What is the typical presentation of mucocutaneous Herpes Simplex Virus (HSV) in children?

Mucocutaneous HSV Presentation in Children

Outside the neonatal period, the most common presentation of mucocutaneous HSV in children is primary gingivostomatitis, characterized by fever, irritability, tender submandibular lymphadenopathy, and superficial painful ulcers affecting the gingival, oral mucosa, and perioral area. 1

Age-Specific Presentations

Neonatal Period (Birth to 3 months)

Three distinct clinical patterns occur:

• Localized skin, eye, and mouth disease (40% of cases): Vesicular lesions typically appear at 10-11 days of age, with vesicular rash present in approximately 80% of affected neonates 1
• CNS disease (35% of cases): Encephalitis presentation, though vesicular rash is present in only 60% of these infants 1
• Disseminated multiorgan disease (25% of cases): Usually appears at 9-11 days of age, with encephalitis occurring in 60-75% and vesicular rash present in only 60% 1

Critical pitfall: Absence of vesicular rash does not exclude serious HSV disease—40% of neonates with CNS or disseminated disease lack visible skin lesions. 1

Beyond Neonatal Period (>3 months)

Primary infection typically manifests as:

• Orolabial disease (most common): Fever, irritability, tender submandibular lymphadenopathy, and superficial painful ulcers involving gingival, oral mucosa, tongue, lips, buccal mucosa, hard and soft palate, and perioral areas 1, 2
• Incubation period: Approximately 1 week before mucocutaneous vesicular eruptions appear 2
• Lesion characteristics: Vesicles contain clear fluid with infectious viral particles that burst and form shallow ulcers with desquamation 3

Distribution patterns: HSV can affect any skin surface, including fingertips, genital areas, abdomen, and other body regions through autoinoculation from rubbing infected areas 3, 4

Immunocompromised Children

HIV-infected or otherwise immunocompromised children experience more severe manifestations:

• Severe local lesions: Episodes involving the entire oral cavity or extending across the face 5
• Frequent recurrences: 5-10% of children with AIDS and primary gingivostomatitis develop frequent recurrences with severe ulcerative disease and symptoms similar to primary infection 1
• Disseminated disease: Rare but can involve visceral organs (esophagus, CNS, genitals, liver, adrenals, lung, kidney, spleen, brain) with generalized skin lesions 1
• Prolonged viral shedding: More extended shedding with both primary and reactivation infections compared to immunocompetent children 1

Recurrent Infections

Reactivation disease presents differently:

• Herpes labialis: Vesiculo-ulcerative lesions at mucocutaneous junctions, particularly the lips, occurring at variable intervals 2
• Intraoral recurrence: Uncommon in otherwise healthy children but more extensive and aggressive in immunocompromised patients 2
• Neonatal recurrences: Even after successful treatment, neonates with skin lesions may have cutaneous recurrences during the first 6 months 1

Clinical Diagnosis

Diagnosis is based on:

• Typical appearance: Vesicles and ulcers with characteristic distribution 1
• Confirmatory testing: Viral culture from vesicular fluid (detectable within 1-3 days) or PCR provides definitive diagnosis 6, 5
• Multiple site cultures for neonates: Blood, skin vesicles, mouth/nasopharynx, eyes, urine, and stool/rectum; positive cultures >48 hours after birth indicate viral replication rather than intrapartum contamination 1, 3

Important caveat: Primary HSV-1 infections in children are often asymptomatic, so many cases go unrecognized. 2 The prevalence increases progressively from childhood, with seroprevalence inversely related to socioeconomic background. 2