the next day I came down with whatever they had gotten. They started to develop a rash on their hands, so did I but not as bad. Took them to the Dr to look at the rash, quick reply fro thre Dr HMF, I asked if adults could get it , reply from Dr on rare occasion or if you lived in a bubble. I showed her my hand and she said yes hmf, you must have lived in a bubble. I have been reading and it seems to be very rare in adults and occurs with adult who have an immune system problem. I dont have any known immune system problems, do you have any issues with your immune system, or is this somethine even a heatlty adult can get? Your thoughts?

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  3. I am 57 and got hfm from my 17 yo son. Neither of us should have gotten it. His got better. I have been ill for over and month and don't seem to be getting much better.

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  5. Thanks a lot collegue, on this interesting article. It is very instructive for other collegues, and at the same time, warning that HFMD is contagious and can be transmitted to adults. It is not an exclusive childhood disease. As an epidemiologist, this days I am facing epidemics in nursery schools. It seems that lot of children, and adults too, have minor illnes or asymptomatic HFMD infection. Sometimes, we can see only complications, without skin lesions...

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