Herpangina: Symptoms, Types, Causes and Treatment

Herpangina is a common, highly infectious viral illness that primarily affects children. Characterized by sudden fever and distinctive small sores in the mouth and throat, herpangina is often confused with other childhood illnesses but has unique features and risks. Understanding the symptoms, types, causes, and best treatment strategies is vital for caregivers, healthcare professionals, and anyone interacting with young children. This comprehensive article brings together the latest evidence and expert insights to provide a clear, actionable overview of herpangina.

Symptoms of Herpangina

Herpangina often makes its dramatic entrance with a high fever, sore throat, and a sudden refusal to eat or drink—especially in young children. These symptoms can be alarming but usually resolve within a week. Recognizing the telltale signs is key to timely and effective care.

Symptom	Typical Features	Duration	Source(s)
Fever	Sudden onset, often >38°C	3–5 days	2 6 8
Sore Throat	Painful, especially when swallowing	4–6 days	1 2 9 11
Oral Lesions	Vesicles/ulcers on soft palate, uvula, tonsillar pillars	4–7 days	1 2 7 9
Loss of Appetite	Refusal to eat/drink, irritability	Variable	2 6
Other	Headache, vomiting, cough, rash (rare)	Variable	2 4 12

Table 1: Key Symptoms

Typical Clinical Presentation

Herpangina starts abruptly, usually with a high fever that may reach or exceed 39°C (102°F) 2 6. Children may become irritable, refuse to eat, or complain of a sore throat. Within 24–48 hours, small red spots appear at the back of the mouth—specifically on the soft palate, tonsillar pillars, and uvula. These quickly turn into tiny vesicles (blisters) and then shallow ulcers, which are intensely painful and can make swallowing difficult 1 7 9 11.

Course and Duration

• Fever: Usually lasts 3–5 days, often peaking in the first 1–2 days 2 6.
• Oral Lesions: Appear after the fever, usually within the first 1–2 days, and typically resolve over a week 1 7.
• Other Symptoms: Some children experience headache, vomiting, or, rarely, skin rashes or complications such as febrile seizures (seizures related to high fever) and encephalitis 2 4 12.

Distinguishing Features

• The oral lesions of herpangina are distinct: they are typically small (2–4 mm), grayish-white with a red border, and limited to the back of the mouth 1 9 11.
• Unlike hand, foot, and mouth disease (HFMD), herpangina usually does not involve lesions on the hands or feet 3 5.

Types of Herpangina

While herpangina is generally considered a single clinical entity, its presentation and severity can vary depending on the causative virus and patient factors. Understanding these types helps with diagnosis and treatment.

Type	Main Features	Prevalence/Population	Source(s)
Classic	Fever, oral vesicles/ulcers only	Most common, children <10	2 4 5 6
Atypical	May include skin rash, prolonged fever, or neurological symptoms	Rare, infants/immune-compromised	2 4 11
Severe/Complicated	Encephalitis, pulmonary edema, shock	Rare, especially with EV71	4 8

Table 2: Types of Herpangina

Classic Herpangina

This is the presentation most clinicians expect: sudden fever, sore throat, and ulcers in the posterior oral cavity, mostly in young children under 10 years of age 2 6. The disease is generally mild and self-limiting.

Atypical Herpangina

Occasionally, herpangina may present with unusual features:

• Skin Rash: Sometimes occurs, leading to confusion with HFMD or erythema multiforme 1 2.
• Prolonged Fever or Severe Pain: May occur in infants or children with weakened immune systems 4 11.
• Gastrointestinal Symptoms: Vomiting, diarrhea, or abdominal pain are less common but possible 2.

Severe/Complicated Herpangina

Certain enterovirus strains—especially Enterovirus 71 (EV71)—can cause severe complications:

• Neurological Involvement: Encephalitis, meningitis, or febrile seizures 4 8.
• Cardiopulmonary Complications: Pulmonary edema or shock, primarily in young children 4.
• These forms are rare but can be life-threatening and require prompt medical attention.

Causes of Herpangina

Herpangina is caused by a group of highly contagious viruses, most often from the enterovirus family. Understanding the specific pathogens and how they spread is crucial for prevention and control.

Cause/Agent	Main Virus Types/Serotypes	Transmission Route	Source(s)
Coxsackievirus	A2, A4, A6, A10, A16, B2, B4	Fecal-oral, droplets	1 3 5 6 8
Enterovirus	EV71, Echovirus 30, others	Fecal-oral, droplets	2 4 8 9
Seasonality	Peak in summer, sometimes early fall	Higher in children <10	4 6 8
Outbreaks	Epidemics in schools, childcare	Close contact	4 5 6

Table 3: Main Causes and Transmission

Main Viral Agents

• Coxsackievirus A is the most common cause, especially serotypes A2, A4, A6, A10, and A16 1 3 5 6 8.
• Enterovirus 71 (EV71) is of special concern due to its association with severe neurological complications 2 4 8.
• Other enteroviruses, including certain echoviruses and coxsackie B viruses, may also be implicated 8 9.

Multiple serotypes may co-circulate during outbreaks, and the dominant strains can shift over time and geography 3 5 6 8.

How Herpangina Spreads

Herpangina spreads easily, especially in environments where children are in close proximity:

• Fecal-Oral Route: The virus is shed in stool and can contaminate hands, objects, or food.
• Respiratory Droplets: Coughing, sneezing, or even talking can transmit infectious droplets 1 6.
• Surface Contamination: Toys, doorknobs, and other shared items can harbor the virus temporarily.

Seasonality and Outbreaks

• Peak Incidence: Most cases occur in the summer and early fall, though outbreaks can happen year-round in warmer climates 4 6 8.
• At-Risk Groups: Children under 10, especially those in daycares or schools, are most susceptible 4 6.

Epidemiological Considerations

• Outbreaks may involve dozens or even thousands of cases, as seen in China and Taiwan 4 6 8.
• Rapid identification and isolation of cases, along with strict hygiene measures, are key to prevention 9.

Treatment of Herpangina

There is no specific cure for herpangina, but supportive care is usually effective. In rare, severe cases, hospitalization and intensive management may be required. Recent research is exploring new antiviral and herbal therapies.

Treatment	Purpose/Action	Example/Details	Source(s)
Supportive Care	Symptom relief, hydration	Fluids, soft food, rest	1 9 11 12
Analgesics	Reduce pain/fever	Ibuprofen, acetaminophen	11 12
Topical Agents	Soothe oral ulcers	Benzydamine spray, aloe vera	11 12
Antivirals	Rare, mostly for severe cases	Inosine pranobex, ribavirin	10 12
Herbal Injections	Alternative therapy, mostly in China	Reduning, Shuanghuanglian	10
Complication Management	Hospitalization, intensive care	For severe complications	4 9 11

Table 4: Main Treatments

Supportive Management

For most cases, treatment is focused on comfort and preventing dehydration:

• Fluids: Offer cool drinks and avoid acidic or spicy foods that may irritate ulcers 12.
• Pain and Fever Relief: Ibuprofen or acetaminophen can help reduce pain and fever 11 12.
• Rest: Encourage bed rest, especially during the feverish phase 11.

Oral Care

• Topical Analgesics/Sprays: Benzydamine spray, aloe vera mouthwash, and similar agents can numb pain and promote healing of oral lesions 11 12.
• Good Oral Hygiene: Gentle brushing and rinsing with water or saline can help prevent secondary infection.

Antiviral and Alternative Therapies

• Antivirals: Medications such as inosine pranobex or ribavirin may be considered in severe or prolonged cases, but evidence for their routine use is limited 10 12.
• Chinese Herbal Injections: In China, certain herbal preparations like Reduning, Shuanghuanglian, and others have shown promise in studies, sometimes outperforming ribavirin for symptom relief and recovery time 10. However, more safety data are needed before widespread adoption.

When to Seek Medical Attention

• Signs of Dehydration: Dry mouth, decreased urination, lethargy.
• Neurological Symptoms: Severe headache, neck stiffness, seizures, confusion—these may signal rare but serious complications 4 9 11.
• Persistent High Fever: Especially if lasting more than 3–5 days or unresponsive to medication.
• Breathing Difficulty: Could indicate pulmonary complications.

Prognosis

• Most children recover fully within 4–7 days without complications 9 12.
• Severe cases, particularly those involving EV71, may require hospitalization and carry a risk of lasting effects or, rarely, death 4 8.

Conclusion

Herpangina is a common viral illness of childhood, typically characterized by sudden fever and painful oral lesions. While it is often mild and self-limiting, certain strains and patient factors can lead to severe complications. Early recognition, supportive care, and good hygiene practices are the cornerstones of management.

Key takeaways:

• Symptoms: Sudden fever, sore throat, and vesicular ulcers in the mouth are hallmark features.
• Types: Classic, atypical, and rare severe forms exist, largely depending on the viral strain and patient health.
• Causes: Primarily caused by coxsackievirus A subtypes and other enteroviruses, spread via fecal-oral and respiratory routes.
• Treatment: Focuses on supportive care, pain relief, hydration, and, in rare cases, antivirals or herbal therapies; severe cases may require hospitalization.
• Prevention: Good hygiene and prompt isolation during outbreaks are essential to control spread.

Being informed about herpangina helps parents, caregivers, and health professionals provide prompt, compassionate care—ensuring the best possible outcomes for affected children.