Download - Viral infections ug lecture 2003
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VIRAL INFECTIONS
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INTRODUCTION• Cutaneous manifestations – common in viral
infections
• Characterized by definite morphology and
distribution - clinically diagnosed
• Light microscope - visualized only when
aggregated into inclusion bodies
Intranuclear inclusion bodies are seen in the
herpes virus group and papilloma virus group
Intracytoplasmic inclusion bodies are seen in
the poxvirus group
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COMMON VIRAL INFECTIONS OF SKIN DNA VIRUSES:
Papova virus - Human Papilloma Virus - Genital & Non-genital warts
Pox virus - Molluscum Contagiosum, small pox, milker’s
nodules, Orf
Herpes virus - Varicella Zoster Virus - Varicella, Herpes
Zoster; Herpes Simplex Virus I & I I- Herpes Simplex
RNA VIRUSES:
Picornavirus – Coxsackie virus – Hand foot mouth disease
Retrovirus - HIV
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MANIFESTATIONS DUE TO VIREMIA AND HYPERSENSITIVITY
• Viral exanthems
First disease - Measles (Rubeola)
Third disease - Rubella (German Measles)
Fifth disease - Erythema Infectiousum
Sixth disease - Roseola Infantum
• Hypersensitivity reactions
Pityriasis rosea
Gianotti crosti syndrome
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ETIOPATHOGENESIS
Cell lysis - Herpes
Cell proliferation - Pox, HPV
Carcinogenesis - Cervical Ca, Hepatoma
Exanthemata - Viraemia, Type 3 hypersensitivity
(Arthus) reaction, virus lodged in dermal
capillaries and replicate in epidermis
Persistent infection: Periods of latency and
reactivation (HSV, VZV)
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HUMAN PAPILLOMA VIRUS INFECTION - WARTS Most common mucocutaneous viral infection
Incubation period: few weeks to about one year
Asymptomatic latent infection to warts to squamous
cell carcinoma
Direct or indirect contact (nail biters, shaving,
occupational, swimming pool); sexual transmission;
autoinoculation
Koebnerization – pseudo Koebner phenomenon
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CLINICAL TYPESNon genital: Verruca vulgaris (Common warts) – HPV
2
Verruca Plana (Plane warts) - HPV 3, 10
Filiform
Digitate
Palmoplantar
Periungual
Genital: Condyloma Acuminata – HPV 6,11, 16,18
Bowenoid papulosis – HPV 16
Buschke-Lowenstein tumor – HPV 6,11
Epidermodysplasia verruciformis
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HISTOPATHOLOGY
Hyperkeratosis
Papillomatosis
Acanthosis
Vacuolation in the stratum granulosum and stratum spinosum
- koilocytes
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TREATMENT
Topical Keratolytics : Salicylic Acid, Urea, Wart solution (Lactic
acid/Salicylic Acid)
Chemical cautery: Podophyllin, TCA
Cryotherapy
Electrocautery
Radiosurgery
Laser therapy
Photodynamic Therapy
Others: Formalin soaks, Imiquimod, 5FU, retinoids, immunotherapy,
Bleomycin, Interferon
Systemic Immunomodulators: Levamisole, Cimetidine
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SMALL POX
• Eradicated in 1977. Only humans, no carriers
• Eosinophilic inclusions - Guarnieri’s bodies
• IP=12-14 days
• Fever, chills, myalgia, rash 3-4 days later
• Firm papulovesicles, pustular in 10-12 day
• All in the same stage of evolution
• Edward Jenner - vaccinia virus
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MOLLUSCUM CONTAGIOSUM
• MCV-1 to – 4 ; MCV 1 – children, MCV 4 – HIV infected
• Incubation period: 2 weeks to 6 weeks
Transmission: contact, fomites, sexual
Dome shaped, pearly white, discrete umbilicated papules - Face,
neck, trunk, peri-genitals (sexual transmission), eyelids (HIV).
Pseudo Koebner’s phenomenon
Giant Molluscum Contagiosum (1.5 cm) – HIV infected
Differential – cryptococccosis, histoplasmosis, penicilliosis
Tzanck – Henderson Patterson bodies
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TREATMENT
Expression / Curettage
Chemical cautery, Electrodessication, Cryotherapy.
Topical: Imiquimod, KOH, Phenol, Cantharidine,
Cidofovir.
Systemic: Levamisole, Cimetidine, cidofovir
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HERPES SIMPLEX VIRUS
HSV 1: Facial (above waist)
HSV 2: Genital (sexual)
Incubation Period : 3-7 days
First clinical episode - true primary infection or non primary
Persist in sensory ganglion - period of latency
Recurrent infection
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CLINICAL FEATURES Grouped vesicles on erythematous base followed by
erosions and healing
Primary attack: severe with lymphadenopathy and systemic
complaints
Non primary : lower frequencies of systemic symptoms,
shorter duration of pain, fewer lesions, shorter healing time
Recurrences: mild with shortened clinical course, smaller
size of the vesicles, close grouping and absence of systemic
symptoms
Predisposing factors: trauma, sunburn, stress, coitus,
premenstrual, high grade fever, infections, surgery,
dermabrasion
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HERPES SIMPLEX- CLINICAL TYPES
Herpes Simplex Virus I :
Herpes Labialis, Herpetic Gingivostomatitis, Herpetic
whitlow, Herpetic gladiatorum, Herpes sycosis,
Keratoconjunctivitis
Herpes Simplex Virus II:
Herpes progenitalis, Herpetic vulvovaginitis, recurrent
lumbosacral herpes, HSV infection in newborn
Complicated:
Eczema herpeticum, Disseminated HSV
Herpes Simplex Virus in HIV:
Chronic, recurrent, ulcer, eschar formation and
dissemination
Chronic HSV more than 1 month – AIDS defining
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COMPLICATIONS
Radiculoneuropathy
Dissemination
Meningitis / encephalitis
Erythema multiforme
Eczema herpeticum
Ocular complications
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INVESTIGATIONS
Tzanck smear : Multinucleated giant cells
Histopathology : Ballooning degeneration,
intraepithelial blisters, inclusion bodies
HSV antibody titre : IgG/IgM
Culture
Immunofluoroscence, PCR
Electron microscopy
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TREATMENT
Symptomatic
Topical: Acyclovir, Penciclovir, Cidofovir
Systemic:
Resistant – foscarnet, cidofovir
Antiviral Primary
(10 days)
Recurrence
(5 days)
Suppressive
6months-1yr
Acyclovir 200mg
5times/day
400mg tid 400 mg bd
Valaciclovir 1gm bd 500mg bd 500-1000 mg bd
Famciclovir 250mg tid 125mg bd 250mg bd
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VARICELLA ZOSTER VIRUS
Chicken pox and zoster (shingles)
Transmission: Droplet infection - nasopharynx
Varicella : primary viraemia
Zoster: Reactivation of residual latent virus in
the sensory nerve ganglion
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VARICELLA - CLINICAL FEATURES
Incubation period: 2-3 weeks
2-10 years
Prodromal symptoms
Pleomorphic, centripetal distribution, dewdrops on rose petal
appearance
Vesicles, papulovesicles, crusting, haemorrhagic, umbilicated
lesions
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COMPLICATIONS
Secondary infection
Encephalitis
Pneumonitis
Hepatitis
Varicella in HIV- Progressive, haemorrhagic, complicated
Chronic varicella- Hyperkeratotic lesions, Acute retinal
necrosis
Reye syndrome
Congenital varicella syndrome
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TREATMENT
Symptomatic:
Rest, Antibiotics, Anti-inflammatory, Calamine lotion
Antivirals - Indicated in adult varicella; reduces severity, duration &
infectivity in childhood chicken pox
Acyclovir : 800 mg 5 times/day
Valcyclovir : 1gm tds - contraindicated in immunosuppresed
individuals - Thrombotic thrombocytopenic purpura and hemolytic
uremic syndrome
Prophylaxis:
Vaccine, Immunoglobulin, Acyclovir
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HERPES ZOSTER
Reactivation of latent virus in the dorsal root ganglion of
sensory nerve
Older age group >50 years
Unilateral, dermatomal, grouped vesicles
Cranial (V, VII commonly), spinal (thoracic commonly)
Pre-herpetic, herpetic and post-herpetic neuralgia
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HERPES ZOSTER : CRANIAL NERVE
INVOLVEMENT
V Nerve:
Ophthalmic division: Herpes Zoster Ophthalmicus
Hutchinsons sign (vesicles on nose tip)
Ocular complications: uveitis, keratitis, conjunctivitis,
scleritis, ocular palsy
Maxillary division: uvula / tonsils
Mandibular division : tongue / buccal mucosa
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HERPES ZOSTER : CRANIAL NERVE
INVOLVEMENT
VII nerve :
Ramsay Hunt syndrome:
Earache, vesicles on pinna, facial palsy
Hearing loss, vertigo and taste sensation impaired
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COMPLICATIONS
Secondary infection
Post herpetic neuralgia
Scarring
Nerve Palsy
Encephalitis : in disseminated zoster
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HERPES ZOSTER IN HIV
Younger patient
Severe pre, herpetic and post-herpetic neuralgia
Multi-dermatomal, cranial nerve involvement
Haemorrhagic, disseminated
Protracted course, verrucous lesions
Acute retinal necrosis
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TREATMENT
Symptomatic
Antivirals:
Acyclovir 800mg x 5times/day
Famciclovir 500 mg tds
Valaciclovir 1gm tds
Duration : 1week in immunocompetent
2weeks in immunosuppressed
Steroids : in cranial nerve involvement
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TREATMENT OF POST HERPETIC NEURALGIA
Steroids
Analgesics
Amitryptilline, Doxepine
Phenytoin, Carbamazapine, Sodium valproate
Gabapentine
Methylcobalamine
Topical EMLA cream
Topical capsaicin
Intralesional Steroids
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HAND-FOOT-AND-MOUTH DISEASE
• Coxsackie virus A16, A5, A7, A9, and B 1, 2, 3; enterovirus 71
• IP - 4-6 days
• Vesicles painful erosions and ulcers on an erythematous base on buccal mucosa, tongue, palate, uvula.
• Gray-white vesiculopustules on palms, soles, dorsal or lateral surfaces of hands and feet., buttocks, thighs, and external genitalia
• Cervical and submandibular lymphadenopathy
• Encephalitis, aseptic meningitis, and myocarditis
• Hand hygiene
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VIRAL EXANTHEMS
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MEASLES (RUBEOLA/ MORBILLI)
• Preschool children; IP - 10-12 days
• 3 C’s —cough, coryza and conjunctivitis
• Koplik’s spots - blue white spots with a red halo on
buccal mucosa opposite the premolar teeth
• Maculopapular rash begins on the 4th day; face,
behind the ears trunk and extremities in 24-36
hrs maximum intensity in 3 days fades after 5-
10 days with desquamation
• Pneumonia, bronchitis, otitis media, gastroenteritis,
myocarditis, encephalitis
• Vitamin A supplementation; Vaccination at 9 -15
months
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RUBELLA (GERMAN MEASLES/ 3 DAY MEASLES)
• > 15 years ; IP-12 to 25 days
• Posterior auricular Lymphadenopathy 4 to 7 days
before; maximal at onset; resolve in a week
• Forcheimer spots - petechiae of soft plate
• Maculopapular rash begins on neck or facetrunk
and extremities in a dayconfluent on face 2nd
day confluent on trunk, fades in face3rd day fully
fades
• Arthralgia, arthritis, encephalitis, thrombocytopenia
• Congenital rubella syndrome
• Vaccination at 15 months or older; 3 months
contraception
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ERYTHEMA INFECTIOSUM
• 2-15 years
• 3 overlapping stages - facial erythema (slapped
cheek); Fades in 4 days 2 days laternet
pattern erythema – on extremities ; extends to
trunk and buttocks for 6-14 daysrecurrent
phase - fades and reappears in the next 2 to 3
weeks
• Papular-purpuric gloves and socks syndrome;
petechial exanthems
• Arthritis, transient aplastic crisis, chronic anemia
• In utero infection- hydrops fetalis, congenital
anemia
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ROSEOLA INFANTUM EXANTHEM SUBITUM, “SUDDEN RASH”, 3 DAY FEVER
• 6 months- 2 years of age
• IP - 5-15 days
• Inappropriately well for the degree of fever
• Mild to moderate lymphadenopathy
• Seizures
• Rash begins as the fever subsides
• Pale-pink, almond-shaped confluent macules on
trunk and neckfade in a few hours to 2 days
without scaling or pigmentation
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PAPULAR ACRODERMATITIS OF CHILDHOODGIANOTTI-CROSTI SYNDROME
• Hepatitis B (ayw), EBV (commonest), CMV, coxsackie, respiratory virus, parvoviruses, rotavirus, and HHV 6
• Vaccination –MMR, oral polio, DPT, hepatitis B.
• 2-6 yrs, males common
• Asymptomatic, symmetrical, edematous, erythematous, monomorphous, papules and papulovesicles, on face, extensors of upper and lower extremities
• Lymphadenopathy, hepatomegaly and anicteric hepatitis
• Self limited, lasts for 2-8 weeks.
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