Multiple - Acute

Question 1

Multipl3e acute lesions listed

Answer 1

Primary Herpes Simplex Virus (HSV)
Multiple Aphthous Ulcers → See Ulcer Portion
Varicella Zoster Virus (Chickenpox / Shingles)
Allergic Reaction
Erythema Multiforme
Coxsackievirus Infections
◦ Herpangina
◦ Hand-Foot-Mouth

Question 2

Recurrent Herpes Lesions / Herpes Labialis (DNA)

Answer 2

Type 1- Oral
Type 2 – Genital
Virus will remain dormant in TRIGEMINAL GANGLION until reactivation
◦ 90% occur on lip/perioral
◦ 10% occur intra-orally
Triggers include: Trauma (dental treatment), UV light/ Sun exposure, immune compromise, stress
Stages:
◦ Prodromal (TAKE ANTI-VIRAL NOW!! Or treat with laser)
◦ Blister
◦ Ulcer
◦ Scabbing
◦ Healing
High Lysine diet may help prevent reoccurrence (Lysine supplements, meats, peanuts, cheese and black beans are high in lysine)
Rx for 1 day Valtrex (Valacyclovir), 8 tabs of 500mg each, Take 4 Tabs at prodromal and 4 more Tabs 12h after primary dose.
NO Antibiotics…..ONLY if secondary bacterial infection exists on top of primary viral issue

Question 3

Primary Herpes Simplex Virus (HSV)

Answer 3

Primary Infection, increased risk after 6-months of age
◦ 60% of population carry virus
◦ 99% of primary infections are subclinical → Misdiagnosed as URI in cases
◦ 1% become acute
Primary Herpetic Gingivostomatitis
◦ Most common cause of severe oral ulcerations in children
◦ Prodromal sign and generalized marginal gingivitis
◦ Typically seen between 6 months of age and 6 years old….peak at 2-4 years old (Daycare starts),
Seasonal spikes
◦ Anterior oropharynx is primary site of lesions/vesicles
◦ Symptoms include fever, malaise, poor eating, generalized gingival erythema, heals without
scarring in 1-2 weeks…..KEEP them HYDRATED!
◦ New toothbrush, no sharing toys/pacifiers with young siblings
Differential Diagnosis!!
◦ Varicella (Typically on trunk of body)
◦ Impetigo (Cause and Tx ???)
◦ Coxsackie A (HFM)

Question 4

Primary Herpetic Gingivostomatitis

Answer 4

May initially present as a pharyngitis
Typically seen in 6 month old up to 5 year old
Cervical lymphadenopathy, fever, nausea, irritabile
Treatment: Palliative or Acyclovir suspension (Children 15mg/kg) in the first 3 days of illness;
Rinse and swallow 5 times/day for 5 days in total

Question 5

Varicella (Chicken Pox)

Answer 5

Highly contagious and caused by the varicella-zoster virus
◦ More common decades ago due to no vaccine
◦ Vaccine now routinely administered and decreased incidence of virus (90% effective
to prevent)
Starts as rash that turns itchy and then fluid filled blisters, that crust over
◦ FACE, CHEST and BACK are first places seen
◦ THEN, spread to extremities (mouth, arms, legs)
Secondary skin infections can complicate healing and prolong
blistering/scabbing
Can reoccur later in life as same virus, but referred to as Shingles
◦ Extremely painful, but adult inoculations do exist for at risk or older patients.

Question 6

Varicella Zoster (VZV) or Shingles

Answer 6

Commonly referred to as Chicken Pox prior to vaccination became available
Varicella zoster typically occurs in younger, unvaccinated child
Prior exposure to Varicella or Chicken Pox can lead to Shingles flare-up in older patient
Vaccine for Shingles does exist, check titer levels for varicella to verify levels
◦ May need Shingles booster
Shingles can be EXTREMELY painful
Are expressed on dermatome and typically unilaterally

Question 7

Erythema Multiforme

Answer 7

Erythema multiforme (EM) is a mild, self limiting and recurring mucocutaneous reaction of the
skin and mucous membrane
Wide variability in expression
Most commonly seen in school aged to college age children
◦ 7 to 21 years old
SYMMETRICALLY distributed skin lesions
Caused by HERPES SIMPLEX VIRUS (HSV) in 60-70% of cases
Some drugs can cause EM reaction as well
◦ Sulfonamides, NSAIDs, Penicillin and more

Flat lesion with symmetrical presentation
Central area of lesion may appear to have blister or appear necrotic
Over 70% of EM cases will have oral mucosal lesions present
◦ May occur with absent or few skin lesions and only as oral mucosal lesions
◦ Lesions are common on lips, alveolar mucosa and palate
EXTREMELY painful lesions
◦ Can impact speech and eating
◦ Be careful to keep patient hydrated
◦ NO scarring with healing

Treatment is based on severity of symptoms
Topical steroids are easy and effective in managing the painful oral ulcers that present
Systemic antiviral agents will help resolve and control underlying viral etiology
◦ Valacyclovir 500 mg BID
◦ OR
◦ Acyclovir 200 mg 5 x Day
Systemic steroids can be used for 48-72 hours

Question 8

Coxsackie Virus (RNA)

Answer 8

Coxsackievirus – Group A is most common viral infection in the oral cavity
Virus responsible for:
◦ Herpangina
◦ Acute lymphonodular pharyngitis
◦ Hand-foot-and-mouth disease

Question 9

Herpangina

Answer 9

Painful mouth ulcerations that result from coxsackie A virus(most commonly)
◦ Can also be caused by coxsackie B and echovirus
Associated with sudden onset, sore throat, dysphagia, headache, neck pain/tenderness and then 24-48 hours later
with erythema and vesicular eruption
Most common areas for ulcers to appear is in and around tonsillar pillars / posterior oropharynx / soft palate
◦ Primary gingivostomatitis has primary vesicles/ulcers in anterior area of the mouth
Higher correlation during summer and warmer weather

Question 10

Hand Foot Mouth (HFM)

Answer 10

Fairly common, virally caused outbreak of small vesicles
in hand, feet and in mouth
Present with headache, fever, sore throat and painful
lesions on tongue, cheeks.
◦ 1-2 days after fever, lesions will appear
Lesions can be present on soles of feet, palms of hands
and buttocks
Palliative treatment only, ensure the child is hydrated
Coxsackie A16 is most common cause of infection and
high frequency with daycare infants and toddlers
Coxsackie A6 subtype can be extremely aggressive and
result in hospitalization and loss of fingernails in weeks
to follow