hand , foot , and mouth disease ( hfmd ) is a common childhood illness characterized by fever , malaise and vesicular eruptions on the hands , feet and oral mucosa . the most common etiological agents are enterovirus 71 ( ev71 ) and coxsackievirus a16 ( cv - a16 ) although other viruses in the genus enterovirus , such as coxsackievirus a6 ( cva6 ) , have also been associated with this illness . ev71 has been associated with severe and sometimes fatal neurological complications such as aseptic meningitis , acute flaccid paralysis , encephalitis and neurogenic pulmonary edema . hfmd is spread from person to person by contact with saliva , respiratory secretions , fluid in vesicles and feces . hand , foot , and mouth disease was first reported in canada in 1957 , and has since been detected throughout most of the world including africa , asia , australia , brazil , europe and the united states . historically , hfmd has been associated with sporadic cases and small outbreaks ; however , in the last 15 years , there has been an alarming increase in the size , frequency and severity of hfmd outbreaks in southeast asia . anecdotal evidence suggests that hfmd occurs in mexico ; for instance , promed was recently notified through its social media facebook page of several apparent cases of hfmd in mexico city ( promed , archive no . however , to the best of our knowledge , there are no articles in the pubmed database that report the presence of hfmd in mexico . due to this gap in our knowledge we describe a case of hfmd in a 5-year - old male ( weight : 18 kg , height : 112 cm ) from merida city in the yucatan peninsula of mexico . the patient developed mild flu - like symptoms approximately two weeks before the initial consultation . the patient s mother reported that he had interacted with an older relative with similar clinical manifestations about one week prior to illness onset . the physician was also informed that the patient had not traveled outside the state during the preceding 12 months . a clinical and physical examination revealed that the patient had a fever ( 38.0c ) , generalized rash , fatigue , odynophagia , throat edema , hyperemia , clear lesions on the hands and soles of the feet , and blisters in the mouth mucosa and soft pallet ( figure 1 ) . a pulmonary auscultation revealed that the patient also had a dry cough due to a mild respiratory infection with a slight increment in fremitus , but not sibilant rales , detected during inhalation and expiration . hypoventilation in the pulmonary base was ruled out and no signs of dyspnea were observed . an abdominal scrutiny revealed no pain following superficial or deep palpation but generalized bloating was observed . the child was sent home with a support regime of hydration , a soft diet and rest . complementary palliative care was given and consisted of nimesulide ( 45 mg every 12 hours ) and metisoprinol ( 250 mg of every 8 hours ) per os for 5 days each . the physician performed a follow - up examination once the patient had completed the treatment regimen . the physician noted that the mouth blisters and all lesions had disappeared with the exception of several mild dried scars . to determine whether the patient had acquired hfmd as a result of an enterovirus infection , an aliquot ( 100 l ) of the saliva sample was added to 500 l of trizol reagent ( invitrogen , carlsbad , ca , usa ) and total rna was extracted according to the manufacturer s recommendations . complementary dnas were generated using the improm - ii reverse transcription system with random hexamer primers ( promega , madison , wi , usa ) . pcrs were performed using taq polymerase ( invitrogen ) and enterovirus - specific primers , denoted as primer 1 ( 5-caagcacttctgtttccccgg-3 ) and primer 3 ( 5-attgtcaccataagcagcca-3 ) , which amplify a highly conserved 440-nt region of the 5 untranslated region . pcr amplifications were conducted by using the following reaction conditions : 94c for 3 min ; 40 cycles of 94c for 1 min , 42c for 1 min , and 72c for 2 min ; followed by a final extension at 72c for 10 min . rt - pcrs performed with diethyl pyrocarbonate - treated distilled water in place of nucleic acid were included as negative controls . pcr products were examined by 2% agarose gel electrophoresis , visualized with ethidium bromide and extracted using the qiaquick gel extraction purification kit ( qiagen , valencia , ca , usa ) . purified dnas were sequenced in both directions using an abiprism dna sequencer at the instituto de biotecnologa in the national mexican university , mexico city , mexico . pcr products of the expected size were observed when the saliva sample was tested by rt - pcr using enterovirus - specific primers . kp 218059 ) and shown to have greatest ( 90.4% ) nucleotide identity to the corresponding regions of ev71 isolates from the netherlands in 2007 and singapore in 2008 . the next closest matches were to the corresponding regions of ev71 isolates from hong kong in 2008 ( 90.1% ) , canada in 2007 ( 89.8% ) , the united kingdom in 2006 ( 89.8% ) and france in 2009 ( 89.6% ) . we describe the clinical presentations of a laboratory - confirmed case of hfmd in a 5-year - old male in merida city in the yucatan peninsula of mexico . the patient displayed symptoms characteristic of hfmd ( i.e. blisters in the oral cavity and lesions on the hands and feet ) and , after a convalescent period of almost three weeks , made a complete recovery . we consider it likely that hfmd commonly affects children in mexico since it is common childhood illness in most countries , including the united states which borders mexico to the north . furthermore , anecdotal evidence suggests that hfmd occurs in mexico ; for example , several cases of hfmd apparently occurred among children in a daycare center in mexico city in 2012 ( promed , archive no . nevertheless , prior to our study , there was no compelling evidence available in the public domain demonstrating that hfmd occurs in mexico . an extensive search of the pubmed database failed to yield any articles reporting the detection of hfmd in mexico . likewise , a search of the genbank database did not produce any sequences corresponding to ev71 or cv - a16 isolates from mexico . it is also important to note that limited information was provided in the aforementioned promed announcement . details on the laboratory tests ( if any ) that were performed were not provided and , despite a request from the promed moderator for additional information on the status of hfmd in mexico , no further information was posted . therefore , the importance of our case report can not be understated because it provides compelling evidence that hfmd occurs in mexico . the ev71 sequence identified in this study exhibits a minimum of 9.6% nucleotide divergence from the corresponding regions of all other ev71 sequences in the genbank database . a likely explanation for this considerable divergence is because our virus is spatially distinct from all other ev71 isolates listed in the genbank database ; as already noted , we report the first ev71 sequence data from mexico . it is also interesting to note that our sequence exhibits greatest nucleotide identity to virus isolates from the eastern hemisphere . similar observations were reported during an outbreak of hfmd in cuba in 2011 to 2103 ; the cva6 isolates collected during the outbreak were most closely related to isolates from europe and southeast asia . hand , foot and mouth disease is a non - notifiable disease in mexico and this presumably is a major reason as to why there is limited information on this illness in the country . it is therefore very important that patient case studies such as this one are reported . information on the clinical presentations , patient outcomes , treatment regimens and incidence of hfmd in mexico will lead to an increased awareness of hfmd among the general public and local medical health professionals , and will result in improved ev71 screening in the pediatric community . this will in turn result in more timely diagnoses , more effective treatments and more favorable patient outcomes as well as the implementation of strategies to will reduce the spread and transmission of the disease . improved diagnosis and treatment of ev71 is especially important given that this virus has been associated with severe and sometimes fatal neurological disease .
we report a case of hand , foot and mouth disease ( hfmd ) in a 5-year - old male from merida city in the yucatan peninsula of mexico . 
 a clinical and physical examination revealed that the patient had symptoms typical of hfmd , including fever , fatigue , odynophagia , throat edema , hyperemia , lesions on the hands and feet , and blisters in the oral cavity . 
 the patient fully recovered after a convalescence period of almost three weeks . 
 reverse transcription - polymerase chain reaction and nucleotide sequencing revealed that the etiological agent was enterovirus 71 ( ev71 ) . 
 the sequence has greatest ( 90.4% ) nucleotide identity to the corresponding regions of ev71 isolates from the netherlands and singapore . 
 although hfmd is presumably common in mexico , surprisingly there are no data in the pubmed database to support this . 
 this case report provides the first peer - reviewed evidence of hfmd in mexico .