Highlights
- •An enanthem is a mucosal eruption that precedes, follows, or occurs simultaneously with an exanthem.
- •Enanthems may be triggered by an underlying infection or a drug received by the patient, or both.
- •Patterns are: Vesicular, macular, maculopapular, maculopapular-petechial, and petechial.
- •Erythemato-vesicular and petechial patterns are most frequent in adults.
- •Some enanthems are pathognomonic for a disease, such as Köplik spots for measles.
Abstract
Introduction
Enanthems associated with viral infections—human herpesviruses
HSV-1 and HSV-2
VZV
CMV
EBV

HHV-6 and HHV-7

HHV-8
Measles virus

PB19 V
Enteroviruses
CV

Echoviruses
Adenoviruses
HIV
Viruses transmitted by arthropods: Arboviruses
Bunyaviridae
Bunyaviruses
Hantaviruses
Flaviviridae
DENV
Zika virus
Yellow fever virus
Omsk hemorrhagic fever and Kyasanur Forest disease viruses
Togaviridae
Alphaviruses
Viruses transmitted by rodents
Arenaviruses
Classic New World arenaviruses
Old World arenaviruses
Lassa virus
Other zoonotic viral infections
Filoviruses
Monkeypox virus
Severe acute respiratory syndrome coronavirus 2

Martín Carreras-Presas C, Amaro Sánchez J, López-Sánchez AF, Jané-Salas E, Somacarrera Pérez ML. Oral vesiculobullous lesions associated with SARS-CoV-2 infection. Oral Dis. 2020 May 5:10.1111/odi.13382. doi:10.1111/odi.13382. Epub ahead of print. PMID: 32369674; PMCID: PMC7267423.
Ansari R, Gheitani M, Heidari F, et al. Oral cavity lesions as a manifestation of the novel virus (COVID-19): a letter-to-editor [e-pub ahead of print]. Oral Dis. doi:10.1111/odi.13465.
Ciccarese G, Drago F, Boatti M, Porro A, Muzic SI, Parodi A. Oral erosions and petechiae during SARS-CoV-2 infection. J Med Virol. 2021 Jan;93(1):129-132. doi:10.1002/jmv.26221. Epub 2020 Jul 6. PMID: 32579237; PMCID: PMC7362051.
Ciccarese G, Drago F, Boatti M, Porro A, Muzic SI, Parodi A. Oral erosions and petechiae during SARS-CoV-2 infection. J Med Virol. 2021 Jan;93(1):129-132. doi:10.1002/jmv.26221. Epub 2020 Jul 6. PMID: 32579237; PMCID: PMC7362051.
Martín Carreras-Presas C, Amaro Sánchez J, López-Sánchez AF, Jané-Salas E, Somacarrera Pérez ML. Oral vesiculobullous lesions associated with SARS-CoV-2 infection. Oral Dis. 2020 May 5:10.1111/odi.13382. doi:10.1111/odi.13382. Epub ahead of print. PMID: 32369674; PMCID: PMC7267423.
Ansari R, Gheitani M, Heidari F, et al. Oral cavity lesions as a manifestation of the novel virus (COVID-19): a letter-to-editor [e-pub ahead of print]. Oral Dis. doi:10.1111/odi.13465.
Martín Carreras-Presas C, Amaro Sánchez J, López-Sánchez AF, Jané-Salas E, Somacarrera Pérez ML. Oral vesiculobullous lesions associated with SARS-CoV-2 infection. Oral Dis. 2020 May 5:10.1111/odi.13382. doi:10.1111/odi.13382. Epub ahead of print. PMID: 32369674; PMCID: PMC7267423.
Ansari R, Gheitani M, Heidari F, et al. Oral cavity lesions as a manifestation of the novel virus (COVID-19): a letter-to-editor [e-pub ahead of print]. Oral Dis. doi:10.1111/odi.13465.
Ciccarese G, Drago F, Boatti M, Porro A, Muzic SI, Parodi A. Oral erosions and petechiae during SARS-CoV-2 infection. J Med Virol. 2021 Jan;93(1):129-132. doi:10.1002/jmv.26221. Epub 2020 Jul 6. PMID: 32579237; PMCID: PMC7362051.
Viral infectious agent | Transmission | Incubation period (d) | Disease | Exanthem morphology | Enanthem morphology |
---|---|---|---|---|---|
HSV-1/2 | saliva, genital secretions, direct contact with muco-cutaneous lesions | 1-26 | herpes labialis/genitalis | painful grouped vesicular lesions in orolabial/genital areas evolving to erosions and crusts | |
VZV | direct contact or airborne droplets | 10-23 | Varicella | MP, EV | EV |
VZV | direct contact or airborne droplets | 10-23 | shingles | MP, EV with unilateral distribution | |
CMV | oral/vaginal secretions, urine, semen, placenta, breast milk, blood transfusions, organ transplantations | 20-60 | infectious mononucleosis, atypical exanthem, GCS | MP, U in immunocompetent; P, PE, VB, PU in immunosuppressed | MPP |
EBV | saliva | 30-60 | Mononucleosis, atypical exanthems, GCS, APEC | MP, U, PE | MP |
HHV-6/7 | saliva | 5-15 | Pityriasis rosea, atypical exanthems, DRESS, GCS, APEC | M, MP, MPP | M, MP, MPP |
HHV-8 | saliva | unknown | Kaposi sarcoma, atypical exanthems | MP | MP |
measles virus | airborne droplets | 7-21 | measles | MP, sometimes MPP, U | white lesions on a red granular appearance (Köplik spots) |
PB19 V | airborne droplets | 4-14 | Fifth disease, atypical exanthems, GCS | M, MP | M, MP |
Coxsackieviruses | airborne droplets | 3-10 | HFMD, atypical exanthems, AGEP, GCS | EV, MP | EV, MP |
Echoviruses | airborne droplets | 3-10 | HFMD, atypical exanthems, AGEP | M, MP, MPP, U | EV, MP |
Enteroviruses | airborne droplets | 3-10 | HFMD, atypical exanthems, AGEP | EV, MP | EV |
Adenoviruses | airborne droplets | 3-10 | Atypical exanthems, AGEP, GCS, APEC | MP, EV, PE | PE, MPP |
HIV | blood, vaginal secretions, semen | 28-56 | seroconversion illness with atypical exanthem | MP | M, MP |
Arboviruses | arthropod vectors | 1-8 | hemorrhagic fever with atypical exanthems | MP, MPP | MP, MPP |
Arenaviruses | rodent vectors | 7-10 | hemorrhagic fevers with atypical exanthems | PE | PE |
Filoviruses (Marburg and Ebola viruses) | direct contact with body fluids and person-person spread | 3-7 | hemorrhagic fever with atypical exanthems | MP, PE | PE |
SARS-CoV-2 | airborne droplets | 1-14 | COVID-19 with atypical exanthems | MP, EV, U, MPP, PE | PE, PU, erosions, ulcerations, blood crusts |
Enanthems associated with bacterial infections
Chlamydia pneumoniae
Mycoplasma pneumoniae
Francisella tularensis
Salmonella typhi
Haemophilus influenzae
Pseudomonas aeruginosa
Listeria monocytogenes
Acinetobacter species
Fusobacterium necrophorum
Treponema pallidum

N meningitidis

N gonorrhoeae
Rickettsiae
Rocky mountain spotted fever

Epidemic typhus
Murine typhus
Scrub typhus
Mediterranean spotted fever
Rickettsialpox
Staphylococcus aureus
Staphylococcal scalded skin syndrome
Toxic shock syndrome

Recalcitrant, erythematous, desquamating disorder
Staphylococcal scarlatiniform eruption
Streptococcus pyogenes
Scarlet fever

Toxin-mediated erythema (recurrent toxin-mediated perineal erythema)
Erythema scalariform desquamative recidivans
Kawasaki disease
Conclusions
Bacterial infectious agent | Transmission | Incubation period | Disease | Exanthem morphology | Enanthem morphology |
---|---|---|---|---|---|
Chlamydia pneumoniae | airborne droplets | 3-4 wk | pneumonia with mucositis | vesico-bullae and erosions on the oral mucosa | |
Mycoplasma pneumoniae | airborne droplets | 1-3 wk | pneumonia with atypical exanthem | MP, VB, PE | VB, hemorrhagic crusts |
Francisella tularensis | tick/arthropod bite | 2-5 d | tularemia with atypical exanthems | MP, EV, PU | nonexudative pharyngitis |
Salmonella typhi | water or contaminated food (oro-fecal transmission) | 1-3 wk | salmonellosis with atypical exanthems | MP | typhoid tongue |
Hemophilus influenzae | airborne droplets | 2-4 d | pneumonia/meningitis with atypical exanthem | PE (during bacteremia) | nonexudative pharyngitis |
Pseudomonas aeruginosa | direct contact, airborne trasmission, contaminated water | 2-3 d | infection of the ear, lung, skin, or urinary tract in case of diminished host resistance; atypical exanthem | PU; during septicemia: MPP, VB, PE | MPP |
Lysteria monocytogenes | airborne droplets, contaminated water | 10-70 d | listeriosis with atypical exanthems | PU, EV in adults; MP, PE, MPP with neonates | M, PE in neonates |
Acinetobacter baumanii | direct/indirect contact | not defined | atypical exanthems | MP, MPP | PE |
Fusobacterium necrophorum | airborne droplets | not defined | Lemierre's syndrome with atypical exanthems | MP | pharyngitis |
Treponema pallidum | direct contact, genital secretions | 10-90 d | roseola syphilitica | M, MP | M, MP, erosions |
Neisseria meningitidis | airborne droplets | 3-4 d | meningitis and atypical exanthems | PE | MPP |
N gonorrhoeae | genital secretions | 2-7 d | gonorrhoea; gonococcemia with atypical exanthems | PU, PE during gonococcemia | pharyngitis |
Rickettsia akari | bite of house mouse mites | 2-4 d | Rickettsialpox with atypical exanthems | PV | EV |
Staphylococcus aureus | direct/indirect contact, airborne droplets | 2-7 h | endocarditis, osteomyelitis with atypical exanthems | PE | PE |
Sta aureus | direct/indirect contact, airborne droplets | 2-7 h | Staphylococcal scalded skin syndrome | M, MP | crusts on the lips |
Sta aureus | direct/indirect contact, airborne droplets | 2-7 h | toxic shock syndrome | M | M, PE |
Streptococcus pyogenes | airborne droplets | 2-4 d | scarlet fever | M, PE in flexural locations | M, PE |
Sta aureus | direct/indirect contact, airborne droplets | 2-7 h | Kawasaki disease | M, MP, U | erythematous or fissured lips, strawberry tongue |
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