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Herpangina Clinical Presentation

  • Author: Sandra G Gompf, MD, FACP, FIDSA; Chief Editor: Michael Stuart Bronze, MD  more...
 
Updated: Sep 02, 2015
 

History

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

All enteroviral infections may cause fever, which may be the first apparent symptom. Patients with enteroviral infection typically develop a temperature of 101-104°F.

Most symptomatic patients report malaise.

Sore throat and pain upon swallowing may develop and precedes the development of the enanthem by a few hours to one day.

Older children frequently report headache and backache.

Persons with enteroviral infection may experience anorexia, emesis, or abdominal pain, which may mimic appendicitis.

Infants with enteroviral infection may appear listless.

Exanthem: Characteristics and occurrence rates vary, depending on the viral subtype. Persons with enteroviral infection may develop a rash that is not pruritic and that does not cause skin desquamation. The following are other rash characteristics:

  • Macular
  • Maculopapular
  • Papulopustular
  • Papulovesicular
  • Vesicular
  • Morbilliform
  • Urticarial
  • Petechial
  • Hemangiomalike

Epidemics of enterovirus 71 complicated by encephalomyelitis, nonpolio paralytic disease, and central nervous system sequelae emerged in the late 1990s, especially affecting Southeast Asia.[5, 4] In addition to the above, history may include the following:

  • Headache
  • Neck stiffness with anterior flexion
  • Confusion or altered personality
  • Seizures
  • Muscular weakness
  • Poliolike paralysis
  • Difficulty in breathing
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Physical

See the list below:

  • Oropharyngeal lesions (herpangina)
    • Hyperemia of the pharynx is associated with lesions that characteristically appear as discrete erythematous-based macules. These evolve into papules that vesiculate and then ulcerate centrally, creating an erythematous halo.
    • In most cases, these lesions are the first physical finding of herpangina. The lesions are typically smaller than 5 mm in diameter. Most cases of herpangina involve 2-12 lesions.
    • Uninvolved portions of the pharynx usually appear normal. The most commonly affected structures include the anterior pillars of the fauces, soft palate, uvula, tonsils, and posterior pharyngeal wall.
    • Occasionally, lesions caused by herpangina appear on the tongue and posterior buccal mucosa (see Table for differential diagnoses of oral lesions).
    • The ulcers may persist for up to one week, even after 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, and/or exanthem.
  • Bilateral, anterior, cervical lymphadenopathy may develop.
  • Acute lymphonodular pharyngitis is a variant of herpangina associated with coxsackievirus A10 infection. Tiny nodules of packed lymphocytes develop in the same distribution as herpangina oropharyngeal lesions. However, unlike the lesions of herpangina, these recede without vesiculation or ulceration. [10]
  • Encephalitis, meningitis, and myelitis associated with enterovirus 71: In addition to herpangina, altered sensorium, muscular weakness, poliolike paralysis, and seizures have been recorded.
  • Brainstem encephalomyelitis with Enterovirus 71: Rare sudden cardiopulmonary collapse with noncardiogenic pulmonary edema has been reported with Enterovirus 71 in Southeast Asia, associated with minimal neurologic symptoms. Extensive damage to medulla and pons has been found on postmortem examination.
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Causes

Coxsackieviruses A 1-10, 12, 16, and 22 represent the most common pathogens that cause herpangina.

Less-common causes of herpangina include the following:

  • Coxsackievirus B 1-5
  • Echovirus 3, 6, 9, 11, 16, 17, 22, 25, and 30
  • Enterovirus 71 (see Pathophysiology)
  • Parechovirus 1
  • Herpes simplex virus
  • Adenovirus
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Contributor Information and Disclosures
Author

Sandra G Gompf, MD, FACP, FIDSA Associate Professor of Infectious Diseases and International Medicine, University of South Florida College of Medicine; Chief, Infectious Diseases Section, Director, Occupational Health and Infection Control Programs, James A Haley Veterans Hospital

Sandra G Gompf, MD, FACP, FIDSA is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Coauthor(s)

Burke A Cunha, MD Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Beata Catherine Casanas, DO Associate Professor, Department of Internal Medicine, Division of Infectious Diseases and International Medicine, University of South Florida College of Medicine

Beata Catherine Casanas, DO is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, American Medical Association, American Osteopathic Association, Florida Medical Association, Infectious Diseases Society of America

Disclosure: Received honoraria from ViiV for speaking and teaching; Received honoraria from Pfizer for speaking and teaching.

Moise Carrington, MD Physician, Internal Medicine, Infectious Diseases Specialty

Moise Carrington, MD is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, Oklahoma State Medical Association, Southern Society for Clinical Investigation, Association of Professors of Medicine, American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

Thomas E Herchline, MD Professor of Medicine, Wright State University, Boonshoft School of Medicine; Medical Director, Public Health, Dayton and Montgomery County, Ohio

Thomas E Herchline, MD is a member of the following medical societies: Alpha Omega Alpha, Infectious Diseases Society of Ohio, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

References
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  2. Cherry JD, et al. Herpangina. Textbook of Pediatric Infectious Diseases. 6th ed. 2009. Vol 1: Chap 11.

  3. Chen KT, Chang HL, Wang ST, Cheng YT, Yang JY. Epidemiologic features of hand-foot-mouth disease and herpangina caused by enterovirus 71 in Taiwan, 1998-2005. Pediatrics. 2007 Aug. 120(2):e244-52. [Medline].

  4. Tsai JD, Kuo HT, Chen SM, Lue KH, Sheu JN. Neurological Images and the Predictors for Neurological Sequelae of Epidemic Herpangina/Hand-Foot-Mouth Disease with Encephalomyelitis. Neuropediatrics. 2013 Nov 20. [Medline].

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Coxsackievirus B4 virions under electron microscopy. (This image is in the public domain and thus free of any copyright restrictions. Content provider: Centers for Disease Control and Prevention)
Table 1. Clinical Manifestations of Herpangina, Herpes Simplex Virus (HSV), and Hand-Foot-and-Mouth Disease
Clinical Manifestations Herpangina HSV Hand-Foot-and-Mouth Disease
 



Causative organism



 



Enteroviruses



 



HSV-1 and HSV-2



 



Enteroviruses



 



Oral vesicular/ulcerative lesions



 



+



 



+



 



+1



 



Anterior pharynx



 



-



 



+



 



+



 



Posterior pharynx



 



+



 



+/-



 



-



 



Gingivostomatitis



 



-



 



+/-



 



-



1 Lesions may also occur on the buccal



mucosa



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