Cause of Herpangina
Herpangina is caused by enteroviruses, most commonly Coxsackievirus A serotypes, with Coxsackievirus A2, A4, A6, and A10 being the predominant causative agents. 1, 2
Primary Causative Agents
The enterovirus family is responsible for herpangina, with specific serotypes identified as the main culprits:
- Coxsackievirus A serotypes are the classic and most frequent cause, particularly associated with the characteristic clinical pattern of herpangina 1, 2
- Coxsackievirus A2 has been documented as highly prevalent, accounting for 33.33% of cases in recent surveillance studies 3
- Coxsackievirus A4 represents another significant serotype, responsible for 15.8% of documented cases 3
- Coxsackievirus A6 and A10 have emerged as important causes of herpangina outbreaks, with A10 accounting for 39.9% and A6 for 28% of cases in European surveillance 4
Additional Enterovirus Serotypes
Beyond Coxsackievirus A, other enteroviruses can cause herpangina:
- Enterovirus A species members are frequently implicated 2, 4
- Echovirus serotypes have been identified as causative agents 2
- Coxsackievirus B viruses can occasionally cause herpangina, though they are more classically associated with epidemic myalgia (devil's grip) 1
Transmission and Epidemiology
Understanding the transmission pattern is critical for prevention:
- Respiratory droplet transmission is the primary mode of spread 5
- Fecal-oral route is also possible, as the human alimentary tract is the natural habitat for enteroviruses 1
- Young children are the primary affected population, with infections circulating predominantly in summer and fall 1, 2
- Incubation period typically ranges from 3-6 days before symptom onset 2
Clinical Implications
The enteroviral etiology has important clinical ramifications:
- Self-limited course lasting 4-6 days with good prognosis is typical 2
- Symptomatic treatment is the mainstay, as no specific antiviral therapy targets these enteroviruses effectively 2, 5
- Multiple serotypes can cause identical clinical presentations, making serotype-specific diagnosis less clinically relevant for management 1, 4
- Neurological complications are rare with herpangina-causing serotypes, unlike enterovirus 71 which poses greater risk 4
Important Distinction from Herpes Simplex
A critical pitfall to avoid is confusing herpangina with herpes simplex virus (HSV) infection:
- Despite the name "herpangina," this condition is NOT caused by herpes simplex virus 1, 2, 5
- HSV-1 causes oral herpes with different distribution (typically anterior mouth, lips, gingiva) and recurrent pattern at the same anatomical site 6, 7
- Herpangina lesions characteristically affect the posterior pharynx, soft palate, and tonsils 2, 5
- Enterovirus infections do not establish latency in nerve ganglia like HSV, so true recurrences at identical sites do not occur 1