Primary Herpetic Gingivostomatitis.

Abstract

An 82-year-old female presented with painful oral lesions associated with fever and dysphagia since 3 days. Examination revealed multiple grouped tender white to yellow plaques and few discrete vesicles on an erythematous base over the tongue and palate [Figure 1] with tender cervical lymphadenopathy. Tzanck smear from the vesicles showed multinucleate epidermal giant cells [Figure 2]. A diagnosis of primary herpetic gingivostomatitis was made and the lesions resolved following treatment with oral valacyclovir 1 g twice daily for 7 days [Figure 3]. Herpetic gingivostomatitis is typically caused by Herpes simplex virus type-1 (HSV-1), but cases caused by HSV-2 have also been reported. HSV-1 spreads by direct contact, via droplets, or by sexual contact. Primary herpetic gingivostomatitis usually presents with yellow to white plaques and vesicles which rupture and coalesce to form ulcers over the buccal mucosa, tongue, palate, gingiva, and the lips. Severe cases can have associated fever, malaise, myalgia, and local lymphadenopathy. Following the primary episode, the virus being neurotropic may become latent in the peripheral nerves and ganglions, with subsequent reactivations causing recurrent infections in around one-thirds of patients. Recurrent herpes simplex infections can present as localized vesicles commonly on the vermillion border of the lips, perioral skin, or the hard palate.[1] The diagnosis of herpes gingivostomatitis is primarily clinical. The differential diagnoses include aphthous stomatitis, oral candidiasis, herpangina, Behcet disease, erythema multiforme, Steven–Johnson syndrome, hand, foot and mouth disease and immunobullous disorders.[2] Tzanck smear from vesicles demonstrating viral cytopathic changes can support the diagnosis; however, it cannot distinguish between HSV-1, HSV-2, or varicella zoster virus. Crusted or ulcerative lesions are diagnosed by more accurate tests like direct fluorescent antibody test, polymerase chain reaction, and viral cultures. Serological tests are useful but not generally indicated for acute infections; also many people exposed to HSV may demonstrate asymptomatic seroconversion.[12]Figure 1: Multiple grouped tender white to yellow plaques and discrete vesicles on an erythematous base over the tongue and palateFigure 2: Tzanck smear showing multinucleate epidermal giant cellFigure 3: Complete resolution post treatmentMost cases of herpes gingivostomatitis are self-resolving, requiring only supportive measures. Severe cases may require systemic antiviral therapy – oral Acyclovir 15 mg/kg five times a day; or valacyclovir, 1g twice daily; or famciclovir, 500 mg twice daily; for 5 to 7 days. In case of frequent recurrences, prophylactic suppressive acyclovir (400 mg twice daily), valacyclovir (500 mg orally once daily), or famciclovir (250 mg twice daily) may be considered.[23] Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.