Further Outpatient Care

Because symptoms associated with herpangina are usually short-lived and resolve within 1 week, patients generally do not need outpatient follow-up care.

Deterrence/Prevention

Enteroviruses are spread through the fecal-oral route; therefore, emphasis is placed on measures that may help reduce this mode of spread, especially hand hygiene. A Chinese study of risk factors for herpangina found increased risk posed by playing with neighborhood children, visiting an outpatient clinic within the week before onset of illness, and exposure to crowded public spaces. The same study found significant correlation of good hand hygiene practices with reduced incidence of disease. Low hand hygiene scores were found in 50% of cases versus 2.5% of controls; on the other hand, high hand hygiene scores were found in 12% of cases versus 78% of controls.^[21]

The development of a vaccine to eradicate enterovirus 71 has been a priority. Recently, preliminary results of several in vitro and animal studies are encouraging. In particular, VP1 capsid protein of enterovirus 71, identified as a potent inducer of neutralizing antibody titer, shows promise in the development of a potential vaccine.^[22]

Complications

Herpangina is a self-limited viral illness. Most cases resolve without complications. However, more severe enteroviral manifestations such as aseptic meningitis and neurological manifestations occur in very rare cases. Note a possible association of herpangina during pregnancy with low birth weight, small-for-gestational-age infants, or preterm delivery. See Mortality/Morbidity.

Prognosis

Except for rare cases in which herpangina is accompanied by more severe manifestations of enterovirus infection, herpangina carries an excellent prognosis.

Questions

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Cherry JD, et al. Herpangina. Textbook of Pediatric Infectious Diseases. 6th ed. 2009. Vol 1: Chap 11.
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Chang YK, Chen KH, Chen KT. Hand, foot and mouth disease and herpangina caused by enterovirus A71 infections: a review of enterovirus A71 molecular epidemiology, pathogenesis, and current vaccine development. Rev Inst Med Trop Sao Paulo. 2018 Nov 8. 60:e70. [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.
Takechi M, Fukushima W, Nakano T, Inui M, Ohfuji S, Kase T, et al. Nationwide Survey of Pediatric Inpatients With Hand, Foot, and Mouth Disease, Herpangina, and Associated Complications During an Epidemic Period in Japan: Estimated Number of Hospitalized Patients and Factors Associated With Severe Cases. J Epidemiol. 2019 Sep 5. 29:354-362. [QxMD MEDLINE Link]. [Full Text].
Kim B, Moon S, Bae GR, Lee H, Pai H, Oh SH. Factors associated with severe neurologic complications in patients with either hand-foot-mouth disease or herpangina: A nationwide observational study in South Korea, 2009-2014. PLoS One. 2018 Aug 10. 13:e0201726. [QxMD MEDLINE Link]. [Full Text].
Chang LY, Lin HY, Gau SS, Lu CY, Hsia SH, Huang YC, et al. Enterovirus A71 neurologic complications and long-term sequelae. J Biomed Sci. 2019 Aug 8. 26:57. [QxMD MEDLINE Link]. [Full Text].
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].
Li ML, Shih SR, Tolbert BS, Brewer G. Enterovirus A71 Vaccines. Vaccines (Basel). 2021 Feb 27. 9:199. [QxMD MEDLINE Link]. [Full Text].
Lin JY, Kung YA, Shih SR. Antivirals and vaccines for Enterovirus A71. J Biomed Sci. 2019 Sep 3. 26:65. [QxMD MEDLINE Link]. [Full Text].
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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; AbbVie; Insmed; ViiV/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.