Herpangina Workup

  • Author: Sandra G Gompf, MD, FACP, FIDSA; Chief Editor: Michael Stuart Bronze, MD   more...
 
Updated: Apr 17, 2012
 

Laboratory Studies

Herpangina is a clinical diagnosis. Laboratory studies are generally not indicated because herpangina 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)
    • Age
    • Exposure history
    • Clinical symptoms
  • The WBC count is usually within the reference range.
  • Isolation of enterovirus in cell culture remains the criterion standard for diagnosis.[7] To isolate the virus, obtain cultures from swabs of the nasopharynx. Other specimens that may produce an isolate include stool and rectal swabs, urine, serum, and CSF.
  • Serum antibodies to 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 enteroviral RNA of the throat, blood, CSF, urine, feces, and tissue specimens.
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Histologic Findings

No histopathologic findings are specific to herpangina.

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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 and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Coauthor(s)

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, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

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.

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, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Specialty Editor Board

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 America, and Infectious Diseases Society of Ohio

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

Ronald A Greenfield, MD  Professor, Department of Internal Medicine, University of Oklahoma College of Medicine

Ronald A Greenfield, MD is a member of the following medical societies: American College of Physicians, American Federation for Medical Research, American Society for Microbiology, Central Society for Clinical Research, Infectious Diseases Society of America, Medical Mycology Society of the Americas, Phi Beta Kappa, Southern Society for Clinical Investigation, and Southwestern Association of Clinical Microbiology

Disclosure: Pfizer Honoraria Speaking and teaching; Gilead Honoraria Speaking and teaching; Ortho McNeil Honoraria Speaking and teaching; Abbott Honoraria Speaking and teaching; Astellas Honoraria Speaking and teaching; Cubist Honoraria Speaking and teaching; Forest Pharmaceuticals Speaking and teaching

Eleftherios Mylonakis, MD  Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital

Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

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

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

Disclosure: Nothing to disclose.

References

  1. Mandell GL, et al. Enteroviruses. In: Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. Vol 1. 7th ed. 2010:817-818.

  2. Cherry JD, et al. Herpangina. In: Textbook of Pediatric Infectious Diseases. Vol 1. 6th ed. 2009: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. Aug 2007;120(2):e244-52. [Medline].

  4. Sano T, Saito T, Kondo M, Watanabe S, Onoue Y, Konnai M, et al. Enterovirus detection status of patients with herpangina and hand, foot and mouth disease in epidemic season 2007, Kanagawa Prefecture, Japan. Jpn J Infect Dis. Mar 2008;61(2):162-3. [Medline].

  5. Chen YH, Lin HC, Lin HC. Increased risk of adverse pregnancy outcomes among women affected by herpangina. Am J Obstet Gynecol. Jul 2010;203(1):49.e1-7. [Medline].

  6. Mandell GL, et al. Herpangina. In: Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. Vol 2. 7th ed. 2010:2355-56.

  7. Wang SM, Liu CC. Enterovirus 71: epidemiology, pathogenesis and management. Expert Rev Anti Infect Ther. Aug 2009;7(6):735-42. [Medline].

  8. Li C, Wang H, Shih SR, et al. The efficacy of viral capsid inhibitors in human enterovirus infection and associated diseases. Curr Med Chem. 2007;14(8):847-56. [Medline].

  9. Ruan F, Yang T, Ma H, Jin Y, Song S, Fontaine RE, et al. Risk factors for hand, foot, and mouth disease and herpangina and the preventive effect of hand-washing. Pediatrics. Apr 2011;127(4):e898-904. [Medline].

  10. Chen HL, Huang JY, Chu TW, Tsai TC, Hung CM, Lin CC, et al. Expression of VP1 protein in the milk of transgenic mice: a potential oral vaccine protects against enterovirus 71 infection. Vaccine. Jun 2 2008;26(23):2882-9. [Medline].

  11. Chang LY, King CC, Hsu KH, et al. 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].

  12. Chawareewong S, Kiangsiri S, Lokaphadhana K, et al. Neonatal herpangina caused by Coxsackie A-5 virus. J Pediatr. Sep 1978;93(3):492-4. [Medline].

  13. Cherry JD. Enteroviruses: Coxsackieviruses, Echoviruses, and Polioviruses. In: Textbook of Pediatric Infectious Diseases. Vol. 2. 1998:1787-1839.

  14. 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].

  15. Christie AB. Enteroviral infections (Coxsackieviruses and echoviruses). In: Infectious Diseases: Epidemiology and Clinical Practice. 1987:753-81.

  16. Delaney JE, Keels, MA. Soft tissue lesions of the oral cavity in children. UpToDate. Available at www.uptodate.com. Accessed November 10, 2009.

  17. Foo DG, Alonso S, Phoon MC, Ramachandran NP, Chow VT, Poh CL. Identification of neutralizing linear epitopes from the VP1 capsid protein of Enterovirus 71 using synthetic peptides. Virus Res. Apr 2007;125(1):61-8. [Medline].

  18. Haskell R. Oral vesiculo-bullous lesions. J Laryngol Otol. Jan 1976;90(1):101-4. [Medline].

  19. Ho M, Chen ER, Hsu KH, et al. An epidemic of enterovirus 71 infection in Taiwan. Taiwan Enterovirus Epidemic Working Group. N Engl J Med. Sep 23 1999;341(13):929-35. [Medline].

  20. Kung CM, King CC, Lee CN, et al. Differences in replication capacity between enterovirus 71 isolates obtained from patients with encephalitis and those obtained from patients with herpangina in Taiwan. J Med Virol. Jan 2007;79(1):60-8. [Medline].

  21. 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. [Medline].

  22. Melnick JL. Enteroviruses: Polioviruses, Coxsackieviruses, Echoviruses, and Newer Enteroviruses. In: Field's Virology. 1990:549-98.

  23. Miyazawa I, Azegami Y, Kasuo S, Yoshida T, Kobayashi M, Shiraishi T. Prevalence of enterovirus from patients with herpangina and hand, foot and mouth disease in Nagano Prefecture, Japan, 2007. Jpn J Infect Dis. May 2008;61(3):247-8. [Medline].

  24. Modlin JF. Clinical manifestation and diagnosis of enterovirus infections. UpToDate. Available at www.uptodate.com. Accessed November 10, 2009.

  25. Rosenblatt RM, Domb GH. Herpangina in an anesthesiologist. Anesth Analg. May 1980;59(5):384-5. [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. Clinical Manifestations of Herpangina, Herpes Simplex Virus (HSV), and Hand-Foot-and-Mouth Disease
Clinical ManifestationsHerpanginaHSVHand-Foot-and-Mouth Disease
Causative organismEnterovirusesHSV-1 and HSV-2Enteroviruses
Oral vesicular/ulcerative lesions+++1
Anterior pharynx-++
Posterior pharynx++/--
Gingivostomatitis-+/--
1 Lesions may also occur on the buccal



mucosa



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