Group A streptococcal pharyngitis can present with a characteristic “strawberry tongue,” with hypertrophic red papillae on a thick white coat, tonsillar hyperemia, hypertrophy, and exudate, and palatal petechiae ( Fig 52.2 ) If an erythematous, papular “sandpaper” rash is present, most commonly on the trunk, the condition is termed scarlet fever Ludwig angina is a rapidly progressive cellulitis of the sublingual and submandibular space, resulting in skin erythema, pitting edema, trismus, and high fever, with the potential for airway compromise if inadequately treated Treatment includes surgical drainage and broad spectrum antibiotics Koplik spots are pinpoint white macules on markedly erythematous mucous membranes, occurring with cough, coryza, conjunctivitis, and fever during the prodrome of measles They generally resolve before the characteristic rash occurs Varicella lesions occurring in the mouth are self-limited, painful vesicles on an erythematous base, sometimes found unroofed Pain may lead to reluctance to swallow TABLE 52.1 DIFFERENTIAL DIAGNOSIS OF ORAL LESIONS Congenital oral lesions Epstein pearls Epithelial pearls Bohn nodules Dental lamina cysts Natal teeth Ankyloglossia Epulis (gum boil) Lymphatic malformation Hemangioma Vascular malformation Dermoid/epidermoid cyst Foregut duplication cyst White sponge nevus Infectious oral lesions Candidiasis Median rhomboid glossitis Herpes simplex Gingivostomatitis—primary Labialis—recurrent (cold sores) Hand–foot–mouth disease Herpangina Scarlet fever Streptococcal pharyngitis Ludwig angina Measles Varicella Human immunodeficiency virus infection Dental–alveolar abscess Pericoronitis Acute necrotizing ulcerative gingivitis (trench mouth) Noma Syphilis Acquired (secondary) Congenital Hairy tongue Tumorous oral lesions Eruption cyst Odontogenic cyst Oral papilloma Peripheral ossifying fibroma Peripheral giant cell granuloma Desmoid Mucocele Ranula Pyogenic granuloma Lingual thyroid tissue Fibroma Melanotic neuroectodermal tumor of infancy Juvenile xanthogranuloma Neurofibroma Rhabdomyosarcoma Oral lesions associated with systemic disease Stevens–Johnson syndrome Erythema multiforme Mycoplasma-induced rash and mucositis Toxic shock syndrome Mucositis Palatal mucormycosis Kawasaki disease Crohn disease Behỗet syndrome Contusions (consider bleeding disorders or child abuse) Epidermolysis bullosa Angular cheilitis Parulis Miscellaneous oral lesions Aphthous stomatitis (including as part of PFAPA) Erythema migrans (geographic tongue) Frictional keratosis