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Herpetic Gingivostomatitis

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


Any oral ulceration should be evaluated for herpes infection.

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


Age 1 to 10 years.

Gender M = F.

Incidence 90% HSV-1 seropositive by age 10.

Etiology HSV-1 >> HSV-2.


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 fomitic spread is unlikely. Infection occurs via inoculation onto susceptible mucosal surface or break 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 both symptomatic and asymptomatic primary infection.


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.

Physical Examination

Skin Findings

Type Plaque, vesicles, ulcerations (Fig. 23-1).


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

Arrangement Herpetiform (grouped) vesicles.

Distribution Oral mucosa, oropharynx.

General Findings

Fever and LAD

Other Headache, fever, nuchal rigidity, ± positive HSV cerebrospinal fluid culture.

Differential Diagnosis

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, chemotherapy mucositis.

Laboratory Examinations

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).


Herpetic infection, Tzanck smear Giemsa’s stain of vesicle contents demonstrating multinucleated giant cells (fused virally infected keratinocytes) are indicative of a herpetic infection.

Direct Immunofluorescence Cells from the base of an intact vesicle can be smeared on a glass slide and ...

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