Herpangina Symptoms and Signs
Sores or localized abnormalities inside the mouth can arise from a number of causes. Mouth sores can occur on the tongue, gums, lips, or inside the cheeks.
What is herpangina?
Herpangina is an acute, self-limited viral illness often seen in young children during the summer months. Affected children usually complain of mouth sores and fever. A number of viruses, all members of the Enterovirus family, cause herpangina. Coxsackievirus, a member of the Enterovirus family, is the most common cause of the infection. At the onset of symptoms, most children develop a high fever and complain of a sore throat. They then develop vesicles (blisters) or ulcers (sores) at the back of the throat and palate. Children, especially younger children, may refuse to eat or drink because of the pain and are at risk for developing signs and symptoms of dehydration.
What causes herpangina?
Several common members of the Coxsackie A virus family and a number of other enteroviruses (for example, enterovirus 71) can cause herpangina. The viruses are usually spread via the “fecal-oral route” (contamination of hands and other surfaces with fecal matter) or via the “respiratory route” (air droplets from coughing or sneezing). One can develop the illness from contact with either of these materials from an individual infected with one of these viruses. Interestingly, half of individuals infected with some of these Enterovirus family members remain asymptomatic (having no symptoms) which makes preventing transmission more difficult.
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Is herpangina contagious?
Coxsackievirus infections are extremely contagious and can easily pass from child to child through contaminated surfaces, unwashed hands, and through sneezing and coughing. Typically, people infected with the virus are most contagious during the first week of illness. Animals and home pets do not pass virus from person to person.
How long is the incubation period for herpangina?
The normal course of the infection involves an incubation period (the duration between exposure to the virus and development of symptoms) lasting anywhere from 1 to 2 weeks. The infected individual is generally thought to be contagious during the incubation period.
What are herpangina symptoms and signs?
Typically, children with herpangina have the following:
- Sore throat
- Small blisters and ulcers may cover the soft palate, uvula, tonsils, and posterior pharynx (the back part of the mouth). The rest of the mouth is normal in appearance. The gingiva (“gums”), buccal mucosa (inner cheek region) and tongue are not generally involved. These blisters can last for up to a week.
- Sometimes tender and enlarged lymph nodes along the neck (lymphadenopathy)
- Rash may or may not be present. A rash is relatively rare.
How do health care professionals diagnose herpangina?
Since herpangina is a clinical diagnosis, and the illness is self-limited, there is no real reason to perform any laboratory studies. Some children (hospitalized or immune-compromised for example) may have viral studies performed on specimens from the nose or throat. Isolating virus from these samples takes a long time, and generally, symptoms resolve long before the identification of the virus is available. It’s possible to measure antibodies to Coxsackievirus if desired, but that is generally unnecessary.
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What are treatment options and home remedies for herpangina?
Treatment is supportive, just like for most virus infections. Fever and pain control with acetaminophen (Tylenol) or ibuprofen (Advil/Motrin) are generally the primary treatments. It is important to keep children well hydrated as well, and often young children will be resistant to drinking or eating. The aptly named “magic mouthwash” is an alternative treatment used to control the mouth pain associated with herpangina. There are various recipes, but most include a topical pain medication such as viscous lidocaine, as well as some sort of additional liquids that function as a barrier. A child’s health care provider might prescribe one of these mixtures. These medications are designed either to be “swished” in the mouth or gargled. Drinking excessive lidocaine my affect the patient’s heart rhythm. Remember that since a virus causes herpangina, antibiotics have no role in the treatment, nor do any antiviral medications currently available. Many young patients find that a diet of cold, soft items provide a special treat and lessen their symptoms (if only by a placebo effect). Ice cream, smoothies, milk shakes, yogurt and frozen yogurt may all be helpful.
How long does herpangina last? What is the prognosis for herpangina?
The entire duration of the illness is usually four to seven days. The prognosis is usually excellent. Very rarely, younger patients may refuse to drink or eat and will require hospitalization for intravenous fluids for hydration. It is important to manage a young child’s pain to prevent this from occurring. Rarely, enteroviral infections can also cause viral or aseptic meningitis. These patients usually recover fully.
What is the difference between herpangina and hand, foot, and mouth disease?
Enteroviruses cause both herpangina and hand, foot, and mouth (HFM) disease. Both cause oral blisters and ulcers. Both conditions spread by the fecal-oral route or respiratory route (see above). The locations of the blisters differ, with HFM lesions occurring at the front of the mouth and herpangina lesions occurring at the back of the mouth. Approximately 75% of children with HFM also develop skin lesions on the palms and soles (as the name implies), but children with herpangina rarely develop any typical rashes. Both conditions may have infected individuals who never develop symptoms or signs.
What is the difference between herpangina and herpes simplex-1 (HSV-1)?
Herpes simplex 1 (HSV-1) infections are also very common in young children. Unlike herpangina, HSV-1 infections do not have a seasonal preference. Gingivostomatitis is another term for HSV-1 infection. The characteristic changes in the mouth are zones of multiple small (1-2 mm) vesicles with a surrounding 1-2 mm halo of inflamed tissue. Areas involved are more varied than seen in herpangina. HSV-1 infections commonly involve the buccal mucosa (inner cheek tissue), gingiva (gums), tongue (also known as “stomatitis”) and the hard and soft palate. Approximately 60% of infected people will develop lesions on the lips and adjacent skin, commonly known as “cold sores.”
Common characteristics shared by herpangina and HSV-1 infections include moderate fever, reduced appetite, headache, and malaise. The typical HSV-1 infection lasts for 7 to 10 days. Herpangina symptoms generally last for 4 to 7 days. While there are no antiviral drugs to treat herpangina, it’s possible to lessen HSV-1 infection symptoms if an individual starts oral acyclovir immediately upon developing early symptoms. Topical preparations of acyclovir are not helpful.
Is it possible to prevent herpangina?
Prevention of herpangina depends upon good hygiene (for example, frequent hand washing with soap and water and wearing gloves during diaper changing — especially at day care centers) and avoidance of individuals infected with Coxsackievirus. This is easier said than done, since as mentioned earlier, 50% of infected individuals remain asymptomatic. There is no vaccine.
Where can people find more information about herpangina?
“Non-Polio Enterovirus,” CDC
“Viral Exanthems,” Dermatology Online Journal
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Medically Reviewed on 8/9/2019
American Academy of Pediatrics. “Enteroviruses.” Red Book: 2018-2021 Report of the Committee on Infectious Diseases, 31st Ed. Eds. D.W. Kimberlin, M.T. Brady, M.A. Jackson, and S.S. Long. Elk Grove Village, IL: American Academy of Pediatrics, 2018: 331.
American Academy of Pediatrics. “Herpes Simplex.” Red Book: 2018-2021 Report of the Committee on Infectious Diseases, 31st Ed. Eds. D.W. Kimberlin, M.T. Brady, M.A. Jackson, and S.S. Long. Elk Grove Village, IL: American Academy of Pediatrics, 2018: 437.
Dyer, J.A. “Childhood Viral Exanthems.” Pediatric Annals. 36.1 Jan. 2007: 21-29.
Lee, T.C. “Diseases Caused by Enterovirus 71 Infection.” Ped Infect Dis J. 28.10 Oct. 2009: 904-910.