Herpangina, hand, foot, and mouth disease (HFMD), and herpes simplex gingivostomatitis are the primary infections that cause stomatitis in children and are all viral. The vast majority of pharyngitis is caused by viral infections; however, group A β-hemolytic Streptococcus (GABHS) and Neisseria gonorrhoeae are bacterial infections that require accurate diagnoses. The identification and treatment of GABHS pharyngitis is important to prevent the suppurative complications and the sequelae of acute rheumatic fever.
Herpangina causes a vesicular enanthem of the tonsils and soft palate, affecting children 6 months to 10 years of age during late summer and early fall. The vesicles are painful and can be associated with fever and dysphagia. HFMD usually begins as macules which progress to vesicles of the palate, buccal mucosa, gingiva, and tongue. Similar lesions may present on the palms of hands, soles of feet, and buttocks. Herpes simplex gingivostomatitis often presents with abrupt onset of fever, irritability, and decreased oral intake with edematous and friable gingiva. Vesicular lesions often with ulcerations are seen in the anterior oral cavity.
Peak seasons for GABHS are late winter or early spring, the peak age is 5 to 15 years, and it is rare before the age of 2 years. Symptoms include sore throat, fever, headache, abdominal pain, enlarged anterior cervical nodes, palatal petechiae, and hypertrophy of the tonsils. With GABHS there is usually the absence of cough, coryza, laryngitis, stridor, conjunctivitis, and diarrhea. A scarlatinaform rash associated with pharyngitis may indicate GABHS and is commonly referred to as scarlet fever.
Epstein-Barr Virus (EBV) is a herpes virus and often presents much like streptococcal pharyngitis. Common symptoms are fever, sore throat, and malaise. Cervical adenopathy may be prominent and often is posterior. Hepatosplenomegaly and splenomegaly may be present. EBV should be suspected in the child with pharyngitis nonresponsive to antibiotics in the presence of a negative throat culture.
Gonococcal pharyngitis in children and nonsexually active adolescents should alert one to the possibility of sexual abuse. Gonococcal pharyngitis may be associated with infection elsewhere including proctitis, vaginitis, urethritis, or arthritis.
Diagnosis and Differential
The diagnoses of herpangina, HFMD, and herpes simplex gingivostomatitis are based on clinical findings. To diagnose GABHS, current guidelines recommend the use of Centor criteria to determine which patients require testing: (a) tonsillar exudates, (b) tender anterior cervical lymphadenopathy, (c) absence of cough, and (d) history of fever. With two or more criteria, testing should be performed with a rapid antigen detection test and/or culture. If the rapid antigen test is negative, a confirmatory throat culture is recommended.
Diagnosis of EBV is often clinical. A heterophile antibody (monospot) can aid in the diagnosis. The monospot may be insensitive in children <2 years of age and is often negative in the first week of illness. If obtained, the white blood cell count may show a lymphocytosis with a preponderance of atypical lymphocytes. Diagnosis of gonococcal pharyngitis is made by culture on Thayer-Martin medium. Vaginal, cervical, urethral, and rectal cultures also should be obtained if gonococcal pharyngitis is suspected.
Emergency Department Care and Disposition
Treatment of herpangina, HFMD, and herpes simplex gingivostomatitis is primarily supportive. Systemic analgesics such as a combination of ibuprofen and acetaminophen should be considered. Parenteral hydration may be necessary if the child cannot tolerate oral fluids. Occasionally oral narcotics may be required.
Antibiotics for the treatment of GABHS pharyngitis should be reserved for patients with a positive rapid antigen test or culture. Antibiotic choices for GABHS include penicillin V (children 250 mg PO twice daily, adolescent/adult 500 mg PO twice daily) for 7 to 10 days; benzathine penicillin G 1.2 million units IM (600,000 units IM for patients weighing less than 27 kg) once; or amoxicillin 50 mg/kg once daily for 7 to 10 days.
Treat gonococcal pharyngitis with ceftriaxone 250 mg IM. When gonococcal pharyngitis is suspected, empiric treatment of chlamydia is recommended with azithromycin 1 g PO given in the emergency department. Appropriate follow-up should be encouraged for treatment failure and symptomatic contacts. Follow-up for suspected gonococcal pharyngitis should include local reporting agencies and social service investigations.
EBV is usually self-limited and requires only supportive treatment including antipyretics, fluids, and rest.