History
The patient was unaware of the oral ulcers. When questioned about a sore throat, the patient state that he indeed had a sore throat that started two days earlier. When questioned about other signs and symptoms, the patient claimed an overall feeling of malaise. The patient's medical history was reviewed and no significant findings were noted. At the time of the examination, the patient was taking Tylenol® for the sore throat pain.
Examinations
Examination of the head and neck regions revealed enlarged superficial cervical and submandibular lymph nodes. All vital signs were within normal limits. No skin lesions were apparent in the head and neck regions. Examination of the hands and feet revealed no skin lesions. Oral examination revealed small ulcerations limited to the soft palate area (see photo).
Clinical diagnosis
Based on the clinical information provided, which one of the following is the most likely diagnosis?
• Hoof and mouth disease
• Hand, foot, and mouth disease
• Herpangina
• Primary herpetic gingivostomatitis
• Herpetiform aphthous ulcers
Diagnosis
• Herpangina
Discussion
Herpangina is a contagious disease caused by the coxsackieviruses. The coxsackieviruses are divided into two groups: group A and group B. Within these two groups, viral isolates have been described and numbered sequentially. Herpangina is usually caused by the coxsackieviruses A 1-6, 8, 10, or 22; this disease may also be caused by the coxsackieviruses A 7, 9, or 16 or coxsackieviruses B 2-6.
The routes of transmission for the coxsackieviruses include the fecal-oral route and spread via contact with respiratory droplets. The coxsackieviruses gain entrance to their human host via the oropharynx and then replicate in the epithelial and lymphoid cells of the intestinal tract. From there, the viruses spread to the other sites via the blood stream. The coxsackieviruses are shed from the oropharynx and urine for one week, and in the feces for up to one month. The incubation period for the coxsackieviruses is short, usually four to seven days.
The two coxsackievirus diseases that have oral im-plications include hand, foot, and mouth disease and herpangina. These diseases associated with the coxsackieviruses tend to occur in epidemics. Outbreaks may occur in small groups (schools or day care centers, for example) or in selected communities. Outbreaks may also become widespread and affect regional, national, or international areas. In temperate climates, most cases occur in the summer or early autumn. In tropical climates, there is no seasonal pattern. Poor hygiene and crowded conditions facilitate the spread of these viruses.
Clinical features
Although herpangina may occur in either children or adults, most cases are seen in children between the ages of one and four years. Herpangina typically begins with a significant sore throat and dysphagia. Constitutional symptoms may include an overall feeling of malaise, cervical lymphadenopathy, and low-grade fever. Occasionally, herpangina is accompanied by a cough and headache, or vomiting and diarrhea.
Clinically, herpangina is characterized by the eruption of multiple, tiny vesicles limited to the soft palate and tonsillar pillar regions. The vesicles rupture shortly after they are formed and tiny ulcerations result. The tiny ulcers exhibit shallow, necrotic centers and red borders. These lesions are limited to the oropharyngeal regions. Rarely are other oral locations involved. A diffuse redness of the soft palate may also be seen. No skin lesions are seen with this disease.
Diagnosis
The vesicular-ulcerative lesions of herpangina may resemble a number of oral disease entities. However, the characteristic distribution of lesions on the soft palate and tonsillar pillar areas eliminates other diseases from the differential diagnosis. Herpangina is most often diagnosed on a clinical basis; the diagnosis is established based on the clinical signs, symptoms, and patient history. In instances of questionable diagnosis, laboratory confirmation via viral culture may be required.
Treatment
Herpangina is a self-limiting disease, and recovery usually occurs within one to two weeks. As with many other viral diseases, there is no specific treatment. Supportive therapy includes a nonaspirin antipyretics to reduce fever and analgesics to control pain. Palliative rinses may be recommended to alleviate oral discomfort. Herpangina is not a recurrent disease. Following infection, a permanent immunity develops. Most adults have antibodies against numerous strains of the coxsackieviruses.
References available upon request.
Joen Iannucci Haring, DDS, MS, is an associate professor of clinical dentistry, Section of Primary Care, The Ohio State University College of Dentistry.
