Hand, Foot, and Mouth Disease with Aseptic Meningitis

A 13-month-old boy, previously well, developmentally normal child, was brought to the emergency room (ER) with a history of fever for 2 days and a generalized tonic-clonic seizure 30 min ago. There was no history of respiratory/gastrointestinal symptoms. He had been fully immunized, there was no family history of seizures, and the child was in daycare for 8 h/day. By the time he reached the ER, he had stopped convulsing and was crying but consolable. A general physical examination revealed a well-nourished child. His body temperature was 104.4 °F, with proportionate tachycardia and tachypnea without respiratory distress, a flat anterior fontanelle, no rashes or flushing, and a normal capillary refill time. Meningeal signs could not be elicited as he was crying. There were no rashes, and systemic examination was normal. He was hospitalized for evaluation. The laboratory findings revealed normal hemoglobin and platelet count, a white blood cell (WBC) count of 7200/cu mm, with 66% polymorphs, a procalcitonin (PCT) level of 0.52 ng/dL, and a C-reactive protein level of 1.2 mg/dL. Lumbar puncture was done after fundus examination. The cerebrospinal fluid (CSF) was clear, and the cell count was 137 WBCs/cu mm with 52% lymphocytes suggestive of meningitis. CSF was sent for biochemical analysis and culture. Intravenous (IV) antibiotics were started. The CSF biochemistry was reported as glucose 50 mg/dL with corresponding blood glucose being 92 mg/dL. CSF protein level was 72 mg/dL, and brain magnetic resonance imaging (MRI) was normal. On day 3 of fever, the child was noted to have rashes in the soles and palms which spread to involve the knees and buttocks over the next 2 days. A diagnosis of hand, foot, and mouth disease (HFMD) with aseptic meningitis was made. Antibiotics were stopped when the culture reports came out negative. Painful oral lesions necessitated parenteral fluid administration for 48 h to maintain hydration. The fever subsided on day 5. There were no neurological sequelae. The child was discharged and on review, the lesions had resolved.