Documente Academic
Documente Profesional
Documente Cultură
Herpangina 1
August 5, 2015
A ward case protocol submitted in partial fulfillment of the requirements in the Department of Pediatrics clinical clerkship
rotation (July 22 Sept 15, 2015) Batch 2016.
Medical Problems
Father
None
Mother
None
Siblings
Medical
Problems
for
Any
Blood
Relative
Cancer
None
Present
/
Absent
Absent
Diabetes
Hypertension
Thyroid
Disorders:
Goiter
Hyperthyroidism
Absent
Absent
Heart Disease
Absent
Stroke
Kidney Disease
Absent
Blood Disorder
Absent
Asthma
Epilepsy
Absent
Psychiatric Disorder
Absent
PERSONAL
AND
SOCIAL
HISTORY
Patient
was
born
youngest
in
a
brood
of
4.
Born
on
Oct.
31,
2012
full
term
(38
weeks
AOG)
in
a
G4P3
(3003)
mother
via
normal
spontaneous
vaginal
delivery
with
no
fetomaternal
complications.
The
mother
had
regular
prenatal
check-ups,
without
any
other
complication
throughout
her
pregnancy
aside
from
a
urinary
tract
infection
during
her
2nd
trimester.
Developmental
history:
Patient
was
developmentally
at
par
with
age
with
no
developmental
delay.
Month
Motor
development
Language
Social
1
Largely
reflex,
hands
fisted;
reacts
to
pain
Responds
to
noise
Regards
human
face;
establishes
eye
contact
2
Eyes
follow
object
to
midline;
hold
head
up
when
Vocalizes
Social
smile;
recognizes
prone
parent
4
Eye
follow
object
past
midline;
rolls
over
Laughs
and
squeals
Regards
hand
6
Sits
well
unsupported;
transfers
objects
hand
to
Babbles
Recognizes
strangers
hand
(switches
hands);
rolls
prone
to
supine
9
Pincer
grasp
(10mos);
crawls;
cruises
(walks
Mama/dada;
bye-bye
Starts
to
explore
holding
furniture)
12
Walks;
throws
object
1-3
words;
follows
1-step
Stranger
and
separation
commands
anxiety
2
yrs
Walks
up
and
down
stairs;
copies
a
line;
runs;
kick
a
2-3
word
phrases;
refers
to
self
Parallel
play
ball
by
name;
pronouns
Nutritional
history:
Patient
was
exclusively
breastfed
for
the
1st
2
months
of
life
then
shifted
to
milk
formulas
S26,
Nan,
Promil,
and
Nido
at
present.
Breastfeeding
was
interrupted
because
of
failure
of
lactation.
Solid
foods
were
introduced
when
patient
was
around
8
months
old.
Patient
is
currently
being
given
Vitamin
C
as
daily
vitamin.
REVIEW
OF
SYSTEMS:
Constitutional
Eyes
ENT
Cardiovascular
Respiratory
Gastroenterology
Genitourinary
Musculoskeletal
Skin
Neurology
Psychiatry
Endocrine
Hematology
Immuno/Allergy
PHYSICAL
EXAMINATION
General
Survey:
fairly
nourished;
conscious;
coherent;
able
to
make
eye
contact;
follows
simple
commands;
not
in
cardiorespiratory
distress
Vital
Signs/Anthropometric
measurement:
Temperature
(axillary):
37.3C
left
axilla
Height:
89cm
(0
z-score)
Ideal
Height:
89cm
RR:
25
bpm
Weight:
11kg
(-2
z-score)
Ideal
Weight:
12kg
2
PR:
125
bpm
BMI:
15.15kg/m (-1
z-score)
Skin:
fair
in
color,
non-jaundiced,
afebrile,
warm
and
moist
to
touch,
good
skin
turgor;
no
discoloration
of
nail
unit
HEENT:
Head:
normocephalic,
atraumatic,
symmetric
skull
and
facial
bones,
no
depression,
mass,
or
tenderness
Eyes:
eyebrows:
thin
and
equal,
symmetrical
eyelid,
no
edema;
lacrimal
apparatus:
no
swelling,
excessive
tearing,
nor
drying;
anicteric
sclera;
pinkish
palpebral
conjunctiva;
unremarkable
vascular
pattern,
no
nodules,
no
swelling;
eyeballs
not
sunken;
good
visual
acuity;
pupils
constrict
4mm
to
3mm
equally
reactive
to
light;
full
extraocular
muscles;
uniform
convergence;
no
lid
lag
Ears:
symmetrical
external
ear,
no
deformities
nor
lumps,
good
gross
hearing
Nose:
symmetrical,
no
deformities;
no
frontal
or
maxillary
sinus
tenderness;
no
obstruction
on
each
nasal
ala
Mouth:
lips
pinkish
and
dry,
no
fissures;
oral
mucosa
pinkish,
no
nodules,
with
multiple
yellowish-white
ulcers
1-2mm
in
diameter
on
an
erythematous
base
at
the
pharyngeal
area
and
at
the
tongue
Neck:
with
R
submandibular
and
R
post-auricular
lymphadenopathy;
trachea:
midline;
left
and
right
spaces
symmetrical;
thyroid
gland:
soft
to
touch,
moves
with
deglutition,
no
tenderness;
no
neck
vein
engorgement
Chest
and
Lungs:
regular
breathing
pattern;
no
chest
deformities,
no
masses;
no
equal
bronchial
and
bronchovesicular
breath
sounds;
no
crackles,
no
wheezing
Heart:
no
chest
deformities;
no
visible
pulsation;
no
sign
of
bulging
or
depression;
no
heaves
or
thrills,
PMI
at
5th
LICS
MCL,
normal
rate,
regular
rhythm;
no
murmur;
distinct
S2
at
the
base
and
S1
at
the
apex,
no
S3/S4;
Abdomen:
globular;
no
scar;
symmetric;
sunken
umbilicus;
normoactive
bowel
sounds;
nontympanitic;
liver
edge
1-2cm
below
the
right
costal
margin;
tip
of
spleen
and
left
kidney
are
also
felt;
no
direct
or
rebound
tenderness
over
all
quadrants
Musculoskeletal:
no
gross
deformities;
full
and
equal
peripheral
pulses;
no
edema,
clubbing,
cyanosis;
capillary
refill
time
<2secs
Neurologic
Evaluation:
no
neurological
deficit;
patient
is
awake,
active,
playful,
follows
simple
commands;
no
sensory
or
motor
deficit
SALIENT
FEATURES:
Patient
is
a
2-year
old
male,
Filipino,
from
Paraaque
City,
who
was
brought
in
due
to
2-day
history
of
oral
sores
initially
localized
at
the
pharyngeal
area
then
progressed
to
involve
the
tongue.
Patient
also
had
fever
(Tmax
38C)
and
decrease
in
appetite
with
sore
throat.
The
sores
were
characterized
as
ulcerative,
yellowish-white,
1-2mm
in
diameter
with
erythematous
base.
Given
Carbenoxolone
Na
oral
gel
2%,
Inosiplex
250mg/5mL
syrup,
Paracetamol
250mg/mL,
and
Vit
C.
INITIAL
WORKING
IMPRESSION:
Herpangina
DIFFERENTIAL
DIAGNOSES:
Coxsackie
virus
Hand-Foot-and-Mouth
Disease
(Coxsackie
virus
A16)
Hand, foot and mouth disease is most commonly seen among children aged one to five years. In 75% of cases it
presents with an eruption of vesicles on the palms of the hands and on the feet. Occasional vesicles may also be found on
the proximal extremities and buttocks. There are also vesicles in the anterior part of the mouth. An associated low-grade
fever and malaise are usually present.
Acute
lymphonodular
pharyngitis
(Coxsackie
virus
A10)
Acute
lymphonodular
pharyngitis
is
considered
a
variant
of
herpangina.
The
pattern
of
distribution
of
oral
lesions
is
similar
to
that
observed
in
herpangina.
The
main
difference
is
that
in
acute
lymphonodular
pharyngitis,
the
pharyngeal
lesions
remain
papular
without
progression
to
vesicles
and
ulcers.
The infection that accompanies primary herpetic gingivostomatitis is usually subclinical in early childhood and
only a small percentage of patients develop an acute primary infection. This usually occurs in older children and consists
of fever, malaise, headache, cervical lymphadenopathy and a vesiculo-ulcerative eruption on the peri-oral skin, vermilion
or any intra-oral mucosal surface. The vesicles, which are 2 to 3 mm in diameter, rupture, leaving painful ulcers that heal
without scarring after seven to ten days. The gingivae are swollen and reddish due to a general inflammation. The virus
then migrates to the trigeminal ganglion, where it remains latent. In the case of cervical lymphadenopathy, the vesicles
and ulcers on the tonsils and posterior pharynx can resemble infectious mononucleosis or a streptococcal sore throat
infection.
COURSE
IN
THE
WARD
AND
MANAGEMENT
Hospital
day
0
afebrile
(+)
oral
lesions
(+)
sore
throat
poor
appetite
FINAL
DIAGNOSIS:
Herpangina
DISCUSSION
Herpangina
is
a
febrile
disorder
caused
by
numerous
group
A
Coxsackie
viruses
and
occasionally
other
enteroviruses
including
enterovirus
71.
Herpangina
is
characterized
by
sudden
onset
of
fever,
sore
throat,
dysphagia,
and
lesions
in
the
posterior
pharynx.
Temperatures
range
from
normal
to
41C
(106F);
fever
tends
to
be
greater
in
younger
patients.
Headache
and
backache
may
occur
in
older
children,
and
vomiting
and
abdominal
pain
occur
in
25%
of
cases.
Characteristic
lesions,
present
on
the
anterior
tonsillar
pillars,
soft
palate,
uvula,
tonsils,
posterior
pharyngeal
wall,
and,
occasionally,
the
posterior
buccal
surfaces,
are
discrete
1-2
mm
vesicles
and
ulcers
that
enlarge
over
2-3
days
to
3-4
mm
and
are
surrounded
by
erythematous
rings
that
vary
in
size
up
to
10
mm.
Typically,
approximately
5
lesions
are
present,
with
a
range
of
1
to
>15.
The
remainder
of
the
pharynx
appears
normal
or
minimally
erythematous.
Most
cases
are
mild
and
have
no
complications;
however,
some
are
associated
with
meningitis
or
more
severe
illness.
Fever
generally
lasts
1-4
days,
and
resolution
of
symp-
toms
occurs
in
3-7
days.
A
variety
of
enteroviruses
cause
herpangina,
including
enterovirus
71,
although
coxsackie
A
viruses
are
implicated
most
often.
PATHOPHYSIOLOGY
Transmission
is
via
fecal-oral
route
but
may
also
occur
via
direct
contact
with
nasal
and
throat
secretions
from
individuals
who
are
infected.
The
virus
attaches
and
replicates
in
susceptible
areas
of
the
pharynx
or
in
the
distal
part
of
the
GI
tract.
After
multiplying
in
the
submucosal
lymphoid
tissues,
enteroviruses
move
to
the
regional
lymph
nodes
(cervical
and
mesenteric)
and
produce
a
minor
viremia
that
is
transient
and
undetectable.
Most
infections
are
subclinical,
and
viral
replication
stops
or
is
halted
by
host
defense
mechanisms.
Oral
and
cutaneous
lesions
result
from
secondary
infection
of
the
small
blood
vessels
during
the
viremia
stage.
The
incubation
period
is
2
days
to
2
weeks
but
is
generally
3-5
days.
A
patient
who
is
infected
sheds
the
virus
several
days
before
symptoms
appear
and
can
continue
to
excrete
the
virus
several
weeks
after
the
illness.
DIAGNOSIS
Diagnosing
herpangina
is
based
on
clinical
symptomatology
however,
isolation
of
enterovirus
in
cell
culture
remains
the
criterion
standard
for
diagnosis.
Laboratory
studies
may
not
be
indicated
since
herpangina
is
a
mild
and
self-limited
illness.
When
blood
examination
is
taken,
WBC
count
is
usually
within
the
reference
range.
Serum
antibodies
to
coxsackievirus
may
be
measured
after
the
onset
of
clinical
symptoms.
The
antibody
titer
should
show
a
4-fold
rise
in
serial
samples
performed
2-3
weeks
apart.
Polymerase
chain
reaction
can
be
performed
for
enteroviral
RNA
of
the
throat,
blood,
CSF,
urine,
feces,
and
tissue
specimens.
MANAGEMENT
Herpangina
is
a
self-limited
illness,
hence
no
specific
therapy
is
indicated.
Treatment
is
generally
supportive
and
based
on
the
symptoms
the
patient
presents.
Supportive
therapy
includes
hydration,
antipyretics,
and
topical
analgesics.