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  • 1. VIRAL DISEASES OF THE SKIN By Dr. Mengistu Hiletework Consultant Dermatovenereologist
  • 2. Introduction • Structural components of a viral particle ( virion); nucleic acid, capsid, and in certain groups of viruses only, an outermost membrane or envelope • DNA and RNA virus groups • DNA virus types are parvovirus, papovirus, adenovirus, herpesvirus, and poxvirus • RNA viruses are picornavirus, togavirus,coronavirus,retrovirus,etc..
  • 3. Herpesvirus Group • Double-stranded DNA • Viruses in this group are varicella-zoster virus, herpes simplex virus-1 and-2, cytomegalovirus, Epstein-Barr virus, human herpesviruses-6,-7,and-8,etc.
  • 4. Herpes simplex • HSV-1 and HSV-2 infections • Can be asymptomatic; latent infection • “First episode” or “Recurrent” • Most patients have no lesions or findings when they are initially infected with an HSV.The first clinical lesion is already a recurrence.
  • 5. Orolabial Herpes • Clinical presentation • Triggering factors of recurrence
  • 6. D/Dg of HS • Herpes zoster • Syphilitic chancre • Chancroid • In herpetic gingivostomatitis, apthosis,steptococcal infections, diptheria,coxsackie virus infections, and oral erythema multiforme
  • 7. Histopathology of Herpes simplex infection • The vesicles are intraepidermal • The affected epidermis and adjacent inflamed dermis are infiltrated with leukocytes. • Ballooning degeneration of the epidermal cells to produce acantholysis. • The most characteristic feature is the presence of multinucleated giant cells.
  • 8. Genital Herpes( GH) • Usually due to HSV-2 • Clinical presentation has a broad clinical spectrum from totally asymptomatic to severe genital ulcer disease. Classical manifestation symptomatic shedding Asymptomatic shedding
  • 9. Other clinical manifestations of HS • Herpetic sycosis • Herpes Gladiatorium • Herpetic Whitflow • Herpetic keratoconjunctivitis • Eczema Herpeticum( Kaposi varicelliform eruption) • Intrauterine and Neonatal Herpes simplex
  • 10. Intrauterine(IH) and Neonatal Herpes( NH) Simplex • 85% occur at the time of delivery, 5% occur in utero with intact membranes, and 10% to 15% from nonmaternal sources after delivery. • Inutero infection may result in fetal anomalies like limb hypoplasia, intracerebral calcifications,. including skin lesions and scar. • The risk of infection for an infant delivered vaginally when the mother has active recurrent genital herpes infection is b/n 2-5%, where as it is 26% to 56% if the maternal infection at delivery is a first episode.
  • 11. Treatment of Orolabial Herpes simplex • Topical Acyclovir cream( not ointment) • Oral therapy: acyclovir, valacyclovir, famciclovir • In frequent orolabial recurrences, chronic acyclovir suppressive therapy in a dose of 400 mg. twice a day can reduce the number of outbreaks by 50%.
  • 12. Management of GH • Initial clinical episode with oral acyclovir, 200 mg, 5xa day or 400 mg 3xa day, famciclovir,250 mg, 3x a day, or valacyclovir 1000mg twice a day, all for 7-10 days. • For recurrent genital herpes, acyclovir 200 mg. 5x a day or 800 mg. twice a day or famciclovir 125 mg. twice a day , both for 5 days. Valacyclovir may be used as a dose of 500 mg twice a day for 3 days.
  • 13. Management of GH Cont… • For patients with more than 6-12 frequent recurrences per year, suppressive therapy of acyclovir 400 mg. twice a day, 200 mg 3x a day, or 800 mg. once a day will suppress 85% recurrence. It can be stopped after 10 years. • Chronic suppressive therapy reduces asymptomatic shedding by almost 95%. • Chronic suppressive therapy is safe and lab. Monitoring not required.
  • 14. Management Of NH • Iv acyclovir • Vacuum- assisted delivery increases the relative risk of neonatal varicella by between 2-27% • Cesarean section in the setting of active genital lesions or prodromal symptoms.
  • 15. Varicella • Commonly known as chickenpox • The primary infection with VZV • Incubation period is 10 t0 21 days( usually 14 to 15 days) • Transmisson is by direct contact with the lesions and by the respiratory route, with the initial viral replication in the nasopharynx and conjunctiva
  • 16. Varicella, Cont… • An initial viremia between 4 and 6 days seeding the liver, spleen, lungs, and perhaps other organs. • A secondary viremia occurs at days 11 to 20, resulting in infection of the epidermis and appearance of characteristic skin lesions. • Individuals are infectious for at least 4 days before and 5 days after the appearance of the exanthem.
  • 17. Varicella, Clinical Manifestation • Severity of the disease is age dependent, with adults having more severe disease and a greater risk of visceral disease • Lifelong immunity • Second episode of “varicella” indicates either immunosuppression or another viral infection such as coxsackievirus
  • 18. Pregnant Women and Neonates • Maternal infection with the VZV during the first 20 weeks of gestation may result in a syndrome of congenital varicella syndrome (CVS) as well as severe illness in the mother. • CVS is characterized by anomalies like hypoplastic limbs,cutaneous scars, and ocular and CNS disease.
  • 19. Immunocompromised patients • Varicella can be extremely severe and even fatal in immunosuppressed patients, especially in individuals with impaired cell-mediated immunity. • Prior varicella does not always protect the immunosuppressed host from multiple episode. • Immunosuppression , especially hematologic malignancy and HIV infection increase the risk for zoster.
  • 20. Pregnant Women and Neonates, Cont,… • In some cases increased preterm labor. • The risk of zoster occurring postnatally is greatest in foetus infection of 25 to 36 weeks of gestation. • If the mother develops 5 days before and 2 days after delivery, neonatal varicella can occur and be severe, as transplacental delivery of antivaricella antibody has been inadequate.
  • 21. Diagnosis of Varicella • Clinically • Tzanck smear, characteristic multinucleate giant cells • If needed, DFA test, which is rapid, and will both confirm the infection and type of the virus. • VZV grows poorly and slowly, so culture is rarely needed.
  • 22. Complications of Varicella • Secondary bacterial infection with staphylococcus aureus or a streptococcal organism • Rarely osteomyelitis, other deep-seated infections or septicemia • Pneumonia uncommon in normal children, but seen more in adults. • Cerebellar ataxia and encephalitis • Asymptomatic myocarditis and hepatitis
  • 23. Varicella Complications, Cont… • Reye syndrome, a syndrome of hepatitis and acute encephalopathy, is associated with the use of aspirin to treat the symptoms of varicella. • Aspirin is absolutely contraindicated in patients with varicella.In any child with varicella and severe vomiting, Reye syndrome should be excluded. • Symptomatic thrombocytopenia is a rare manifestation, which occurs either with the exanthem or several weeks after • Purpura fulminans, a form of disseminated intravascular coagulation with low levels of protein C and S.
  • 24. Treatment • Acyclovir therapy to be started early within 24 h of the appearance of the eruption • Aspirin is contraindicated • Topical antipruritic lotions • Dressing the patient in light, cool clothing, and keeping the environment cool • Severe fulminant cutaneous disease and visceral complications are treated with IV acyclovir, 10 mg/kg every 8 hour.
  • 25. Varicella Vaccine • A single live attenuated viral vaccine for children aged 1 to 12, and persons aged 13 and older, two vaccinations , 4 t0 8 weeks apart. • In healthy children,97% of efficacy during the first year and 84 % efficacy for the next 8 years. • Immunized children may develop varicella of reduced severity on exposure to natural varicella.
  • 26. Zoster ( Shingles, Herpes Zoster) • Zoster is caused by reactivation of VZV. • VZV remains latent in the dorsal root ganglion cells. • Replication of the virus some later time, traveling down the sensory nerve into the skin. • Immunosuppression, especially haematologic malignancy and HIV infection increase the risk for zoster.
  • 27. Classical presentation of zoster • Dermatomes mostly affected are thoracic (55%), cranial(20%), the trigeminal nerve being the most common single nerve involved. Lumbar (15%), and sacral(5%) • A correlation with the pain severity and extent of the skin lesions • Elderly persons tend to have more severe pain.
  • 28. Herpes Zoster, Cont… • Lesions may become hemorrhagic, necrotic, or bullous. • Rarely the patient may have pain, but no skin lesions (Zoster sine herpete) • Lesions may develop on the mucous membrane within the mouth in zoster of the maxillary or mandibular division of the facial nerve or in the vagina in the S2 or S3 dermatomes. • Zoster may appear in recent surgical scars.
  • 29. Complications of Herpes zoster • Disseminated Herpes Zoster • Opthalmic zoster * If external division of the nasociliary branch affected ( Hutchinson’s sign) * If vesicles on the lid margin • Ocular involvement is most commonly uveitis and keratitis. Less common ones are glaucoma, optic neuritis, encephalitis,hemiplegia, and acute retinal necrosis.
  • 30. Complications of Zoster, Cont.. • Ramsay Hunt syndrome , resulted from involvement of the facial and auditory nerves,caused by herpetic inflammation of the geniculate ganglione • Delayed contralateral hemiparesis, a rare but serious complication that occurs by affecting the first branch of the trigeminal nerve by direct extension on the nerve , gaining access to the CNS and infecting the cranial arteries.
  • 31. Complications of Zoster, Cont… • Motor neuropathy in about 3% of patients with zoster. • If S3 or less often S2 or S4 are involved, urinary hesitancy or acute urinary retention • Pseudo-obstruction, colonic spasm, dilatation, obstipation, constipation and reduced anal sphincter tone in T6 to T12, lumbar, or sacral zoster
  • 32. Zoster assosciated Pain( Postherpetic Neuralgia) • Preceding, within and after the eruption • Oral analgesia, nonsteroidal antiinflammatory drugs, and opiate analgesia • Capsaicin topically every few hours, but the application itself may cause burning • Local anaesthtics such as 10% lidocaine in gel form
  • 33. Postherpetic Neuralgia, Cont… • Sublesional anaesthesia, epidural blocks, and sympathetic blocks with and without corticosteroids. • Systemic corticosteroids are controversial • Tricyclics such as antitriptyline/or nortriptyline, and despiramine started at 25 mg/night or 10 mg. over the age of 65- 70. Dose gradually increased upto 100 mg.
  • 34. Zoster in immunosuppressed patients • Increased rate in immunosuppressed individuals by organ transplantation, connective tissue disease, or by agents to treat these conditions (corticosteroids, chemotherapeutic agents,cyclosporin, sirolimus, and tacrolimus) • Zoster is 30x more common in HIV- infected persons.
  • 35. Zoster in immunosuppressed patients, Cont… • Murmatomal, more ulcerative and necrotic,severe scar and disseminated zoster • Disseminated zoster may be associated with the syndrome of inappropriate antidireutic hormone secretion (SIADH)and present with hyponatemia, abdominal pain and ileus. Here the skin lesions may be small and resemble “papules” rather than vesicles
  • 36. Herpes zoster in immunosuppressed, Cont… • Often have recurrence of zoster upto 25% of patients with AIDS • Two atypical presentations of zoster in AIDS patients: Ecchtymatic lesions, which are punched out ulcerations with a central crust, and verrucous lesions
  • 37. Diagnosis of Zoster The same techniques used for the diagnosis of varicella
  • 38. Histopathology of Zoster • As in HS, the vesicles in zoster are intraepidermal • Acidophilic inclusion bodies similar to those seen in herpes simplex are present in the nuclei of the cells of the epithelium • Multinucleated keratinocytes, nuclear moulding, and perpheral condensation of the nucleoplasm are characteristic and confirmatory of an infection with either HSV or VZV.
  • 39. D/ Dg of HZ Herpes simplex if the HS lesions are linear (zosteriform) or the zoster lesions are small and localized to one side, not involving the whole dermatome.
  • 40. Isotopic Response • Following zoster, within a month and rarely larger than 3 months after zoster inflammatory skin lesions may rarely occur within the affected dermatome. • Clinically, flat-topped or annular papule in the dermatome. • Histologically granulomatous inflammation
  • 41. Treatment of HZ • Middle-aged and elderly patients, restrict physical activity or even stay home in bed • Local applications of heat, as with an electric heating pad or a hot-water bottle • Simple local application of gentle pressure with the hand or with an abdominal binder
  • 42. Treatment of HZ, Cont… • Antiviral therapy: The main benefit is in reduction of the duration of the zoster-associated pain and more rapid resolution of skin lesions. Valacyclovir ( 100o mg.), famciclovir( 500 mg.),3x a day are as effective or superior to acyclovir ( 800 mg.,5x a day) probably because of better absorption.