TP2:

VESICULO BULLOUS INFECTIONS

HERPES SIMPLEX
VARICELLA HAND FOOT HERPANGINA MEASLES
VIRUS INFECTION
ZOOSTER VIRUS MOUTH DISEASE
INFECTION

1) primary
1) varicella
herpetic gingivo
stomatitis

2) secundary
2) herpes
herpetic
zooster
stomatitis

3) labial herpes

4) herpes
panaritium by: Ons Ahmouda and Mouna Fatouhi
DIAGNOSIS Primary Herpetic Gingivostomatitis:
HSV -1 : herpes simplex virus type 1
AGENT ETYOLOGIC Incubation period: 5 to 7 days / 2 to 12 days

INCIDENCE Children and young adults

Prodormal symptoms: fever, headache, malaise, irritability and oral
SYMPTOMS paraesthesia.

**painfull bilateral satellite lymphadenopathy

The oral mucosa is congested and oedematous with many vesiclesgrouped in

DESCRIPTION bunches (oral lesion are dessiminated but isolated lesions are possible to occur)

These vesicles will break down the next 24h --> superficial, painful ulcerations
covered by dark grey pseudo-membranes surrounded by an erythematous halo.

The disease develops in stages:

next 3-5 days--> new vesicles will appear.
Ulcerations --> heal in 10 –14 days, leaving no marks.

**location: the gingival mucosa causing an acute marginal gingivitis, other

areas of the oral mucosa can be affected, including perioral areas.

1.Histopathologic examination: on microscope the intraepithelial vesicles

COMPLEMENTARY contain exudates, inflammatory cells and epithelial cells with intranuclear viral
TEST inclusions.
2.Culture and isolation of virus
3.Antibodies titeris important, yet rarely necessary in routine clinical cases.
4.Immunologic testingusing monoclonal antibodies or DNA hybridization

herpetic aphthous ulcerations / streptococcal stomatitis (gingivo-stomatitis)

DIFFERENCIAL polymorphous erythema / hand foot mouth disease / herpangina /
DIAGNOSIS acute ulcer-necrotic gingivitis

* severe case: acyclovir 1st 24-48h

TREATMENT *mild and medium forms: supportive ttt: antipyretic liquid diet
Topic anesthesia: lidocaine solution: 5 - 10% or Benadryl
Benzocaine gel 20%
Oral hygiene: antiseptic solutions: chlorhexidine 0.4 % / local app gentian
violet 2% / methylene blue 1%
*!!!no ATB / corticosteroids strongly contraindicated
DIAGNOSIS
secundary herpetic stomatitis
Reactivation of HSV 1
AGENT ETYOLOGIC
INCIDENCE most common in adults
absence of general symptoms
SYMPTOMS
The lesions are preceded by a prodromal period characterized by tingling and
burns (24h before).

numerous vesicles grouped in bunches,

DESCRIPTION
location: hard palate / gingival fiber-mucosa.

Vesicles---> ulcerations (1-3 mm diam) --> heal the next 7-10 days, leaving no
visible marks. (The healing process could be delayed by a secondary infection).

Subjective signs are minor, while general symptoms are absent. Considering the
COMPLEMENTARY typical clinical aspect of the condition, positive diagnosis is easy to establish
TEST
Recurrent aphthae (recurrent herpetic aphthous stomatitis)
DIFFERENCIAL
DIAGNOSIS Herpetic dermatitis

Oral herpes zoster

Chemical burns

-Supportive
TREATMENT -Acyclovir: *systematically (200mg x5/7 days)

*suspension (400mg/5ml/x5/day, 7days)

and it prevents recurrence, although it is not to be used in occasional or minor

manifestations of the condition.
DIAGNOSIS
labial herpes
HSV -1 : herpes simplex virus
AGENT ETYOLOGIC
INCIDENCE Female 1/2
prodromal stage: burning sensations + itching + irritations + mild discomfort.
SYMPTOMS

Location: upper lip / the lower one.

DESCRIPTION
 discrete congestion + an edema of the vermilion border and the surrounding
skin, followed by the vesicle eruption.

 Each vesicle has 1-3 mm diameter, while the lesion reaches 1 –2 cm.

 people with immunodeficiency will present larger lesions associated with

discomfort and physiognomic alterations.

 The vesicles --> ulcerations --> covered by dry scabs --> heal in the course
of 1 –2 weeks.

 relapses : 1 a year to several every month, ( influenced by fever,

menstruation, UV exposure and emotional stress)

No need the diagnosis is based on clinical examination

COMPLEMENTARY
TEST
 trauma lesions
DIFFERENCIAL
DIAGNOSIS  impetigo pustules.

 supportive.
TREATMENT
 Local therapy: *Acyclovir ointment 5% (5 times a day)

*Vidarabine and idoxuridine (ointment 3%)

 systemic: * valacyclovir: (valtrex 4g)

 prophylactic: * ointment based on zinc oxyde or titanium dioxide UVexp
DIAGNOSIS
Herpes panaritium
Herpes simplex virus
AGENT ETYOLOGIC
INCIDENCE *In sero negative staff (contact with infected patients/ inoculation)
The vesicle-ulcerative eruption is associated with pain,congestion + swelling +
SYMPTOMS axillary / epitrocheal lymphadenopathy.

*duration : 4 to 6 weeks.
DESCRIPTION
*location: finger

Vesicle ulcerative eruptions + congestion + swelling

Relapses are also common and they will have the same location.

COMPLEMENTARY
TEST

DIFFERENCIAL
DIAGNOSIS
*protection measures: wearing surgical gloves
TREATMENT
DIAGNOSIS
Varicella - chickenpox
Varicella-zoster virus (VZV)
AGENT ETYOLOGIC Incubation: 10 to 12 days

INCIDENCE Spc: children rare: adult / season: winter and spring

 moderate fever + headache + myalgia + the classic pox rash with
SYMPTOMS papules affecting the torso, face and skull.

 itchy rash: -->

 Oral description:
DESCRIPTION
*location: palate and lips

* small vesicles (3-4 mm) quickly --> erosions surrounded by erythematous halo

 skin lesions: * vesicul --> pustula --> get covered by dry scabs

No need because the diagnosis is based on epidemiologic data and clinical

COMPLEMENTARY manifestations
TEST
Hand –foot –mouth disease
DIFFERENCIAL
DIAGNOSIS Primary HSV infection

 supportive:
TREATMENT
*rigorous body hygiene,* mint alcohol 1% or mint talc.
*antipyretic *antihistaminic *antiseptic solution (oral lesions)

 Antiviral : * Acyclovir, *Vidarabine or Interferonis recommended

!!! only in patients with immunodeficiency.

Prevention : varicella vaccine --> 100% protection to the virus.

!!! Children and teens: no aspirin (Reye syndrome: a rare, yet severe condition
causing irreversible lesions such as acute encephalopathyand hepatic fatty
degeneration)
DIAGNOSIS
Herpes zooster
AGENT ETYOLOGIC Varicella zooster virus reactivated (vzv)
INCIDENCE  Elderely patients
 Patients with general desease that cause suppression of immune system:
Hodgkin's disease -Lymphocyte leukemia -Different types of cancer -AIDS
 patient who had chemiotherapy, immunosuppressive cytoxic or
corticosterois treatment / patients with organ transplant (==> high risk of
infection)
 ramsay-hunt syndrome characterized by facial paralysis and vesicular
SYMPTOMS eruption on the external ear, temporary hearing loss and vertigo.

 Prodromal phase: *malaise/ tiredness/ fever /headache /anorexia.

*Locally, on the dermatomal trajectory appear abnormal sensations,as

burning, paraesthesia and deep, intense pain

Local symptoms dominated by pain, precede, accompany and follow the eruption.
*Eruption : 2-4 days later as maculo-papular lesions --> vesicles -->, 2-3 days -->
DESCRIPTION pustules. --> 5 –10 days--> dry scabs will cover the lesions -->healing 2 –3
weeks later.

location : one side only is the main clinical sign of herpes zoster. affect the
second and the third line of trigeminal nerve
Oral description:
*lesion of the mucosa are associated with the lesion of the face
* Intra-oral eruption is preceded by pain that can mimic pulpitis.
*Vesicles are grouped in bunches, evenly distributed and --> after 2-3 days
-->ulcerations circumscribed by an erithematous border.
*Healing process will take 2 –3 w leaving no marks.
COMPLEMENTARY * cytological examination
TEST * immunological testing
*The increase of antibodies titer (rare) (herpes with no eruption, herpes sine herpes)
DIFF DIAGNOSIS Herpes sine herpes / Secundary herpetic stomatitis
 Targets: * the reduction of the duration of disease
TREATMENT *preventing post-herpetic neuralgia + dissemination with immunodeficiency patient
less severe or mild cases : ttt is supportive painkillers/ sedatives / acyclovir 800 mg
5 t/ day for 7-10 days shortens the evolution of the disease and reduces the incidence
of residual neuralgia.
*corticosteroids ( prevent post-herpetic neuralgia).
local therapy: *Capsaicin or antiviral (solutions or ointments)
*Xyline or Novocain infiltration on the affected nerve.
severe manifestations: syst adm high doses of Acyclovir, Vidarabine or Interferon
DIAGNOSIS Hand mouth foot desease
AGENT ETYOLOGIC Coxsackie virus A9 and A16 ( types of A or B)
Incubation: very short
INCIDENCE Children / young adults (highly contagious) during
outbreaks or scarce cases
the virus affects the oral mucosa + the dorsal and lateral
SYMPTOMS sides of fingers + toes.
- transitory fever + malaise + adenopathy
Oral discreption:
DESCRIPTION Intra-oral eruption : small vesicles not more than 5 –
10,blister -->superficial ulcerations with 2-4 mm diameter
circumscribed by an erythematous halo.
*locations :tonguepalate buccal mucosa -lips.

skin lesions :Vesicular lesions-->ulcerations -->covered by

dry scabs-->healing period lasts 2 –3 weeks.

 The culture of the virus

COMPLEMENTARY
TEST  the detection of antibodies (in atypical cases)

*primary herpetic stomatitis

DIFFERENCIAL *herpangina
DIAGNOSIS
*chickenpox
*minor or herpes aphthous ulcerations
supportive :
TREATMENT
antipyretics
topic anesthetics
DIAGNOSIS herpangina
AGENT ETYOLOGIC Coxsackie virus A1-6, A8, A10, A22, B3 and sometimes other types of viruses.

INCIDENCE Children teens and young adults / summer and automn

burning mouth symptomatology, high fever (38 - 40°C) + headache + anorexia +
SYMPTOMS dysphagia --> by diffused erythema of the mucosa and a vesicular eruption 24-48 h
later.

Location: *soft palate / uvula / tonsils / anterior pillars / posterior pharynx

DESCRIPTION *absence of lesions on lips gums and palate (spc for herpangina) !!

Oral description: small and numerous vesicles --> painful ulcerations, not
very deep, --> heal in 7-12 days.

COMPLEMENTARY based on unique clinical criteria and no complementary examinations are required.
TEST

DIFFERENCIAL
DIAGNOSIS *primary herpes stomatitis
*chickenpox
* hand -foot - mouth disease
* herpes aphthous ulcerations
*acute lymphonodular pharyngitis

TREATMENT Supportive.
DIAGNOSIS Measles
specific paramyxovirus
AGENT ETYOLOGIC
INCIDENCE Winter and spring
period of incubation is 8 –12 days.
Prodromal phase lasts 3 –4 days and it is characterised by:
SYMPTOMS
-fever (38-39°C) / indisposition / headache / ocular-nasal catarrh /
pharyngeal and laryngeal pains / cough

-oral enanthem: koplik's spots

Intra-oral description:
DESCRIPTION location: the region of the last molars !!!

koplik's spots: 10-12 isolated or grouped lesions on the buccal mucosa. these
lesions are very small, slightly bold, they have a white-bluish colour and are
surrounded by a red halo. that occure 24 to 48h before exanthema--> disapear
leaving hemorrhagic spots on the congested mucosa

General description: Cutaneous rash occurs 3 –4 days after prodromal phase

characterised by amaculo-papular eruption --> behind the back of the ears and the
frontal region -during the next 24 h --> quickly spreads to cover the
rest of the face, neck, torso and extremities.

No need
COMPLEMENTARY
TEST *Serological testing / the culture / isolation of the virus (atypical forms)

prodromal stage: respiratory infections. .

DIFFERENCIAL the eruptive stage: chickenpox and infectious mononucleosis.
DIAGNOSIS
Supportive:
TREATMENT
-hygiene and diet regime -antipyretics -painkillers -cough remedies

Antibiotics are recommended only when complications occur.