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Viral Infections

4th year by Hidayah Bahrin

Viral Infections

Herpes simplex virus

Varicella zoster virus
Epstein -Barr virus
Coxsackie virus
Human papilloma virus

Diagnostic Tests
Clinical Diagnosis,
remember that the diagnosis of most viral infections is primarily made on
clinical grounds.

Tissue Culture(24 hours)

is most useful but it is lengthy and expensive. It requires incubate the tissue for
24 hours before u get the results.

Serologic tests (10-24) days

are a lengthy process; it takes longer duration before we have an established
diagnosis. And in most cases it is retrospective, although in sometimes we have
to establish the diagnosis based on serologic tests.

it is direct & rapid test that can be used in the clinic or at least can be used in
the lab probably, you will have the results within 12 hours if you have a lab close
to your clinic.

Molecular techniques,
which look at the DNA of each virus, and in some cases it is the only technique
that distinguish between HSV type 1 and HSV type 2 and Varicella zoster virus.

1.Herpes Simplex
Type 1 : Oral mucosa, pharynx, skin, Bells palsy.
The most common disease with type 1 HSV is primary herpetic
gingivostomatitis can affect the skin and cause recurrent infection.

Type 2 : genital lesions, and rarely oral lesions

HHV 6 & 7 : Roseola Infantum
condition which is very similar to measles, occur in infants

HHV 8 : Kaposis sarcoma

CMV : associated with salivary gland disease and oral ulcers
especially in the new borns and immune compromised patients.
EBV :remember the 4 lesions associated with EBV.
Varicella zoster virus: cause chickenpox &shingles

Primary Herpetic

The most common viral infection of the mouth

95% are subclinical, that means that the patients can transmit the disease
without showing any signs or symptoms
Reaches a peak between 2-3 years of age
It affects mainly children and toddlers but still you can find them in adults
(in 40s and 50s) who have no previous contact with the virus.
2-3 days of prodromal symptoms; malaise, sore throat, submandibular
When the disease progresses oral and perioral vesicles appears
is the whole mark of this infection, means that you cannot make a
diagnosis of Primary herpetic gingivostomatitis without involvement of the
Thats a hint to distinguish between erythema multiforme a very simple
condition, and Primary herpetic gingivostomatitis.
Some books could refer to erythema multiforme as a condition that might
involve the gingival but this is not true,at least vesicles and ulceration will
not be seen on the gingival.
Recovery over 10-14 days, without treatment
Self-limiting disease unless pt. immunocompromised

Primary Herpetic Gingivostomatitis

Most rapid,straight forward

Tissue Culture (most positive method)

the best test to be used in the diagnosis of
Primary herpetic gingivostomatitis
not used routinely because it takes long
The medium will include cells that are used to
keep the virus. And then cellular changes will be
seen under microscope. This technique is a
100% specific, sensitivity is less than that.

Primary Herpetic Gingivostomatitis


Serology implies the detection of the antibody to the virus. Serology

deals with identification of IgM & IgG when you want to confirm a diagnosis of
viral infection.
Is a lengthy lengthy and expensive process, not all labs are equipped with
required instruments and devices to perform that test. And it is retrospective
diagnosis. What does that means? It probably needs 3 weeks to confirm a
diagnosis of Primary herpetic gingivostomatitis, by the time you will have a
diagnosis, the lesion will be healed and the symptoms have subsided.
In serology we need to observe a fourfold rise in IgM antibody. (Correct the
mistake in your book). IgM rises in acute infection. As the patient develops
symptoms the titer of that antibody will raise.
You have to have two specimens, one specimen in the first week of infection and
then the other specimen after three weeks and compare. If the titer increased
by fourfold you can make a diagnosis of acute Primary herpetic
If IgG is detected without IgM, that is not an indicative of acute Primary herpetic
gingivostomatitis. It means that the patient had the virus before and now he has
immunity to that virus.
But in certain patients that should be done, especially patients who are
immune-compromised, patient who wants to undergo stem cells
transplant, or patients who receives an organ transplant, the titer of HSV
should be determined before the procedure, because those patients are in risk of

This is a comparison between viral and

serological classification of infection
with genital (HSV) *

Encephalitis (inflammation of the brain, caused by
infection or an allergic reaction.)

Hepatitis (a disease characterized by inflammation of

the liver)

Adrenals can be involved

Lung complications such as pneumonia
Infants born to asymptomatic carriers and
immune-compromised patients are at risk.

This is how primary herpetic gingivostomatitis presents, pts usually have

vesicles, ulcerations. Earliest lesions start as an erythema and then to
vesicles, then these vesicles disrupt causing ulceration. And if you look at the
gingival you will observe gingivitis, vesicles and ulcerations. Tongue is also
involved. Severity differs among individuals.

Eating is extremely painful in those patients, and you have to advice your
patient how to maintain their nutrition. It can cause dehydration in infants and
children, and have consequences.

Antiseptic mouthwashes
patients who have fever can be given paracetamol or
Acetomeniphen. However this is debatable

is prescribed for patients with resistance cases to Acyclovir

Patient who are immune-suppressed systemic anti-virals are

prescribed like Acyclovir
Systemic Acyclovir is not routinely given as treatment of choice for
patients with primary herpetic gingivostomatitis unless they are
immune-compromised, and they are not recommended for patients
who are under 12 years of age.

Valacyclovir, famciclovir

Recurrent Herpes
HSV-1 remains latent thereafter in the
trigeminal ganglion but can be reactivated.
Occurs in 20-40% of patients: reactivation of
latent herpes virus
(recurrent attack -> resolve -> attack again)
Most commonly seen on keratinized mucosa: lips,
palate, gingivae, skin
Prodromal symptoms include itching, burning
before vesicular eruptions
We use topical acyclovir
Recurrent lesion are localized

What reactivates HSV?
Mechanical trauma
Common cold (avoid contact with people
who have cold)

Emotional factors
triggering factor)


(stress-usually the most

Clinical Manifestation
Prodromal Stage: burning, itching, irritation
Vesicle stage (highly infectious)
remember that when you educate your patient
about his disease, that although it doesnt
have severe complications but it can have
serious implications on other family members
who are immune-suppressed.
Healing without scarring in 10 days
Lesions tend to involve the same area in
successive episodes
Although these lesions heal within 14 days, large
chronic lesions are seen in
immunocompromised patients that lasts for
2 months or more than that.

Clinical Manifestation
The prodromal symptoms are more severe in
primary herpetic gingivostomatitis than in
recurrent herpes.
Primary herpetic gingivostomatitis ->
fever, malaise,fatigue,lymph node
Recurrent herpes ->
itching&burning sensation at the site where
herpetic lesion will appear (there are no
systemic manifestation) its localized

Diagnosis and
Diagnosis: Cytology, viral cultures, clinical(most
Management: Avoidance of triggers, sunblock,
acyclovir, penciclovir cream
Acyclovir 400mg twice daily for frequent deforming
is recommended but not all patients. Specially for famous people (e.g. Nancy
Ajram :P) or whose work requires good appearance can take prophylactically
That will not treat the disease but Acyclovir will prevent virus replication, so
those patients will still develop latencies but the periodicity of those latencies
is reduced.

Frequent means more than 5 times a year.

Diagnosis and
Patients especially infants or
nurses can develop herpetic
lesions of the fingers that get
in contact with a fresh viral
lesion, and these lesions are
called herpetic whitlow.
May be transmitted from the
mouth / genitalia
Contagious and very painful

How to differentiate between

recurrent oral herpes and other
ulcerative conditions?
Recurrent herpes occurs on
keratinized mucosa, preceded by
Apthous ulcers do not affect
keratinized mucosa, is not preceded
by vesicles.
Kaposi sarcoma is caused by HHV8,
it is observed in HIV patients,
especially oral Kaposi sarcoma, and
is more commonly observed in Males
rather than females.

2. Varicella Zoster

Chicken pox is the primary infection with VZ, while the latent
condition is called Shingles

Varicella Zoster Chicken pox

Incubation period of 14-21 days
Oral small ulcers appear before skin rash- Usually not diagnosed
Maculopapular itchy lesions develop into vesicles
Fever, lymphadenopathy (systemic symptoms)
Treatment: supportive (symptomatic)
Complications: encephalitis, pneumonia
*pt. Should avoid itching the lesion because scrap will develop then
scars are formed
*this disease is highly contagious, now it has vaccine
*Dermatologist distinguished between chicken pox lesions from other
lesions on the skin, by observing the stages of chicken pox, so the
earliest stage is dew drop on a rose petal and then in late
stages while include crusted lesions and ruptured vesicles.

Varicella Zoster - Shingles

The recurrent lesion
70% of affected patients are above 50
years of age
Few neonates and young patients but
with very mild symptoms.
Debilitating diseases and immunesuppression are predisposing factors
(stress may also be a predisposing

Clinical manifestation
Prodromal sever pain for 2-3 days precede
vesicular eruptions.
Vesicular eruptions in the area of distribution of a
sensory nerve
15% affect the trigeminal nerve (ophthalmic
division in most cases)
Oral lesions in some cases resemble herpetic
Recovery in 2-4 weeks
Complications: corneal ulceration, post herpetic
The lesions are unilateral, in most doesnt cross the
midline, and it follows the sensory distribution of

Treatment of Varicella

Antivirals within 48-72 hours of rash onset.

If you were late in introducing the medication, dont start the patient on these

Acyclovir 800mg 5 times for 7 days

Valacyclovir 1000 mg 3 times for 7 days
Famicyclovir 500mg 3 times for 7 days
Control the symptoms by Analgesics and tricyclic
antidepressants (amitriptyline 25 mg qhs), mainly those
who developed post herpetic neuralgia.

*Post herpetic neuralgia is difficult to treat and the symptoms are usually sever,
and it is caused by scarring of the nerve, through which the virus was
reactivated, and therefore controlling their symptoms should include tricyclic
*Bells palsy is caused by HSV-1 and Varicella zoster both viruses are implicated
in the etiology.
*If a patient has ear rashes and vesicles without facial nerve
involvement the diagnosis will be shingles not Ramsay Hunt syndrome.

3. Epstein Barr Infections

Infectious mononucleosis *kissing
Burkitts lymphoma
Nasopharyngeal carcinoma
Hairy leukoplakia

a. Infectious
Synonyms: glandular fever, kissing disease
Affects young adults and they presents with

Febrile illness
Sore throat, tonsillitis
Oral ulcerations
Petechiae on the palate
They may develop generalized lymphadenopathy, similar to that
in lymphoma.

Blood test to confirm the diagnosis which is called the WBC

monospot, so if it is positive in a patient with lymphoma like
symptoms then a diagnosis of infectious mononucleosis is
Treatment : supportive
Some patients with infectious mononucleosis develops
symptoms that can last up to 6 months with organomegaly
(hepato-megaly, generalized lymph node enlargement)

*50% of patients with infectious mononucleosis develop

petechiae of the soft palate
*Patients with Sore throat and tonsillitis symptoms, If they
were misdiagnosed and were given amoxicillin antibiotics they
will develop skin rash

b. Burkitts lymphoma
Is a malignant tumor
Affects African children
It is also caused by EBV

c. Hairy leukoplakia
Usually at the lateral borders of
the tongue
In most cases it is bilateral white
It is seen in patients with
immune-suppression (HIV or
organ transplant or those on
corticosteroids systemic therapy)
*If you are dealing with bilateral
lesion of the tongue then you are
likely to diagnose it as hairy
*one of the most common oral
disorders in persons infected with
HIV, occurring in approximately
15 to 20% ofpatients.

4. Coxsakievirus
Group A: 24 types: causes hand,
foot and mouth disease, herpangina,
acute lymphonodular pharyngitis
Group B: 6 types: hepatitis,
meningitis, myocarditis, pericarditis
and acute respiratory disease

a.Hand Foot and Mouth


Caused by mostly by (A16) , A5,A7, A9, A10,B2, B5

Fever, oral vesicles and ulcers
Macules, papules, vesicles on hands and feet
Diagnosis: clinical
Treatment: supportive
The disease lasts five to eight days.

*These lesion looks like the herpetic lesion but there will be
vesicles,macules,papules on the hands&feets
*there is no available antiviral medication to treat coxsakie lesion.
Acyclovir is a antiviral medication only to herpetic lesion.

Hand Foot and Mouth


b. Herpangina
Coxsakie A1 to
A10, A16 to A22
Occurs in
more common in
patients may be
affected more
than once

Clinical Manifestations

Incubation: 2-10 days

Fever, chills and anorexia
Sore throat, dysphagia(difficulty in swallowing) and sore mouth
Recovery in one week (in 95% of the cases is self-limiting)
Diagnosis: smear
Treatment: supportive
Deaths were related to non coxsackie virus causing similar
*Acyclovir is not effective in herpangina, because coxsackie
virus is not a herpes virus
Coxsakievirus affect the posterior part of the soft palate ,posterior
part of the buccal mucosa and the posterior part of the tongue.
HSV affect anterior part of the oral cavity

5. Paramyxovirus
Caused by morbilli virus
Nasal discharge, kopliks spots intraorally (that is very
similar to fordyces granules) and conjunctivitis, skin
Complications: encephalitis, pneumonia
Treatment: supportive
*Patient will be severely ill
*Those patients develop oral kopliks spots before skin rash, so if you have
a patient with conjunctivitis, cough and sever fever with Fordyces
granules like on the buccal mucosa you can make a diagnosis of measles.
*But there is a difference between Fordyces granules and Kopliks spots
which is the erythematous base is associated with kopliks spots.

Viral infection affecting the
salivary glands.
Incubation 14-21 days
Bilateral parotid
enlargement, trismus, dry
mouth,fever, headache.
not always bilateral, some
patients develop
unilateral enlargements.
Diagnosis: clinical, serum
amylase levels, serology
Complications: deafness,
orchitis (inflammation of the testes),
myocarditis and oophoritis
(inflammation of the ovaries), encephalitis
Treatment: symptomatic

6.Human papilloma virus

Common warts
Hecks disease

(verruca vulgaris)

(self-limiting, associated with multiple lesions, focal epithelial hypoplasia,

it tends to affect certain families American-latin in origin)

Condyloma acuminatum
(its significance, if you see it in children that means the child may be
sexually abused)

Carcinoma of the cervix

*Nowadays there is a vaccine against HPV, which has been used to
vaccinate young girls primarily and young boys against HPV, in an
attempt to prevent cervical cancer
*And now there is a discussion about preventing oral squamous cell
carcinoma which can be induced by HPV, but the efficacy of that
vaccine is questionable.

7. HIV and Aids

Stages of HIV infection
Initial stages are asymptomatic and when we
say that a pt is HIV positive, that means that
his blood shows antibody to HIV.

Oral manifestations of HIV infection


hairy leukoplakia,
periodontal disease,
kaposis sarcoma,
mycobacterial infection,
Melanotic pigmentation,
salivary gland disease,