Primary Oral Herpes (Herpetic Gingivostomatitis)

This picture is from a 4 year old child who was brought to the pediatrician with temperatures of 103◦F at home for 2–3 days. She has had no upper respiratory symptoms. Her oral intake has decreased, but she is maintaining good urine output. She has had no vomiting or diarrhea.

The examination reveals a febrile child that is slightly irritable. She is nontoxic and not dehydrated. Her oral cavity shows increased tonsil size with ulcers on her tongue and lips but not on the tonsillar pillars. Her anterior cervical lymph nodes are enlarged. The rest of her exam is noncontributory.

What is the most likely diagnosis?

A) Streptococcal pharyngitis.

B) Hand, foot, and mouth disease (coxsackie virus).

C) Herpetic gingivostomatitis.

D) Varicella.

E) Infectious mononucleosis.

Answer And Discussion

The correct answer is “C.”  Herpetic gingivostomatitis.

Primary oral herpes (herpetic gingivostomatitis) is associated with a relatively high fever and anteriorly placed ulcerations and vesicles (gums, tongue, and lips). Symptoms tend to start relatively abruptly with pain, salivation, refusal to eat, and fever. Herpes gingivostomatitis may recur during life in the form of “cold sores.” 

“B” is incorrect because the patient does not have hand and foot lesions.

“D,” varicella, can occur in the oral pharynx but would have lesions elsewhere in various stages and respiratory symptoms as well. 

Infectious mononucleosis is not associated with vesicular lesions or mucosal ulcerations.