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

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 moment there is no antiviral medication aimed at treating tomato flu nor is there any vaccination, which is the biggest challenge in treating the individuals who are contracting this disease, especially the immunocompromised patients3. Efforts and recommendations When diagnosing tomato flu, a clinical examination reveals the presence of painful, red blisters all over the body. These blisters seem to be remarkably like monkeypox blisters. To rule out other viral infections, molecular and serological tests, including polymerase chain reaction, are conducted when symptoms, including exhaustion, nausea, vomiting, diarrhea, fever, dehydration, swelling of the joints, body pains, and typical influenza-like symptoms, are present3. Supportive therapy, such as isolation, rest, lots of fluids, and hot water sponges for the alleviation of irritation and rashes, are typically used throughout the course of treatment. Paracetamol can also be used as a symptomatic treatment for fever and body aches3. The only method to stop the spread of tomato flu is to take precautions because there is now no antiviral medicine for either treating or preventing the illness. As tomato flu is a highly contagious illness, strict isolation procedures must be followed to prevent the infection of close contacts3,10. If an individual in the community is suspected to have contracted the illness, they should be quarantined and given the right amount of fluids to drink11. After the onset of symptoms, isolation must be used for 5–7 days3. The mainstay of treatment for treating dehydration is fluid consumption. The best defense against tomato flu is proper hygiene and sanitization3,10. One of the main causes of illness propagation on a local level is a lack of knowledge and education, particularly in rural areas. As a result, it is important to inform the community about the disease, its symptoms, and available preventative methods. Flyers, banners, door-to-door outreach, education, and small-scale village meetings can all be used to accomplish this10. Public awareness can also be raised through awareness initiatives run by non–governmental organizations and municipal governments10. Local hospitals and community centers, especially those in rural regions, must also be fully stocked with supplies like medicine and fluids because a delay in getting them might hasten the spread of disease. Although news and social media can be utilized to raise awareness, it is important to maintain a balance of accurate information to avoid public panic. To evaluate patient outcomes, disease surveillance and additional follow-up are required as there are presently no antiviral medications or vaccines available for the prevention or treatment of tomato flu10. Such diseases must be promptly controlled as they can spread to become pandemics like the monkeypox and COVID-19 pandemics. Collaborations between government representatives, medical professionals, and the local health community are required to inform people about the severe repercussions of the disease10. Containment strategies for the tomato flu outbreak in India To effectively contain the tomato flu outbreak in India, several key strategies can be implemented. Firstly, robust surveillance and contact tracing measures should be established to identify and isolate infected individuals. This includes rigorous monitoring of cases, tracing close contacts, and conducting timely testing to prevent further transmission. Secondly, public health education campaigns should be launched to raise awareness about tomato flu and promote preventive measures, such as regular handwashing, avoiding close contact with infected individuals, and practicing respiratory hygiene. Strengthening the health care infrastructure is crucial to handle the burden on health care facilities. Adequate allocation of resources, including personal protective equipment and medical supplies, is essential for the effective management of tomato flu cases. Research efforts should focus on better understanding the virus, its transmission dynamics, and potential treatment options. In addition, vaccine development should be prioritized to prevent future outbreaks and protect vulnerable populations. International collaboration with health organizations and continuous monitoring and evaluation of the outbreak response is vital for a coordinated and effective containment strategy. By implementing these measures, it is possible to mitigate the spread of tomato flu and safeguard public health in India. Conclusion Children are more likely to be exposed to tomato flu, as viral illnesses are widespread in children and propagation is most probable through close contact. As there are no antiviral medications or vaccinations against the virus as of yet, it is imperative that confirmed or suspected cases be carefully isolated, along with other preventative measures to stop the spread of the virus. To comprehend the need for prospective therapies, additional follow-up and observation for significant outcomes and sequelae are required. Ethical approval Ethical approval was not required for this correspondence. Sources of funding Not applicable. Authors contribution W.B., A.N., and M.A.K.: study concept, collection of the data, drafting, literature review, data validation, supervision, and editing of the manuscript. L.I.V. and N.R.: literature review and revising of the manuscript for important intellectual content. Conflicts of interest disclosure 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) Not applicable. Guarantor Nahid Raufi.