Dermatology MCQ - Viral Infections - Herpangina,

A 4-year-old child presents with sudden onset of high fever, sore throat, and refusal to drink. On examination, you note multiple small vesicles and ulcers on the soft palate and tonsillar pillars. The child is irritable but has no rash on the hands, feet, or trunk. Which of the following is the most likely causative agent and the recommended management?

A) Herpes simplex virus type 1; oral acyclovir
B) Coxsackievirus A; supportive care
C) Group A Streptococcus; amoxicillin
D) Epstein-Barr virus; corticosteroids
E) Adenovirus; intravenous fluids

Correct Answer: B) Coxsackievirus A; supportive care

Explanation

This presentation is classic for herpangina, a common childhood illness caused by enteroviruses, most frequently coxsackievirus A.

Key Clinical Features of Herpangina:

• Sudden onset of high fever (often up to 104°F/40°C).

• Sore throat and dysphagia leading to refusal to eat or drink.

• Enanthem: Multiple small vesicles (1-2 mm) that rapidly ulcerate, surrounded by erythematous halos. These are localized to the soft palate, uvula, and tonsillar pillars.

• No exanthem: Unlike hand, foot, and mouth disease, herpangina lacks skin lesions on the hands, feet, or buttocks.

• Irritability due to pain and fever.

Virologic Cause:

• Causative Agent: Most commonly coxsackievirus A (serotypes A1-10, A16, A22) and other enteroviruses.

• Transmission: Fecal-oral route and respiratory droplets.

• Seasonality: Most common in summer and early fall.

Why Not the Other Options?

• (A) Herpes simplex virus type 1: Causes herpetic gingivostomatitis, which features widespread oral ulcers on the lips, gums, tongue, and buccal mucosa (not limited to the posterior pharynx). Lesions are larger, more painful, and often associated with gingivitis. May require oral acyclovir if severe.

• (C) Group A Streptococcus: Causes bacterial pharyngitis with exudates, fever, and cervical lymphadenopathy, but no vesicles or ulcers.

• (D) Epstein-Barr virus: Causes infectious mononucleosis with exudative pharyngitis, lymphadenopathy, and fatigue, but no discrete vesicles.

• (E) Adenovirus: Can cause pharyngoconjunctival fever with conjunctivitis and pharyngitis, but no characteristic vesicles.

Management:

• Supportive care is the mainstay:

  • Hydration: Encourage cool fluids, popsicles, or oral rehydration solutions.

  • Analgesics: Acetaminophen or ibuprofen for pain and fever.

  • Topical analgesics (e.g., magic mouthwash) may be used for severe pain.

• No role for antibiotics or antivirals.

• Hospitalization may be required if dehydration is severe.

Prognosis:
Self-limiting illness resolving within 5-7 days. Complications are rare but can include dehydration due to odynophagia.

Note: Herpangina is often confused with hand, foot, and mouth disease (HFMD). The key distinction is the absence of skin lesions in herpangina. Both are caused by enteroviruses and managed supportively.