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โรคมือ เท้า ปาก. ศาสตราจารย์เกียรติคุณ นายแพทย์ประเสริฐ ทองเจริญ ราชบัณฑิต สาขาแพทยศาสตร์ ที่ปรึกษาคณะแพทยศาสตร์ศิริราชพยาบาล มหาวิทยาลัยมหิดล ที่ปรึกษากรมควบคุมโรค กระทรวงสาธารณสุข คณะกรรมการที่ปรึกษาการเตรียมความพร้อมรับมือไข้หวัดใหญ่ องค์การอนามัยโลก

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Hand foot mouth disease hfmd

Hand, Foot & Mouth Disease (HFMD)

  • (?)

  • ()


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()

Hand, foot and mouth disease (HFMD)


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HFMD? CA16 & EV71

coxsackievirus A16 (CA16)

enterovirus 71(EV71)

Coxsackieviruses A & B, echoviruses


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enteroviruses

http://www.vaccineorb.com/_common/updateable/img/news/

main/safety-and-immunogenicity-of-05111503.jpg


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4


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10

(sodium hypochlorite), providone iode

70%, chrohexidine


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http://s3.hubimg.com/u/3032810_f520.jpg

http://www.folkshealth.com/wp-content/uploads/handwashing.jpg


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  • coxsackievirus A16

  • 7 10

  • EV71


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HFMD 71 (EV71)

EV71

..

..

.. HFMD


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  • (Sibu)


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  • , . ,


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  • , ,

  • Sinus trachycardia EKG (arrythmia)

  • ( )


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  • (maculopapule) (vesicle)

  • (Hand, Foot, and Mouth Disease HFMD)


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  • (acute flaccid paralysis)

  • CSF

  • lymphocytosis


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  • private clinic , ( . )


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  • , ( )


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  • (Enterovirus 71)


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Enteroviruses

Enteroviruses

  • Hand, Foot and Mouth Disease syndrome .. Coxsackievirus A 16 Coxsackievirus A10, A5 A9

  • Coxsackievirus A 16, Coxsackievirus A10, A5 A9 Enterovirus


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  • MMWR .. The New England Journal of Medicine ..


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MMWR : -

  • , Sentinel site ,


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  • (.)


Lab investigation

Lab. investigation

  • , / ( ,/ -, ) . / ( /) ,/ ( , - , )

  • CSF / ( - )

  • / ( - /) / ( - /)


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  • cyanosis

  • Film chest


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  • (acute encephalomyelitis)

  • Interstitial Pneumonitis

  • (myocarditis)

  • (enterovirus 71 -EV71) -


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  • ( ) coarse rhonchi


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  • . ( )

  • CBC ,/ ( )

  • . / ,/

  • . ( . ) . ( - )


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  • CSF / ( ) / / dobutamine dopamine


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  • ( ) - ( ) -


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  • ( - )

  • ( )

  • ( )


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. -


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  • %


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%

  • * =


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  • ()

  • polymerase chain reaction PCR


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/

  • ,,,

  • ,

  • ,,

  • ,,

  • ,

  • ..

  • /sentinel sites


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  • Hand, Foot and Mouth Disease HFMD A Guide to Clinical Management and Public Health Response for Hand, Foot and Mouth Disease (HFMD) ..


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  • papulovesicular rash

    (maculopapular rash)


Who case definition

WHO Case Definition

  • HFMD:Febrile illness with papulovesicular rash on palms and soles with or without vesicles/ulcer in the mouth. Rash may occasional be maculopapular without vesicular lesion and may also involve buttock, knee or elbow, particularly in small children and infants.


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.. -

  • /.. //

  • /, , coxsackie-like illness

  • /aseptic meningitis, HFMD ( )

  • /aseptic meningitis, HFMD ()

  • , -,/HFMD,

  • /aseptic meningitis,

  • /HFMD, , ,

  • /, ,

  • /HFMD, , , Encephalomyeliis

  • /

  • -, , ,

    ,


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.. -

.. .

-/Aseptic meningitis, Encephalitis

/.Aseptic menin, Encephalitis,

HFMD

Aseptic meningitis, Rash, Polyneuritis, Acute respiratory

infection

Aseptic meningitis, HFMD


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  • ,/HFMD, aseptic meningitis, ,

  • /HFMD, herpangina, Meningoencephalitis, ,

  • ,/, aseptic meningitis, /,

  • /,

  • /HFMD, , , ,


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  • >,Hand, foot and mouth disease, Aseptic

    meningitis

  • Aseptic meningitis, Encephalitis,

    acute myocarditis, Polio-like paralysis

  • *Aseptic meningitis, Encephalitis, Polio-like

    paralysis

  • ?Monoplegia

  • ?CNS involvement

  • . Polio-like paralysis, Meningitis, Encephalitis

  • ?Hand, foot and mouth disease


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  • /.. //

  • /HFMD, , ,

  • ,/HFMD,

  • /, HFMD, herpangina,

  • /HFMD, ,

    ,

  • -

  • /, , ,

  • /, ,

  • /, , ,

  • /, ,

  • /HFMD,

  • /HFMD, ,

  • /HFMD, ,


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  • - (fecal-oral route) ( ) --


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  • - viremia apoptosis


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  • . .-/ ) ( )


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  • ()

  • - ( ) - . - - . -


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  • ( )


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  • ( )


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  • /

  • ( ) ( )


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  • ( )

  • spectrum of disease


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  • () arythmia / ()


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(Dehydration)


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ANS dysregulation

  • ANS dysregulation

  • autonomic nervous system ANS (ANS regulation) ANS dysregulation


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  • ( )


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  • Herpetic gingivostomatitis

  • Aphthous stomatitis

  • Scabies infestation

  • Chickenpox (varicella)

  • Measles


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  • Herpetic gingivostomatitis

  • Measles


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  • Aphthous stomatitis

  • Scabies infestation


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  • Chickenpox (varicella) HFMD


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.

.

.

  • (nasopharyngeal aspirates)


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()


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HFMD

3-7


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  • Throat swab swab VTM (virus transport medium)

  • (gargle) (nasopharyngeal wash)

  • ( )


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  • ( )

  • (IVIG)


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  • ( )

  • -


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  • ..

  • .


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..

  • .

  • .

  • .-

  • .


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..


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.

. -

. - -


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  • .

  • .

  • . ( )

  • .

  • .


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..2555


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..

  • B5 C4


Ev71 genotypes in 2012

EV71 genotypes in 2012

Coxsackie A6

Coxsackie A16

EV71 genotypes B5 and C4


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/

  • ...

  • ,

  • ,

  • ,

  • ,


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Summary of human enterovirus 71 (HEV71) genotypes circulating in the Asia-Pacific region since 1997


Old classification of human enteroviruses

Old classification of human enteroviruses

Poliovirus types 1-3

Coxsackie A virus types 1-24 (no type 23)

CoxA 23 was shown to be echo 9

Coxsackie B virus types 1-6

Echovirus types 1-33 (no types 8, 10, 22, 23 and 28)

echo 8 was shown to be echo 1

echo 10 was shown to be reovirus 1

echo 22 and 23 moved to parechovirus 1 and 2

echo 28 was shown to be rhinovirus A1

Human parechovirus 1 and 2

Enterovirus types 68-71

Formerly, enterovirus type 72 was hepatitis A virus


Re and re classification

Re- and re-classification

Order Picornavirales

Family Picornaviridae comprises 12 genera

Genus Enterovirus comprises 10 species of >100 types of viruses that infect man and animals.

Human enterovirus A : EV71, CA3-8,CA16,,

Human enterovirus B : CB1-6, CA9, echovirus, EV88, 93, 97,98, .

Human enterovirus C: poliovirus 1-3, CA , EV116

Human enterovirus D : EV68, 70, 94, 111

Bovine enterovirus

Simian enterovirus


Ev71 genotypes

EV71 genotypes

Genogroups :A, B and C

A is consisted of only one lineage

B is consisted of 5 sub-genogroups: B1, B2, B3, B4 and B5)

C is consisted of 5 sub-genogroups: C1, C2, C3, C4 and C5)


Coxsackie virus a 16 genogroups

Coxsackie virus A 16 genogroups

  • Based on different groups of investigators

    A, B and C or

    A and B (B is further divided into 2 lineages: 1 and 2)


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Virus isolation rates from HFMD suspected cases:

Siriraj Hospital(N=92)

* Two EV71 isolates were isolated from throat swab specimens only

# Mixed EV71 and HSV-1 were isolated from one case


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.. - ..


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EV71 outbreaks associated with HFMD in the Asia Pacific region from 1997 to 2009


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