Background Hand-foot-mouth disease (HFMD) is a viral illness that typically presents in children under the age of five with fevers and characteristic papulovesicular lesions of the hands, feet, and oral mucosa. With the rise of coxsackievirus-A6 and atypical Hand-foot-mouth disease (HFMD) presentations with ear lesions, providers need to consider a broad differential for external ear lesions that includes HFMD. Case Presentation A 3-year-old previously healthy male patient presents to his primary care clinic with a worsening rash. Three days ago, he developed fever, congestion, and rhinorrhea, and two days later, he developed a rash. The rash initially started on his hands, feet, and perioral region, but has since developed ear lesions. He has known sick contacts with fever and rash only on their hands and feet. On exam, he is afebrile. Skin exam is notable for pruritic, crusting, erythematous papulovesicular eruption concentrated on his palms, soles, and perioral regions. He has multiple, similarly-appearing lesions on the auricles of both ears, but no lesions within the helix or external canal. Oral exam is notable for erythematous macules on the soft palate, posterior oropharynx, and lower inner lip with normal gingiva and tongue.

Discussion With the patient’s ear lesions, causes such as vascular, inflammatory, neoplastic, and traumatic causes were considered. However, because of his associated symptoms, an infection was more likely. Infections such as CV-A6, Rocky Mountain Spotted Fever, impetigo, Herpes Simplex Virus, Varicella Zoster Virus, and Monkeypox are all potential causes of papulovesicular ear lesions. Given the patient’s age and exposure to known sick contacts with typical HFMD presentation, CV-A6 was the most likely. In recent years CV-A6 has been associated with outbreaks of more severe disease and atypical HFMD worldwide – including China, Spain, Taiwan, the United States, and the UK.

External ear lesions are a rare atypical presentation of HFMD. When patients have no other symptoms, clinicians must consider the broad differential for papulovesicular ear lesions.