dermatology.Viral diseases.(dr.ali el-ethawe)
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  • 1. Viral diseases of the skin &mucous membrane DR. Ali El-ethawi Specialist Dermatologist M.B.CH.B , F.I.C.M.S , C.A.B.D 5 th class lecture
  • 2.
    • Viruses are not cellular organism because they do not have functional ribosome's or other cellular organelles.
    • (i.e.; obligate intracellular parasite because their replication depend on host cell)
    • Viral genome consist of only single type of nucleic acid (RNA ,DNA)
    • Two main groups of viruses are distinguished:
    • DNA
    • RNA .
  • 3. DNA Viruses
    • Herpes virus; HSV, VZV, CMV, EBV
    • Hepadna virus ; HBV
    • Adenovirus
    • Papovavirus ; HPV
    • Parvovirus* ; Erythema Infectiosum
    • Poxvirus ; Molluscum, Smallpox, Orf, Milker’s Nodule
  • 4. RNA Viruses
    • Paramyxo-virus; Measles, Mumps
    • Togavirus ; Rubella
    • Rhabdovirus ; Rabies
    • Retrovirus; HIV, HTLV
    • Reovirus**; Rotavirus
    • Picornavirus; Enterovirus, Coxsackie
  • 5.
    • Viral infections of skin and mucosa produce a wide spectrum of clinical manifestations.
    • Some Viruses not causing any clinical lesions. (produce latent, but lifelong infection)
    • Some cause benign epithelial proliferations , i.e., warts.
    • Some viruses cause febrile illness with exanthems.
    • In the setting of immunocompromise , these viruses can become active and cause disease with significant morbidity and mortality rates.
  • 6.
    • are medium-sized viruses ds -DNA replicate in the cell nucleus .
    • produce latent , but lifelong infection by infecting immune cells and nerves.
    • Intermittently have replicative episodes with amplification of the viral numbers .
    • The vast majority of infected persons remain asymptomatic .
    • Viruses in this group are ;
    • herpes simplex virus (HSV) (HHV-1,2)
    • varicella zoster virus (VZV) (HHV-3)
    • Epstein-Barr virus (EBV) (HHV-4)
    • cytomegalovirus (CMV) (HHV-5)
    • Human herpesviruses (HHV6) Exanthem Subitum, Sixth Disease, Roseola Infantum
    • Human herpesviruses (HHV-7)
    • Human herpesviruses (HHV-8)
    HERPESVIRUS GROUP
  • 7. Herpes simplex viruses (HSV)
    • are common human DNA viral pathogens that intermittently
    • re-activate.
    • The virus is ubiquitous and carries continue to shed virus particles in their saliva &tears.
    • There are two types of HSV: HSV-1 and HSV-2.
    • HSV-1 is mostly associated with orofacial disease, whereas HSV-2 usually causes genital infection, but both can infect oral and genital areas and cause acute and recurrent infections.
    • Most of the adult population is seropositive for HSV-1, and the majority of infections are acquired in childhood while acquisition of HSV-2 correlates with sexual behavior.
  • 8. Clinical presentation
    • HSV infections are classified as either;
    • primary “(first episode )“ or "recurrent.“
    • 1. primary infections
    • Primary HSV -1 is often asymptomatic or not recognized in most cases,
    • but they can also cause severe disease as acute gingivostomatitis .
    • Primary HSV -2 infection Usual transmitted sexually often asymptomatic or , cause multiple & painful Genital & perianal blisters which rapidly ulcerate
    • 2.Recurrent infections ;
    • These strike in roughly the same place each time .
    • They may ppt. by RTI, UVR ,menstruation or even stress
    • Common site face ,lips (HSV-1) and the genitals (HSV-2) But lesions can occur any where .
    • Most recurrences are not symptomatic (asymptomatic shedding), with most transmissions occurring by asymptomatic shedding.
  • 9.  
  • 10. Recurrent facial herpes simplex
  • 11.
    • Primary Gingivostomatitis
    • HSV-1
    • Kids/young adults
    • 1% of all primary HSV infections of lips/face
    • Fever, sore throat
    • Painful erosions covered with characteristic gray membrane on tongue, palate, mucosal surfaces
    • Lesions are clustered (helps distinguish from aphthous ulcers)
    • Recurrent facial herpes simplex or Herpes Labialis
    • HSV-1 > HSV-2
    • Cold sore/fever blister
    • Primary infection may present as
    • gingivostomatitis in kids or mono-like syndrome in young adults
    • Recurrent lesions Most common on vermillion border
  • 12.
    • Primary Genital Herpes
    • HSV-2 > HSV-1
    • Most prevalent STD in US
    • Asymptomatic infection is rule rather than exception
    • 3-7 days post-exposure get tender LAD, malaise, anorexia, fever, localized pain, tenderness and burning; Vesicles  pustules, resolves in 2-6 weeks
    • Travel by retrograde axonal flow to dorsal root ganglia and establish latency until reactivation
    • Recurrent Genital Herpes
    • HSV-2 > HSV-1
    • Reactivated by: stress, UV, fever, tissue damage or immunosuppression
    • Decrease in # of lesions, severity and duration
    • Frequency of recurrences correlates directly with severity of primary infection
    • Average of 4-7 outbreaks annually
  • 13. Recurrent Genital herpes
  • 14. Herpetic Whitlow
    • HSV-1, HSV-2
    • Herpes simplex infection of the digits
    • Common in children, medical personnel , and people who do IPL bikini hair removal
  • 15. Herpes Gladiatorum
    • HSV-1 infection
    • highly contagious occur in athletes involved in contact sports
    • such as wrestling ( transmitted via direct skin-to-skin contact).
    • Most common Sites
      • Arms #1
      • Head/neck
  • 16.
      • Complications
      • 1.Eczema herpeticum (Kaposi's varicelliform eruption)
      • 2. Recurrent  Erythema multiforme
      • 3. Disseminated herpes simplex
      • 4.Herpes encephalitis or meningitis
      • 5. Herpes simplex infection of the eye can cause recurrent dendritic ulcer leading to corneal scarring
  • 17. Eczema herpeticum.
  • 18. Diagnosis & Treatment
    • Diagnosis is depending on the clinical presentation
    • polymerase chain reaction (PCR)
    • viral culture,
    • Serology; ( Serologic detection of antibodies to HSV )
    • Treatment ( Many HSV infections require no specific treatment at all)
    • acyclovir, valacyclovir, or famciclovir.
    • Regimens and dosages vary with the clinical setting.
    • Resistance is rare in other than immunocompromised patients.
  • 19. Varicella Zoster Virus (VZV) (HHV-3)
    • Chickenpox ( primary infection )
      • 90% of kids <10 years old (before vaccine)
    • Herpes zoster ( reactivation)
      • Develops in 20% of adults
    • Varicella in Pregnancy
    • Immunocompromised
      • Extensive, atypical eruption with hemorrhagic or purpuric lesions and visceral involvement (lung, liver, CNS)
  • 20.
    • A. During primary varicella-zoster virus (VZV) infection (varicella or chickenpox), virus infects sensory ganglia.
    • B. VZV persists in a latent phase within ganglia for the life of the individual.
    • C. With diminished immune function, VZV re-activates within sensory ganglia, descends through sensory nerves, and replicates in skin .
  • 21.  
  • 22.  
  • 23. Chickenpox (Varicella)
    • Varicella is the highly contagious primary infection caused by VZV
    • Incubation Period ; 14 days (range, 10 to 23 days).
    • Prodrome ;
    • in children; Uncommon , Characteristically absent or mild.
    • in adults; more common : headache, general aches and pains, severe backache, malaise.
    • Skin Lesions ;
    • Exanthem appears within 2 to 3 days
    • Exanthem starts on scalp and face, then spreads to the trunk
    • Different stages;
    • Rapid evolution of lesions from macule to papule to Vesicles ( Dew Drops on a Rose Petal &quot;drops of water &quot;) to pustule and crust over an 8- to 12-h period
    • Often single, discrete lesions or scanty in number in children and much more dense in adults.
    • Scarring is rare unless the lesions were traumatized by the patient or superinfected with bacteria.
  • 24. COMPLICATIONS
    • Secondary bacterial Skin infection .; it is the most common complication in children .
    • Neurologic complications . Encephalitis and Reye's syndrome are complications of chickenpox.
    • Reye's syndrome
      • Acquired encephalopathy & hepatitis with ASA use
        • 20% mortality
    • Pneumonia .; Pneumonia is rare in normal children, but it is the most common serious complication in normal adults.
  • 25. Treatment
    • Normal
    • Neonate ; Acyclovir, 500 mg/m2 q8h × 10 days
    • Child ; Symptomatic treatment alone, or acyclovir, 20 mg/kg PO qid × 5 days
    • Adolescent, adult, or glucocorticoids used ; Acyclovir, 800 mg PO 5×/day × 7 days
    • Immunocompromised
    • Mild varicella or mild compromise; Acyclovir, 800 mg PO 5×/day × 7-10 days
    • Severe varicella or severe compromise; Acyclovir, 10 mg/kg IV q8h × 7 days or longer;
    • Acyclovir resistant (advanced acquired immunodeficiency syndrome) Foscarne t, 40 mg/kg IV q8h until healed
  • 26. Herpes zoster (HZ) ,Shingles
    • it is an acute dermatomal infection associated with reactivation of endogenous VZV
    • Age of Onset ; More than 66% are >50 years of age;
    • 5% of cases in children <15 years.
    • C/F;
    • Prodrome : pain/pruritis, tingling, hyperesthesia, Pre eruptive pain (pre-herpetic neuralgia), unilateral, dermatomal, precedes the eruption by 4 to 5 days.
    • Prodromal symptoms may be absent, particularly in children.
    • ERUPTIVE PHASE.
    • Single dermatome ;Does not cross midline
    • The eruption begins with red, swollen plaque of varying sizes and spreads to involve part or all of a dermatome
    • The vesicles arise in clusters from the erythematous base and become cloudy with purulent fluid by day 3 or 4.
    • Successive crops continue to appear for 7 days.
    • Vesicles either umbilicate or rupture before forming a crust , which falls off in 2 to 3 weeks.
    • The elderly or debilitated patients may have a prolonged and difficult course.
    • The major morbidity is post-herpetic neuralgia (PHN).
  • 27.  
  • 28.  
  • 29. Herpes zoster (ophthalmic zoster). Involvement of the first branch of the fifth nerve. Vesicles on the side of the nose are associated with the most serious ocular complications.
  • 30. R x
    • The aim of treatment is the suppression of inflammation, pain, and infection.
    • Oral antiviral agents
    • oral acyclovir (800 mg five times a day for 7 days),
    • famciclovir (500 mg every 8 hours for 7 days)
    • valacyclovir (1 g three times a day for 7 days) are recommended in all patients over 50 with pain in whom blisters are still present, even if they are not given within the first 96 h of the eruption.
    • Oral analgesia ; acetaminophen, NSAIDs, and opiate analgesia as required.
    • Antiviral therapy and analgesics aid acute pain control
    • TOPICAL THERAPY ; Local anesthetics, such as 10% lidocaine in gel form, or lidocaine patches (Lidoderm), may acutely reduce pain
    • post-herpetic neuralgia; lidocaine patch (5 %), gabapentin, pregabalin, opioids, and tricyclic antidepressants may reduce it .
  • 31. Exanthems were previously consecutively numbered according to their historical appearance
    • Diseases that begin with exanthems may be caused by bacteria, viruses, or drugs
    • 1. first disease, measles ;
    • 2.second disease, scarlet fever ; (bacterial)
    • 3.third disease, rubella;
    • 4. fourth disease, &quot; Dukes' disease &quot; (probably coxsackie virus or echovirus);
    • 5.fifth disease, erythema infectiosum ;
    • 6.sixth disease, roseola infantum
  • 32. MEASLES( Rubeola)
    • Measles is a highly contagious childhood viral infection.
    • Significant morbidity and mortality occur in acute and chronic course.
    • Childhood immunization by combined MMR vaccine is highly effective at preventing infection
    • Etiology; Paramyxovirus (RNA)
    • Epidemic disease; worldwide distribution
    • Host/reservoir : humans
    • Transmission: respiratory droplets
    • Incubation period ; 10-14 days
      • Highly contagious period
    • Clinical course ; Prodrome+ Exanthem
      • Prodrome ; ;Fever, malaise, 3 “C’s” ; Cough ,Coryza, Conjunctivitis,
      • K oplik spots; ( Pathognomonic) Cluster of tiny bluish-white spots on red background on buccal mucosa opposite premolar teeth.
      • Exanthem ; Generalized erythematous macules and papules
      • Appears over 2-4 days
      • Cephalocaudad spread from the forehead and behind the ears to the trunk and extremities.
      • Fades on day 5 in the same cephalocaudad direction
      • More severe disease in immunocompromised or malnourished individuals.
  • 33. Measles. Evolution of the signs and symptoms .
  • 34.  
  • 35.
    • Treatments;
    • First line
      • Supportive care
      • Treat secondary infections
      • Vitamin A
      • Immune globulin, IM
      • Measles vaccine
    • Second line
    • Ribavirina
    • Delayed complication
      • Subacute Sclerosing Panencephalitis
  • 36. German measles( RUBELLA)
    • 3-day measles.
    • Epidemic disease; worldwide distribution.
    • Cause; is an enveloped RNA virus in the Togaviridae family
    • Incubation period ;about 18 days
    • Short prodrome; pink macular rash ,which fades ,first on the turnk over the course of few days.
    • Enlargement of cervical, suboccipital, and postauricular glands.
    • rubella during the first trimester carries high risk of fetal malformations with congenital infection (microcephaly, congenital heart disease, deafness).
    • Prevention by vaccination with the combined MMR vaccine
  • 37. Erythema infectiosum (fifth disease)
    • is caused by the B19 parvovirus.
    • It is relatively common and mildly contagious
    • appears sporadically or in outbreaks, often in the spring.
    • children between 5 and 14 years of age.
    • Incubation period; is 13 to 18 day
    • Asymptomatic infection is common.
    • Prodrom; Symptoms are usually mild or absent.
    • ERUPTIVE PHASE. There are three distinct, overlapping stages.
    • Facial erythema (&quot;slapped cheek&quot;).
    • Reticular erythema of the shoulder.
    • Recurrent phase . The eruption may fade and then reappear in previously affected sites on the face and body during the next 2 to 3 weeks.
  • 38. GIANOTTI-CROSTI SYNDROME (Papular acrodermatitis of childhood)
    • Common, self-limited dermatosis.
    • The exanthem occurs in children 1 to 6 years old,
    • presenting as discrete non-pruritic, erythematous monomorphic dome-shaped or flat-topped papules symmetrically distributed on face, buttocks and extensor extremities.
    • Typically, the trunk is spared
    • Associated with multiple viral triggers and immunizations.
    • Historically associated with hepatitis B infection, but now more often triggered by Epstein-Barr virus.
    • Duration is 2 to 3 weeks .
  • 39.  
  • 40. Roseola Infantum (Exanthem Subitum, Sixth Disease)
    • a common cause of sudden, unexplained high fever in young children between 6 and 36 months of age.
    • Prodromal fever is usually high and convulsions and lymphadenopathy may accompany it.
    • Suddenly, on about the fourth day, the fever drops.
    • a morbilliform erythema consisting of rose-colored discrete macules
    • Sites ; the neck, trunk, and buttocks, and sometimes on the face and extremities.
    • The eruption may also be papular or, rarely, even vesicular.
    • The mucous membranes are spared.
    • Complete resolution of the eruption occurs in 1 to 2 days.
  • 41.  
  • 42.  
  • 43. Human Papillomavirus Infections (HPV)
    • Papovavirus
      • dS DNA,55 nm diameter, Naked (non- enveloped)
      • Resistant to drying, freezing, and solvents
    • More than 150 types of HPV have been identified.
    • Causing subclinical infection or a wide variety of benign clinical lesions on skin and mucous membranes
    • They also have a role in the oncogenesis of cutaneous and mucosal premalignancies (SCC in situ) and malignancies (invasive SCC).
  • 44. wart
    • Transmission ; Skin-to-skin contact.
    • Other Factors ; Immunocompromise, such as occurs in HIV disease or after iatrogenic immunosuppression with solid organ transplantation, is associated with an increased incidence of and more widespread cutaneous warts. Occupational risk associated with meat handling.
    • Duration of Lesions ; Warts often persist for several years if not treated.
    • Verruca Vulgaris (Common Warts)
    • first begin as smooth, flesh colored papules,
    • lesion enlarge into dome-shaped, gray-brown irregular growths with rough hyperkeratotic clefted surface, with vegetations.
    • Characteristic &quot; brown-black dots&quot; are better seen with hand lens and are pathognomonic, representing thrombosed capillary loops.
    • The hands are the most common site but warts may be found on any skin surface.
    • Occur at sites of trauma
    • more often multiple than single
    • Pain is rare
    • Butcher's warts : large cauliflower-like lesions on hands of meat handlers.
    • Filiform warts have relatively small bases, extending out with elongated cap.
  • 45. Common warts (Verruca vulgaris)
  • 46.  
  • 47.  
  • 48. R x
    • Aims of therapy are
    • 1) to remove the wart;
    • 2) not to produce scarring;
    • 3) to induce lifelong immunity to prevent recurrence.
    • Cryotherapy is a reasonable first line therapy for most common warts.
    • Products containing salicylic acid +/- lactic acid
    • Simple occlusion with a relatively impermeable tape can be effective in eradicating warts.
    • Surgical destruction with cautery or ablation of warts can be effective treatment, but even complete destruction of a wart and the surrounding skin does not guarantee the wart will not recur. for warts that are refractory
    • Bleomycin has high efficacy and is an important treatment for recalcitrant common warts.
  • 49.  
  • 50. plane Warts (Verruca Plana)
    • Sharply defined, flat papules (1 to 5 mm); &quot;flat&quot; surface, skin-colored or light brown.
    • Round, oval, polygonal, linear lesions (inoculation of virus by scratching).
    • Generally they are numerous & painless but may be few
    • Lesions that arise after trauma may have a linear arrangement.
    • Sites; Occur on face (,forehead , about the mouth) , the backs of the hands, beard area, shins.
    • Treatment ; Flat warts frequently undergo spontaneous remission.
    • topical tretinoin
    • Tazarotene cream or gel may also be effective
    • Imiquimod cream used up to once a day can be effective.
    • 5-FU cream 5% applied twice a day may be very effective.
    • light cryotherapy . If lesions are few
    • For refractory lesions ;
    • laser therapy (in very low fluences )
    • photodynamic therapy .
    • electrodesiccation ( risk of scarring)
  • 51.  
  • 52.  
  • 53. Plantar Warts
    • Warts of the soles are called plantar warts .
    • These have a rough surface which
    • protrude only slightly from the skin & surrounded
    • by bony collar .
    • On paring , the presence of the bleeding
    • capillary loops allows planter warts to be
    • distinguish from corns .
    • Often multiple .
    • It can be painful
    • A cluster of many warts that appears
    • to fuse is referred to as amosaic wart
  • 54.  
  • 55. Plantar Warts
    • In general, plantar warts are more refractory to any form of treatment
    • than are common warts.
    • Initial treatment usually involves daily application of salicylic acid in liquid, film, or plaster form after soaking.
    • In failures, cryotherapy or cantharidin application may be attempted, alone or in combination.
    • A second freeze-thaw cycle is beneficial when treating plantar warts with cryotherapy.
    • Bleomycin injections, laser therapy, or topical immunotherapy, may be used in refractory cases.
    • Surgical destruction with cautery or blunt dissection should be reserved for failures with nonscarring techniques, since a plantar scar may be persistently painful.
    • CO2 laser may also result in plantar scars.
  • 56. Genital warts Condylomata Acuminata
    • Genital warts are the most common STD Among sexually-active young adults in the US and Europe,
    • are pale pink with numerous, discrete, narrow-to-wide projections on a broad base.
    • The surface is smooth or velvety, moist, and lacks the hyperkeratosis of warts found elsewhere
    • Can appear any where in genital area .
    • The warts may coalesce to form a large, cauliflower-like masses in moist, occluded areas such as the perianal skin, vulva, and inguinal folds.
    • Another type is seen most often in young, sexually active patients. Multifocal, often bilateral, red- or brown pigmented slightly raised, smooth papules .
    • The presence of anogenital warts in children raise the spectra of sexual abuse ,but is usually caused by auto inoculation from common wart elsewhere
  • 57.  
  • 58.  
  • 59. Genital wart
    • Because no effective virus-specific agent exists for the treatment of genital warts, their recurrence is frequent.
    • Podophyllin is more effective in treating warts on occluded or moist surfaces, such as the mucosa or under the prepuce. as a crude extract, usually in 25 % in tincture of benzoin.
    • Purified podophyllotoxin 0.5% solution or gel is applied by the patient twice a day for 3 consecutive days of each week in 4- to 6-week treatment cycles.
    • Imiquimod, an immune response modifier which induces IFN locally at the site of application,
    • Trichloroacetic acid (TCA) 35 % to 85 % weekly or biweekly. TCA is safe for use in pregnant patients.
    • Cryotherapy with liquid nitrogen
    • Electrofulguration or electrocauterization
    • The use of CO2 laser in the treatment of genital warts has not been demonstrated to be more effective than simpler surgical methods.
    • Any surgical method that generates a smoke plume is potentially infectious to the surgeon.
    • 5-FU 5% cream applied twice a day may be effective, 5-FU is not commonly recommended for the treatment of typical external genital warts because other methods of treatment are available.
    • The efficacy of systemic and intralesional IFN-a therapy has been found to be relatively low in eradicating genital warts.
  • 60. Molluscum Contagiosum
    • Molluscum contagiosum (MC), is a self-limited epidermal viral infection.
    • Etiology ; a double-stranded DNA poxvirus .
    • Types MCV-1 and MCV-2.
    • Age, Sex ; 1.Children;
    • 2. sexually active adults ; males > females.
    • Transmission ;Skin-to-skin contact. spreads via autoinoculation, scratching, or touching a lesion and fomites
    • clinically ; skin-colored papules that are often umbilicated, occurring in children and sexually active adults.
    • In HIV-infected individuals, however, numerous large mollusca often arise on the face , causing significant cosmetic disfigurement
    • Sites; in children ; most commonly on the face, trunk, axillae, extremities ,
    • in adults in the pubic and genital areas
    • Unlike warts, the palms and soles are not involved
  • 61.  
  • 62.  
  • 63.
    • Classification by Risk Groups
    • Children ; exposed skin sites. Child-to-child transmission relatively low. Resolve spontaneously. Usually caused by MCV-1.
    • Sexually Active Adults ; Occur in genital region. Virus transmitted during sexual activity. Can Resolve spontaneously.
    • HIV-Infected Individuals ; Most commonly occur on the face, spread by shaving. Usually caused by MCV-2
    • Most lesions are self-limiting and clear spontaneously in 6 to 9 months; however, they may last 2 to 4 years or longer.
    • Genital molluscum contagiosum may be a manifestation of sexual abuse in children .
    • Treatment must be individualized.
    • Conservative non scarring methods should be used for children who have many lesions.
    • Genital lesions in adults should be definitively treated to prevent spread by sexual contact .
    • Treatment are;
    • Curettage
    • Imiquimod (Aldara cream) ,
    • podophyllotoxin 0.5% (Condylox) ,
    • Tretinoin (Retin-A) cream ,
    • Salicylic acid (Occlusal)
  • 64. Human Orf ;( Ecthyma contagiosum, Contagious Pustular Dermatitis)
    • cause; poxvirus of the genus Parapoxvirus
    • • Endemic in sheep and goats, presenting as nodules on the nose and mouth
    • • Transmitted from infected animals to humans
    • • Most common in shepherds, farmers, and veterinarians
    • • Typically presents as a papule/nodule on the dorsal index finger.
    • Other Findings; Ascending lymphangitis and lymphadenopathy may occur.
    • Bacterial superinfection may occur.
    • More extensive infection may occur in the immunocompromised host
    • Course; lesion resolves spontaneously in 4 to 6 weeks, healing without scar formation
    • Management; Antiviral agents are not effective.
    • Treat bacterial superinfection; manage pain.