viral infections (herpes & varicella)

Viral InfectionsViral Infections

Eman Elmorsy, M.D.A. Professor of Dermatology & Andrology

Eman Elmorsy, M.D.A. Professor of Dermatology & Andrology

Viral infectionsViral infections

Papular1. Warts2. Molluscum

VesicularHerpes Simple• Primary• Recurrent

Varicella• Herpes zoster• Chicken pox

Herpes Virus InfectionsHerpes Virus Infections

TaxonomyTaxonomy

Virus Code. 31.1.1.0.001. Virus Accession number 31110001.Synonym(s): human (alpha) herpes virus 1; herpes simplex virus 1.Approved acronym: HHV-1. Virus infects vertebrates. Description is on taxonomic level of species. Virus is the type species of the genus. Virus belongs to the genus Simplex virus (VC 31.1.1. ); subfamily Alpha herpes virinae (VC 31.1. ); family Herpes viridae (VC 31. ).

Virus Code. 31.1.1.0.001. Virus Accession number 31110001.Synonym(s): human (alpha) herpes virus 1; herpes simplex virus 1.Approved acronym: HHV-1. Virus infects vertebrates. Description is on taxonomic level of species. Virus is the type species of the genus. Virus belongs to the genus Simplex virus (VC 31.1.1. ); subfamily Alpha herpes virinae (VC 31.1. ); family Herpes viridae (VC 31. ).

Herpes simplexHerpes simplex

OrganismHerpes virus hominis type 1 (mainly face non-genital areas) or type 2 (ano-genital).

OrganismHerpes virus hominis type 1 (mainly face non-genital areas) or type 2 (ano-genital).


PathogenesisPrimary infection: in infants and children where no immunity against the virus. The virus ascend the peripheral nerves to the dorsal root ganglion. After healing the virus remains latent in the dorsal root ganglion.

Secondary infection: latent virus particles descent from the dorsal root ganglion along the nerves skin recurrent infection.

PathogenesisPrimary infection: in infants and children where no immunity against the virus. The virus ascend the peripheral nerves to the dorsal root ganglion. After healing the virus remains latent in the dorsal root ganglion.

Secondary infection: latent virus particles descent from the dorsal root ganglion along the nerves skin recurrent infection.

Pathology:Ballooning and reticular degeneration of the epidermis with giant cells.

Derma cellular infiltration and vasculitis.

Pathology:Ballooning and reticular degeneration of the epidermis with giant cells.

Derma cellular infiltration and vasculitis.


A- Primary Herpes simplexA- Primary Herpes simplex

Constitutional symptoms and usually wide spread.

MorphologyGrouped painful vesicles on erythematous base rupture erosions, crustation or plaque formation.

Course2-6 weeks.

Constitutional symptoms and usually wide spread.

MorphologyGrouped painful vesicles on erythematous base rupture erosions, crustation or plaque formation.

Course2-6 weeks.


LocalizationPrimary gingivostomatitis:

Erosions on the mouth interfere with feeding. May coalesce yellowish plaque.

LocalizationPrimary gingivostomatitis:

Erosions on the mouth interfere with feeding. May coalesce yellowish plaque.


LocalizationKeratoconjunctivitis:

Dentritic painful keratitis and conjunctivitis corneal opacity.

LocalizationKeratoconjunctivitis:

Dentritic painful keratitis and conjunctivitis corneal opacity.


LocalizationVulvovaginitis:

Pain dysuria vesicles vagina cervix.

Urtheritis and cystitis.

Groin skin may be affected

LocalizationVulvovaginitis:

Pain dysuria vesicles vagina cervix.

Urtheritis and cystitis.

Groin skin may be affected


LocalizationPrimary genital in the male

The vesicles and erosions on the penis and pubic area with tender lymphadenopathy.

LocalizationPrimary genital in the male

The vesicles and erosions on the penis and pubic area with tender lymphadenopathy.


LocalizationPrimary inoculation herpes (whitlow):

In dentists and surgeons.

At the site of trauma (fingers with supratrochlear or axillary lymph nodes.)

LocalizationPrimary inoculation herpes (whitlow):

In dentists and surgeons.

At the site of trauma (fingers with supratrochlear or axillary lymph nodes.)


LocalizationKaposi varicellifom eruption:

In children suffering of atopic dermatitis, and Dareir’s disease.

Generalized vaccinator eruption with umblicated bullae.

LocalizationKaposi varicellifom eruption:

In children suffering of atopic dermatitis, and Dareir’s disease.

Generalized vaccinator eruption with umblicated bullae.

B- Recurrent Herpes simplexB- Recurrent Herpes simplex


Precipitating factors:Common cold, influenza and other febrile condition.

Sun exposure.

Gastro-intestinal troubles

Septic focus

Psychological stress or anxiety.

Drug or food allergy.

Precipitating factors:Common cold, influenza and other febrile condition.

Sun exposure.

Gastro-intestinal troubles

Septic focus

Psychological stress or anxiety.

Drug or food allergy.


LocalizationFace:

Orificial, periorifcial: lips, nostrils, ears and eyes and cheeks.

Mucous membrane: Buccal mucosa, tongue, pharynx, larynx and conjunctiva

Genitalia:Glans penis, clitoris, labia, cervix and urethra.

LocalizationFace:

Orificial, periorifcial: lips, nostrils, ears and eyes and cheeks.

Mucous membrane: Buccal mucosa, tongue, pharynx, larynx and conjunctiva

Genitalia:Glans penis, clitoris, labia, cervix and urethra.


MorphologyGrouped vesicles on an erythematous base.

Vesicles contain clear fluid purulent rupture (few days) crust formation under which epitheliazation occurs.

Or leave erosion within 4-12 hours and heal spontaneously within 5-7 days.

MorphologyGrouped vesicles on an erythematous base.

Vesicles contain clear fluid purulent rupture (few days) crust formation under which epitheliazation occurs.

Or leave erosion within 4-12 hours and heal spontaneously within 5-7 days.


DiagnosisClinical picture

Tzank test: scrapping the vesicle base Giemsa giant multinucleated cells

Viral culture

Immunofluorescence

PCR

Electron microscopy.

Differential diagnosis: other cause of bullous eruption.

DiagnosisClinical picture

Tzank test: scrapping the vesicle base Giemsa giant multinucleated cells

Viral culture

Immunofluorescence

PCR

Electron microscopy.

Differential diagnosis: other cause of bullous eruption.


Treatment

General measuresAvoid predisposing factors.

In severe cases hospitalization and immuno-stimulant .

Treatment

General measuresAvoid predisposing factors.

In severe cases hospitalization and immuno-stimulant .


Treatment

Local measures:Compresses: remove crust (K permengnate/saline).

Local antiviral: (acyclovir, iodoxurdidine).

Drying agent: gentian violet in oozing lesions.

Local antibiotics: in secondary infection.

Local analgesic creams.

Treatment

Local measures:Compresses: remove crust (K permengnate/saline).

Local antiviral: (acyclovir, iodoxurdidine).

Drying agent: gentian violet in oozing lesions.

Local antibiotics: in secondary infection.

Local analgesic creams.


Treatment

Systemic:Usually needed in the first attack and severe recurrent cases:

Acyclovir (Zovirax®): 200 mg 5 times daily for 5-10 days; 200 x 5 x 5

Famcyclovir (Famvir®) 125 twice daily for 5 days.

Treatment

Systemic:Usually needed in the first attack and severe recurrent cases:

Acyclovir (Zovirax®): 200 mg 5 times daily for 5-10 days; 200 x 5 x 5

Famcyclovir (Famvir®) 125 twice daily for 5 days.

C- Herpes zoster (Shingles)C- Herpes zoster (Shingles)

Organism: Varicella zoster virus.

Pathogenesis:Droplet viral infection olfactory bulb nervous system dorsal root ganglion skin along the peripheral nerves.

Some-times spread to anterior horn cells paralysis.

Organism: Varicella zoster virus.

Pathogenesis:Droplet viral infection olfactory bulb nervous system dorsal root ganglion skin along the peripheral nerves.

Some-times spread to anterior horn cells paralysis.


Predisposing factors:Trauma.

Acute inflammation.

Debilitating diseases.

Immunosupression.

Predisposing factors:Trauma.

Acute inflammation.

Debilitating diseases.

Immunosupression.


Pathology:Ballooning degeneration of basal cell layer by marked acantholysis due to damage of intercellular bridges separation formation of unilocular vesicle with the presence of multinucleated cells (characteristic).

Pathology:Ballooning degeneration of basal cell layer by marked acantholysis due to damage of intercellular bridges separation formation of unilocular vesicle with the presence of multinucleated cells (characteristic).


Pathology:Reticular degeneration due to increased intracellular edema cell distension rupture coalescence of nearby cells multilocular vesicles.

Dermal changes: inflammatory cellular infiltrate, damage of capillary endothelium (haemorrahgic).

Pathology:Reticular degeneration due to increased intracellular edema cell distension rupture coalescence of nearby cells multilocular vesicles.

Dermal changes: inflammatory cellular infiltrate, damage of capillary endothelium (haemorrahgic).


Clinical Picture:Symptoms:

Pain (mild to severe) usually at the site of eruption. I may precede, associate or follow eruption.

Localizations: Usually unilateral along the course of a nerve or nerves.

Pectoral region: commonest

Head: along facial, trigeminal nerve

Abdomen: intercostals or lumbar nerves

Lower limbs

Genitals

Clinical Picture:Symptoms:

Pain (mild to severe) usually at the site of eruption. I may precede, associate or follow eruption.

Localizations: Usually unilateral along the course of a nerve or nerves.

Pectoral region: commonest

Head: along facial, trigeminal nerve

Abdomen: intercostals or lumbar nerves

Lower limbs

Genitals


Clinical Picture:Morphology:

Grouped vesicles on erythematous base, which contains clear fluid purulent contents some vesicles rupture crustation the others may dry up.

Clinical Picture:Morphology:

Grouped vesicles on erythematous base, which contains clear fluid purulent contents some vesicles rupture crustation the others may dry up.


Clinical Types:A. According to the site:

Herpes zoster pectoralis:Involve one of the intercostals nerves eruptions in one side of the chest and back.Pain may be mistaken as chest pain.

HZ cervicalis: Along the cervical nerves.

HZ abdomenalis: Abdominal nerves may be mistaken as renal or gall bladder or even appendicitis.

HZ lumbosacral: In genitals, groin and sacral regions.Sine-herpetes urinary manifestation without cutaneous lesions.

Clinical Types:A. According to the site:

Herpes zoster pectoralis:Involve one of the intercostals nerves eruptions in one side of the chest and back.Pain may be mistaken as chest pain.

HZ cervicalis: Along the cervical nerves.

HZ abdomenalis: Abdominal nerves may be mistaken as renal or gall bladder or even appendicitis.

HZ lumbosacral: In genitals, groin and sacral regions.Sine-herpetes urinary manifestation without cutaneous lesions.


Clinical Types:HZ cranialis:

Frontalis: Involvement of supra-orbital nerve (trigeminal TG branch) forehead and scalp.

Ophthalimicus: ophthalimic division of TG eye (conjunctivitis or keratitis) may be affected if nasociliary branch affected vesicles at the side of the nose.

Maxillary branch of TG vesicles on uvula and tonsillar area.Mandibular branch of TG vesicles on posterior tongue, buccal mucosa.Facial:

Ramsy Hunt syndrome due to involvement of geniculate ganglion ear pain and vesicles on external ear+ facial palsy and loss of hearing (auditory nerve).

Clinical Types:HZ cranialis:

Frontalis: Involvement of supra-orbital nerve (trigeminal TG branch) forehead and scalp.

Ophthalimicus: ophthalimic division of TG eye (conjunctivitis or keratitis) may be affected if nasociliary branch affected vesicles at the side of the nose.

Maxillary branch of TG vesicles on uvula and tonsillar area.Mandibular branch of TG vesicles on posterior tongue, buccal mucosa.Facial:

Ramsy Hunt syndrome due to involvement of geniculate ganglion ear pain and vesicles on external ear+ facial palsy and loss of hearing (auditory nerve).


Clinical Types:Bilateral:

Rare associated with constitutional manifestation in debilitating diseases and immunocompromised patients.

Clinical Types:Bilateral:

Rare associated with constitutional manifestation in debilitating diseases and immunocompromised patients.


Clinical Types:B. According to morphology:

Classical

AbortiveGrouped papular healing

HaemorrahgicVesicles filled with blood in debilitating & immunocompromised.

GangenerousGangrene develops at the site of infection due to thrombosis of derma vessels.

Clinical Types:B. According to morphology:

Classical

AbortiveGrouped papular healing

HaemorrahgicVesicles filled with blood in debilitating & immunocompromised.

GangenerousGangrene develops at the site of infection due to thrombosis of derma vessels.


ComplicationsSecondary bacterial infections.Eczematization.Gangrene.Post hereptic neuralgia.Systemic affectionOcular

Keratitis

NeurologicalFacial palsy, meningitis& myelitis.

Urinary bladder Cystitis

ComplicationsSecondary bacterial infections.Eczematization.Gangrene.Post hereptic neuralgia.Systemic affectionOcular

Keratitis

NeurologicalFacial palsy, meningitis& myelitis.

Urinary bladder Cystitis


TreatmentSystemic:

Analgesic to relief pain and as anti-inflammatory in some case you may give corticosteroid or ACTH.

Vitamin B1&12 to support the nerve.

Acyclovir (Zovirax®) 800 mg 5 times daily for 7-10 days.

Famcyclovir (Famvir®) 500mg daily for 5 days help to decrease post herpetic neuralgia (antiviral).

Antibiotics: for secondary bacterial infections.

TreatmentSystemic:

Analgesic to relief pain and as anti-inflammatory in some case you may give corticosteroid or ACTH.

Vitamin B1&12 to support the nerve.

Acyclovir (Zovirax®) 800 mg 5 times daily for 7-10 days.

Famcyclovir (Famvir®) 500mg daily for 5 days help to decrease post herpetic neuralgia (antiviral).

Antibiotics: for secondary bacterial infections.


TreatmentLocal treatment

Analgesic creams.

Anesthestic cream.

Antibiotics if secondary infected

Antiviral acyclovir in early lesions.

Drying agents.

TreatmentLocal treatment

Analgesic creams.

Anesthestic cream.

Antibiotics if secondary infected

Antiviral acyclovir in early lesions.

Drying agents.

Chicken pox (varicella)Chicken pox (varicella)

OrganismVaricella zoster virus primary infection

Incubation period2 weeks.

Clinical picture:Mild constitutional manifestation

LocalizationOn the trunk, scalp, face, mucous membrane and extremities

OrganismVaricella zoster virus primary infection

Incubation period2 weeks.

Clinical picture:Mild constitutional manifestation

LocalizationOn the trunk, scalp, face, mucous membrane and extremities


MorphologyPapules or macules vesicles or bullae pustules crust. All the lesions are present at the same time (polymorphism) usually heal within 7-10 days with normal skin.

MorphologyPapules or macules vesicles or bullae pustules crust. All the lesions are present at the same time (polymorphism) usually heal within 7-10 days with normal skin.


Differential diagnosis

ComplicationSecondary infection

Systemic involvement ( pneumonia).

Differential diagnosis

ComplicationSecondary infection

Systemic involvement ( pneumonia).


TreatmentBed rest

Systemic antibiotics

Local drying agents or antibiotic

In severe cases: Acyclovir or gammaglobulins.

TreatmentBed rest

Systemic antibiotics

Local drying agents or antibiotic

In severe cases: Acyclovir or gammaglobulins.

Thank youThank youEman El MorsyEman El Morsy

viral infections (herpes & varicella)

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