A 4-year-old boy is brought to the office with 3 days of fever, irritability, and oral lesions. His parents are concerned due to his refusal to eat or drink and lack of urination today. Physical examination demonstrates painful ulcers on the tongue and gingiva, swollen gums, and cervical lymphadenopathy. The remainder of his examination is unremarkable. Microscopic examination of an oral ulcer base scraping is shown in the image below. Which of the following is most likely the cause of this patient's condition?

Question

A 4-year-old boy is brought to the office with 3 days of fever, irritability, and oral lesions.  His parents are concerned due to his refusal to eat or drink and lack of urination today.  Physical examination demonstrates painful ulcers on the tongue and gingiva, swollen gums, and cervical lymphadenopathy.  The remainder of his examination is unremarkable.  Microscopic examination of an oral ulcer base scraping is shown in the image below.  Which of the following is most likely the cause of this patient's condition?

Quizplus · Accepted Answer

11ec160b_3836_59ae_9249_5fc14bbc0de0_MD0001_00 The above image depicts a Tzanck smear, in which epithelial cells are scraped from an ulcer base and stained. The presence of multinucleated giant cells is suggestive of herpes simplex virus (HSV) infection, which is consistent with this child's symptoms. Tzanck smears are insensitive and do not differentiate between HSV and varicella-zoster virus infection. Therefore, Tzanck smears largely have been replaced by polymerase chain reaction testing. Primary infection with HSV-1 results in herpetic gingivostomatitis. Peak age for primary infection is age 6 months to 5 years. Prodromal symptoms (eg, fever, malaise, chills) begin approximately 1 week after contact with an infected person (who is generally asymptomatic). Painful vesicles appear, extensively covering the lips and gingiva, and may include the palate, tongue, or oropharynx. The vesicles organize into extensive ulcers and resolve within 1-2 weeks. The pain of gingivostomatitis often results in dehydration, the most common reason for hospitalization. (Choice A) An abortive viral infection refers to an infection in which the virus enters the cell but does not successfully produce new infective virus. Therefore, an abortive infection is not capable of causing disease. (Choice B) HSV is capable of latency by integrating into the trigeminal (or sacral, for HSV-2) ganglia. However, during latency no virus is produced and therefore no clinical disease occurs. (Choice D) A slow virus infection is characterized by a prolonged incubation period that lasts months to years. During this time, the virus gradually multiplies before finally causing clinically apparent disease. Examples of slow viral infections include HIV, hepatitis C, and subacute sclerosing panencephalitis following measles infection. (Choice E) Reactivation of HSV from the trigeminal ganglia causes herpes labialis. In contrast to gingivostomatitis, recurrent labialis disease is usually mild, unilateral, and limited to the lips due to host immune mechanisms (eg, presence of neutralizing antibody & HSV-specific cytotoxic T cells). Educational objective: Herpetic gingivostomatitis is a severe vesicular or ulcerative disease following primary infection with herpes simplex virus type 1. The diagnosis is supported by the presence of multinucleated giant cells in a Tzanck smear. Involvement of the gingiva, tongue, palate, and pharynx along with systemic symptoms (eg, fever, malaise) is common. In contrast, herpes reactivation in the trigeminal ganglia generally results in mild perioral vesicles. __________ References: Acute primary herpetic gingivostomatitis. (http://www.ncbi.nlm.nih.gov/pubmed/23839615)

A 4-Year-Old Boy Is Brought to the Office with 3