Mouth Ulcers in a Febrile Young Child

I saw a child, the day before yesterday, with a rash on her upper back and forehead, and odd little almost-coalescent red-ringed blisters and ulcers on the back of her tongue and mouth. She had had a fever but was not too unwell apart — except that she had not been eating so much.

The rash on her upper back and face looked much like these on this child’s hand. [Image:
The oral lesions looked much like this …

What are the causes of mouth ulcers/blisters in children?

Hand-Foot-Mouth Disease (HFMD) is the most common cause of multiple ulcers in the mouth in children aged 1 to 5 years of age. The ulcers usually sit on the tongue and sides of the mouth. Accompanying blisters on the palms and soles helps confirm the diagnosis of a Coxsackievirus infection.

However, other conditions need to be considered. Herpangina is similar to HFMD but usually causes blisters in the posterior tongue and palate rather than anteriorly, as in HFMD.

Gingivostomatitis, a general term but often connoted with primary Herpes simplex infection, often causes severe ulceration of the gums, tongue, and lips, usually in a younger child (under 3 years old) who has come into contact (been kissed by) an adult with cold sores. Look for ulcers on the outer lips or skin around the mouth. Recurrent cold sores around the mouth/lips can occur any time thereafter but, more common in teens and adolescents, are devoid of accompanying oral lesions.

According to the Seattle Children’s Hospital, Canker Sores (aphthous ulcers) are the most common cause of one or two mouth ulcers in children over the age of 5. Otherwise, mouth injury from self-bites and hot-food burns can cause ulceration and often leave a white trace where they have healed. There are more obscure causes also.

In the young lady in question, I believe she had Herpangina.

Herpangina is an enteroviral infection, usually caused by the highly-contagious coxsackie A16 virus but other coxsackie strains may be the culprit. Other viruses that have been implicated with herpangina include:

  • echoviruses
  • enterovirus 71
  • herpes simplex virus
  • parechovirus 1
  • adenoviruses

About half of patients are asymptomatic or at most have a fever, but can still spread the disease no less.

Peak season: summer or autumn

A mild-moderate self-limited infection, serious neurological, heart, and lung problems may complicate some enterovirus infections.

Diagnosis is clinical and treatment expectant symptomatic.

For childcare settings, nasopharyngeal swabs, urine, faeces, and blood samples can be used to detect IgM antibodies

DermNet NZ, however, has this to say:

Herpangina can be distinguished from hand, foot and mouth disease, another enterovirus infection, by the lack of skin lesions. Primary herpes simplex virus infection of the mouth is usually more extensive including the gums, is very painful and lasts longer.

In that case, the diagnosis is HFMD. But I’m not so sure. We will look into this further. Either way, the argument is academic as both HFMD and Herpangina are generally self-limiting viral illnesses (both usually caused by enteroviruses).

Excluded the child until the blisters have dried. Good hand hygiene is important, including adults before preparing food or eating.


Herpangina – DermNet NZ

Mouth Ulcers – Raising Children

Mouth Ulcers – Seattle Children’s Hospital

Coxsackie virus – Best online MD