Insights on the tomato flu outbreak in India: could this outbreak be contained?

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Children in India are being infected with a rare, dangerous virus known as “tomato flu”1. It is thought of being either a novel variety of the viral hand, foot, and mouth disease or a consequence of chikungunya or dengue fever2. According to the Centers for Disease Control and Prevention, hand, foot, and mouth disease is an extremely infectious disease caused by the coxsackievirus A16 that spreads rapidly through an affected person’s nasal and oral secretions, excretions, and blister fluid. As per experts, young children, particularly between 1 and 9 years of age are more susceptible to contracting this disease owing to their compromised immune systems, with the highest prevalence seen in children under 5 years of age1. The first case of tomato flu was reported on May 6, 2022, in the Kollam district of Kerala in India with government health care facilities subsequently documenting infection in further 82 children by July 26, 20222. The Regional Medical Research Centre in Bhubaneswar revealed that an additional 26 children in the state of Odisha had contracted the illness. Other than Kerala, Tamil Nadu, and Odisha, no other parts of India have experienced the virus’s effects as yet3. The hallmark of this disease is blisters all over the body, especially the hands, feet, and oral cavity characterized by a tomato-red hue and the size of a tiny tomato, giving it the moniker “tomato flu or tomato fever.” Complimenting it are symptoms, such as pyrexia, exhaustion, and body pains, reminiscing about coronavirus disease 2019 (COVID-19). Doctors have also noticed a loss of nails and lesions in unusual places, including the buttocks4,5. The incubation period of the disease is 5–7 days with diagnosis made by affected individuals going through molecular and serological tests for the diagnosis of the Zika virus, chikungunya, and dengue6. As it is a self-limiting disease, the treatment is mainly supportive, including bed rest, adequate hydration, paracetamol for fever, and ways to reduce the discomfort and irritability caused by the rashes2. In comparison to COVID-19, tomato flu is less contagious, rarely affects the elderly population, and is non–life-threatening until now6. Symptoms of tomato flu Tomato flu is characterized by several distinctive symptoms that set it apart from other viral illnesses. The hallmark of tomato flu is the presence of tomato-red blisters, resembling tiny tomatoes (Fig. 1), which appear all over the body, particularly on the hands, feet, and oral cavity. Individuals infected with tomato flu may also experience symptoms, such as pyrexia (fever), exhaustion, body pains, and rashes resembling those seen in measles (Table 1). In addition, nail loss and lesions in unusual places, including the buttocks, have been observed. It is important to note that these symptoms closely resemble those of other viral diseases like COVID-19, dengue, and chikungunya, which can lead to initial misdiagnosis and delayed treatment. To confirm tomato flu, molecular and serological tests are conducted to rule out other viral infections (Table 2).Figure 1: Vesiculobullous blister in a patient with “tomato flu” (image credit: Istockphoto.com/apomares). Table 1 - Clinical features of “tomato flu.” Clinical features Description Primary symptoms Fever, anorexia, nausea, vomiting, diarrhea, dehydration, swollen joints, and body pain Rash Small red spots that develop into blisters and ulcers Rash location Tongue, inside of cheeks, gums, palms, and soles Additional symptoms Coughing, sneezing, runny nose, discoloration of hands, knees, a buttocks Severity Self-limiting and non–life-threatening Complications Possible, but no major complications or deaths reported Transmission Fecal-oral route, direct contact, and respiratory droplets Prevention and treatment Handwashing, proper hygiene, and isolation, symptomatic relief (eg, acetaminophen) Antiviral drugs Acyclovir and oseltamivir have shown potential benefits Vaccines No licensed vaccines against CV-A16, existing vaccines are effective against EV-A71 Table 2 - Differences between “tomato flu,” dengue, and chikungunya symptoms. Symptoms Tomato flu Dengue Chikungunya Fever Present High-grade fever High-grade fever Rash Small red spots that develop into blisters and ulcers Petechial rash (small red or purple spots) Maculopapular rash (red spots or patches) Joint pain Swollen joints, body pain Joint pain, severe body, and muscle pain Joint pain, severe body, and muscle pain Other common symptoms Anorexia, nausea, vomiting, diarrhea, and swollen joints Nausea, vomiting, abdominal pain, headache, and fatigue Headache, fatigue, nausea, vomiting, and muscle aches Rash location Tongue, inside of cheeks, gums, palms, and soles Dispersed on the body Dispersed on the body Transmission Fecal-oral route, direct contact, and respiratory droplets Mosquito-borne (Aedes mosquitoes) Mosquito-borne (Aedes mosquitoes) Geographic region Outbreak reported in India (Kerala and other states) Global distribution, especially in tropical and subtropical regions Global distribution, especially in tropical and subtropical regions Complications Generally self-limiting with no major complications reported Severe cases can lead to hemorrhagic fever, organ damage, or death Severe cases can lead to chronic joint pain and neurological issues Challenges Just like how any other viral disease has its challenges in controlling its spread and eradicating it, tomato flu being a viral illness has its own set of challenges on individual and a national level ranging from difficulties in controlling the spread of disease in Kerala, one of India’s most densely populated areas, housing almost 3% of India’s whole population7 to the production of a timely vaccine by the health care system. One of the biggest challenges India, specifically Kerala, has to face is the fact that this outbreak occurred amidst the fourth wave of COVID-193, which resulted in a burden on the already overwhelmed health care facilities of a developing nation, such as India. Tomato flu’s symptoms closely resemble the symptoms of dengue which include fever, fatigue, and body ache8, and this may initially result in misdiagnosis leading to the possibility of the case being overlooked and going unreported. Apart from this, due to the similarity in rashes in this disease with other more serious illnesses, such as measles, it can result in the latter not being treated on time resulting in a serious complication4. Due to similarity with other diseases, as mentioned earlier, diagnosis of tomato flu can only be made after negative test results of dengue, chikungunya, Zika virus, varicella-zoster virus, and herpes through molecular and serological tests3. These tests may be costly for the population of India and many individuals might choose to not get tested at all. As a result, cases will not be diagnosed and subsequently, isolation will be maintained leading to a more rapid spread of the disease. Like other influenza viruses, tomato flu is also very contagious and spreads rapidly through close contact. As mentioned previously, children aged 1–9 years tend to lack basic knowledge when it comes to hygiene, such as touching unclean surfaces and placing random objects into their mouths. With this being said it can be seen that they have an increasingly difficult time avoiding close contact with infected individuals which in turn puts others around them at a much greater risk of contracting the infection3. Daniel Lucey, a clinical professor of medicine at the Dartmouth Geisel School of Medicine in New Hampshire stated that tomato flu is not a virus or flu itself9. It is believed that it is just a different clinical manifestation of diseases like chikungunya or hand, foot, and mouth disease or even monkeypox on the basis of blisters produced. Based upon our assumption, the disease might not be deemed serious and treated accordingly. It is likely that this will delay the development of its vaccine. At this mo

Ce résumé expose les affirmations des auteurs. BNTIC ne l’interprète pas comme une validation indépendante des résultats.