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Photo Essay

An Atlas of Lingual Lesions, Part 2

Volume 59 - Issue 6 - June 2019

  • Herpetic Gingivostomatitis

    Herpetic gingivostomatitis is the most common specific clinical manifestation of primary herpes simplex virus (HSV) infection in children.1 More than 90% of cases are caused by HSV type 1 (HSV-1).1-4 Herpetic gingivostomatitis can occur in adolescents and adults but most commonly affects children aged 6 months to 5 years, with a peak incidence between age 1 and 3 years.1-4 HSV-1 is primarily transmitted via direct contact with infected oral secretions or active lesions of other patients.5 On the other hand, HSV type 2 is spread mainly through genital sexual contact.

    Herpetic gingivostomatitis has a mean incubation period of 4 days (ranging from 2 to 12 days).1 The prodrome consists of a sensation of burning or paresthesia at the inoculation site, fever, malaise, irritability, anorexia, loss of appetite, sleeplessness, and headache.2,6 

    Oral lesions typically appear 1 to 2 days later and are usually accompanied by severe pain in the mouth, fever, hypersalivation, halitosis, and refusal to eat or drink.1,4 These oral lesions consist of clusters of vesicles throughout the mouth; they subsequently break down rapidly to form 1- to 5-mm shallow ulcers with a yellow-gray base and an erythematous halo.4-6 Adjacent lesions may coalesce to form irregular ulcerations.4 

    Lesions may develop throughout the oral cavity, in particular on and around the lips, along the gingivae, on the anterior of the tongue (as shown in the Figure), and the hard palate.1,5 The ulcers are extremely painful and have a tendency to bleed but eventually heal without scarring.4 Typically, the gingiva is inflamed, swollen, fiery red, friable, and bleed easily when touched.5 The cervical, submandibular, and submental lymph nodes are usually swollen and tender.1,2,6 The disease process typically resolves in 10 to 14 days.1

    herpetic gingivostomatitis

    The major complication is dehydration that may result from poor fluid intake, compounded by fever and hypersalivation.4 The infection may spread to other parts of the body by autoinoculation, resulting in, for example, perioral lesions, herpetic esophagitis, herpetic whitlow, herpetic keratitis, and eczema herpeticum.2,4 Reactivation of the virus in the trigeminal sensory ganglion may result in herpes labialis.2 Other complications can include secondary bacterial infection, secondary bacteremia, viremia, Bell palsy, and meningoencephalitis.1,4

    The diagnosis is mainly clinical, based on the typical appearance and location of the lesions.4 On occasion, viral culture, Tzanck smear, direct fluorescent antibody testing, and amplification of viral DNA using polymerase chain reaction may be performed to establish a definitive diagnosis.4,5 The gold standard for laboratory diagnosis is the viral culture.5

    Treatment is mainly symptomatic with antipyretic analgesics such as ibuprofen and acetaminophen, and adequate hydration.3,7 Chlorhexidine gluconate mouthwash has been used to decrease mucosal pain and to prevent secondary infection of the ulcers.5 Systemic acyclovir may be considered for severe herpetic gingivostomatitis and, in order to be maximally effective, should be initiated within 3 days of the onset of symptoms.3

     

    REFERENCES:

    1. Leung AKC. Herpetic gingivostomatitis. In: Leung AKC, ed. Common Problems in Ambulatory Pediatrics: Specific Clinical Problems. Vol 1. New York, NY: Nova Science Publishers; 2011:313-316.
    2. Aslanova M. Herpetic gingivostomatitis. StatPearls. https://www.statpearls.com/kb/viewarticle/22847. Updated October 27, 2018. Accessed May 14, 2019.
    3. Goldman RD. Acyclovir for herpetic gingivostomatitis in children. Can Fam Physician. 2016;62(5):403-404.
    4. Keels MA, Clements DA. Herpetic gingivostomatitis in young children. UpToDate. https://www.uptodate.com/contents/herpetic-gingivostomatitis​-in-young-children. Updated June 2, 2018. Accessed May 14, 2019.
    5. Mohan RP, Verma S, Singh U, Agarwal N. Acute primary herpetic gingivostomatitis [published online July 8, 2013]. BMJ Case Rep. doi:10.1136/bcr-2013-200074.
    6. Mangold AR, Torgerson RR, Rogers RS III. Diseases of the tongue. Clin Dermatol. 2016;34(4):458-469.
    7. de Suremain N, Guedj R, Fratta A, et al. Acute gingivostomatitis in children: epidemiology in the emergency department, pain, and use of codeine before its restriction. Arch Pediatr. 2019;26(2):80-85.

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