PANCE Blueprint EENT (7%)

6-year-old with painful vesicle and prodromal discomfort

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
• The illness lasts for 2–3 weeks, with viral shedding continuing for several weeks

Diagnosis of HSV infection is often clinical based on characteristic lesions

• A Tzanck test/smear (a superficial scraping from the base of a freshly ruptured vesicle stained with Wright-Giemsa stain) often reveals multinucleated giant cells in HSV
• Definitive diagnosis is with culture, PCR, and antigen detection

Symptomatic treatment with antipyretics and analgesia (viscous lidocaine or topical benzocaine) is recommended. IV hydration is sometimes needed in cases of decreased oral intake

• First episode:
  • Oral acyclovir 400 mg TID x 7-10 days
    • peds: (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.
  • Valacyclovir 1 g BID x 7-10 days
  • Famciclovir 250 mg TID x 7-10 days
• Recurrent episodes: 
  • Acyclovir 400 mg TID x 5 days
  • Valacyclovir 1 g PO BID x 1 day
  • Famciclovir 1 g PO BID x 1 day
• Suppressive therapy
  • Acyclovir 400 TID
  • Famciclovir 500 mg BID
  • Valacyclovir 1 g BID