viral skin infection /viral exanthems 2021

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Viral skin infection /Viral Exanthems 2021 Assoc. Prof. Chulapan Engchanil Pediatric (Infectious disease), Clinical Pathology, Family-Medicine. Dept.of Microbiology ,Faculty of Medicine, KhonKaen University, Thailand. [email protected]

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Page 1: Viral skin infection /Viral Exanthems 2021

Viral skin infection /Viral Exanthems2021

Assoc. Prof. Chulapan Engchanil

Pediatric (Infectious disease),

Clinical Pathology, Family-Medicine.

Dept.of Microbiology ,Faculty of Medicine,

KhonKaen University, Thailand.

[email protected]

Page 2: Viral skin infection /Viral Exanthems 2021

Outline: Viral Exanthems Virology, Clinical sign and Symptoms, LAB diagnosis and treatment

Erythematous maculopapular rash

• Measles

• Rubella

• Roseola Infantum

• Infectious mononucleosis

• Fifth Disease

• Kawasaki syndrome ?

Vesiculopustular rash

• Herpes simplex infection

• Varicella zoster infection

• Hand foot and mouth disease

HPV and Pox virus

Page 3: Viral skin infection /Viral Exanthems 2021

Exanthematous fever

• Infection : Bacteria, Virus

• Non infection: drug rash

- ซกประวตการรบประทานยาในชวง 3 สปดาหกอนเกดนน

- หยดยานนทนท นนมกหายไปภายใน 24-48 ชนวโมง

Page 4: Viral skin infection /Viral Exanthems 2021

Erythematous maculopapular rash

• Measles

• Rubella

• Exanthem subitem (Roseola Infantum)

• Infectious mononucleosis

• Fifth disease

Vesiculopustular/vesiculopapular rash

• Herpes simplex infection

• Varicella zoster infection

Page 5: Viral skin infection /Viral Exanthems 2021

Measles• RNA virus family paramyxovirus• Transmission: airborne• Pre-school age • Incubation period: 10-12 d• Prodromal period: 3-5 d : 3 C*

cough ,coryza, conjunctivitis+ Koplik’s spot• Rashes 2-3 d → desquamation• Hyperpigmentation ซนงเปนลจากการมเลอดออกในหลอดเลอดฝอย จากนนจะหลดลอก

เปนแนบางๆ • Contagious period: 4 d before and after rashes*• Severe in malnutrition and Vit A def

Page 6: Viral skin infection /Viral Exanthems 2021

MeaslesMeasles

Page 7: Viral skin infection /Viral Exanthems 2021

Measles /Rubeola

( 3C) Cough,Coryza,Conjunctivitis+ Koplik’s spots

Page 8: Viral skin infection /Viral Exanthems 2021

Koplik’sspots

(pathognomonic)

Measles

Page 9: Viral skin infection /Viral Exanthems 2021

Measles

Page 10: Viral skin infection /Viral Exanthems 2021

Measles

Page 11: Viral skin infection /Viral Exanthems 2021

Measles complication

Dx: Measles IgG, IgMTx: Supportive tx

Page 12: Viral skin infection /Viral Exanthems 2021

- พบ 30% : อาย< 5ป/ > 20 ป

- “Epithelial surface destruction and Immune suppression”

-Otitis media, Pneumonia, mesenteric adenitis,

- Encephalitis, Subacute sclerosing panencephalitis (SSPE) พบได 1 ใน 100,000 มกเกดหลงจากเปนหดแลว 1-12 ป,

Measles complication

Page 13: Viral skin infection /Viral Exanthems 2021

• Symptomatic treatment; < 2 ป ให Vit A

• Prevention: MMR vaccine

• Post exposure prophylaxis: - Vaccine ภายใน 72 hr

- คนทอง/ เดก< 1ป /immunocompromise, HIV

- Measle IG : ภายใน 72 ชม-6 วน - IVIG

ในทารกอายต นากวา 6 เดอน หรอเดกทนเคยออกหดแลว ไมตองท าอะไร เนนองจากมภมคมกน

Measles Prevention

Page 14: Viral skin infection /Viral Exanthems 2021

ผปวยทใหประวตออกหดมากอน เปนหดจรงหรอไม

• ถาไมไอไมใชหด

• ถาเปนหดจรง วนทผนขนจะตองมไขอย ถาไขลงแลวไมใชหด

• เมอไขลงโรคหดมกม hyperpigmentation อกหลายวน

• เปนดวยกน หลายคนจะชวยสนบสนนโรคหดมากขน

• เปนไขกวนกอนผนขน ในโรคหดมกจะมผนขนประมาณวนท หลงจากมไข

• อายของผปวย ถาต ากวา เดอนมกไมใชหด

Page 15: Viral skin infection /Viral Exanthems 2021

Rubella (German Measles)

• Rubella Virus, Family Togaviridae

• Teenage

• Incubation period: 12-23 d

• Prodromal period: Low grade fever

• droplet transmission: ระยะตดตอ 5 วน กอนนนขน จนถง 7 วนหลงนนขน

• Maculopapular rashes with

“ Retroauricular , posterior cervical, postoccipital lymphadenopathy”

Page 16: Viral skin infection /Viral Exanthems 2021

Rubella

Page 17: Viral skin infection /Viral Exanthems 2021

3 days rashes

Rubella

Page 18: Viral skin infection /Viral Exanthems 2021

Pathogenesis Rubella

Page 19: Viral skin infection /Viral Exanthems 2021

Congenital rubella syndrome

• IUGR (Intra uterine Growth retardation)

• Cataract, Glaucoma

• Deafness

• Cardiac : PDA (patent ductus arteriosus),

PS (pulmonary stenosis)

• Blueberry Muffin Skin lesion,

• Mental retardation, microcephaly

• Bony radiolucency : Celery stalk metaphysis“Generalized viral induce progressive Necrotizing Vasculitis”

“Rubella Triad”

สามารถตรวจพบเชอใน nasopharyngeal secretion และปสสาวะไดนานถง 1 ป

Page 20: Viral skin infection /Viral Exanthems 2021

“Generalized viral induce progessiveNecrotizing Vasculitis”

Congenital Rubella

Page 21: Viral skin infection /Viral Exanthems 2021

Blueberry Muffin Skin lesion

Congenital infections (rubella, cytomegalovirus, parvovirus B19),

Dermal erythropoiesis

Page 22: Viral skin infection /Viral Exanthems 2021

Blueberry Muffin Skin lesion

Page 23: Viral skin infection /Viral Exanthems 2021

Celery stalk metaphysis.

Congenital Rubella

Page 24: Viral skin infection /Viral Exanthems 2021

Complication• 1. Arthritis: adult female

• 2. Thrombocytopenia

LAB:

• ELISA, PCR

PreventionMMR vaccineคนทอง ถาสมสโรค :ให IG ลดอาการ แตไมลด viremia : ตรวจ rubella Ab 2 ครง

Rubella

Page 25: Viral skin infection /Viral Exanthems 2021

Roseola infantum

Page 26: Viral skin infection /Viral Exanthems 2021

• HHV 6-7 ( Human Herpes virus 6,7)• Infant 90%• Sudden onset of high grade fever• Bulging anterior fontanel, convulsion• Look well despite high feverFever fall on 3th -4th day with eruption of maculopapular rashSupportive Tx.

Roseola infantum

Page 27: Viral skin infection /Viral Exanthems 2021
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Epstein Barr virus (EBV)

(Human herpes virus 4)

“Lymphocytotropic virus” เพนมจ านวน ใน WBC

Acute: Infectious mononucleosis (IM)

Latent:

• Burkitt’s Lymphoma,

• CA nasopharynx

•Lymphoproliferative disease

Page 30: Viral skin infection /Viral Exanthems 2021

Infectious mononucleosis (IM)

• Epstein-Barr virus (HHV 4) • พบบอยในเดกโต

• มไขสง 4-14 วน

• LN โต เจบคอ รวมกบม whitish patch

• Hepatosplenomegaly, ตาบวม (Hoagland sign ), ตาเหลอง

• นนพบไดในสปดาหแรก 10-15 %

• ได ยา ampicillin หรอ amoxicillin นนขน จะพบไดสงถงรอยละ 90 ของปวย

Page 31: Viral skin infection /Viral Exanthems 2021

IM (EBV)

Hoagland sign

Page 32: Viral skin infection /Viral Exanthems 2021

•Rashes after ampicillin

IM

IM (EBV)

Page 33: Viral skin infection /Viral Exanthems 2021

EBV: Oral hairy leukoplakia in HIV•Rashes after ampicillin in IM

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Page 34: Viral skin infection /Viral Exanthems 2021

IM (EBV)

Page 35: Viral skin infection /Viral Exanthems 2021

• CBC : Lymphocytosis ; Atypical lymph 20-40%

Thrombocytopenia, hemolytic anemia

• Diagnostic : PCR : anti-VCA IgM, Hetrophile Ab

• Tx: supportive

• Steroid :- Airway obstruction -Thrombocytopenia with hemorrhage, - Autoimmune hemolytic anemia (AIHA) - CNS

Infectious mononucleosis

Page 36: Viral skin infection /Viral Exanthems 2021

Atypical lymphocyte

“Downey cells”large lymphocyte ม cytoplasm สน าเงน และจะม RBC อยรอบ ๆ -->

Infectious mononucleosis

Page 37: Viral skin infection /Viral Exanthems 2021

Infectious mononucleosis

Page 38: Viral skin infection /Viral Exanthems 2021

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Parvovirus B19 (Fifth Disease)erythema infectiosum"slapped cheek”childhood

Lace like rash

Page 39: Viral skin infection /Viral Exanthems 2021

Parvovirus B19

Immune complex

Page 40: Viral skin infection /Viral Exanthems 2021

Transient aplastic crisis

Pure red cell aplasia Parvovirus B19

Page 41: Viral skin infection /Viral Exanthems 2021

Parvovirus B19

Page 42: Viral skin infection /Viral Exanthems 2021

• Replication in erythroid progenitor cell

• Transmission : airborne, droplet

• Disease

• Fifth disease: erythema infectiosum ( Fever, rash )

• Pure red cell aplasia

• Aplastic crisis

• Congenital parvovirus : Hydrops fetalis

• Associated: Encephalitis, SLE, Henoch Schoenlein purpura etc.

• Dx IgG, IgM, PCR

• Tx, supportive tx

Parvovirus B19

Page 43: Viral skin infection /Viral Exanthems 2021

Vesiculopustular eruption

1. Herpes simplex Virus

- Type I ; Herpes gingivostomatitis

- Type II ; Genital Herpes, Neonatal herpes

2. Varicella virus infection

- Chicken pox

-Herpes Zoster

3. Enterovirus infection

- Hand Foot and Month disease

Page 44: Viral skin infection /Viral Exanthems 2021

Herpetoviridae (Human herpesvirus)

DNA virus/ Inclusion body/Latent infection

Herpes simplex virus type 1 ( HSV-1)

•Herpes simplex virus type 2 ( HSV-2)

•Varicella zoster virus ( VZV)

•Human herpes virus 4: Epstein Barr virus( EBV)

•Human herpes virus 5: Cytomegalovirus( CMV)

•Human herpes virus 6 : Roseolar infantum

•Human herpes virus 7: Roseolar infantum( mild)

•Human herpes virus 8: Kaposi's sarcoma

Page 45: Viral skin infection /Viral Exanthems 2021

Herpes simplex virus

Primary herpes gingivostomatitis

Herpes labialis

Mucocutaneous HSV: Acyclovir 400 mg x5x 7 d

Page 46: Viral skin infection /Viral Exanthems 2021

HSV - 1 HSV - 2

1.Transmission

2. Clinical feature

3. การตดเชอซ า

4.Cancer

5. Treatment

หายใจ, สมผส

herpes labialis

gingivostomatitis, keratitis

นอยกวา

Oral cancer

Acyclovir

เพศสมพนธ

แม ลก (สมผส) genital,

บอยกวา

Cervical cancer

Acyclovir

Page 47: Viral skin infection /Viral Exanthems 2021

Pathogenesis Herpes simplex virus

Page 48: Viral skin infection /Viral Exanthems 2021

Herpes keratitis

Herpes whitlow Multinucleated giant cell

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Herpes simplex virusHerpes simplex virus

Page 51: Viral skin infection /Viral Exanthems 2021

Multinucleated giant cell

Tzanck TestHerpes simplex virus

LAB –PCR- Tzanck test

Tx: Acyclovir

Page 52: Viral skin infection /Viral Exanthems 2021

Varicella zoster Viruses( HHV-3)

• Chicken pox - primary infection

• Herpes zoster - reactivation of infection

Chicken pox

• Rash: rapid evolution 6-8 hr, multistage, various stage

• LAB:

• Tx Acyclovir in severe varicella• Prevention:

Varicella vaccineVaricella Immunoglobulin: VZIG

IgG, IgM

Page 53: Viral skin infection /Viral Exanthems 2021

multistage, various stage rash

Page 54: Viral skin infection /Viral Exanthems 2021

Potential routes taken by VZV during its life cycle.

Page 55: Viral skin infection /Viral Exanthems 2021

Chicken pox

Page 56: Viral skin infection /Viral Exanthems 2021

Neonatal chickenpox

• first 10 days of life

• mother develops varicella from 5 days before to 2 days after delivery,

Most common clinical manifestations

• Disseminated fulminant ,

• Diffuse pneumonia,

• Severe hepatitis

• Meningoencephalitis

• Approximately 1/3 die,

Page 57: Viral skin infection /Viral Exanthems 2021

Herpes zoster(Shingles)

- เกดในคนทนเคยเปน chicken pox,

-ม vesicles ตามแนว dermatome

-เกด post herpetic neuralgia

-Tx Acyclovir

-800 mg x 5 x 7-10 days

Page 58: Viral skin infection /Viral Exanthems 2021

Herpes zoster(Shingles)

Page 59: Viral skin infection /Viral Exanthems 2021

ChickenpoxChickenpox

Page 60: Viral skin infection /Viral Exanthems 2021

CMV: Cytomegalovirus HHV-5

Page 61: Viral skin infection /Viral Exanthems 2021

Congenital CMVHHV-5

Page 62: Viral skin infection /Viral Exanthems 2021

Congenital CMV

Page 63: Viral skin infection /Viral Exanthems 2021

CMV : Treatment

• Ganciclovir

• Valganciclovir

• Foscarnet

• Cidofovir

CMV LAB : IgG, IgM

Page 64: Viral skin infection /Viral Exanthems 2021

Kaposi's sarcoma (HHV8)

• Vascular tumor in HIV

Page 65: Viral skin infection /Viral Exanthems 2021

Hand Foot and Mouth Disease

• Enterovirus 71, Coxsackie A 16

• Fecal Oral route

• Fever + vesicles

• Complication :

• Brainstem encephalitis , Myocarditis,

Page 66: Viral skin infection /Viral Exanthems 2021

ComplicationEnterovirus 71

Aseptic meningitisBrain stem encephalitis(Rhombencephalitis)Autonomic nervous system dysregulation

LAB: PCRTx IVIG

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Page 67: Viral skin infection /Viral Exanthems 2021

Molluscum contagiosumOncogenic virus

• Molluscum contagiosum virus

• Family Poxviridae,

• direct contact : sexual transmission

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Molluscum contagiosum : Treatment

• Trichloroacetic acid

• Topical podophyllotoxin cream (Condylox)

• Imiquimod

• Cryosurgery

Page 71: Viral skin infection /Viral Exanthems 2021

Human papillomavirus (HPV)

• Papillomaviridae : Oncogenic Virus

• HPV 16,HPV 18 (13%) : cervical cancers

• HPV 11 HPV 16 : skin lesion

• Wart (common, plantar, palmar warts)

• Condyloma acuminata (genital wart, perianal wart)

• Laryngeal papillomatosis

• Anogenital cancer

• Tx: Imiquimod, Podofilox, Podophyllin, Cryotherapy

Page 72: Viral skin infection /Viral Exanthems 2021
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Condyloma acuminata (genital wart, perianal wart)

Page 74: Viral skin infection /Viral Exanthems 2021

Laryngeal papillomatosis

Page 75: Viral skin infection /Viral Exanthems 2021

HSV, VZV

CSF

Temporal lobe

VZIG?

Ramsay hunt syndrome ?

PCR

Page 76: Viral skin infection /Viral Exanthems 2021

CMV, EBV, HHV6-8

Infectious mononeucleosis-Lymphadenopathy

-Atypical L-Hepatosplenomegaly

Roseolar infantum

HIV

Page 77: Viral skin infection /Viral Exanthems 2021

Mumps,Measle, Rubella

Celery stalk . Cong rubella.

3C:Conjunctivitiscough, coryza,

Vaccine?

Page 78: Viral skin infection /Viral Exanthems 2021

Adeno V, Parvo V

Fifth disease

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