Herpangina Clinical Presentation

Updated: Aug 24, 2018
  • Author: Sandra G Gompf, MD, FACP, FIDSA; Chief Editor: Michael Stuart Bronze, MD  more...
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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



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.



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