Tomato flu: misnomer for a common disease? – Authors' reply

We thank Saurav Paul and colleagues for their response to our Correspondence.1Chavda VP Patel K Apostolopoulos V Tomato flu outbreak in India.Lancet Respir Med. 2023; 11: e1-e2Google Scholar Our original Correspondence was written at a time when scarce scientific information was available on this uncommon presentation referred to as tomato flu; hence we included media reports in our references. The main aim of our Correspondence was to increase awareness of this unusual presentation, based on the information available to us at the time; however, we appreciate that discussion of the COVID-19 pandemic in relation to tomato flu might have caused unnecessary concern. We did not intend to claim the emergence of a new virus, and the use of such language was indeed premature. Instead we meant to say that some cases of tomato flu, as described by various media reports,2Dhillon A Tomato flu outbreak in India spreads to two more states. The Guardian, Aug 23, 2022https://www.theguardian.com/world/2022/aug/23/tomato-flu-outbreak-in-india-spreads-to-two-more-statesDate accessed: December 5, 2022Google Scholar had similar symptoms to other diseases, such as joint pain and limb pain, which are common in many other viral illnesses. The Ministry of Health and Family Welfare in India issued a health advisory on Aug 24, 2022, to states regarding tomato flu or hand, foot, and mouth disease, detailing where the infection had been reported and the number of cases.3All India RadioNews Services Division. Centre issues advisory to states on tomato flu.https://newsonair.gov.in/Main-News-Details.aspx?id=446498Date: Aug 24, 2022Date accessed: December 5, 2022Google Scholar Experts in the research and health communities now consider tomato flu to be a variant of hand, foot, and mouth disease, caused by a virus from the enterovirus family—the coxsackie virus.4Sah R Dor VJ Satapathy P et al.An old virus with atypical presentation—tomato flu?.Lancet Reg Health Southeast Asia. 2022; 7100096Google Scholar The hand, foot, and mouth disease virus constantly changes, both in terms of its epidemiology5Hong J Liu F Qi H et al.Changing epidemiology of hand, foot, and mouth disease in China, 2013–2019: a population-based study.Lancet Reg Health West Pac. 2022; 20100370Google Scholar and genetics,5Hong J Liu F Qi H et al.Changing epidemiology of hand, foot, and mouth disease in China, 2013–2019: a population-based study.Lancet Reg Health West Pac. 2022; 20100370Google Scholar, 6Ma E Lam T Chan KC et al.Changing epidemiology of hand, foot, and mouth disease in Hong Kong, 2001–2009.Jpn J Infect Dis. 2010; 63: 422-426Google Scholar, 7Ganorkar NN Patil PR Tikute SS et al.Genetic characterization of enterovirus strains identified in hand, foot and mouth disease (HFMD): emergence of B1c, C1 subgenotypes, E2 sublineage of CVA16, EV71 and CVA6 strains in India.Infect Genet Evol. 2017; 54: 192-199Google Scholar, 8Tang JW Barer MR Iqbal A et al.Kerala tomato flu—a manifestation of hand foot and mouth disease.Pediatr Infect Dis J. 2022; 41: e501-e503Google Scholar meaning that clinical presentations of the disease might also change.9Lott JP Liu K Landry M-L et al.Atypical hand-foot-and-mouth disease associated with coxsackievirus A6 infection.J Am Acad Dermatol. 2013; 69: 736-741Google Scholar, 10Huang W-C Huang L-M Lu C-Y et al.Atypical hand-foot-mouth disease in children: a hospital-based prospective cohort study.Virol J. 2013; 10: 209Google Scholar Hence, it is important to monitor and discuss any unusual presentations to understand what changes to the virus might be occurring. Ultimately, the end goal is that the treatments administered are appropriate. We agree with Paul and colleagues that studies on the symptomatology of tomato flu in the current outbreak and genomic analysis of the virus would provide a clearer diagnosis, and would help us to understand the mechanisms behind such presentations. Future studies could also confirm definitively whether these cases are atypical hand, foot, and mouth disease because, to our knowledge, publications so far have been preliminary communications rather than full length original research articles. Long-term follow up of patients is also recommended, to monitor the outbreak and potential spread of the disease, and to ensure any treatments are effective.11Kundu M Ghosh S Das S The emergence of tomato flu: another pandemic in making?.Ann Med Surg. 2022; 81104523Google Scholar, 12Sriwjitalai W Wiwanitkit V Hand foot and mouth disease, tomato flu and new emerging outbreak.J Stomatol Oral Maxillofac Surg. 2022; (published online Aug 31.)https://doi.org/10.1016/j.jormas.2022.08.017Google Scholar, 13Wiwanitkit S Wiwanitkit V Rapid response to: Reports of “tomato flu” outbreak in India are not due to new virus, say doctors.BMJ. 2022; 378o2101Google Scholar We declare no competing interests. Tomato flu outbreak in IndiaJust as we are dealing with the probable emergence of a fourth wave of COVID-19, a new virus known as tomato flu, or tomato fever, has emerged in India in the state of Kerala in children younger than 5 years.1 The rare viral infection is in an endemic state and is considered non-life-threatening; however, because of the dreadful experience of the COVID-19 pandemic, vigilant management is desirable to prevent further outbreaks.2 Full-Text PDF Tomato flu: misnomer for a common diseaseWe read with great interest the Correspondence by Vivek Chavda and colleagues1 regarding the tomato flu outbreak in India. The authors gave an overview of the current outbreak of a viral illness that has been termed tomato flu, owing to its characteristic painful vesicular red-coloured eruptions resembling tomatoes. There are several concerns regarding this Correspondence. Full-Text PDF