2015-03-20

Cocksackied: A Mystery

If you have children in daycare, and you're wondering whether adults can get hand, foot, and mouth disease, let me assure you that the answer is an unequivocal yes.

If you're like most people, however, you probably would never even think to ask the question. For my part, I don't think I had ever heard of hand, foot and mouth disease (HFMD) until my daycare facility provided me with a letter informing me - along with all the other parents - that a child in the facility had been officially diagnosed with HFMD. Naturally, my first reaction was concern for the health of my own child. Little did I know that my second reaction would be a bit more, shall we say, feverish.

* * *

Web searches for "hand foot and mouth disease" produce links that almost put one at ease about the matter. Most articles discuss how to comfort a child who falls victim to HFMD. The Wikipedia article is a case in point. Its simple language paints the picture of a common childhood malady.
Hand, foot and mouth disease (HFMD) is a common human syndrome... HFMD mainly affects infants and children, but can occasionally occur in adults.[3] ... The rash generally goes away on its own in about 1 week, and most cases require no treatment other than symptomatic relief.[7] No antiviral treatment or vaccine is currently available for HFMD, but development efforts are underway.[8] ... Medications are usually not needed as hand, foot and mouth disease is a viral disease that typically gets better on its own. Currently, there is no specific curative treatment for hand, foot and mouth disease.[13] Disease management typically focuses on achieving symptomatic relief. Pain from the sores may be eased with the use of analgesic medications. Infection in older children, adolescents, and adults is typically mild and lasts approximately 1 week, but may occasionally run a longer course. Fever reducers and lukewarm baths can help decrease body temperature.
Et cetera, et cetera, et cetera. My, that almost sounds like a simple cold or flu virus. What are we talking about here? A fever and a rash? Big deal.

* * *

On Monday night, as the evening wound down and we turned on a movie before bed, my body began to ache and my head started swimming. I begrudgingly admitted to myself that there was a small possibility I was coming down with a flu. An hour later, I had the chills and started to worry about having to deal with vomiting and nausea - never a fun prospect for anyone, least of all a type 1 diabetic. And yet, when I woke up the next morning, I didn't have the telltale flu symptoms I expected. There was no runny nose, no nausea, no coughing. I had only a very mild sore throat, and what continued to feel like a fever.

As my head swam, my dear wife took my temperature and confirmed that I was running a fever, but only slightly. My temperature was 100.8 F. Other than this, I felt fine, so I hopped in the car and hurried off to work.

By noon, however, the fever had entered that part of the human mind responsible for things like good decision-making, competent work, critical thinking, and intelligibility. I made an executive decision: I had to go home. I spent the remainder of the day drinking fluids, resting and relaxing, allowing myself the lone mental luxury of an Xbox.

* * *

A deep enough dive into the far corners of Google's search algorithms finally produces some real information on HFMD, such as this Medscape article. It starts out much the same as all the others - HFMD is a daycare disease, mostly affecting infants and toddlers. Again, the author reiterate that the virus is "mild."
Hand-foot-and-mouth disease (HFMD) is more severe in infants and children than adults, but generally, the disease has a mild course. Coxsackie A6 often presents with more generalized involvement, as well as with more severe systemic symptoms.[4]
Of course, thereafter things get interesting:
Enteroviral infections may also cause myocarditis, epididymitis, pneumonia, meningoencephalitis, and even death.[5] MicroRNA profiles and elevated circulating histones have been used to characterize more severe disease.[6, 7]... 
Infection in the first trimester may lead to spontaneous abortion or intrauterine growth retardation. 
A large outbreak of HFMD in Taiwan caused by enterovirus 71 had a high mortality rate of 19.3% in the severe cases; the deaths resulted from pulmonary hemorrhage. During this outbreak, mortality rates were highest in children younger than 3 years.[8] 
In a large epidemic (138 cases) of HFMD related to enterovirus 71 in Singapore, 7 fatalities occurred, most from interstitial pneumonitis or brainstem encephalitis. The report's conclusions were that in general, HFMD is a benign disease but the presence of unusual physical findings, elevated total white blood cell count, and vomiting and the absence of oral ulcers may signify a patient with higher risk of a fatal outcome.[9] Newer reports of large outbreaks of HFMD in China have shown that longer duration of fever, elevated serum C-reactive protein (CRP), and hyperglycemia are risk factors for increased severity of disease.[10] 
A later study of an HFMD epidemic (14 children) in Australia, again with enterovirus 71, reported that 9 (64%) developed severe neurologic disease in which the host immune response seemed to cause most of the neurologic manifestations.[11] 
In one study of an outbreak HFMD in Sarawak, Malaysia caused by human enterovirus 71, the authors identified 3 clinical risk factors to help detect children at risk for neurologic complications. Total duration of fever for 3 or more days, peak temperature elevation greater or equal to 38.5°C, and a history of lethargy all were independently associated with cerebrospinal fluid pleocytosis and neurologic disease.[12] 
In a recent outbreak in the Republic of Korea with enterovirus 71, duration of fever longer than 4 days, peak temperature elevation greater than 39°C, vomiting, headache, neurologic signs, and serum glucose value over 100 mg/dL were all significant risk factors for neurologic complications.[13]
Wait, what was that last thing? Serum glucose value over 100 mg/dL?

* * * 

On Tuesday evening, I went to bed at 9:30 PM, thinking the extra sleep would serve me well. I woke up but an hour later, drenched in sweat. Finally, I thought, my fever has broken. I drank a glass of water, blinked a few times, and looked around. I felt great!

In the interest of good diabetes management, I tested my blood sugar. The number that appeared on the glucometer can only be described as "whopping." That disturbed me a little, especially considering how completely normal I felt physically. But I chalked it up to the breaking of the fever, managed my reading appropriately, and then went back to bed, thinking to myself that this was certainly the strangest flu I'd ever had. I had no symptoms other than a mild fever, which quickly ran its course and left me feeling no worse for wear.

The next morning, at work, I noticed a red and itchy spot on my finger. It looked and felt exactly like eczema, of which I have been a lifetime sufferer. I put some lotion on the affected area and went back to work. As I typed at my keyboard, I noticed a painful spot on my thumb. At first, it was an invisible painful spot, but already my mind had started to connect the dots.

Within two hours, all of the following had happened: The painful spot on my thumb had become a blister, the itchy spot on my hand had become larger and deeper beneath the surface than eczema, but otherwise still felt like eczema, a second blister had appeared - this one on the underside of my tongue - more phantom itchy spots had started to make themselves known on my other hand, and I had done sufficient Googling to admit to myself that I had probably contracted HFMD from my child's daycare provider.

* * *
Leukocyte counts are 4000-16,000/┬ÁL. Occasionally, atypical lymphocytes are present. 
Recent studies show that elevated serum concentration of C-reactive protein (CRP) and fasting and elevated blood glucose were significantly higher in severe cases than in mild ones.[10]
There it is again, elevated blood glucose levels, especially for severe cases of HMFD. Interesting. And yet, there is a bright note in this:
The prognosis for hand-foot-and-mouth disease is excellent; except in large epidemics caused by human enterovirus 71 in which neurologic complications and death have been reported, especially in children.
Once having traveled this far down the medical rabbit hole, however, one cannot resist the urge to try another Google search: "diabetes hand foot and mouth disease."

* * * 

I woke up with a start that night. It was midnight, which is a highly unusual time for me to wake up. My hands were so unbelievably itchy; so much so that I had to get up and read to try to take my mind off the itching or risk scratching all the flesh off my hands and fingers.

I tiptoed into the living room, grabbed my tablet, and set out to Google the ultimate HFMD itch relief strategy. Somewhere in the darkest corners of the parenting message boards, I came across a woman who declared that the one and only relief she was able to discover was putting ice on the affected regions. I decided to give that a try. I pulled an ice pack out of the freezer and pressed it onto the itchiest part of my hand.

Aaaahh! Instant relief. I continued the cold compress until my hands couldn't take anymore. 

The relief lasted long enough for me to get back to sleep, but an hour later the itching had returned. Back to the freezer, back to the ice pack, back to the cold compress, and finally relief again. I held on to the ice pack until my hands burned and ached from the cold, then hurried back to bed to try to fall asleep before the relief subsided again. 

It worked. I slept through the night.

* * *

Deep in the aforesaid rabbit hole, one finds this:
Group B coxsackieviruses tend to infect the heart, pleura, pancreas, and liver, causing pleurodynia, myocarditis, pericarditis, and hepatitis (inflammation of the liver not related to the hepatotropic viruses). Coxsackie B infection of the heart can lead to pericardial effusion. Muffled heart sounds and pulsus paradoxus are signs of this. 
The development of insulin-dependent diabetes (IDDM) has recently been associated with recent enteroviral infection, particularly coxsackievirus B pancreatitis. This relationship is currently being studied further.
Then, on a diabetes parenting blog, one young girl's "Diagnosis Story" begins as follows:
Arden turned two years old on July 22nd 2006. A few weeks later she had her two year well visit with our pediatrician. Everything looked great, she got her immunizations and we went home. The next day Arden seemed sick, she had a slight fever and was lethargic, I assumed that was from the inoculations. When she didn't get better after a few days I took her back to the doctors office. Arden was then diagnosed with Hand, Foot and Mouth disease (HFMD). A common illness for infants and small children. What was strange about the diagnosis was that she already had HFMD previously and it’s supposed to be one of those things you get once and then build a natural defense against, like chicken pox.
It's a throw-away comment. HFMD does not play a role in the rest of the diagnosis story except to set the scene for the fact that Arden's lethargy and frequent urination were "off the radar" for her parents at the time.

Still, it's haunting. There are no sure-fire, known causes of type 1 diabetes. There exists some evidence that it is an auto-immune response. Sometimes it is caused by certain bacterial infections. Sometimes people report a recent history of food poisoning. Some say it pertains to stress. Some say viruses.

The problem with all of these stories is that they are just vague enough to be convincing. Anyone who has type 1 diabetes can think back to the time before they had the disease, and say to themselves, "You know... I do seem to remember getting sick..." or "I think I did have a bout of food poisoning 6 months prior..." or "I guess I could have been under a lot of stress at the time."

Medically compelling enough to be studied, but not compelling enough to be scientifically validated, each new dive into Google produces a new look at the disease. But a truly honest look, accounting for all stories and medical research, reveals that while there is plenty of circumstantial evidence to go around, we still don't know what causes type 1 diabetes.

And, anyway, I've already got it. HFMD isn't count to make me any more insulin-dependent than I already am.

* * *

That evening, I had somehow managed to convince myself that the worst of it was over. The itching was starting to die down, and the rash was no longer raised. The blisters in mouth had finally burst and were starting to heal. Things were looking up.

That night, however, the clock struck midnight and I again awoke with what was perhaps the worst itching to date. An ice pack wasn't going to do it this time around. I grabbed a small plastic basin and filled it with ice and cold water. I'm sure I smiled maniacally as I plunged my hands deep into the cold water, so cold it was literally painful. What did pain matter? Any relief from the itching was a positive change. I grit my teeth and held my hands submerged in the water until I absolutely could not take it anymore. Then I lifted them out, let the water drip off of them a bit, and then plunged them back in.

Again, and again I held my hands in the water until they felt like blocks of ice attached at the wrist. Finally, I felt well enough to get back to sleep, and before long I was indeed dreaming once again.

When I woke up that morning, my hands were covered by new lesions, almost all of which greatly resembled eczema. The itching was unbearable. My feet, too had blisters on them, to the point that walking around the house felt almost like neuropathy - the lesions tingled to the touch, as though my extremities had lost circulation. Or else they simply and unbearably itched

The sores in my mouth, however, had almost healed, as had those on my face and around my mouth. I noticed a couple of odd ones on my knees and my earlobes, too. The itching was really severe, to the point that the closest comparison I could think of was anaphylaxis.

Well, that's cocksackie virus for you. While a common cold or flu virus will infect the upper respiratory tract, cocksackie viruses infect the skin and the mucus membranes. The good news is that this is one virus that doesn't give you a particularly runny nose, a bad cough or all the usual symptoms of having a common virus. The bad news is that all of these symptoms are replaced by a painful, itching, unyielding maelstrom of lesions and blisters on the hands, feet, mouth, tongue, and anywhere else that seems soft and moist. (Yes, anywhere else that seems soft and moist.)

The worst was behind me, or so I guessed, especially considering that this is one cocksackie virus I will never be able to catch again.