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enanthem and then shortly thereafter by red macules and papules. The oral lesions
begin as small red macules, most often located on the palate, uvula, and anterior
tonsillar pillar, which evolve into small vesicles that ulcerate and heal over a 1- to
6-day period. The exanthem develops into small crescent or football-shaped
vesicles on an erythematous base ( Fig. 88.14 ). These vesicles, which may be
pruritic or mildly tender, are usually located on the dorsal and lateral aspects of
fingers, hands, and feet but may develop on the buttocks, arms, legs, and face.
The lesions improve over 2 to 7 days.
The other types of coxsackievirus cause similar or even indistinguishable
exanthems, which may more commonly involve the face, trunk, and proximal
extremities. Often, children with these exanthems will be diagnosed with
nonspecific viral infections. Other symptoms attributed to coxsackie virus
infection include aseptic meningitis and less commonly myopericarditis, pleuritis,
encephalitis, or paralysis. Severe and/or persistent infections may be seen in
immunocompromised hosts.
Diagnosis is usually made clinically, although the virus can be detected by
PCR directly from the vesicles or from the stool. The virus is commonly shed for
weeks from stool. Coxsackievirus infections are usually self-limiting, so no
specific treatment is necessary. IVIG with high antibody titer may be considered
for immunocompromised patients or in life-threatening neonatal infections.
Coxsackie virus also frequently infects eczema prone areas and in this case is
called eczema coxsackium (similar to eczema herpeticum).
Varicella (Chickenpox)
Although varicella is an easily recognizable vesiculobullous eruption, on
occasion, the earliest phase can be confusing. The initial skin manifestations of
varicella virus infection are small, red macules. Some of the lesions remain as
macules, but most progress to papules and then the characteristic umbilicated,
tear-shaped vesicles. The earliest lesions appear on the chest and spread
centrifugally, but there are many exceptions to the pattern of spread. Mucosal
lesions can be seen but are usually not a prominent feature. Occasionally, a child
with mild chickenpox may have only a few scattered macules with only one or

two progressing to the more typical vesicular lesions. Of children receiving
varicella vaccine, 7% to 8% may develop a mild maculopapular or varicelliform
rash within 1 month of vaccination.
Other Bullae/Vesicles