Working Diagnosis:
Hand, Foot and Mouth Disease

Treatment:
Isolation precautions with either the use of gloves, masks, and good hygiene, or with quarantine. Symptomatic treatment of fevers, ulcers, or any other sequelae. Education of coaches, training staff, and medical personal will help with prompt recognition and diagnosis. Work with staff (athletic and custodial) to make sure all needed cleaning of equipment, locker rooms, weight room, and doctor's office is done properly. No sharing of water bottles or towels. Consider individual drink bottles or have trainers directly hydrate players. All sick athletes should be evaluated by the medical staff, even if a viral source is not suspected.

Outcome:
After the two week mark there were no new cases for the rest of the season. There was no serious sequelae of myocarditis, pneumonia, meningoencephalitis, or death. All infected players were able to return to the field without missing any significant time.

Author's Comments:
Our lockers are in alphabetical order, not by side of the ball or position. As you can tell by the diagram, the spread of the virus was most likely from close contact in the locker room. Viral outbreaks are becoming more common and it is up to the team physician to keep the athlete safe. Prompt recognition of the disease and quick implementation of isolation precautions kept the out break contained.

Editor's Comments:
Teaching points:
1. Commonly spread via the fecal-oral, oral-oral route or via respiratory droplet transmission (references # 1 and 3).
2. From the buccal mucosa or the ileum the virus seeds the GI tract. Over the next 72 hours a viremia is established via spread through nearby lymph nodes (reference #2).
3. Need to minimize contact with the patient's oral and respiratory secretions for up to 2 weeks (references #1 and #3).
4. Good compulsive handwashing is important to minimize the spread of disease (reference #3).
5. The virus may be present in the patient's feces for up to 1 month (reference #1).

References:
Suggested references:
1. Abzug MJ. Nonpolio enteroviruses. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 19th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 242.

2. Habif TP. Exanthems and drug eruptions. In: Habif TP, ed. Clinical Dermatology. 5th ed. St. Louis, Mo: Mosby Elsevier; 2009:chap 14.

3.Ruan F, Yang T, Ma H, et al. Risk factors for hand, foot, and mouth disease and herpangina and the preventative effect of hand-washing. Pediatrics 2011;127:e898–904.

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