Herpangina

Herpangina is a common viral infection that primarily affects infants and young children, characterized by the sudden onset of fever and the development of small, painful ulcers in the mouth and throat. Despite its name, herpangina is not caused by the herpes virus but rather by enteroviruses, particularly coxsackievirus A. The condition is highly contagious and typically occurs during summer and early fall months.

Medical Disclaimer: This information is for educational purposes only and should not replace professional medical advice. If your child develops symptoms of herpangina, consult with a pediatrician for proper evaluation and care.

Overview

Herpangina is an acute viral infection that commonly affects children between 6 months and 4 years of age, though it can occur at any age. The condition is caused primarily by coxsackievirus A (types 2, 4, 5, 6, 8, and 10) and occasionally by coxsackievirus B, echovirus, and other enteroviruses. The name "herpangina" combines "herpes" (referring to the ulcerative lesions) and "angina" (referring to throat pain), though it is unrelated to herpes simplex virus.

The infection is highly contagious and spreads through respiratory droplets, fecal-oral transmission, and direct contact with infected secretions. The incubation period is typically 3-6 days, and children are most infectious during the first week of illness. Herpangina follows a seasonal pattern, with peak incidence occurring during summer and early fall months in temperate climates.

The hallmark of herpangina is the development of characteristic small, gray-white vesicles surrounded by red halos in the posterior mouth and throat. These vesicles quickly rupture to form shallow, painful ulcers that make swallowing difficult and uncomfortable. The illness typically runs its course in 7-10 days, with fever usually resolving within 3-4 days and ulcers healing within a week.

While herpangina is generally a mild, self-limiting condition, it can cause significant discomfort and may lead to dehydration in young children who refuse to eat or drink due to mouth pain. Complications are rare but can include aseptic meningitis, myocarditis, or secondary bacterial infections in immunocompromised individuals.

Symptoms

The symptoms of herpangina typically develop suddenly and can cause significant discomfort, particularly in young children. The clinical presentation is characterized by both systemic and local oral symptoms.

Constitutional Symptoms

  • Fever - often high-grade (101-104°F or 38-40°C)
  • Decreased appetite - due to pain and discomfort
  • Insomnia - sleep disturbances from pain and fever
  • Malaise and irritability
  • Headache in older children
  • General body aches

Oral and Throat Symptoms

  • Sore throat - severe pain, especially when swallowing
  • Mouth ulcer - characteristic small, painful lesions
  • Excessive drooling due to painful swallowing
  • Difficulty eating and drinking
  • Refusal to take fluids (especially in infants)

Associated Symptoms

Characteristic Lesion Progression

  • Day 1-2: Small red spots appear on soft palate and throat
  • Day 2-3: Red spots develop into gray-white vesicles with red borders
  • Day 3-4: Vesicles rupture forming shallow, painful ulcers
  • Day 5-10: Ulcers gradually heal without scarring

Typical Lesion Locations

  • Posterior pharynx (back of throat)
  • Soft palate
  • Uvula
  • Tonsillar pillars
  • Rarely: hard palate, tongue, or lips

Age-Specific Presentations

  • Infants (6-12 months): High fever, feeding refusal, excessive crying
  • Toddlers (1-3 years): Classic triad of fever, mouth ulcers, and throat pain
  • Preschoolers (3-5 years): May verbalize throat pain and discomfort
  • School-age children: Milder symptoms, may complain of headache

Causes

Herpangina is caused by various enteroviruses, with coxsackievirus A being the most common causative agent. Understanding the viral etiology and transmission mechanisms is important for prevention and management.

Primary Viral Causes

  • Coxsackievirus A: Most common cause
    • Types 2, 4, 5, 6, 8, 10 (most frequent)
    • Types 1, 3, 7, 9, 16, 22 (less common)
    • Accounts for 80-90% of herpangina cases
  • Coxsackievirus B: Types 1-5
  • Echovirus: Various serotypes
  • Enterovirus 71: Can cause more severe disease
  • Parechovirus: Rare cause

Transmission Mechanisms

  • Respiratory droplets:
    • Coughing and sneezing
    • Close contact with infected individuals
    • Most common route of transmission
  • Fecal-oral route:
    • Contaminated hands, objects, or surfaces
    • Poor hygiene practices
    • Viral shedding in stool can persist for weeks
  • Direct contact:
    • Contact with infected saliva or throat secretions
    • Sharing utensils, cups, or toys
    • Close physical contact

Viral Pathogenesis

  • Initial infection: Virus enters through oral or nasal mucosa
  • Local replication: Virus multiplies in pharyngeal and intestinal tissues
  • Viremia: Virus spreads through bloodstream
  • Target organ involvement: Primarily affects oral and pharyngeal tissues
  • Immune response: Leads to characteristic vesicular lesions

Environmental Factors

  • Seasonal variation:
    • Peak incidence in summer and early fall
    • Related to enterovirus seasonality
    • Higher transmission in warm, humid conditions
  • Geographic factors:
    • More common in temperate climates
    • Outbreak patterns vary by region
    • Different viral serotypes predominate in different areas

Risk Factors

Several factors increase the likelihood of developing herpangina, with age being the most significant risk factor. Understanding these factors helps in prevention and early recognition.

Age-Related Risk Factors

  • Peak age group: 6 months to 4 years
    • Highest incidence in toddlers (1-3 years)
    • Maternal antibodies protect infants under 6 months
    • Developing immune system in young children
  • Secondary peak: School-age children (5-10 years)
  • Adult cases: Less common but can occur

Environmental and Social Risk Factors

  • Daycare attendance:
    • High transmission rate in group settings
    • Close contact with multiple children
    • Shared toys and eating utensils
  • Large family size: More siblings increase exposure risk
  • Crowded living conditions: Facilitates person-to-person transmission
  • Poor hygiene practices: Inadequate handwashing

Seasonal and Geographic Factors

  • Summer and early fall months: Peak transmission season
  • Warm, humid climates: Favor enterovirus survival
  • Epidemic years: Cyclical outbreaks every 2-3 years
  • Travel to endemic areas: Increased exposure risk

Host Factors

  • Immunocompromised state:
    • Primary immunodeficiencies
    • Chronic illness requiring immunosuppression
    • Malnutrition
  • Previous enterovirus infections: May provide cross-protection or predispose to reinfection
  • Lack of prior exposure: No specific immunity to causative virus

Behavioral Risk Factors

  • Close contact activities: Playing, sharing food, kissing
  • Poor hand hygiene: Not washing hands after toileting or before eating
  • Oral habits: Thumb sucking, putting objects in mouth
  • Sharing personal items: Cups, utensils, toothbrushes

Diagnosis

The diagnosis of herpangina is primarily clinical, based on the characteristic presentation of fever, sore throat, and distinctive oral lesions. Laboratory testing is typically not necessary for typical cases.

Clinical Diagnosis

  • History: Acute onset fever, sore throat, difficulty swallowing
  • Physical examination: Characteristic oral lesions in typical locations
  • Seasonal timing: Summer/early fall presentation
  • Age group: Young children most commonly affected

Characteristic Physical Findings

  • Oral lesions:
    • Small (1-2 mm) gray-white vesicles with red halos
    • Located on posterior pharynx, soft palate, uvula
    • Usually 2-6 lesions total
    • Progress to shallow ulcers within 24-48 hours
  • Associated findings:
    • Fever (often high-grade)
    • Pharyngeal erythema
    • Cervical lymphadenopathy
    • General appearance of illness

Laboratory Testing

  • Usually not necessary for typical cases
  • Consider when indicated:
    • Atypical presentation
    • Immunocompromised patient
    • Outbreak investigation
    • Severe or prolonged illness
  • Available tests:
    • Viral culture (gold standard but slow)
    • PCR testing (rapid, specific)
    • Antigen detection (less sensitive)

Differential Diagnosis

  • Hand, foot, and mouth disease:
    • Also caused by enteroviruses
    • Lesions on hands, feet, and buttocks
    • Oral lesions more anteriorly located
  • Herpes simplex gingivostomatitis:
    • Lesions on lips, gums, tongue
    • More extensive oral involvement
    • Longer duration of illness
  • Aphthous stomatitis:
    • Recurrent, painful oral ulcers
    • No associated fever
    • Different lesion characteristics
  • Streptococcal pharyngitis:
    • No characteristic oral lesions
    • May have tonsillar exudate
    • Rapid strep test helpful

Treatment Options

Treatment of herpangina is primarily supportive, focusing on symptom relief and preventing complications. There is no specific antiviral therapy for enterovirus infections causing herpangina.

Symptomatic Treatment

  • Fever management:
    • Acetaminophen for pain and fever
    • Ibuprofen for children over 6 months
    • Avoid aspirin in children due to Reye's syndrome risk
  • Pain relief:
    • Topical anesthetics (lidocaine, benzocaine)
    • Oral pain medications as above
    • Cold foods and drinks for comfort

Hydration and Nutrition

  • Fluid intake:
    • Encourage frequent small sips
    • Cool, non-acidic fluids preferred
    • Popsicles, ice chips, cold milk
    • Avoid citrus juices and hot beverages
  • Dietary modifications:
    • Soft, bland foods
    • Avoid spicy, acidic, or rough-textured foods
    • Cold foods may be more tolerable
    • Maintain nutrition with acceptable foods

Topical Treatments

  • Mouth rinses:
    • Salt water rinses for older children
    • Antacid rinses (Maalox/Mylanta mixture)
    • Commercial oral pain relief gels
  • Anesthetic agents:
    • Viscous lidocaine (use carefully in young children)
    • Benzocaine-containing products
    • Natural remedies like honey (over 1 year old)

Supportive Care

  • Rest: Adequate sleep and reduced activity
  • Comfort measures: Cool mist humidifier, soft lighting
  • Monitoring: Watch for signs of dehydration or complications
  • Isolation: Keep child home until fever-free for 24 hours

When to Consider Hospitalization

  • Dehydration: Unable to maintain adequate fluid intake
  • Severe illness: High fever, lethargy, signs of complications
  • Immunocompromised patients: Higher risk of complications
  • Very young infants: Under 3 months with fever

Duration of Treatment

  • Fever: Usually resolves in 3-4 days
  • Oral lesions: Heal within 7-10 days
  • Full recovery: Expected within 1-2 weeks
  • Return to activities: When fever-free and feeling well

Prevention

Prevention of herpangina focuses on reducing transmission through good hygiene practices and limiting exposure to infected individuals, especially during peak seasons.

Personal Hygiene Measures

  • Hand hygiene:
    • Frequent handwashing with soap and water
    • Use alcohol-based hand sanitizer when soap unavailable
    • Wash hands after using bathroom, before eating
    • Teach children proper handwashing technique
  • Respiratory etiquette:
    • Cover coughs and sneezes with tissue or elbow
    • Dispose of tissues immediately
    • Avoid touching face with unwashed hands

Environmental Measures

  • Surface cleaning:
    • Regular disinfection of frequently touched surfaces
    • Clean toys, doorknobs, light switches daily
    • Use EPA-approved disinfectants effective against viruses
  • Avoid sharing:
    • Personal items: cups, utensils, toothbrushes
    • Food and drinks
    • Toys that go in mouth (in group settings)

Social Measures

  • Isolation of sick individuals:
    • Keep children home when ill
    • Stay home until fever-free for 24 hours
    • Limit contact with vulnerable individuals
  • Daycare and school policies:
    • Exclusion policies for symptomatic children
    • Enhanced cleaning during outbreaks
    • Parent education about symptoms

High-Risk Period Precautions

  • Summer and fall months: Increased vigilance during peak season
  • Outbreak situations: Enhanced prevention measures
  • Travel precautions: Extra hygiene when traveling

When to See a Doctor

Seek immediate emergency care for:

  • Signs of severe dehydration: no tears when crying, dry mouth, sunken eyes
  • Difficulty breathing or rapid breathing
  • Severe lethargy or difficulty waking up
  • Signs of meningitis: severe headache, neck stiffness, light sensitivity
  • High fever (over 104°F/40°C) not responding to medication

Schedule urgent appointment for:

  • Persistent high fever for more than 3 days
  • Severe sore throat preventing swallowing
  • Signs of dehydration: decreased urination, excessive thirst
  • Worsening mouth ulcers or signs of secondary infection
  • Unusual behavior or extreme irritability

Routine consultation recommended for:

  • Confirmation of diagnosis in unclear cases
  • First episode in very young infants (under 6 months)
  • Children with underlying medical conditions
  • Parents concerned about decreased appetite or fluid intake
  • Questions about return to daycare or school
  • Recurrent episodes or atypical presentation

Related Conditions

References

  1. American Academy of Pediatrics. Enterovirus (nonpoliovirus) infections. In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st ed. Itasca, IL: American Academy of Pediatrics; 2018:329-334.
  2. Zaoutis T, Klein JD. Enterovirus infections. Pediatr Rev. 1998;19(6):183-191.
  3. Amir J. Clinical aspects and antiviral therapy in primary herpetic gingivostomatitis. Paediatr Drugs. 2001;3(8):593-597.
  4. Tebruegge M, Curtis N. Enterovirus infections in neonates. Semin Fetal Neonatal Med. 2009;14(4):222-227.
  5. Modlin JF. Perinatal echovirus infection: insights from a literature review of 61 cases of serious infection and 16 outbreaks in nurseries. Rev Infect Dis. 1986;8(6):918-926.