OVERVIEW

What is herpangina?

Herpangina is an acute upper respiratory tract infection caused by certain enteroviruses (such as Coxsackievirus A and Enterovirus 71). It is primarily characterized by fever, small herpes-like lesions, and shallow ulcers on the mucosa of the pharyngeal isthmus^[1].

There are no specific antiviral drugs for this disease, and treatment is mainly symptomatic. It typically resolves spontaneously within 7 days. Active treatment can help alleviate symptoms and reduce discomfort in affected children^[1].

How is herpangina transmitted?

Herpangina is highly contagious. The virus spreads mainly through respiratory droplets, aerosols, and the fecal-oral route (where pathogens from an infected person's feces are ingested by others). Direct or indirect contact with an infected person's respiratory secretions, oral or rash fluid, or contaminated hands or objects can also transmit the disease.

Respiratory transmission of the virus can persist for up to three weeks, while the virus remains detectable in feces for up to 8 weeks. Patients are most contagious during the first 1–2 weeks of infection^[2].

Is herpangina common?

Herpangina is most prevalent in spring and summer, often occurring in group settings such as kindergartens and schools. It primarily affects children under 5 years old, with an average incubation period of 3–5 days. Outbreaks or clustered cases are common, necessitating isolation and disinfection measures^[1].

Which department should I visit for herpangina?

For children, herpangina is commonly treated in pediatric internal medicine, general pediatrics, pediatric respiratory, pediatric infectious diseases, or pediatric dermatology. Adults can consult dermatology, infectious diseases, or respiratory departments.

SYMPTOMS

What are the manifestations of herpangina?

The average incubation period for herpangina is 3–5 days, with a range of 1–10 days.

Typical clinical manifestations include sudden high fever (38.9°C–40°C or higher), persistent or recurrent fever, refusal to eat, and may be accompanied by convulsions and seizures.

In infants and young children, common symptoms include loss of appetite, vomiting, rapid breathing, and irritability/frequent crying (these may occur alone or together).

Older children may actively complain of feeling unwell, headache, sore throat, difficulty swallowing, lethargy, poor appetite, or abdominal pain.

Throat examination often reveals congestion (bright red pharynx) and small yellowish or grayish-white herpes-like vesicles. After about 24 hours, the vesicles rupture, leaving superficial 3–4 mm yellowish-gray/white ulcers with distinct red borders.

Herpangina is an acute, short-lived illness with complete recovery. Fever typically subsides within an average of two days (range: 2–4 days), and throat ulcers resolve within 5–6 days (range: 3–10 days)^[2].

CAUSES

What causes herpangina?

Herpangina is associated with enterovirus infections. Currently, 22 serotypes of enteroviruses have been identified as causes of herpangina, with Coxsackievirus A serotypes being the most common^[1].
The virus can spread between people through the fecal-oral route, and some serotypes may also spread via respiratory transmission.

Is herpangina contagious?

Yes, it is contagious. Herpangina is an infectious disease caused by enteroviruses, typically transmitted through close contact between people. Infections in children are often linked to exposure to contaminated toys, hands, or utensils, and may also spread through respiratory droplets^[1].

The most effective way to prevent herpangina is to practice good hand hygiene, wash hands frequently, and wear masks during peak seasons.

Who is most commonly affected by herpangina?

Herpangina is a common illness in children, primarily affecting infants and preschool-aged children (mostly under 5–7 years old)^[1].

Can adults get herpangina?

Cases have been reported in older children, adolescents, and adults, so adults can also be infected^[1]. The clinical manifestations in adults are similar to those in older children, with fever and sore throat being the most common symptoms.

Can a child get herpangina again after recovering?

Since there are many serotypes of viruses that cause herpangina, a child who has had it once may get infected again by a different serotype.

What diseases can Coxsackievirus infections cause?

Coxsackievirus infections are the primary pathogens responsible for herpangina and stomatitis. Some cases of hand, foot, and mouth disease and meningitis are also caused by Coxsackievirus infections.

DIAGNOSIS

What tests might be needed for herpangina?

Herpangina is primarily diagnosed based on clinical manifestations: typical oral mucosal lesions (usually at least 10 congestive yellowish or grayish-white papulovesicles located on the palatoglossal arch, soft palate, tonsils, and uvula) accompanied by high fever.

The likelihood of complications from herpangina is very low (only possible when caused by enterovirus A71), so aside from a throat examination, virological testing is generally unnecessary.

When diagnosing herpangina, if other atypical symptoms or physical findings are present, it must be differentiated from other diseases. Based on each patient's specific condition, doctors may selectively recommend tests such as throat secretion pathogen detection, complete blood count (CBC), C-reactive protein (CRP), or blood glucose.

• Physical examination: A throat exam (using a tongue depressor) to observe the presence, size, number, distribution, and characteristics of vesicles or ulcers.
• Complete blood count (CBC): Blood test to check for elevated white blood cells or CRP levels, aiding in infection diagnosis.
• Pathogen testing: Collecting throat swabs, stool, or vesicle fluid samples to isolate and identify the virus.
• Blood glucose test: Blood test to assess glucose levels, evaluating disease progression and severity.
• Immunological testing: Blood test to detect IgG and IgM antibodies for auxiliary diagnosis.

How is herpangina different from hand, foot, and mouth disease (HFMD), and what tests can distinguish them?

The key clinical difference lies in rash distribution: Herpangina lesions appear only on oral mucosa, whereas HFMD rashes affect the mouth, hands, feet (and sometimes buttocks, trunk, or other body parts).

Atypical HFMD cases may present with only oral lesions or only skin rashes, making differentiation from herpangina challenging. Fortunately, management for both conditions is similar.

Clinicians often diagnose HFMD cases with solely oral lesions as herpangina, which is acceptable. However, HFMD carries a higher risk of severe complications, so close monitoring is essential even if herpangina is suspected.

Additionally, the serotype distribution of associated enteroviruses differs between the two diseases, though overlaps exist. Without complications, such testing is rarely performed and holds limited clinical significance.

TREATMENT

Do children with herpangina need to go to the hospital?

Generally, hospitalization for simple herpangina is rare. However, medical attention should be sought promptly in the following situations:

• Severe refusal to eat, leading to or at risk of severe dehydration, such as lethargy, mottled skin, poor skin elasticity, or very little urine output (no urination for ≥ 12 hours), requiring intravenous rehydration.
• Respiratory, cardiovascular, or neurological complications, such as persistent high fever, lethargy, rapid or labored breathing, frequent vomiting, pale complexion, tremors, convulsions, limb weakness, or shock, which may indicate encephalitis, meningitis, flaccid paralysis, myocarditis, etc.

How is herpangina treated?

There is no specific antiviral treatment for enteroviruses. Management mainly involves supportive care and symptom relief, including:

• Rest to boost the child's immunity and restore energy.
• Monitor body temperature. For fever, encourage small, frequent sips of fluids. If the axillary temperature reaches 38.5°C (101.3°F) or the ear temperature exceeds 39°C (102.2°F), or if the child is uncomfortable or irritable due to fever, acetaminophen or ibuprofen can be given for relief.
• For throat pain, offer cold, soft foods (if the child is already accustomed to such foods), such as chilled juice, popsicles, cold yogurt, or ice cream, which can soothe pain and provide energy.
• Home isolation for at least 2 weeks before returning to daycare or contact with other children.
• Watch for abnormal symptoms, such as severe dehydration, encephalitis, or myocarditis, and seek medical attention promptly if complications arise.

Do children with herpangina need intravenous antibiotics?

Herpangina is a viral infection with no specific cure, and it is self-limiting. Treatment focuses on relieving discomfort. Antibiotics target bacteria and some other pathogens and are unnecessary for viral infections^[2].

However, IV fluids are not always antibiotics. They may also replenish fluids lost due to fever. Additionally, administering large amounts of room-temperature fluids can help lower body temperature.

Can herpangina be completely cured?

Herpangina is an acute, short-lived illness with full recovery expected. Fever typically subsides within 2 days (range: 2–4 days), and throat lesions resolve in 5–6 days (range: 3–10 days)^[2].

Can herpangina heal on its own?

Mild cases of herpangina usually resolve on their own within 4–6 days^[4].

DIET & LIFESTYLE

What should parents pay attention to when caring for a child with herpangina?

• Dietary considerations: Opt for soft, bland, palatable, and easily digestible foods, such as age-appropriate cooked soft or liquid/semi-liquid foods like noodle soup, porridge, rice paste, or breast milk. Avoid overly salty, sour, spicy, or other irritating foods. Ensure adequate hydration, as cool water is less irritating to the throat than hot water.

• Oral hygiene: Maintain oral cleanliness. Rinse the mouth with warm water after meals. If the child cannot rinse, let them drink water directly.

• Personal hygiene: Wash hands frequently (especially before meals and after using the toilet). Use soap or hand sanitizer with running water, and avoid wiping hands with dirty towels to prevent reinfection or cross-infection.

• Rest: Adequate rest is crucial during the first week of illness. Limit physical activity to prevent excessive fatigue.

• Disinfection: Thoroughly disinfect items the child has come into contact with, such as toys, utensils, and clothing. Methods include boiling, soaking in hot water for over 30 minutes, or scrubbing with disinfectant.

Can a child with herpangina attend school normally? When can they resume outdoor activities?

The average incubation period for herpangina is 3–5 days, with a range of 1–10 days. Therefore, it is recommended to isolate at home for at least two weeks before returning to kindergarten or interacting with other children.

What should parents do if a child with herpangina has a fever and experiences convulsions or seizures?

If a child has a seizure, parents should remain calm and take the following steps:

• Position the child safely: Place the child on a flat, soft surface, such as a carpet or bed, and remove nearby objects that could cause injury.

• Ensure clear breathing: Lay the child on their side with the head tilted to prevent secretions from entering the airway, and loosen clothing around the neck.

• Clear secretions: Gently wipe away saliva or residue around the mouth with a soft cloth, but avoid inserting anything into the child's mouth.

• Record details: Note the start time, duration, and condition of the seizure. If possible, record it with a phone to assist the doctor in diagnosis.

• Seek medical attention: After the seizure ends, or if it lasts longer than five minutes without relief, take the child to the doctor to determine the cause of the fever.

Seizures typically resolve naturally within 1–5 minutes.

PREVENTION

How to Prevent Herpangina?

• During the peak incidence period from April to July each year, both parents and children should pay attention to household and personal hygiene, wash hands frequently, and avoid crowded or enclosed spaces as much as possible.
• For others, it is recommended to get vaccinated with the EV71 hand-foot-and-mouth disease vaccine at their own expense if possible^[2]. Enterovirus A71 is the primary serotype causing severe hand-foot-and-mouth disease. The EV71 vaccine is an inactivated vaccine targeting this virus, developed mainly to prevent severe cases. It also helps prevent herpangina caused by enterovirus A71^[2].
• Enhance awareness of herpangina, learn its identification methods and transmission routes. If infection is suspected, take isolation measures promptly and seek medical treatment early to prevent the spread of the disease.
• Engage in appropriate physical exercises, such as jogging or swimming, to boost immunity and resist viral infections.