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Herpangina

Sections Herpangina
Overview
Presentation
- History
- Physical
- Causes
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DDx
Workup
Treatment
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Questions & Answers
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Tables
References

DDx

Diagnostic Considerations

Table 1. Clinical Manifestations of Herpangina, Herpes Simplex Virus (HSV), and Hand-Foot-and-Mouth Disease (Open Table in a new window)

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

Differential Diagnoses

Workup

Chapter 174: Coxsackieviruses, Echoviruses, and Numbered Enteroviruses (EV-D68). Bennett JE, Dolin R, Blaser MJ. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases. 8th ed. Philadelphia, PA: Saunders, an imprint of Elsevier, Inc.; 2015. Vol 1: 2080-89.
Cherry JD, et al. Herpangina. Textbook of Pediatric Infectious Diseases. 6th ed. 2009. Vol 1: Chap 11.
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Choi CS, Choi YJ, Choi UY, et al. Clinical manifestations of CNS infections caused by enterovirus type 71. Korean J Pediatr. 2011 Jan. 54(1):11-6. [QxMD MEDLINE Link]. [Full Text].
Lee TC, Guo HR, Su HJ, Yang YC, Chang HL, Chen KT. Diseases caused by enterovirus 71 infection. Pediatr Infect Dis J. 2009 Oct. 28(10):904-10. [QxMD MEDLINE Link].
Chen YH, Lin HC, Lin HC. Increased risk of adverse pregnancy outcomes among women affected by herpangina. Am J Obstet Gynecol. 2010 Jul. 203(1):49.e1-7. [QxMD MEDLINE Link].
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. 2008 Mar. 61(2):162-3. [QxMD MEDLINE Link].
Chen YH, Lin HC, Lin HC. Increased risk of adverse pregnancy outcomes among women affected by herpangina. Am J Obstet Gynecol. 2010 Jul. 203(1):49.e1-7. [QxMD MEDLINE Link].
Mandell GL, et al. Herpangina. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases. 7th ed. 2010. Vol 2: 2355-56.
Wang SM, Liu CC. Enterovirus 71: epidemiology, pathogenesis and management. Expert Rev Anti Infect Ther. 2009 Aug. 7(6):735-42. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. 2011 Apr. 127(4):e898-904. [QxMD MEDLINE Link].
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. 2008 Jun 2. 26(23):2882-9. [QxMD MEDLINE Link].
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. 2002 Jun. 109(6):e88. [QxMD MEDLINE Link].
Chawareewong S, Kiangsiri S, Lokaphadhana K, et al. Neonatal herpangina caused by Coxsackie A-5 virus. J Pediatr. 1978 Sep. 93(3):492-4. [QxMD MEDLINE Link].
Cherry JD. Enteroviruses: Coxsackieviruses, Echoviruses, and Polioviruses. Textbook of Pediatric Infectious Diseases. 1998. Vol. 2: 1787-1839.
Chole RA, Domb GH. Differential diagnosis of superficial ulcerations of the oral mucosa. Otolaryngol Head Neck Surg. 1979 Nov-Dec. 87(6):734-40. [QxMD MEDLINE Link].
Christie AB. Enteroviral infections (Coxsackieviruses and echoviruses). Infectious Diseases: Epidemiology and Clinical Practice. 1987. 753-81.
Delaney JE, Keels, MA. Soft tissue lesions of the oral cavity in children. UpToDate. Available at http://www.uptodate.com. Accessed: November 10, 2009.
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. 2007 Apr. 125(1):61-8. [QxMD MEDLINE Link].
Haskell R. Oral vesiculo-bullous lesions. J Laryngol Otol. 1976 Jan. 90(1):101-4. [QxMD MEDLINE Link].
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. 1999 Sep 23. 341(13):929-35. [QxMD MEDLINE Link].
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. 2007 Jan. 79(1):60-8. [QxMD MEDLINE Link].
Lin TY, Chang LY, Hsia SH, et al. The 1998 enterovirus 71 outbreak in Taiwan: pathogenesis and management. Clin Infect Dis. 2002 May 1. 34 Suppl 2:S52-7. [QxMD MEDLINE Link].
Lum LC, Wong KT, Lam SK, et al. Fatal enterovirus 71 encephalomyelitis. J Pediatr. 1998 Dec. 133(6):795-8. [QxMD MEDLINE Link].
Melnick JL. Enteroviruses: Polioviruses, Coxsackieviruses, Echoviruses, and Newer Enteroviruses. Field's Virology. 1990. 549-98.
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. 2008 May. 61(3):247-8. [QxMD MEDLINE Link].
Modlin JF. Clinical manifestation and diagnosis of enterovirus infections. UpToDate. Available at http://www.uptodate.com. Accessed: November 10, 2009.
Rosenblatt RM, Domb GH. Herpangina in an anesthesiologist. Anesth Analg. 1980 May. 59(5):384-5. [QxMD MEDLINE Link].

Media Gallery

Coxsackievirus B4 virions under electron microscopy. Courtesy of Centers for Disease Control and Prevention (CDC).
Typical ulcerative enanthem of herpangina on the soft palate and posterior oropharynx. The lesions are usually exquisitely painful and make swallowing difficult. Ensuring adequate hydration in children is thus important. Courtesy of Wikimedia Commons/shawn c (https://commons.wikimedia.org/wiki/File:HFMD_soft_palete_oropharynx.jpg).
Typical flat vesicular exanthem of hand, foot, and mouth disease on a child's feet. The lesions may be slightly tender, and the rash often desquamates as it resolves. Courtesy of Wikimedia Commons/Ngufra (https://commons.wikimedia.org/wiki/File:Hand_foot_and_mouth_disease_on_child_feet.jpg).
Typical flat vesicular lesions of hand, foot, and mouth disease that may be associated with herpangina. The lesions may or may not be tender, and often resolve with desquamation. Courtesy of Wikimedia Commons/KlatschmohnAcker (https://commons.wikimedia.org/wiki/File:Hand_Foot_Mouth_Disease_Adult_36Years.jpg).

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Author

Sandra G Gompf, MD, FACP, FIDSA Professor of Infectious Disease and International Medicine, University of South Florida Morsani 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)

Beata Catherine Casanas, DO, FACP, FIDSA Associate Professor, Director of Infectious Disease Fellowship Program, Department of Internal Medicine, Division of Infectious Diseases and International Medicine, University of South Florida Morsani College of Medicine; Executive Medical Director, Hillsborough County Health Department

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

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Pfizer; Allergan; Insmed; GSK.

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; Fellow of the Royal College of Physicians, London

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, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Additional Contributors

Thomas E Herchline, MD Professor of Medicine, Wright State University, Boonshoft School of Medicine; Medical Consultant, Public Health, Dayton and Montgomery County (Ohio) Tuberculosis Clinic

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

Disclosure: Received research grant from: Regeneron.

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.

Herpangina Differential Diagnoses

Diagnostic Considerations

Differential Diagnoses

References

Tables

Contributor Information and Disclosures

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