History

A complete and thorough history and physical examination is necessary to make the diagnosis and to exclude various other childhood disorders that have a similar presentation. Most symptomatic patients report malaise and high-grade fever, which may be high enough to provoke febrile seizures. Young children usually exhibit fussiness, poor feeding, and anorexia. Older children may report back pain and headache. Most patients also develop sore throat a day before the onset of the enanthem. Some patients may also develop anorexia, dehydration, and abdominal pain. An exanthem is also frequently reported by patients with herpangina, but the specific characteristics and rates of occurrence vary depending on the subtype of enterovirus causing the infection. Depending on the severity and organ system involvement, the patients may also report symptoms such as headache, neck stiffness, confusion, seizures, muscle weakness, and difficulty breathing.

Physical Examination

Herpangina is associated with a painful enanthem that typically occurs on the soft palate, tonsils, and posterior pharynx. It is usually characterized by hyperemia of the pharynx with discrete erythematous macules, that evolve into vesicles and eventually ulcerate centrally. The lesions are usually smaller than 5 mm and may occasionally appear on the buccal wall and posterior tongue. They persist up to one week. Other physical examination findings include pharyngitis and cervical lymphadenopathy.[8]

A variant of herpangina caused by the Coxsackie A10 virus serotype is the acute lymphonodular pharyngitis. This condition is characterized by nodular lesions in the same location and distribution as the lesions of herpangina but do not undergo vesiculation or ulceration.[9] A subset of patients may develop a rash on the body with lesions that may be macular, maculopapular, vesicular, papulovesicular, papulopustular, morbilliform, or petechial. The rates of occurrence of the rash and specific characteristics vary, depending on the virus subtype responsible. Neurological physical examination findings, such as neck stiffness or paralysis, may be present if the patient has developed complications such as meningitis, acute flaccid paralysis, encephalitis, or encephalomyelitis. Dehydration is a common complication of herpangina and signs such as dry mouth and decreased skin turgor may be seen.

The history and physical examination should also focus on ruling out other serious and potentially life-threatening febrile exanthems including Kawasaki disease, Rocky Mountain spotted fever, eczema herpeticum, and toxic shock syndrome that have a similar presentation.

The diagnosis of herpangina is usually made clinically. In mild cases, no imaging or laboratory testing is required. Laboratory studies are usually obtained to gain additional information about complications such as dehydration or to rule out alternative diagnoses. The white blood cell count is usually within normal limits, though lymphocytosis may be seen in some situations. Confirmatory testing is usually required only in complicated disease, for the collection of epidemiological data during epidemics, or to differentiate herpangina from more serious diseases such as eczema herpeticum. Isolation of the enterovirus in cell culture is the “gold standard” for confirmatory testing which can often take longer than a week to obtain results. This makes it an impractical test for clinical practice. Polymerase chain reaction (PCR) testing is fast and highly sensitive for enteroviruses. Samples may be obtained from the stool, mucocutaneous ulcers, vesicular fluid, or cerebrospinal fluid. Enzyme-linked immunosorbent assays (ELISA) testing is also available. ELISA testing for enteroviruses is generally less sensitive than PCR and should be utilized only in cases where PCR is not available. Serum antibodies to coxsackievirus may also be measured after clinical symptoms have developed. The antibody titer may show a four-fold rise in serial samples conducted two to three weeks apart.

Herpangina is a self-limited illness and the treatment is primarily supportive. The management can be described as general treatment, symptomatic treatment, and antiviral treatment.

General

Patients should be isolated in well-aerated and clean rooms to prevent cross-infection. The general management includes a healthy diet and adequate hydration. The patient’s diet should comprise of light, liquid or semi-liquid foods with adequate calories, and should avoid hot, spicy, and/or irritating foods. Emphasis should be placed on oral care and it is recommended that patients rinse their mouths with normal saline after meals. Younger children can have their mouths wiped with normal saline. If normal saline is unavailable, salted water can be considered.[10] Oral hydration is very important and for children with high-grade fever and feeding difficulty, proper rehydration with electrolyte solutions is recommended. The patients should be monitored closely while on treatment.

Symptomatic

High-grade fever is the most common symptom reported for herpangina. For patients whose temperature exceeds greater than 101.3 F (38.5 C), several physical cooling options can be considered, including cool compresses of the forehead, fever cooling patches, or sleeping with an ice pack under the head. Antipyretics such as Ibuprofen or acetaminophen can also be considered. The dosage, timing, and duration depend on the patient’s age and symptoms and are administered according to the treating physician’s recommendation. Adequate hydration should be ensured while treating with these drugs. Topical therapies containing lidocaine or diphenhydramine are not generally recommended for symptomatic treatment of the oral lesions that occur in herpangina. This is due to the risks of toxicity associated with these medications and the lack of adequate trials.[11] Younger children with high-grade fever may develop febrile seizures during the disease, which should be controlled and treated immediately. Some sources recommend using intravenous midazolam at slow speed (0.1-0.3 mg/kg/dose).[10]

Antiviral

No specific antiviral drugs are currently available for the treatment of herpangina. Interferon-alpha spray, however, has shown some promising effects. Local administration of the drug can potentially have some local immunomodulatory and antiviral effect, as interferon-alpha plays a key role in maintaining anti-infection immunity for the mucosa.[12] In addition, the topical use of the spray has benefits of being convenient, safe, and makes it easier to maintain good drug compliance in children. Broad-spectrum antiviral drugs, such as acyclovir and gancyclovir play no role in the treatment of herpangina as they are anti-DNA viral drugs and the causative agents of herpangina are RNA viruses. Ribavirin is not recommended either for the routine treatment of herpangina, though it may have some role in the early stages of the disease.[10]

Herpangina has a clinical presentation similar to several childhood disorders. Table 1 gives a summary of the differences in the clinical presentations of these disorders. Other diseases and conditions that should be ruled out before making the diagnosis include:

• Eczema herpeticum
• Toxic shock syndrome
• Measles
• Varicella
• Kawasaki disease
• Insect bites             
• Rocky Mountain spotted fever
• Drug eruption
• Erythema multiforme major

Herpangina is generally a mild and self-limited disease. If appropriate care measures, patient isolation, adequate food intake, and hydration are maintained, the disease resolves in less than ten days. Symptomatic treatment for the patient’s fever and oral lesions and close observation for the development of febrile seizures in young children with high-grade fever also improve the prognosis of the disease. Patients who develop serious neurological complications have a variable course and the prognosis is poor in certain situations. Thus patients should be monitored closely for the development of complications including flaccid paralysis, meningitis/encephalitis, and myocarditis.

Herpangina itself is generally a mild condition but some causative microorganisms, such as enterovirus 71, may result in severe complications including the following:

1. Brain stem encephalitis
2. Acute flaccid paralysis
3. Aseptic meningitis
4. Myocarditis

Such patients are generally deemed critical and necessitate hospitalization. ICU care is advised in some cases.

The patients and their families should be informed about the self-limited nature of the disease. As herpangina is primarily a pediatric disease and can be a source of significant stress for the family members, the families need to be reassured. The families should be educated about the contagion of the disease and that the patient should be isolated in a well-aerated room until the symptoms improve. Emphasis should be placed on adequate diet and hydration and close monitoring of symptoms. Close attention should be paid to hand hygiene and frequent handwashing should be recommended. The importance of handwashing should also be explained to family members in close contact with the patient during care, especially after activities such as changing diapers or feeding the child. The sanitization of surfaces and objects the patient is in contact with is also recommended. Though home treatment is generally preferred, the caretakers should be informed to stay in regular contact with the treating physician and should observe the patient closely for any change in symptoms. Out-patient follow up care is generally not needed as the disease is short-lived.

Herpangina is a viral infection that is generally self-limited but may lead to serious complications. The diagnosis is primarily clinical and specific diagnostic investigations are ordered in unclear presentations. Health-care providers must be well-versed with the range of clinical presentations seen in herpangina and should be able to differentiate it from other pediatric disorders with a similar presentation. They need to educate the family regarding the disease, the home-management, and prevention. A multi-disciplinary approach with effective communication between the members of the health-care team including internists, pediatricians, nurses, and pharmacists is essential for effective patient care and improved outcomes.