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Orofacial herpes simplex virus in Child
See also in: Oral Mucosal Lesion
Other Resources UpToDate PubMed

Orofacial herpes simplex virus in Child

See also in: Oral Mucosal Lesion
Contributors: Sujitha Yadlapati MD, Belinda Tan MD, PhD, Susan Burgin MD, Eric Ingerowski MD, FAAP
Other Resources UpToDate PubMed

Synopsis

Orofacial herpes (cold sores or fever blisters) is most commonly caused by herpes simplex virus type 1 (HSV-1) but may be caused by herpes simplex virus type 2 (HSV-2) as well. The condition is highly contagious and is spread by direct contact or through contact with the secretions of asymptomatic individuals who shed the virus. Childhood infection is common via child-to-child contact or kissing by a parent.

Primary herpetic gingivostomatitis is an acute infection of the oral mucous membranes by HSV that results from initial exposure to the virus. Most primary exposures (approximately 90%) are subclinical and asymptomatic. Herpetic gingivostomatitis occurs most often in children between ages 10 months and 5 years, but it can occur at any age. Patients experience a flu-like illness with fever, loss of appetite, malaise, and lymphadenopathy. Painful mouth sores and a sore throat develop, and difficulty eating and swallowing places the patients at risk for dehydration. The systemic and oral signs and symptoms develop within days of each other.

The virus establishes lifelong latency, and both asymptomatic reactivation as well as recrudescence are common. In recrudescence, patients may report a prodrome of burning, itching, and a tingling sensation before the actual lesions appear. HSV recrudescence on the lips is also known as cold sores, fever blisters, or herpes labialis; inside the mouth, lesions only occur on the keratinized tissues of the tongue dorsum, hard palatal mucosa, and gingiva in healthy hosts, but they may occur on any surface in the immunocompromised host. Intraoral involvement in recrudescent disease in immunocompetent hosts is rare.

Infection with HSV can present in a variety of ways. In some cases, it is preceded by a prodrome, which may consist of pain, tenderness, or burning; in others, infection is asymptomatic. After the primary infection, the virus remains dormant and may be reactivated by various stimuli, including illness, stress, immunosuppression, or ultraviolet (UV) light.

HSV can also disseminate, occurring on skin areas distant from the lips. Two general groups of patients are at risk to develop disseminated HSV: patients with underlying skin disease and immunocompromised patients.

Neonatal HSV is covered separately.

Localized HSV in areas other than the face and mouth, such as herpetic whitlow, are discussed separately. Other related topics include HSV blepharitis, HSV conjunctivitis, HSV encephalitis, HSV gladiatorum, HSV keratitis, and HSV pneumonia.

Codes

ICD10CM:
B00.2 – Herpesviral gingivostomatitis and pharyngotonsillitis

SNOMEDCT:
235055003 – Oral herpes simplex infection

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Diagnostic Pearls

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Differential Diagnosis & Pitfalls

May affect both perioral and intraoral surfaces:
  • Herpes zoster – Oral findings of zoster may be secondary to involvement of the maxillary or mandibular branch of the trigeminal nerve (V2 or V3 respectively). The upper cutaneous lip, palate, and upper gingiva are involved in V2. The remainder of the V2 dermatome, including the cheek and temple, may also be involved. In V3 zoster, the tongue, lower gingiva, buccal mucosa, floor of the mouth, and lower cutaneous lip may be affected. Cutaneous involvement of V3 includes the chin, lower cheek over the mandible, preauricular area, and temporal scalp.
  • Erythema multiforme – A history of HSV infection is often elicited 2-3 weeks before the appearance of these oral ulcers.
  • Fixed drug eruption
  • Reactive infectious mucocutaneous eruption (RIME)
  • Stevens-Johnson syndrome – Typical skin findings as well as severe oral ulcerations differentiate this from HSV infection.
  • Paraneoplastic pemphigus
  • Oral lichen planus – Lips may be involved with white, scaly papules or plaques.
  • Pemphigus vulgaris – These oral ulcers and erosions usually do not heal completely but rather get better and worse.
  • Behçet syndrome
Lip and perioral involvement only:
  • Contact dermatitis (Irritant contact dermatitis, Allergic contact dermatitis )
  • Bullous impetigo
  • Exfoliative cheilitis
  • Angular cheilitis
  • Actinic cheilitis
  • Morsicatio labiorum
Intraoral involvement only:
  • Aphthous stomatitis – This is a common recurrent ulcerative condition, most often misdiagnosed as recrudescent herpes infection. Aphthous ulcers almost always involve only the nonkeratinized mucosa, while recrudescent HSV almost always involves the keratinized mucosa in healthy hosts.
  • Contact stomatitis – A history of recurrent ulcers or blisters caused by a contactant differentiates between the two.
  • Herpangina – This tends to occur in spring or fall and in epidemics. Oral ulcers tend to localize to the back of the mouth and oropharynx.
  • Hand, foot, and mouth disease – Involvement of the palms and dorsa of feet is characteristic.
  • Stomatitis associated with chemotherapy (see Chemotherapy-induced mucositis) – These lesions occur within 7-10 days of the beginning of chemotherapy; however, HSV may recrudesce within these lesions.
  • Necrotizing ulcerative gingivitis – These lesions may resemble recrudescent HSV because ulcers and necrosis are located on the keratinized gingiva. Culture differentiates between the two.
  • Fissured tongue – On the differential for herpetic geometric glossitis.

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References

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Last Reviewed:11/26/2022
Last Updated:12/08/2022
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Orofacial herpes simplex virus in Child
See also in: Oral Mucosal Lesion
A medical illustration showing key findings of Orofacial herpes simplex virus (Recurrent Infection) : Face, Lips, Mouth
Clinical image of Orofacial herpes simplex virus - imageId=428508. Click to open in gallery.  caption: 'Grouped vesicles with a background of erythema and edema on the right upper lip.'
Grouped vesicles with a background of erythema and edema on the right upper lip.
Copyright © 2024 VisualDx®. All rights reserved.