Tomato flu: need to look beyond the frame

Dear Editor, The outbreak of tomato flu in Kerala in India has piqued the interest of the medical community as it possibly indicates toward a possibility of another viral outbreak amidst the COVID-19 pandemic. A total of 8282 cases of tomato flu were detected in children under the age of 5 by late July, 2022. The disease has now spread to other states of India including Tamil Nadu and Odisha1. As the predominant symptoms were a high temperature, rashes, and excruciating joint pain, it was hypothesized that the illness may be a complication of dengue or chikungunya fever. The predominant sign of this illness, however, is the appearance of blisters, which initially appear as little, red patches and then develop to resemble the vegetable tomato. For this reason, the term “tomato flu” has been adopted to describe this illness. When dengue fever, chikungunya, zika virus, varicella-zoster virus, and herpes were ruled out in the course of the investigation by molecular and serological testing, the diagnosis of tomato flu was made. From 2 kids who contracted the same illness during a visit to Kerala, the coxsackievirus A16 (CV-A16) serotype was discovered to be the primary disease-causing agent by UK Health Security Agency. The CV-A16 is a major cause of hand foot and mouth disease (HFMD), a contagious viral infection that often affects newborns and kids under the age of 5. In Birmingham, Alabama, the first incidence of HFMD was documented in 1959. HFMD in human beings is caused by CV-A16 belonging to the family Picornavirida of the genus Enterovirus. This virus is a single-stranded, positive-sense, polyadenylated RNA virus with an icosahedral symmetry structure and contains ~7400 bases. In the present scenario, human beings are the only known natural host for CV-A16. The clinical manifestations of CV-A16 type A and type B include aseptic meningitis, febrile rashes, and nonspecific upper respiratory tract infections. Furthermore, skin and mucous membranes are known to be primary targets for CV-A. A potential cellular receptor for CV-A16 has been identified as human scavenger receptor class B, member 2 (hSCARB2). In addition, 1 investigation has shown that the intranasal infection of hSCARB2 transgenic mice with CV-A16 displayed a predilection for lung and brain tissues2. In most of the cases, CV-A16 is self-limiting and not a fatal infection. The development of the illness is thought to have more severe in HFMD with EV-A71. HFMD can spread from person to person by the fecal-oral route, direct contact, and coughing or sneezing3. Fever, anorexia, nausea, vomiting, diarrhea, dehydration, swollen joints, and body ache are the main symptoms seen in the most recent epidemic and are typical of many viral illnesses. Rashes and intense joint pain similar to those from chikungunya and dengue fever accompany high-grade fever. Small red spots start to emerge on the body 1–2 days after the fever starts, and they gradually develop into blisters and finally ulcerate. The lesions are typically found on the tongue, inside of the cheeks, gums, palms, and soles; however, they can occur elsewhere on the body. Other indications of the “tomato flu” include flu-like symptoms including coughing, sneezing, nasal congestion, and discoloration of the hands, knees, and buttocks. Deaths attributed to this illness have not yet been documented. There are currently no particular antiviral therapies available for HFMD. However, several potential antiviral medications such as oseltamivir and acyclovir have been investigated and few of them exhibited extraordinary clinical outcomes. Moreover, hydration therapy and drinking filtered water are suggested to the patients for faster recovery. Acetaminophen or ibuprofen was found effective in treating fever and body aches4. In conclusion, to not lead tomato flu into another frightful situation, especially for children and immune-compromised adults awareness about the disease, symptoms, treatment, and preventive measures among the people is crucial. Touching unclean surfaces owing to curiosity and putting contaminated things directly into the mouth makes children very prone to tomato flu, hence proper sanitization of the environment is a must. In addition, given the contagious nature, it is crucial to isolate the confirmed or suspected cases for a period of 5–7 days after the initiation of symptoms to prevent further transmission. Scraping of the blisters should be avoided to prevent the progression of lesions into purulent swelling. The disease is self-limiting and usually, the symptoms fade away in 7–10 days. Adoption of prompt preventative measures, such as maintaining good hygiene and sanitation along with vigilant management is crucial for the effective management of tomato flu. Ethical approval None. Sources of funding None. Author contribution R.K.: conceived the idea. S.K.P.: retrieved the data. J.R.: write up of the manuscript. T.B.E.: reviewed and provided inputs. All authors approved the final version of the manuscript. Conflict of interest disclosures The authors declare that they have no financial conflict of interest with regard to the content of this report. Research registration unique identifying number (UIN) None. Guarantor Talha Bin Emran. Provenance and peer review Externally peer reviewed, not commissioned. Data statement No datasets were generated.