PANCE Blueprint EENT (7%)

Oral herpes simplex (ReelDx)

VIDEO-CASE-PRESENTATION-REEL-DX

Herpes Simplex

6-year-old with painful vesicle and prodromal discomfort (watch video)

Patient will present as → a 17-year-old female complaining of a painful rash on her cheek. She says that it has come and gone a few times before and that she usually can feel itching and a tingling discomfort before a break out of the lesions. On physical exam, you observe clusters of small, tense vesicles on an erythematous base.

Herpes simplex virus (HSV) is an enveloped double-stranded DNA virus. It exists as two distinct subtypes, HSV-1 and HSV-2, and is responsible for a wide spectrum of illness ranging from fever blisters to genital ulcers and fatal encephalitis. It establishes lifelong latency and can lead to interval episodes of asymptomatic shedding and disease recurrence.

  • HSV-1 infects 40–80% of the U.S population by young adulthood, and 60–85% by age 60.
  • Infections “above the waist” are classically due to HSV-1, whereas HSV-2 most commonly causes genital infection. However, both serotypes can cause genital and/or mucocutaneous infection.
  • Primary infection is characterized by fever, irritability, and severe pain/burning of the oral mucosa, with vesicular and ulcerative lesions on the lips, gingiva, and tongue.
  • Pharyngitis is also common in older children and adolescents.
  • Illness lasts for 2–3 weeks, with viral shedding continuing for several weeks.

Diagnosis is clinical; laboratory confirmation by culture, PCR, direct immunofluorescence, or serologic testing can be done.

Treatment: Oropharyngeal herpes

  • Symptomatic treatment with antipyretics and analgesia is recommended. IV hydration is sometimes needed in cases of decreased oral intake.
  • Oral acyclovir (15 mg/kg/dose five times per day for 7–10 days; max 200 mg per dose) may decrease the duration of illness if started within 72 hours at the onset of symptoms.
Orolabial herpes in a child.

Orolabial herpes in a child.

Question 1
Which of the following statements is true regarding orolabial herpes?
A
Highest rate of infection occurs in adolescent children.
Hint:
Overall, the highest rate of infection occurs during the preschool years.
B
Lesions are usually painless vesicles that form on the tongue, palate, and gingival area.
Hint:
It typically takes the form of painful vesicles and ulcerative erosions on the tongue, palate, gingiva, buccal mucosa, and lips. Edema, halitosis, and drooling may be present, and tender submandibular or cervical lymphadenopathy is not uncommon.
C
Topical acyclovir is the drug of choice.
D
Recurrent infections are less severe and shorter in duration.
E
Pain associated with lesions typically lasts 2 to 3 weeks.
Question 1 Explanation: 
Orolabial herpes (gingivostomatitis) is the most prevalent form of mucocutaneous herpes infection. Overall, the highest rate of infection occurs during the preschool years. Female gender, history of sexually transmitted diseases, and multiple sexual partners have also been identified as risk factors for HSV-1 infection. Primary herpetic gingivostomatitis usually affects children below the age of 5 years. It typically takes the form of painful vesicles and ulcerative erosions on the tongue, palate, gingiva, buccal mucosa, and lips. Edema, halitosis, and drooling may be present, and tender submandibular or cervical lymphadenopathy is not uncommon. Hospitalization may be necessary when pain prevents eating or fluid intake. Systemic symptoms are often present, including fever (38.4 ° to 40 ° C [101 ° to 104 ° F]), malaise, and myalgia. The pharyngitis and flulike symptoms are difficult to distinguish from mononucleosis in older patients. The duration of the illness is 2 to 3 weeks, and oral shedding of the virus may continue for as long as 23 days. Recurrences typically occur two or three times per year. The duration is shorter and the discomfort less severe than in primary infections; the lesions are often single and more localized, and the vesicles heal completely by 8 to 10 days. Pain diminishes quickly in 4 to 5 days. UV radiation predictably triggers recurrence of orolabial HSV-1, an effect that, for unknown reasons, is not fully suppressed by acyclovir. Pharmacologic intervention is therefore more difficult in patients with orolabial infection.
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