Viral Infections

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

Viral infections

Papular
1. Warts 2. Molluscum

Vesicular
Herpes Simple ‡ Primary ‡ Recurrent Varicella ‡ Herpes zoster ‡ Chicken pox

Herpes Virus Infections

Taxonomy

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

Herpes simplex
Pathogenesis
Primary 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.

Herpes simplex
Pathogenesis
Primary 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.

Herpes simplex
Pathology:
Ballooning and reticular degeneration of the epidermis with giant cells. Derma cellular infiltration and vasculitis.

A- Primary Herpes simplex
Constitutional symptoms and usually wide spread. Morphology
Grouped painful vesicles on erythematous base rupture erosions, crustation or plaque formation.

Course
2-6 weeks.

A- Primary Herpes simplex
Localization
Primary gingivostomatitis:
Erosions on the mouth interfere with feeding. May coalesce yellowish plaque.

A- Primary Herpes simplex
Localization
Keratoconjunctivitis:
Dentritic painful keratitis and conjunctivitis corneal opacity.

A- Primary Herpes simplex
Localization
Vulvovaginitis:
Pain dysuria vesicles vagina Urtheritis and cystitis. Groin skin may be affected cervix.

A- Primary Herpes simplex
Localization
Primary genital in the male
The vesicles and erosions on the penis and pubic area with tender lymphadenopathy.

A- Primary Herpes simplex
Localization
Primary inoculation herpes (whitlow):
In dentists and surgeons. At the site of trauma (fingers with supratrochlear or axillary lymph nodes.)

A- Primary Herpes simplex
Localization
Kaposi varicellifom eruption:
In children suffering of atopic dermatitis, and Dareir¶s disease. Generalized vaccinator eruption with umblicated bullae.

B- Recurrent Herpes simplex

B- 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.

B- Recurrent Herpes simplex

B- Recurrent Herpes simplex

B- Recurrent Herpes simplex

B- Recurrent Herpes simplex
Localization
Face:
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.

B- Recurrent Herpes simplex
Morphology
Grouped 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.

B- Recurrent Herpes simplex
Diagnosis
Clinical picture
Tzank test: scrapping the vesicle base giant multinucleated cells Giemsa

Viral culture Immunofluorescence PCR Electron microscopy.

Differential diagnosis: other cause of bullous eruption.

B- Recurrent Herpes simplex
Treatment General measures
Avoid predisposing factors. In severe cases hospitalization immuno-stimulant . and

B- Recurrent Herpes simplex
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.

B- Recurrent Herpes simplex
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)
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.

C- Herpes zoster (Shingles)
Predisposing factors:
Trauma. Acute inflammation. Debilitating diseases. Immunosupression.

C- Herpes zoster (Shingles)

C- Herpes zoster (Shingles)

C- Herpes zoster (Shingles)

C- Herpes zoster (Shingles)

C- Herpes zoster (Shingles)

C- Herpes zoster (Shingles)

C- Herpes zoster (Shingles)

C- Herpes zoster (Shingles)

C- Herpes zoster (Shingles)
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).

C- Herpes zoster (Shingles)
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).

C- Herpes zoster (Shingles)
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

C- Herpes zoster (Shingles)
Clinical Picture:
Morphology:
Grouped vesicles on erythematous base, which contains clear fluid purulent contents some vesicles rupture crustation the others may dry up.

C- Herpes zoster (Shingles)
Clinical Types:
A. According to the site:
Herpes zoster pectoralis:
Involve one of the intercostals nerves one side of the chest and back. Pain may be mistaken as chest pain. eruptions in

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 cutaneous lesions. without

C- Herpes zoster (Shingles)
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).

C- Herpes zoster (Shingles)
Clinical Types:
Bilateral:
Rare associated with constitutional manifestation in debilitating diseases and immunocompromised patients.

C- Herpes zoster (Shingles)
Clinical Types:
B. According to morphology:
Classical Abortive
Grouped papular healing

Haemorrahgic
Vesicles filled with blood in debilitating & immunocompromised.

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

C- Herpes zoster (Shingles)
Complications
Secondary bacterial infections. Eczematization. Gangrene. Post hereptic neuralgia. Systemic affection Ocular
Keratitis

Neurological
Facial palsy, meningitis& myelitis.

Urinary bladder
Cystitis

C- Herpes zoster (Shingles)
Treatment
Systemic:
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.

C- Herpes zoster (Shingles)
Treatment
Local treatment
Analgesic creams. Anesthestic cream. Antibiotics if secondary infected Antiviral acyclovir in early lesions. Drying agents.

Chicken pox (varicella)
Organism
Varicella zoster virus primary infection

Incubation period
2 weeks.

Clinical picture:
Mild constitutional manifestation Localization
On the trunk, scalp, face, mucous membrane and extremities

Chicken pox (varicella)
Morphology
Papules or macules vesicles or bullae pustules crust. All the lesions are present at the same time (polymorphism) usually heal within 710 days with normal skin.

Chicken pox (varicella)

Chicken pox (varicella)
Differential diagnosis Complication
Secondary infection Systemic involvement ( pneumonia).

Chicken pox (varicella)
Treatment
Bed rest Systemic antibiotics Local drying agents or antibiotic In severe cases:
Acyclovir or gammaglobulins.

Thank you
Eman El Morsy

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