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HERPES SIMPLEX VIRUS

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HERPETIC GINGIVOSTOMATITIS

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Primary herpetic gingivostomatitis is caused by herpes simplex virus 1 (HSV-1) infection in children and characterized by painful vesicular lesions of the mouth.

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INSIGHT Image not available.

Any oral ulceration should be evaluated for herpes infection.

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SYNONYMS Herpes, herpes simplex, cold sore, fever blister, herpes febrilis, herpes labialis.

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EPIDEMIOLOGY
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AGE 1 to 10 years. Peak incidence between 6 months and 5 years age.

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GENDER M = F.

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INCIDENCE 90% HSV-1 seropositive by age 10.

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ETIOLOGY HSV-1 >> HSV-2.

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PATHOPHYSIOLOGY
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Transmission and primary infection of HSV occurs through close contact with a person shedding the virus at a peripheral site, mucosal surface, or through secretion. HSV is inactivated promptly at room temperature; thus, aerosolized or fomite spread is unlikely. Infection occurs via inoculation onto susceptible mucosal surface or breaks in skin. Subsequent to primary infection at the inoculation site, HSV ascends peripheral sensory nerves and enters the sensory or autonomic nerve root ganglia, where latency is established. Latency can occur after either symptomatic or asymptomatic primary infection.

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HISTORY
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Three to seven days after exposure, primary herpetic infections may be asymptomatic (the majority) or symptomatic with gingivostomatitis, high fever, sore throat, and lymphadenopathy. The pain may be so debilitating that hospitalization is necessary for intravenous (IV) hydration.

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PHYSICAL EXAMINATION
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Skin Findings
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TYPE Plaque, vesicles, ulcerations (Fig. 23-1).

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FIGURE 23-1
Herpetic gingivostomatitis

Severe circumferential perioral erosions and ulcerations that prevent the child from being able to eat or drink.

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ARRANGEMENT Herpetiform (grouped) vesicles.

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DISTRIBUTION Oral mucosa, oropharynx.

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General Findings
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FEVER, LAD.

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OTHER Headache, fever, nuchal rigidity, ± positive HSV cerebrospinal fluid culture in severe disease.

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DIFFERENTIAL DIAGNOSIS
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The differential diagnosis for primary HSV gingivostomatitis includes aphthous stomatitis, hand-foot-and-mouth disease (HFMD), herpangina, erythema multiforme, or Behçet's disease, oral candidiasis, and chemotherapy mucositis.

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LABORATORY EXAMINATIONS
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TZANCK SMEAR Cells from the base of an intact vesicle are smeared thinly on a microscope slide, dried, stained with Wright's or Giemsa's stain, showing multinucleated giant keratinocytes (Fig. 23-2). Tzanck smear is positive in 75% of early cases, but does not differentiate HSV-1 from HSV-2 or varicella-zoster virus (VZV).

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FIGURE 23-2
Herpetic infection, Tzanck smear

Giemsa's stain of vesicle contents demonstrating multinucleated giant cells (fused virally infected keratinocytes) are indicative of a herpetic infection.

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DIRECT IMMUNOFLUORESCENCE Cells from the base of an intact ...

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