Viral infections VZV

1. VIRAL
Infections
Vesiculobullous lesions

2. VIRAL
Infections

3. Definition:
Varicella zoster virus (VZV, also known as human
herpes virus 3) is an alphaherpesvirus with double-
stranded DNA genome.
 VZV only naturally infects humans.

4. The same virus can cause 2 different diseases
• Varicella
• (Chicken pox)
Primar
y
• Zoster
• (Shingles or HZI)
Reactivated

5. • Varicella is the primary illness caused by HHV-3 (VZV).
• Chickenpox is highly contagious
• The patient get the disease when the VZV invades the
upper respiratory tract by:
1. contaminated droplet
2. direct contact with fresh skin lesion of patient with
Chicken pox or shingles.
Transmission
Resp route
Chicken pox is a common
disease.
Incubation period: 2-3 weeks.

6. • Age:
 Any age, but the peak incidence is 5-10 years
 Common in winter & spring.
• Prodrome:
F H M

7. Clinical Features
E/O

8. 1) skin rahes:
 Often v.prominent
 Seen mainly on (scalp, face & trunk)
 Begins as pruritic, maculo-papular rash
 Followed by vesicle formation
Crops of rashes continue to appear for 3-6 days due to repeated
waves of viremia. The VZ virus disseminate through blood “viremia” to
skin, mm, & other organs

9. 2) Vesicles:
 Skin rash followed by vesicle that has been described as
“dewdrop-like” or “tear drop” --> fluid filled V
 These Vs turn cloudy and pustular, burst & scab with the
crust falling off after 1-2 weeks.
 Each V begin to crust over & form a scab within 1-2 days.

10. Clinical Features
I/O

11. 1) Multiple Vs which rupture into multiple shallow ulcers.
2) Ulcers: usually not painful, in few pts intraoral ulcers are
indistinguishable from HSV but no associated gingivitis
“AMG”.
3) Cervical LAP.

12. • The illness is severe in older children & deblitating adults
however ,it is mild or absent in younger children.
• Mixed skin eruptions are common in the form of:
1. Papules
2. Vs
3. Pustules
4. Crusts
Possible to see lesions in diff phases @ same time

13. • Fever subside when new lesion cease to develop.
• The lesion heals without scar formation unless 2ry infected.
• Recovery 2-3 weeks.

14.  The diagnosis based on clinical grounds.
 A rising Ab titre is confirmatory.

15. Chickenpox vaccine
VZIG , VariZIG

16. • For healthy individuals chickenpox doesn't usually require
any ttt.
Although it's mild, SLD heals within 7-10 days &
uncomplicated
Symptomatic ttt
-Supportive
measures (Bed rest,
mm pain
&discomfort)
-Antiviral therapy
Prevent or reduce
the risk of
transmission of the
disease
(Pt isolation
during the active
phase of disease)
Prevention
of 2ry
infection

17. 1. Fever : antipyretics
2. Pruritus : topical/ oral antihistamine, calamine (antipruritic)
3. Skin & nail hygiene (daily bath with antibacterial soap + cut
short fingernails) : prevent 2ry bacterial infection and 2ry
complications.
Aspirin should be avoided in Varicella-infected children due
to it's association with Reye syndrome; so acetaminophen
should be the antipyretic of choice in children with
appropriate dosing

18. Treatment of varicella includes the use of acyclovir, & it should be
initiated within 24 hrs of the onset of the rash. Indicated for pts
with:
1. Severe varicella
2. Pts considered at greater risk of developing complications
3. Compromised immunity or
4. Chronic diseases of the skin or lungs

19. • acyclovir is available in both oral & IV formulations
• Oral acyclovir has poor bioavailability;
• Thus, the related drugs valaciclovir and famciclovir, which
have excellent absorption from the intestinal tract, produce
high blood antiviral activity and have a long half-life, should
be used for oral therapy instead.

20. • Use of acyclovir (800 mg 5 t/day) for 7-10 days, will reduces:
1. Infectivity
2. Severity of the lesions
3. Hospitalization for the complications

22. Shingles
HZI

23. cranial nerve ganglia,
dorsal root ganglia, and enteric
and autonomic ganglia
PF:
1. Trauma to spinal cord
2. tumor: CNs
3. Irradiation / surgery: spinal
cord
4. Immunosuppression drugs.
5. Malignancy: lymphoma,

24. It's a viral infection caused by reactivation of virus which has
been latent in the cranial nerve ganglia, (dorsal root ganglia
or enteric and autonomic ganglia) .
The word ZOSTER come from Greek for “belt”, since the lesion
occurs in a belt-like distribution.

25. Involvement of latency:
I. Sensory branches of V n (5th CN)
II. Sensory / motor branches of VII n (7th CN)

26.  Uncommon in children unless:
a) Child infected with the chickenpox: during 1st few months of
life, then the virus been latent & develop shingles early in
childhood.
b) Infected mother with chickenpox: during delivery child
develop conginetal varicella syndrome (occular lesion,
extensive scar, limbs deformity)
Age: - Adults - Older age

27. 1) Prodrome: FHM + unilateral tendernes along involved n.
2) Site: thoracic lesion, lumbar & trigeminal region.
3) Pain + Itching: “occur before, with & after the rashes”
i. Unilateral
ii. Deep , Burning/ stabbing or aching.
iii. Radiating
iv. Constant/ intermittent

28. 3) Skin:
After few days (2-5) rashes 'papules' turn into Vs, charcterized as:
1. Unilateral
2. Linear
3. Cluster
4. Dermatotic distribution on skin +mm supplied by infected n
5. On erythematous base
6. Vs: fluid filled (clear, purulent) / rupture, crust in 1 week.
dermatotic
“zosteriform”

29. 4) Occular lesions:
Opthalmic n involvement lead to:
- Unilateral corneal ulcer.
- Unilateral lesions in forehead & eyelid.

30. 5) Oral manifestations:
Involvement of mandibular division:
- Unilateral lesions involves (Tongue, cheek, lower jaw
vestibules, skin from chin to vertex).

31. 5) Oral manifestations:
Involvement of maxillary division:
- Unilateral lesions involve (upper jaw vestibules, hard & soft
palate, side of the neck, & cheek skin)

32. Lesions associated with occular and oral region, charcterized
by:
 V (unilateral, painful, on erythematous base and
dermatotically distributed)
V
 Ulcer (unilateral, painful, shallow, small, rounded, on
erythematous base)
 Similar to the skin lesion, heals with scar
Ulcer

33.  SLD, tend to heal within 3-4 weeks with scar “2ry infection
is quite common”
 Neurological complications of zoster may exist “common in
elderly & immunocompromised pts”

34. Neurological complications of zoster:
1. Zoster paresis. “arm or diaphragmatic weakness after cervical
zoster”
2. Neuralgia. PHN, the most common complication of zoster, is
defined as pain that persists for at least 3 months after rash
onset.
3. Generalized HZ “Pneuomonia/meningoencephalitis/hepatitis”.
4. VZV and giant cell arteritis.

35. 1) Why lesions in shingles appear
Unilaterally?
2) The lesions of VZI sometimes may
develop bilaterally, why?

37. 1. Cytology
2. Viral isolation
3. Ab titre.

41. Zostavax
 Reduces development of:
1) HZI (51%)
2) PHN (67%)
 Dose: single dose (subcutanous 0.65 ml / deltoid region)

42. Antivira
l
Pain
control
Famciclovi
r

43. 1) Healthy patients:
a) Mild clinical manifestations:
- Sedation & potential analgesics.
- Extreme care to avoid 2ry infection by:
- 5% Acyclovir ointment for skin & eye lesion.
- Topical capsaicin (hot peppers).
*Topical anasthesia are not effective. why?
i. 0.2% CHX mouthwash
ii. Rifampicin elixir mouth bath
q.d.s

44. b) Severe clinical manifestation:
- Acyclovir 800 mg tabs 5 times per day for 7-10 days.
- Famcyclovir (immunocompromised pts):
750 mg once daily for 7 days or
250 mg every 8 hrs for 7 days

45. 2) Disseminated HZ/ immunocompromised pt:
- Acyclovir: I.V 10 mg/kg body weight every 8 hrs for days.
- Famcyclovir: 500 mg, 3 times daily for 10 days.
3) Elderly pt:
- Acyclovir , &
- Prednisone 40-60 mg/day, decreasing over 3 weeks hoping to
prevent PHN.

46. Antivira
l
Pain
control
Famciclovi
r

47. 1. (Acetaminophen + NSAIDs) alone.
2. (Acetaminophen + NSAIDs) in combination with opoids.
analgesic codeine “methylemorphine, 1/12 analgesic potency”

48. 1. Oxycodone “codeine derivetives”
2. Pethidine: I.M/orally “1/10 analgesic potency of
morphine”

49. If the pain not rapidly respond to opoids
1. Gabapentin
2. Antidepressent (carbamezapine)
3. Cs (prednislone)

50.  Lower intensity laser therapy
 Accelerate healing by:
1) improve cellular repair
2) stimulate systems (lymphatic, vascular, immune)

51. Definition: It's a rare form of HZ which affect facial nerve
(geniculate gangilion) & occasionally 'auditory nerve'.

53.  Symptoms: due to inflammation & degeneration of the
nerve.
 P (FHM) + sometimes pain in ear, this pain may radiate to
jaws & neck.
 H.O (herpatic oticus): Unilateral SMVs on the targus of ear,
ext. auditory meatus, occasionally tympanic membrane.

54.  Localized
 Unilateral
 Affect soft palate + ant
2/3 of tongue
 Followed by V formation
PAIN
 Rupture.
 Give raise to oral ulcer
Vesicle

55. I. Facial n: facial n paralysis (facial palsy), loss of taste
sensation.
II. Auditory n: deafness, H.O, tinnitus, vertigo
III. Xerostomia

56.  Resolution within 7-10 days
 Paralysis is permenant

57. Acyclovir +Cs (prednislone), ACTH + antidepressant
(carbamezapine).

58. Thank You