Herpangina, hand, foot, and mouth disease (HFM), 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 gonorrhea 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. HFM disease 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. Symptoms (sudden onset) 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 almost always indicates GABHS and is commonly referred to as scarlet fever.
Ebstein 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 and anterior. Hepatosplenomegaly 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, HFM disease 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, (d) history of fever. With 2 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.