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University of Perpetual Help Rizal

JONELTA Foundation School of Medicine


Pamplona, Las Pias City
DEPARTMENT OF PEDIATRICS

Herpangina 1

Deity A. Celle, Jr.


Clinical Clerk Block 4 Batch 2016

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.

The history was taken on July 22, 2015 at UPHDMC-JONELTA Ward.



GENERAL DATA


Patient J.E. is a 2-year-old male, child, Catholic, Filipino citizen. He was born in Paraaque City on Oct. 31, 2012. He is
currently residing in L11 B93 Helsinki St. Ph3, BF Homes, Paraaque City, Metro Manila 1700 with his parents, three siblings,
grandparents, and cousin.


CHIEF COMPLAINT


May parang mga singaw, as verbalized by the mother

HISTORY OF PRESENT ILLNESS

Patient was in his usual state of health until
2 days prior to admission, patient woke up and started complaining of pain in his mouth. His mother then saw
erythematous ulcers about 1-2mm in diameter on his pharyngeal area. Patient was still able to eat and drink without difficulty.
He had fever (Tmax 38C), but no vomiting, headache, body malaise, nor joint pain. His mother then brought him to a nearby
clinic where he was given Carbenoxolone Na oral gel 2%, Inosiplex 250mg/5mL syrup, Paracetamol 250mg/mL, and Vit C.
1 day prior to admission, fever lysed although the mother still noted patient to be feverish. The ulcers then involved
the tongue both on the dorsal and ventral aspects. Later that night, patient stopped eating because of dysphagia.
Persistence of symptoms prompted the mother to bring patient to UPHDMC-ER for management where he was
subsequently admitted.


PAST MEDICAL HISTORY

Patient does not have any comorbidity such as bronchial asthma, cardiovascular problem, diabetes mellitus,
neurologic problem, cancer, nor allergy to food or medication. Patient has not been hospitalized before due to any medical
illness nor has he undergone any surgical procedure.

Medications:

Current Medications:
Carbenoxolone Na oral gel 2% applied topically to the oral ulcers
Paracetamol 250mg/mL for pain
Inosiplex 250mg/5mL syrup for strengthening of the immune system
Vit C as daily vitamin


Immunization:
BCG at birth
Hep B at birth
DTwP-HepB-Hib 6 weeks, 10 weeks, 14 weeks
OPV 6 weeks, 10 weeks, 14 weeks
Measles 9 months
MMR 15 months

FAMILY HISTORY

Family Member

Medical Problems

Father

None

Mother

None

Siblings
Medical Problems for Any Blood Relative
Cancer

None
Present / Absent
Absent

Diabetes

Present (Paternal side)

Hypertension

Present (Paternal side)

Thyroid Disorders:
Goiter
Hyperthyroidism


Absent
Absent

Heart Disease

Absent

Stroke

Present (Both parents side)

Kidney Disease

Absent

Blood Disorder

Absent

Asthma

Present (Paternal side)

Epilepsy

Absent

Psychiatric Disorder

Absent

Pulmonary Tuberculosis (Primary complex)

Present (Paternal side)



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

Fever Chills Weight loss Fatigue


Acuity changes Diplopia
Hearing loss Sore throat Tinnitus
Chest pain Palpitations Orthopnea Dyspnea
SOB DOB Hemoptysis Cough
Nausea Vomiting Diarrhea Dysphagia
Dysuria Frequency Urgency

Musculoskeletal
Skin
Neurology
Psychiatry
Endocrine
Hematology
Immuno/Allergy

Muscle pain joint pain


Rash Lesions
Headache Dizziness Seizure Focal weakness
Depression Anxiety
Polyuria Polydypsia Heat/Cold intolerance
Adenopathy Bruising
Urticaria


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.

Herpes simplex virus


Primary Herpetic Gingivostomatitis

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

Mouth: multiple yellowish-white


ulcers 1-2mm in diameter on an
erythematous base at the
pharyngeal area and at the tongue

CBC:
RBC 4.28
Hematocrit 0.35
Hemoglobin 113
WBC 4.5
Segmenters 0.49
Eosinophils 0.01
Lymphocytes 0.38
Monocytes 0.12
Platelet count 297
Mouth: multiple yellowish-white
afebrile
(+) oral lesions ulcers 1-2mm in diameter on an
erythematous base at the
improving
(+) sore throat pharyngeal area and at the tongue
minimal
improving
appetite

afebrile
(+) oral lesions
(+) sore throat
poor appetite

Herpangina Diet: Mechanically soft diet


IVF: D5 0.3 NaCl 500cc x 62-63cc/hr
(50/8hrs) 31cc/hr
Medications:
1. Kamillosan spray 1-2sprays inside
the mouth TID after meals and
brushing of teeth
2. Paracetamol drops 1mL Q4 for T
37.8C
3. Paracetamol 100mg IV Q4 for
T39.0C
4. Carbenoxolone Na oral gel 2%
5. Inosiplex 250mg/5mL syrup
6. Vitamin C

Herpangina Continued present management.
Advised discharge with home
medications.

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.

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