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March 4, 2011

March 4, 2011. HSV gingivostomatitis. HSV Gingivostomatitis. Most common manifestation of primary HSV infection children 13-30% Typically HSV-1 Age 6mos – 5yrs Can occur in adolescents Prodromal illness: fever, anorexia, malaise, h/a. HSV Gingivostomatitis.

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March 4, 2011

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  1. March 4, 2011

  2. HSV gingivostomatitis

  3. HSV Gingivostomatitis • Most common manifestation of primary HSV infection children • 13-30% • Typically HSV-1 • Age 6mos – 5yrs • Can occur in adolescents • Prodromal illness: fever, anorexia, malaise, h/a

  4. HSV Gingivostomatitis • Transmission: direct contact with infected oral secretions or lesions • Viral shedding in primary gingivostomatitis: • At least 1wk • Median 3 weeks • Incubation period • 2days – 2 weeks • Reactivation through trigeminal ganglion

  5. Complications • Dehydration (most common) • Herpetic whitlow • Secondary bacterial infection or bacteremia • Esophagitis • HSV encephalitis • Eczema herpeticum • Lip adhesions

  6. Supportive Care • Hydration • Pain control • Barrier for lips • Petroleum jelly • Topical therapies • Magic mouthwash • Various combinations of benadryl, Maalox, Kaopectate, viscous lidocaine

  7. Treatment • Oral acyclovir shortens duration of symptoms and viral shedding • Topical acyclovir not effective • Immunocompromised: IV acyclovir • Prolonged course of disease: • Consider Acyclovir resistance • Use Foscarnet • Superimposed infection: amoxicillin or clinda

  8. Isolation • Children in childcare who do not have control of oral secretions should be excluded • Hospitalized: add contact precautions

  9. Oral candidiasis

  10. Oral Candidiasis • 60% of healthy individuals harbor Candida in oral cavity • Also skin, intestinal, and vaginal area • C. albicans accounts for 80% oral isolates • Others: C. glabrata, C. tropicalis • Infants acquire Candida: • Birth • Postnatally (breast feeding) • Oral candidiasis (thrush) • 2-5% of healthy newborns

  11. Oral Candidiasis: Setup • Altered host defense • Infants: immaturity of immune system • HIV & Other immune deficiencies • Diabetes mellitus • Antineoplastic or immunosuppressive drugs • Inhaled corticosteroids

  12. Oral Candidiasis: Setup • Insult to natural oral flora • Frequent or prolonged antibiotics • Poor oral hygiene may contribute

  13. Oral Candidiasis • Symptoms • Asymptomatic • Sore and painful mouth • Burning • Dysphagia • Infants may have decreased PO intake

  14. Pseudomembranouscandidiasis (thrush) • White to yellow plaques and erythema of tongue, soft palate, and buccal mucosa • Plaques may be wiped off • Raw, erythematous mucosa • Differentiate from “milk curd” • May also see • Angular chelitis • Fissuring or scaling at corners of mouth

  15. Erythematouscandidiasis(atrophic candidiasis) • Denuded lesions: Palate and dorsum of tongue • Seen with • Corticosteroids • HIV

  16. Diagnosis • Clinical diagnosis • Can look for pseudohyphae • If immunocompromised, consider: • Aspergillosis • Cryptococcosis • Histoplasmosis • Blastomycosis • Mucormycosis

  17. Treatment • Usually responds well to topical agents • Nystatin suspension • 4X daily for 2 wks • (2 days beyond resolution of symptoms) • Refractory cases or immunocompromised • Fluconazole

  18. Refractory cases • Children >6y/o with persistent or unexplained frequent relapses, consider immunodeficiency (HIV) • Maternal colonization or infection in breast fed infants

  19. Herpangina

  20. Herpangina • Coxsackie Group A • Age 3-10 years • Sudden onset high fever, sore throat, dysphagia, lesions of post pharynx • Anterior tonsillar pillars, soft palate • 1-2mm vescicles that ulcerate and enlarge to 4mm • Surrounded by erythematous ring (up to 10mm) • Average of 5 lesions

  21. Herpangina • Typically self limited • May be associated with aseptic meningitis

  22. Hand-foot-mouth

  23. Hand-Foot-Mouth • Enteroviruses (Coxsackie A and B) • Multiple viruses • Summer months • < Age 5 • Typically self-limited • Low-grade fever? • Possible aseptic meningitis, encephalitis • Enterovirus 71 (more severe CNS symptoms)

  24. Hand-Foot-Mouth • Scattered vesicles and ulcerative lesions (4-8mm) throughout oropharynx • More numerous than herpangina • Rash hands, fingers, feet, buttocks, groin • May involve palms/soles

  25. HIV gingivitis

  26. HIV Gingivitis • Generalized linear gingival erythema • Brightly inflamed band of marginal gingiva • Painful, bloody, tissue destruction • Enteric strains and yeast • Treatment: • Debridement and antimicrobials

  27. Riga-fede ulceration

  28. Riga-Fede Ulceration • Ventral surface of tongue in infants • Continual movement of tongue over lower incisor • Treatment varies • Observation • Smoothing of tooth edge

  29. Geographic tongue

  30. Geographic Tongue(Benign Migratory Glossitis) • Chronic, recurring • Lesions • Pink to red • slightly depressed • Irregular, elevated, white to yellow borders • Areas of dekeratinization and desquamation of filiform papilla • Typically asymptomatic • Reassure

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