Can herpangina occur with a single ulcer at the soft palate?

Herpangina and Single Ulcer at the Soft Palate

Herpangina can present with a single ulcer at the soft palate, although it typically presents with multiple small vesicles or ulcers in the posterior oropharynx. 1, 2

Clinical Presentation of Herpangina

• Herpangina is an acute viral infection primarily caused by enteroviruses, particularly Coxsackie A viruses, and is typically spread by respiratory droplets 1, 2
• Classical presentation includes multiple small (2-4 mm) vesicles or ulcers with erythematous halos on the soft palate, anterior tonsillar pillars, uvula, or posterior pharynx 1
• However, atypical presentations with fewer lesions, including single ulcers, can occur, especially in the early stages of infection 2
• The infection predominantly affects children but can occur in adults as well 1

Diagnostic Considerations for Single Palatal Ulcers

• When evaluating a single ulcer on the soft palate, several diagnostic possibilities should be considered beyond herpangina 3, 4:
  • Recurrent aphthous ulceration (RAU) - typically well-demarcated with yellow/white base and erythematous border 5
  • Traumatic ulceration - often related to local trauma from sharp food, dental appliances, or iatrogenic causes 5
  • Herpes simplex virus (HSV) infection - can present with single or multiple ulcers 6, 7
  • Other infectious causes (bacterial, fungal) 3
  • Malignancy (especially in chronic, non-healing ulcers) 4

Diagnostic Approach for Single Palatal Ulcers

Initial Assessment

• Document the duration, size, shape, and specific location of the ulcer 3
• Assess for associated symptoms such as fever, sore throat, or systemic symptoms 1
• Evaluate for a history of recent viral illness or exposure to infected individuals 2

Laboratory Testing

• For persistent ulcers (>2 weeks), consider the following tests 8, 3:
  • Full blood count to rule out blood disorders 8
  • PCR testing of lesion can confirm enterovirus infection in suspected herpangina 1
  • Viral culture may help identify the specific viral etiology 6

When to Consider Biopsy

• Biopsy is indicated when the ulcer persists beyond 2 weeks despite treatment 3
• For single ulcers with atypical features or in high-risk patients (smokers, alcohol users, immunocompromised), biopsy should be considered earlier to rule out malignancy 4

Management Considerations

• Herpangina is typically self-limiting, with lesions resolving within 7-10 days 2
• Supportive care includes:
  • Adequate hydration 1
  • Soft, non-irritating diet 1
  • Topical anesthetics for pain relief 1
• In confirmed cases of herpangina, antiviral medications are generally not indicated as the causative agents are enteroviruses, not herpes viruses 1, 2

Important Clinical Pitfalls

• Misdiagnosing a single ulcer as aphthous when it could be early herpangina or another condition 5
• Failing to consider HSV-2 as a potential cause of oral ulceration, as it can cause oro-labial lesions despite being traditionally associated with genital disease 7
• Overlooking systemic conditions that may present with oral ulceration 3
• Treating symptoms without establishing a definitive diagnosis for persistent ulcers 3

When to Refer

• If the ulcer persists beyond 2 weeks despite symptomatic treatment 3
• If there are multiple recurrences without clear etiology 3
• If there are signs of systemic illness accompanying the oral ulceration 3
• If malignancy is suspected based on clinical features or patient risk factors 4