Herpangina is an infectious disease that is caused by Coxsackie virus group A. Other causes include Coxsackie virus group B, echovirus and other enterovirus. It is characterized by short duration of fever followed by typical vesicular or ulcerated lesions over posterior pharynx and soft palate. Posterior pharynx includes the pharynx, tonsils, soft palate and little involvement of the anterior 2/3 the mouth. Predominant age is between 3 months to 16 years and equal between males and females. The incidence is year around in the tropical climate while in temperate climate the incidence is high during summer and fall season.
Some clinical features that may be found are drooling saliva and anorexia due to poor oral intake. The child will complaint of sore throat and local pain. Fever will be short in duration. Other features are malaise, irritability, listlessness. Vomiting, backache, headache, diarrhea and coryza won’t be uncommon. Bilateral discrete vesicles (with gray base) will be found in the post pharynx and soft palate together with erythematous patches. Vesicles may rupture to form ulcer.
There are a few differential diagnosis that should be considered:
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Herpes simplex infection – Multiple ulcers are found over the lips and anterior mouth. Herpes culture will confirm the diagnosis.
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Drug reactions- in this particular case, cutaneous lesions like urticaria and erythema multiforme will almost always present.
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Recurrent aphtous stomatitis – mucosal ulcers are seen over the buccal area, labial and alveolar. Recurrent crops and few systemic symptoms may be present at the same time.
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Lichen planus – painful ulcer with white lacy pattern on the mucosa. The affected person also may have cutaneous lesions which are purple and itchy (pruritic).
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Hand, foot and mouth disease – classic distribution of vesicular rash on hands, buttocks, feet and mouth.
Some labaratory investigations need are full blood count where slight leucocytosis (<50%) noted. Positive viral culture from stool and mouth washings will confirm the diagnosis. Special tests available include complement fixation, hemaggluttinin inhibition tests and serum antibodies to coxsackie virus (titres should show a fourfold rise in serial samples).
In terms of management, herpangina may be treated as outpatient and no need hospital admission unless patient is severely affected and need intravenous fluid resuscitation. It usually self limited and treatment is mainly suuportive including rehydration. Some medications may be prescribed to these patients include analgesic for pain relief (acetaminophen or NSAIDs). Topical anesthetics may be useful particularly in children of young age. Mouthwash will be necessary . For example aqueous solution of 1% dyclonine and 1% diphenhydramine in 50% of attapulgite (Kaopectate). 2% viscous lidocaine solution also useful.
Seems that the risk factor is contact with the affected person, so, prevention is mainly avoid contact. Others are increase hygiene. Complications are rare, there are includes viral exanthema, aseptic meningitis, myocarditis and encephalitis. Prognosis are good where full recovery is expected.
Reference:
1) Griffith’s 5 minute clinical consult. Lippincott Williams and Wilkins. 2005.
