What are the presentation, diagnosis, and management of herpangia in children?

Herpangina in Children

Overview

Herpangina is a self-limited enteroviral infection characterized by acute fever and distinctive vesicular-ulcerative lesions on the posterior pharynx, soft palate, and tonsillar pillars, primarily affecting children under 5 years of age. 1

Clinical Presentation

Characteristic Features

• Acute onset of fever (often high-grade) accompanied by sore throat, odynophagia, and refusal to eat 1
• Pathognomonic oral lesions: Small vesicles (1-2mm) that rapidly evolve into shallow ulcers with erythematous halos, strictly localized to the posterior oropharynx (soft palate, uvula, tonsillar pillars, posterior pharyngeal wall) 1
• Spares the anterior oral structures (gingiva, buccal mucosa, tongue, lips)—this distribution distinguishes herpangina from primary HSV gingivostomatitis 2, 3
• Tender submandibular or cervical lymphadenopathy may be present 1
• Systemic symptoms: irritability, decreased oral intake, occasional vomiting 1

Age Distribution

• Peak incidence in children 1-4 years old, with 84% of cases occurring in children ≤4 years 4
• Summer seasonality with epidemic peaks in July-August 5, 4

Etiology

Causative Pathogens

• Coxsackievirus A is the predominant cause, particularly serotypes A2, A4, A6, and A10 1, 5, 6
• Coxsackievirus A2 was the most prevalent pathogen in recent Chinese outbreaks (61-65% of herpangina cases) 5, 6
• Other implicated serotypes: Coxsackievirus B2, B4, Echovirus 30, and Enterovirus A 1, 5
• Enterovirus 71 (EV71) rarely causes herpangina—when EV71 is detected, it predominantly causes hand-foot-and-mouth disease (HFMD) with or without neurological complications 6

Transmission

• Fecal-oral route and respiratory droplet spread 5
• Highly contagious with peak viral shedding in the first 24 hours of lesion appearance 3

Diagnosis

Clinical Diagnosis

The diagnosis is primarily clinical, based on the triad of: 1

1. Epidemiological context (summer outbreak, exposure to infected contacts)
2. Characteristic posterior pharyngeal vesicles/ulcers
3. Acute febrile illness in a young child

Laboratory Confirmation

Laboratory testing is not routinely required for typical presentations but should be considered when: 3, 1

• Clinical presentation is atypical or uncertain
• Severe systemic illness or complications develop
• Patient is immunocompromised
• Outbreak investigation or surveillance purposes

Diagnostic methods when indicated: 1, 6

• Real-time RT-PCR from throat swabs (most sensitive, 71-86% detection rate) 6
• Viral culture (less sensitive but allows serotype identification) 1
• Direct immunofluorescence or antigen detection 3

Critical Differential Diagnoses

Primary HSV-1 gingivostomatitis is the most important alternative diagnosis: 2, 7, 3

• Affects anterior oral structures (gingiva, buccal mucosa, lips, perioral skin)
• More severe pain and longer duration (12 days vs 4-6 days)
• Prominent gingivitis with bleeding gums
• Larger, more painful ulcers
• May have labial vesicles ("cold sores")
• Requires antiviral therapy with acyclovir

Hand-foot-and-mouth disease (HFMD): 3, 6

• Caused by EV71 or Coxsackievirus A16
• Oral lesions plus characteristic vesicles on palms, soles, buttocks
• Higher risk of neurological complications (especially EV71)

Other considerations: 3

• Varicella: generalized vesicular rash in multiple stages, not limited to oropharynx
• Diphtheria: grayish adherent pseudomembrane that bleeds when removed, predominantly pharyngeal
• Behçet's syndrome: recurrent aphthous ulcers without preceding vesicles

Management

Supportive Care (Mainstay of Treatment)

Treatment is entirely symptomatic as herpangina is self-limited with excellent prognosis. 1

Pain and fever management: 1

• Acetaminophen or ibuprofen for fever and pain control
• Avoid aspirin in children due to Reye's syndrome risk

Oral care and hydration: 1

• Encourage cold fluids and soft foods
• Topical oral anesthetics (lidocaine-containing sprays) may provide temporary relief
• Maintain adequate hydration—monitor for dehydration in children refusing oral intake

Antiviral therapy is NOT indicated for uncomplicated herpangina 1

Expected Course

• Duration: 4-6 days with spontaneous resolution 1
• Fever typically resolves within 2-4 days
• Oral lesions heal without scarring by day 6-7

Indications for Urgent Evaluation

Seek immediate medical attention if: 2, 7

• Signs of dehydration (decreased urine output, dry mucous membranes, lethargy)
• Persistent high fever >3 days
• Severe irritability or altered mental status (concern for meningitis/encephalitis)
• Development of rash on palms/soles (suggests HFMD with potential EV71)
• Immunocompromised status
• Respiratory distress or neurological symptoms

Prevention

Infection Control Measures

• Hand hygiene is the most effective preventive measure 5
• Avoid sharing utensils, cups, or toys during outbreaks 5
• Exclude symptomatic children from daycare/school until fever resolves and oral intake is adequate 1
• Disinfect contaminated surfaces and fomites 5
• No vaccine is currently available 1

Key Clinical Pitfalls

Do not confuse herpangina with HSV gingivostomatitis—the anatomic distribution of lesions is the critical distinguishing feature, as HSV requires antiviral therapy while herpangina does not. 2, 3

Do not assume all enteroviral pharyngitis is benign—if vesicles extend beyond the oropharynx to include hands, feet, or buttocks, consider HFMD with potential for EV71-associated neurological complications requiring closer monitoring. 6

Do not overlook dehydration risk—young children with severe odynophagia may refuse all oral intake and require IV hydration. 1