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Primary Herpetic Gingivostomatitis
Caused primarily by herpes simplex virus type 1. Primary infection is most severe and usually seen in children younger than age 6.
Clinical presentation: Fever and malaise precede the anorexia, oral findings, and cervical lymphadenopathy. There is usually significant lip and gum swelling, erythema, and bleeding. Vesicles form on the lips, tongue, and cheeks, and then ulcerate.
Clinical syndrome of HSV gingivostomatitis lasts 10-14 days. The ulcers are very painful and cause children to refuse to drink, which can result in hospitalization for dehydration.
Diagnosis: Usually based on clinical history and exam findings. Cultures, antigen testing, or PCR can be performed in unclear cases.
Treatment is mainly supportive with hydration maintenance and pain control. May also be treated with the acyclovir family of antiviral medications.
Infection is life-long and recurrences occur as “cold sores” (herpes labialis), usually at times of stress or infection.
Varicella can also present with oral vesicles and ulcers on multiple areas of the oral mucosa. The concurrent cutaneous lesions of varicella should help to distinguish the 2 viruses.

Coxsackie Viral Infections
Herpangina: Multiple small ulcers (2-4 mm) on the soft palate and tonsils, caused by Coxsackie A (less commonly B).
Hand-Foot-Mouth Disease: Ulcers on pharynx, other mucosa, and hard palate with vesicles on the palms and soles caused by Coxsackie A (usually serotype A16).
Clinical presentation: Fever, malaise, sore throat, and anorexia precede appearance of the vesicles. Cervical lymphadenopathy is also present. Symptoms last 7-10 days.
Treatment is supportive care.
The major morbidity of primary HSV infection is dehydration.
Treatment for viral infections with oral manifestations is generally only supportive care.
Consider immunodeficiency in a child who has frequent or persistent candidal infections after 1 year of age.
A strawberry tongue is commonly seen with GABHS infections and Kawasaki Syndrome.
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