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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 to 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 month of vaccination Other Bullae/Vesicles
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