AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Background

Herpangina is an acute febrile illness associated with small vesicular or ulcerative lesions on the posterior oropharyngeal structures. Herpangina typically occurs during the summer and frequently in children, but also young adults. Various enteroviruses cause the condition.

Pathophysiology

The enteroviral agents causing herpangina belong to the Picornaviridae family of viruses. Coxsackievirus A usually causes herpangina; less commonly, the condition is caused by coxsackievirus B, echovirus, and enterovirus.

These viruses typically spread via the fecal-oral route, though the viruses may spread via the respiratory route or through fomites. Fresh water sources (eg, lakes) may act as a reservoir for transmission.

The incubation period is usually 7-14 days. Viremia occurs after inoculation and, subsequently, results in distant sites of infection. Clinical symptoms occur after viral replication at secondary sites of infection. Bilateral, anterior, cervical lymphadenopathy may occur, resulting from infection of the posterior oropharynx. Coxsackievirus A may be recovered from the nasopharynx, feces, blood, urine, and cerebrospinal fluid (CSF). After resolving clinical symptoms, enteroviral infection may continue asymptomatically in the gastrointestinal tract.

Frequency

United States

Enteroviral infections occur most frequently during the summer and fall in temperate climates and year round in tropical climates.

International

Enteroviruses exist throughout the world.

Mortality/Morbidity

Herpangina typically is a mild and self-limited illness. Patients do not appear very ill. Associated complications rarely occur. Enterovirus 71, which can cause herpangina, has more recently been associated with a greater frequency of severe complications that range from the mild typical symptoms to fatal meningoencephalitis. Fatalities, which mostly occur in infants aged 6-11 months, have been reported.

Sex

The male-to-female incidence ratio of herpangina is 1:1.

Age

Herpangina most commonly affects infants and young children aged 3-10 years; less commonly, this infection may occur in adolescents and adults.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

History

Approximately 50% of enteroviral infections are asymptomatic. Clinical manifestations may vary, depending on the strain of virus causing the infection.

• Fever: All enteroviral infections may cause fever, which is the first symptom of the illness that the patient may notice. Typically, the patient's temperature is 101-104°F
• Malaise: Most symptomatic patients report this complaint.
• Sore throat
• Anorexia, emesis, or abdominal pain, which may mimic an appendicitis
• Infants may appear listless.
• Exanthem: Characteristics and occurrence rates vary, depending on the viral subtype that is causing the infection. The rash is not pruritic and does not cause skin desquamation. The following are other rash characteristics:
• • Macular
  • Maculopapular
  • Papulopustular
  • Papulovesicular
  • Vesicular
  • Morbilliform
  • Urticarial
  • Petechial
  • Hemangiomalike

Physical

• Oropharyngeal lesions (herpangina)
• • Lesions characteristically appear as erythematous macules initially, then as vesicles that ulcerate centrally, creating an erythematous halo.
  • Often, these lesions are the first physical finding. The lesions typically are less than 5 mm in diameter, and each patient can present with 2-12 lesions.
  • Uninvolved portions of the pharynx usually appear normal. The most commonly affected structures are the anterior pillars of the fauces, posterior pharynx, soft palate, uvula, and tonsils.
  • Occasionally, lesions appear on the tongue and posterior buccal mucosa (see Table 1 for differential diagnoses of oral lesions).
  • The ulcers may persist for up to one week, even though the fever has subsided.
• Pharyngitis: Erythema of the pharynx may range from mild to severe. Pharyngitis in enteroviral infections may be associated with pleurodynia, meningitis, or exanthem.
• Bilateral, anterior, cervical lymphadenopathy

Causes

• The most common causes of herpangina are coxsackieviruses A 1-10, 16, or 22.
• Less common causes
• • Coxsackievirus B 1-5
  • Echovirus 3, 6, 9, 11, 16, 17, 22, 25, and 30
  • Enterovirus 71

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Other Problems to be Considered

Table 1. Clinical Manifestation Comparison for Herpangina, HSV, and Hand-Foot-and-Mouth Disease

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Lab Studies

• Herpangina is a clinical diagnosis. Laboratory studies generally are not indicated because this is a mild and self-limited illness. Investigate the salient features of the history and physical examination, including the following:
• • Season (depending on the latitude)
  • Patient age
  • Patient exposure history
  • Patient clinical symptoms
• The WBC count usually is normal.
• To isolate the virus, obtain cultures from swabs of the nasopharynx.
• Serum antibodies of the Coxsackievirus may be measured after the onset of clinical symptoms. The antibody titer should show a 4-fold rise in serial samples performed 2-3 weeks apart.
• Polymerase chain reaction can be performed for enterovirus RNA of the throat, blood, CSF, urine, feces, and tissue specimens.

Histologic Findings

Herpangina does not have any specific histopathologic findings.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical Care

No specific therapy is indicated in this self-limited illness.

• Currently, no effective antiviral therapy exists for herpangina. Antibacterial therapy is of no benefit.
• Treatment generally is supportive and includes the following:
• • Hydration
  • Antipyretics (eg, acetaminophen, ibuprofen)
  • Topical analgesics (eg, topical lidocaine)

Diet

Ensure that patients maintain adequate hydration and caloric intake during the illness.

Activity

Limit patient activity as tolerated.

FOLLOW-UP

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Further Outpatient Care

• Because symptoms usually are short lived and resolve within 1 week, patients generally do not need outpatient follow-up care.

Deterrence/Prevention

• Enteroviruses are spread through the fecal-oral route; therefore, practice any measures that may help reduce this mode of spread (eg, washing hands, avoiding contaminated food).

Complications

• Herpangina is a self-limited viral illness.

Prognosis

• Patient prognosis is excellent.

MISCELLANEOUS

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical/Legal Pitfalls

• There are no known medicolegal implications with regard to the clinical illness of herpangina. This is a self-limited viral illness. A missed diagnosis will not change the course of the illness and treatment is entirely based on symptoms.

MULTIMEDIA

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Media file 1:  Coxsackie B4 virus virions under electron microscopy. (This image is in the public domain and thus free of any copyright restrictions. Content provider: Centers for Disease Control)
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Media type:  Image

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

• Chang LY, King CC, Hsu KH. Risk factors of enterovirus 71 infection and associated hand, foot, and mouth disease/herpangina in children during an epidemic in Taiwan. Pediatrics. Jun 2002;109(6):e88. [Medline].
• Chawareewong S, Kiangsiri S, Lokaphadhana K. Neonatal herpangina caused by Coxsackie A-5 virus. J Pediatr. Sep 1978;93(3):492-4. [Medline].
• Cherry JD. Herpangina. In: Textbook of Pediatric Infectious Diseases. Vol. 1. 1998: 156-7.
• Cherry JD. Enteroviruses: Coxsackieviruses, Echoviruses, and Polioviruses. In: Textbook of Pediatric Infectious Diseases. Vol. 2. 1998: 1787-1839.
• Chole RA, Domb GH. Differential diagnosis of superficial ulcerations of the oral mucosa. Otolaryngol Head Neck Surg. Nov-Dec 1979;87(6):734-40. [Medline].
• Christie AB. Enteroviral infections (Coxsackieviruses and echoviruses). In: Infectious Diseases: Epidemiology and Clinical Practice. 1987: 753-81.
• Haskell R. Oral vesiculo-bullous lesions. J Laryngol Otol. Jan 1976;90(1):101-4. [Medline].
• Ho M, Chen ER, Hsu KH. An epidemic of enterovirus 71 infection in Taiwan. Taiwan Enterovirus Epidemic Working Group [see comments]. N Engl J Med. Sep 23 1999;341(13):929-35. [Medline].
• Lin TY, Chang LY, Hsia SH, et al. The 1998 enterovirus 71 outbreak in Taiwan: pathogenesis and management. Clin Infect Dis. May 1 2002;34 Suppl 2:S52-7.
• Melnick JL. Enteroviruses: Polioviruses, Coxsackieviruses, Echoviruses, and Newer Enteroviruses. In: Field's Virology. 1990: 549-98.
• Rosenblatt RM, Domb GH. Herpangina in an anesthesiologist. Anesth Analg. May 1980;59(5):384-5. [Medline].

Article Last Updated: Jun 30, 2006