Updated: Jun 18, 2019
  • Author: Sandra G Gompf, MD, FACP, FIDSA; Chief Editor: Michael Stuart Bronze, MD  more...
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Herpangina is an acute febrile illness associated with small vesicular or ulcerative lesions on the posterior oropharyngeal structures (enanthem). Herpangina typically occurs during the summer and usually develops in children, occasionally occurring in newborns, adolescents, and young adults. Herpangina is one of many manifestations of enterovirus infection and can occur in association with enteroviral exanthem, aseptic meningitis, encephalitis, acute flaccid paralysis, and other clinical syndromes.



Herpangina is a pharyngeal infection typically caused by various enteroviruses. In recent years, coxsackievirus A16, enterovirus 71, and coxsackievirus B have been implicated most often. Less-common causes include echovirus, parechovirus 1, adenovirus, and herpes simplex virus (HSV). [1, 2] Enterovirus 71 has emerged as an important public problem, causing severe clinical illness, encephalomyelitis, and potentially death in young children. [3] . Enteroviruses that cause herpangina belong to the Picornaviridae family.

Coxsackievirus B4 virions under electron microscop Coxsackievirus B4 virions under electron microscopy. Courtesy of Centers for Disease Control and Prevention (CDC).

A distinct phenotype of Enterovirus 71 causes herpangina. This is in contrast to the phenotype of Enterovirus 71 that causes encephalitis, aseptic meningitis, myocarditis, poliomyelitis-like paralysis, and neonatal sepsis. Risk factors for postinfectious neurologic sequelae appear to include myoclonic jerks over 4 times per night. Age younger than 3 years and fever lasting 3 days or longer have been associated with encephalitis in enterovirus 71. infection. [4, 5, 6]

While herpangina is generally a mild disease in adults, infection during pregnancy has been associated with a herpangina associated with a 2.29- (95% confidence interval [CI], 1.42-3.69), 1.67- (95% CI, 1.04-2.68), and 1.63-fold (95% CI, 1.14-2.33) increased risk of low birth weight, preterm delivery, and small-for-gestational-age infants, respectively. [7]

Viruses that cause herpangina are typically spread via the fecal-oral route, although they may spread via the respiratory route or through fomites. Freshwater sources (eg, lakes) may act as a reservoir for transmission.

Herpangina typically has an incubation period of 4-14 days. Viremia occurs after inoculation and subsequently results in distant sites of infection. Viral replication at these secondary sites leads to characteristic clinical symptoms and oropharyngeal lesions. Bilateral, anterior, cervical lymphadenopathy may occur, resulting from infection of the posterior oropharynx. Coxsackievirus A may be recovered from the nasopharynx, feces, blood, urine, and cerebrospinal fluid (CSF). After clinical symptoms have resolved, asymptomatic enteroviral infection may persist in the gastrointestinal tract.




United States

Enteroviral infections are most common during the summer and fall in temperate climates and occur year-round in tropical climates.


Enteroviral infections occur worldwide. Acute fatal epidemics have been reported in at least 5 parts of the world, the most recent being described in Kanagawa Prefecture, Japan, in 2007. [8]


Herpangina is typically a mild and self-limited illness. Although most children who develop herpangina recover, the disease is occasionally complicated by CNS lesions and cardiopulmonary failure. Fatalities associated with herpangina have been reported, primarily in infants aged 6-11 months.

Notably, herpangina has been associated with the potential for adverse pregnancy outcomes. A Taiwanese population-based study of 242 pregnant women with herpangina found an associated 2.29-fold greater risk for low birth weight, 1.67-fold greater risk for preterm delivery, and 1.63-fold greater risk for small-for-gestational-age infants, after adjustment for income, maternal, and fetal characteristics. [9]


Herpangina does not have a sexual predilection.


Herpangina most commonly affects infants and young children aged 3-10 years. Herpangina is less common in adolescents and adults.