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.
Incidence 90% HSV-1 seropositive
by age 10.
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)
Type Plaque, vesicles, ulcerations
Herpetic gingivostomatitis Severe
circumferential perioral erosions and ulcerations that prevent the
child from being able to eat or drink.
Arrangement Herpetiform (grouped)
Distribution Oral mucosa, oropharynx.
Other Headache, fever, nuchal rigidity,
± positive HSV cerebrospinal fluid culture.
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.
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
Direct Immunofluorescence Cells
from the base of an intact vesicle can be smeared on a glass slide