What are the causes and management of viral herpangina?

Viral Herpangina: Causes and Management

Etiology of Herpangina

Herpangina is primarily caused by enteroviruses, with Coxsackievirus A being the predominant pathogen. The main causative agents include:

• Coxsackievirus A (particularly serotypes A2, A4, A6, and A10) is the most common cause of herpangina 1, 2, 3
• Enterovirus A and Echovirus are also significant pathogens 1, 4
• Other enteroviruses may occasionally cause herpangina as part of the clinical spectrum of enteroviral infections 4

The disease is characterized by:

• Multiple vesicular or ulcerative lesions on the tonsils and soft palate 1, 2
• Primarily affects young children, though can occur in any age group 1, 4
• Seasonal pattern with peak incidence during summer and fall months 4, 5

Clinical Presentation

Herpangina presents with distinctive clinical features:

• Sudden onset of fever (observed in approximately 80% of cases) 3
• Sore throat and painful swallowing 1
• Characteristic vesicular or ulcerative lesions on the posterior pharynx, soft palate, tonsils, and uvula 1, 2
• The lesions typically appear as small (2-4mm) grayish papules that evolve into shallow ulcers with erythematous halos 1
• Symptoms may include headache, loss of appetite, and malaise 1, 4
• Disease course typically lasts 4-6 days with good prognosis 1

Diagnosis

Diagnosis of herpangina is primarily clinical and should include:

• Epidemiological history, especially during outbreak seasons or exposure to infected individuals 1, 5
• Identification of characteristic pharyngeal lesions 1, 2
• Virological testing when necessary, including:
  • RT-PCR of throat or buccal specimens for enterovirus detection 2, 3
  • Viral culture from throat swabs 6

Differential diagnosis should consider:

• Other viral infections such as herpes simplex virus (HSV) infection 6
• Hand, foot, and mouth disease (which may co-occur with herpangina) 3, 5
• Bacterial pharyngitis 6
• Aphthous stomatitis 6

Management

Treatment of herpangina is primarily supportive as the disease is typically self-limiting:

• Symptomatic relief measures:

  • Adequate hydration and soft diet to minimize pain during swallowing 1
  • Antipyretics for fever management 1
  • Topical oral sprays or rinses for pain relief 1

• Antiviral medications:

  • While specific antiviral therapy targeting enteroviruses is limited, topical oral sprays with antiviral properties may provide symptomatic relief 1
  • Systemic antivirals used for herpes simplex virus (acyclovir, valacyclovir, famciclovir) are NOT effective against enteroviruses causing herpangina 6

• Monitoring for complications:

  • Most cases resolve without complications within 4-6 days 1
  • Rare complications may include dehydration due to painful swallowing 1

Prevention

Preventive measures are crucial to limit transmission:

• Hand hygiene is the most effective preventive strategy:

  • Regular and thorough hand-washing significantly reduces risk of infection 5
  • A study showed that good hand-washing practices reduced the risk of herpangina and HFMD by over 99% 5

• Social distancing during outbreaks:

  • Avoiding crowded places reduces risk (OR: 7.3) 5
  • Limiting contact with neighborhood children during outbreaks (playing with neighborhood children increased risk with OR: 11) 5

• Avoiding healthcare facilities when not necessary:

  • Visiting outpatient clinics increased risk significantly (OR: 20) 5

• Proper disinfection of contaminated surfaces and items 1

• Isolation of infected individuals, particularly in childcare settings 1, 5

Special Considerations

• Immunocompromised patients may experience more severe or prolonged symptoms 6
• Herpangina should be distinguished from herpetic gingivostomatitis (caused by HSV), which requires different management 6
• During outbreaks, surveillance and reporting to public health authorities may be warranted 1, 3