Herpetic Gingivostomatitis
A 2-year-old boy has 3 days of fever, refusal to eat or drink, and drooling. His gingivae are friable, swollen and bleed on light contact, with vesicles and ulcers on the tongue, buccal mucosa and inner lips, and grouped vesicles on the vermilion border and chin. His palms, soles and buttocks are free of lesions. A Tzanck smear shows multinucleated giant cells. Which organism is the most likely cause?
- A.Coxsackievirus A16
- B.Epstein-Barr virus
- C.Staphylococcus aureus
- D.Herpes simplex virus type 1Correct
Explanation
Primary herpetic gingivostomatitis is the most common clinical manifestation of first infection with herpes simplex virus type 1 and typically occurs between 6 months and 5 years of age. The hallmark that separates it from other causes of childhood stomatitis is the involvement of the gingivae, which become swollen, erythematous and friable and bleed easily, together with perioral vesicles and anterior mouth ulcers. A Tzanck smear showing multinucleated giant cells with intranuclear inclusions is characteristic of herpesvirus infections including herpes simplex, varicella zoster and cytomegalovirus, and it is also positive in pemphigus vulgaris; it is a useful bedside screening test but is neither sensitive nor specific enough to be diagnostic, so polymerase chain reaction or viral culture confirms the diagnosis. Management centres on analgesia and aggressive attention to hydration, since pain-related refusal to drink frequently causes dehydration requiring admission, and oral acyclovir started within the first 72 hours shortens the duration of symptoms and viral shedding. Herpangina and hand, foot and mouth disease from coxsackievirus A produce ulcers on the soft palate and tonsillar pillars, spare the gingivae, and in hand, foot and mouth disease are accompanied by acral vesicles. Epstein-Barr virus causes exudative pharyngitis with posterior cervical lymphadenopathy rather than vesicular gingival disease. Staphylococcus aureus does not cause a vesicular stomatitis. Autoinoculation may lead to herpetic whitlow or, in atopic children, eczema herpeticum.
Why each option
- A.
- Coxsackievirus causes posterior oral ulcers in herpangina or acral vesicles in hand, foot and mouth disease, and it spares the gingivae.
- B.
- Epstein-Barr virus produces exudative tonsillitis, posterior cervical adenopathy and hepatosplenomegaly rather than a vesicular gingivostomatitis.
- C.
- Staphylococcus aureus causes impetigo and skin abscesses but does not produce vesicular oral lesions with multinucleated giant cells.
- D.
- Correct. Bleeding friable gingivae with perioral and anterior oral vesicles and a Tzanck smear showing multinucleated giant cells indicate primary herpes simplex virus type 1 infection.
Reference: Nelson Textbook of Pediatrics, 22nd ed., 2024
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