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HERPES  VIRIDAE Prevalent as early as ancient Greek times.  Hippocrates  described the cutaneous spreading of lesions.  Sh...
The members of this family are also known as  herpesviruses . Name is derived from the Greek word  herpein  ("to cree...
<ul><li>Medically important viruses – Three subfamilies. </li></ul><ul><li>Alpha herpes virinae. </li></ul><ul><ul><ul><li...
<ul><li>Gamma herpes virinae </li></ul><ul><ul><ul><li>Grow  in Lymphoblastoid cells. </li></ul></ul></ul><ul><ul><ul><li>...
<ul><li>Morphology   </li></ul><ul><ul><ul><li>Enveloped (Lipid) </li></ul></ul></ul><ul><ul><ul><li>Double stranded DNA  ...
<ul><ul><ul><ul><li>Virus  replicates in host cell  nucleus. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Cowdry type A   ...
<ul><li>1.Continuous cell line cultures. </li></ul><ul><ul><ul><li>Monkey  or  Rabbit  kidney. </li></ul></ul></ul><ul><ul...
2 .Growth on Chick  embryo  CAM   Shiny,  non  necrotic  pocks.
Pathogenesis   Enters ‘thru’  defects in skin  &mucus  membranes. Local  multiplication  Local  LN  involvement. Retrograd...
<ul><li>Primary infection   </li></ul><ul><li>Vesicle formation </li></ul><ul><li>(Ballooning degeneration of intra-epithe...
<ul><li>Neuroinvasiveness </li></ul><ul><li>Neurotoxicity </li></ul><ul><li>Latency in dorsal root ganglion of CNS </li></...
<ul><li>1. Mucocutaneous  infections  </li></ul><ul><ul><ul><li>Cheeks, chin,  forehead. </li></ul></ul></ul><ul><ul><ul><...
. Herpetic lesions in oral cavity  Dental  anomalies  followed  by Herpes viral infections.
<ul><li>Skin infections   </li></ul><ul><li>Herpetic whitlow ,   </li></ul><ul><ul><ul><li>Toddlers, </li></ul></ul></ul><...
Eczema herpeticum     Severe form of Atopic eczema (Kaposi's   varicelliform eruption.)   Extensive ulceration. Eye infect...
<ul><li>Visceral  HSV:   </li></ul><ul><ul><ul><li>Esophagitis </li></ul></ul></ul><ul><ul><ul><li>Tracheobronchitis </li>...
-Symptomatic infections with sores, fever and lymphadenopathy of  genital tract ,  heal within 2-4 weeks.  -Patients may s...
Genital  herpes Shaft of the Penis Labial herpes Perianal herpes
2.Neonatal  herpes Localized to Skin , eyes,  mouth. Disseminated  infection leads to Multi  organ involvement  (Liver, Ad...
<ul><li>1.  Smears   </li></ul><ul><ul><ul><li>Scrapings from  </li></ul></ul></ul><ul><ul><ul><li>base of Vesicle  </li><...
3.Antigen detection :  Fluorescent antibody , ELISA 4.Viral isolation: Cell line culture – growth within 1 -3 days. 5.Mole...
<ul><li>Varicella-Zoster virus  </li></ul><ul><li>Varicella </li></ul><ul><ul><li>Mildest childhood exanthemata </li></ul>...
<ul><li>Hemorrhagic & bullous. </li></ul><ul><li>Interstetial Pneumonia. </li></ul><ul><li>Postviral encephalitis. </li></...
Lab. Diagnosis :  Same as HSV. Specimens :  Buccal /  Cutaneous lesions Prophylaxis  :   V – Z immunoglobulins.   Live att...
<ul><li>Old age  (>60 years). </li></ul><ul><li>Latent virus in  dorsal root or  </li></ul><ul><li>cranial nerve  ganglia ...
<ul><li>Complications : </li></ul><ul><li>LMN  Paralysis. </li></ul><ul><li>Meningo-encephalitis </li></ul><ul><li>Ramsay ...
<ul><li>Cytomegalovirus  (Salivary gland virus)   </li></ul><ul><ul><ul><li>Infected cells : Cytomegaly  (Owl’s eye appear...
<ul><li>Modes of transmission </li></ul><ul><ul><ul><li>Transplacental.  </li></ul></ul></ul><ul><ul><ul><li>Sexual contac...
<ul><li>1 . Transplacental route: </li></ul><ul><li>Condition severe if infection occurs during first  </li></ul><ul><li>t...
IMN  like disease: Young adults. Hepatitis, fever, atypical lymphocytosis. (No pharyngitis, no lymphadenopathy,  Negative ...
Lab.  Diagnosis: Adults:   Urine, Saliva, BAL,    Semen  &  Cervical secretions. Neonate:  Urine 1.  Microscopy: Centrifug...
2.Isolation:   “ Human diploid fibroblast cell”  culture.   Large retractile cells with cytoplasmic      granules. 3.Serol...
<ul><li>Epstein – Barr (EB)  Virus   </li></ul><ul><ul><ul><li>Burkitt's lymphoma in 1964 . </li></ul></ul></ul><ul><ul><u...
Pathogenesis  Infected  saliva. Pharyngeal epithelial cells (Multiplies locally).   Persistence     Shed in saliva   Invad...
<ul><li>Clinical Diseases </li></ul><ul><li>Incubation period : 4 – 7 weeks </li></ul><ul><li>1.Infectious Mononucleosis <...
2.Chronic  fatigue  syndrome. 3.Malignancies  associated  with  EB.   Burkitt’s lymphoma  (Malignant B cell lymphoma of ja...
Lab diagnosis 1.Blood smear examination : Atypical Lymphocytosis. 2.Paul  -  Bunnel test: Heterophile  antibody  detection...
<ul><li>HHV – 6 </li></ul><ul><li>Isolated in 1986 from AIDS patient   </li></ul><ul><li>T - lymphocytotropic (CD+) </li><...
<ul><li>HHV – 7 </li></ul><ul><li>Isolated  from AIDS  </li></ul><ul><li>patient in 1990. </li></ul><ul><li>No  disease  <...
Alzheimer's disease atherosclerosis cholangiocarcinoma Crohn's disease chronic fatigue syndrome  fibromyalgia Irritable bo...
Prepared for   e -learning   by   Dr .P.SRINIVASULU REDDY ,  M D., Professor, Department of Microbiology Narayana Medical ...
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Herpes viruses

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Herpes viruses

  1. 1. HERPES VIRIDAE Prevalent as early as ancient Greek times. Hippocrates described the cutaneous spreading of lesions. Shakespeare is thought to have been familiar with these lesions and their transmission and mentioned in his Romeo and Juliet . In 1893 Vidal recognized the human transmission of HSV infection from one individual to another. In 1919, Lowenstein confirmed experimentally the infectious nature of HSV. In 1920's and 1930's, the natural history and range of infections of HSV were studied. By the 1940's and 1950's, research established on diseases caused by HSV .
  2. 2. The members of this family are also known as herpesviruses . Name is derived from the Greek word herpein (&quot;to creep or crawl&quot;). Latent, reactivation , recurring and lytic infections are typical of this group of viruses. Herpesviridae , a large family of DNA viruses that cause diseases in animals and humans.
  3. 3. <ul><li>Medically important viruses – Three subfamilies. </li></ul><ul><li>Alpha herpes virinae. </li></ul><ul><ul><ul><li>Rapid growth, </li></ul></ul></ul><ul><ul><ul><li>Latent infection in sensory ganglia. </li></ul></ul></ul><ul><ul><ul><li>HSV – 1, HSV – 2, V – Z Virus. </li></ul></ul></ul><ul><li>Beta herpes virinae </li></ul><ul><ul><ul><li>Slow growth. </li></ul></ul></ul><ul><ul><ul><li>Grow best in Fibroblasts. </li></ul></ul></ul><ul><ul><ul><li>Latent infection in salivary gland. </li></ul></ul></ul><ul><ul><ul><li>HHV – 5 ( CMV ) HHV– 6 , HHV – 7 </li></ul></ul></ul>
  4. 4. <ul><li>Gamma herpes virinae </li></ul><ul><ul><ul><li>Grow in Lymphoblastoid cells. </li></ul></ul></ul><ul><ul><ul><li>Latent infection in Lymphoid tissue. </li></ul></ul></ul><ul><ul><ul><li>HHV – 4 (Epstein – Barr Virus) </li></ul></ul></ul><ul><ul><ul><li>HHV – 8 ( Kaposi’s sarcoma herpes virus) </li></ul></ul></ul><ul><li> </li></ul>Neurotropic viruses: HSV,VZV; Lymphotropic viruses: EBV,HHV6,HHV7
  5. 5. <ul><li>Morphology </li></ul><ul><ul><ul><li>Enveloped (Lipid) </li></ul></ul></ul><ul><ul><ul><li>Double stranded DNA </li></ul></ul></ul><ul><ul><ul><li>Icosahedral capsid </li></ul></ul></ul><ul><ul><ul><li>“ Tegument” </li></ul></ul></ul><ul><ul><ul><li>Glycoprotein spikes </li></ul></ul></ul><ul><ul><ul><li>( Surface spikes) </li></ul></ul></ul>Naked virus
  6. 6. <ul><ul><ul><ul><li>Virus replicates in host cell nucleus. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Cowdry type A intranuclear inclusion bodies. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Susceptible to Ether Chloroform Bile salts. Heat labile. </li></ul></ul></ul></ul>Replication and susceptibility
  7. 7. <ul><li>1.Continuous cell line cultures. </li></ul><ul><ul><ul><li>Monkey or Rabbit kidney. </li></ul></ul></ul><ul><ul><ul><li>Human amnion cell line cultures. </li></ul></ul></ul><ul><ul><ul><li>HeLa cell cultures. </li></ul></ul></ul><ul><li>Cytopathic effects : </li></ul><ul><ul><ul><li>Well defined foci with heaped up cells & syncitial formation. </li></ul></ul></ul>
  8. 8. 2 .Growth on Chick embryo CAM Shiny, non necrotic pocks.
  9. 9. Pathogenesis Enters ‘thru’ defects in skin &mucus membranes. Local multiplication Local LN involvement. Retrograde axonal flow from sensory nerves …. Reaches Ganglia. Maintains latency Viral replication in the nerves. Decreased CMI. Centrifugal migration to skin & mucus membranes. Recurrence of the disease. Physical, Emotional stress. Trauma, Fever. Sun light. Trigeminal, Sacral
  10. 10. <ul><li>Primary infection </li></ul><ul><li>Vesicle formation </li></ul><ul><li>(Ballooning degeneration of intra-epithelial cells) </li></ul><ul><li>Site of eruption shows </li></ul><ul><li>Pain, tingling, warmth & itch, </li></ul><ul><li>erythema & papule  Thin walled </li></ul><ul><li>umbilicated vesicle  roof </li></ul><ul><li>breaks down and forms an ulcer. </li></ul><ul><li>with fever (cold sore or fever blisters). </li></ul><ul><li>Mucus membrane, non-keratinized </li></ul><ul><li>epithelia. </li></ul><ul><li>Recurrent infections are seen with severe </li></ul><ul><li>pain, ulceration. </li></ul>
  11. 11. <ul><li>Neuroinvasiveness </li></ul><ul><li>Neurotoxicity </li></ul><ul><li>Latency in dorsal root ganglion of CNS </li></ul><ul><li>Damaged epithelium is repaired by Natural </li></ul><ul><li>killer cells. </li></ul><ul><li>Viral glycoproteins initiates the T-cell </li></ul><ul><li>activity which activate primed B cells to </li></ul><ul><li>produce antibodies . </li></ul>
  12. 12. <ul><li>1. Mucocutaneous infections </li></ul><ul><ul><ul><li>Cheeks, chin, forehead. </li></ul></ul></ul><ul><ul><ul><li>Napkin rash in infants. </li></ul></ul></ul><ul><ul><ul><li>Acute gingivostomatitis </li></ul></ul></ul><ul><ul><ul><li>Around the mouth & on lips. </li></ul></ul></ul><ul><ul><ul><li>Pre-school children. </li></ul></ul></ul><ul><ul><ul><li>Majority of primary infections; </li></ul></ul></ul><ul><ul><ul><li>Teething / oral thrush. </li></ul></ul></ul>Pathological lesions Herpetic gingivostomatitis Ruptured lesions
  13. 13. . Herpetic lesions in oral cavity Dental anomalies followed by Herpes viral infections.
  14. 14. <ul><li>Skin infections </li></ul><ul><li>Herpetic whitlow , </li></ul><ul><ul><ul><li>Toddlers, </li></ul></ul></ul><ul><ul><ul><li>Dentists, </li></ul></ul></ul><ul><ul><ul><li>Nurses, </li></ul></ul></ul><ul><li>Herpes gladiatorum </li></ul><ul><li>(Wrestlers) </li></ul><ul><ul><ul><li>Painful, swollen, </li></ul></ul></ul><ul><li>grouped vesicles with pus. </li></ul>
  15. 15. Eczema herpeticum Severe form of Atopic eczema (Kaposi's varicelliform eruption.) Extensive ulceration. Eye infections: Branching/dendritic corneal ulcer.
  16. 16. <ul><li>Visceral HSV: </li></ul><ul><ul><ul><li>Esophagitis </li></ul></ul></ul><ul><ul><ul><li>Tracheobronchitis </li></ul></ul></ul><ul><ul><ul><li>Pneumonitis </li></ul></ul></ul><ul><li>CNS: Sporadic, fatal encephalitis (HSV 1). </li></ul><ul><li>Seizures, Hemi paresis and paraesthesia </li></ul><ul><li>Congenital infections : </li></ul><ul><ul><ul><li>Transplacental infection. </li></ul></ul></ul><ul><ul><ul><li>Congenital malformations are rare. </li></ul></ul></ul>
  17. 17. -Symptomatic infections with sores, fever and lymphadenopathy of genital tract , heal within 2-4 weeks. -Patients may suffer with 4-5 outbreaks (recurrent) within a year. -Causes psychological distress. -Infection during late pregnancy poses a greater risk of transmission to the baby. - Sacral radiculopathy common with urinary retention. HSV- 2 transmitted by auto infection, sexual /orogenital contact. Most infections are asymptomatic.
  18. 18. Genital herpes Shaft of the Penis Labial herpes Perianal herpes
  19. 19. 2.Neonatal herpes Localized to Skin , eyes, mouth. Disseminated infection leads to Multi organ involvement (Liver, Adrenals, Brain) Complication: Neurological impairment. 3.Aseptic meningitis:
  20. 20. <ul><li>1. Smears </li></ul><ul><ul><ul><li>Scrapings from </li></ul></ul></ul><ul><ul><ul><li>base of Vesicle </li></ul></ul></ul><ul><ul><ul><li>CSF, </li></ul></ul></ul><ul><ul><ul><li>Saliva. </li></ul></ul></ul><ul><li>Serum </li></ul><ul><li>- Primary infection. </li></ul><ul><li>-ELISA most useful. </li></ul><ul><li>-CFT. </li></ul>Laboratory diagnosis Microscopy: Tzanck smear 1 % Aqu. sol. of Toludine blue . Multinucleated giant cells with faceted nuclei , ground glass chromatin. (Tzanck cells) Best : Giemsa, Papanicolou stain
  21. 21. 3.Antigen detection : Fluorescent antibody , ELISA 4.Viral isolation: Cell line culture – growth within 1 -3 days. 5.Molecular techniques: PCR and DNA probes. Treatment : No cure. Acyclovir : Primary infection (< 72 hrs). Reduce the recurrences. Famciclovir: For resistant cases.
  22. 22. <ul><li>Varicella-Zoster virus </li></ul><ul><li>Varicella </li></ul><ul><ul><li>Mildest childhood exanthemata </li></ul></ul><ul><ul><li>Source: Patient </li></ul></ul><ul><ul><li>Droplet nuclei from Respiratory tract </li></ul></ul><ul><ul><li>Inhalation. Incubation period 7– 23 days </li></ul></ul><ul><ul><li>Centripetal distribution. </li></ul></ul><ul><ul><li>Macule  Papule  Vesicle  Pustule  Scab </li></ul></ul><ul><ul><li>Vesicular rash surrounded by a ring (Trunk) </li></ul></ul><ul><ul><li>Superficial “Drop of water” </li></ul></ul>
  23. 23. <ul><li>Hemorrhagic & bullous. </li></ul><ul><li>Interstetial Pneumonia. </li></ul><ul><li>Postviral encephalitis. </li></ul><ul><li>Guillain- Barre syndrome. </li></ul><ul><li>Recovery is spontaneous. </li></ul><ul><li>Can cross placenta  </li></ul><ul><li>Neuromuscular disorders. </li></ul>Appears in crops, Profuse in adults
  24. 24. Lab. Diagnosis : Same as HSV. Specimens : Buccal / Cutaneous lesions Prophylaxis : V – Z immunoglobulins. Live attenuated varicella vaccine.
  25. 25. <ul><li>Old age (>60 years). </li></ul><ul><li>Latent virus in dorsal root or </li></ul><ul><li>cranial nerve ganglia </li></ul><ul><li>Neuritic pain, Parasthesia for </li></ul><ul><li>weeks / months. </li></ul><ul><li>Unilateral, painful eruption in </li></ul><ul><li>thoracic region. </li></ul><ul><li>Commonest sites: </li></ul><ul><li>Areas innervated by spinal cord segments D3 – L2 & Trigeminal nerve. </li></ul>Herpes Zoster (Creeping girdle) Herpes zoster ophthalmicus.
  26. 26. <ul><li>Complications : </li></ul><ul><li>LMN Paralysis. </li></ul><ul><li>Meningo-encephalitis </li></ul><ul><li>Ramsay Hunt syndrome </li></ul><ul><li>Facial palsy + eruption on tympanic membrane & external auditory canal </li></ul>
  27. 27. <ul><li>Cytomegalovirus (Salivary gland virus) </li></ul><ul><ul><ul><li>Infected cells : Cytomegaly (Owl’s eye appearance) </li></ul></ul></ul><ul><ul><ul><li>Most of the infections are unapparent. </li></ul></ul></ul><ul><ul><ul><li>Commonest cause for congenital defects . </li></ul></ul></ul><ul><li>Pathogenesis: </li></ul><ul><ul><ul><li>Latent infection : Mononuclear leucocytes </li></ul></ul></ul><ul><ul><ul><li>(Monocytes, B -lymphocytes) </li></ul></ul></ul><ul><ul><ul><li>Secretary glands </li></ul></ul></ul><ul><ul><ul><li>Kidney. </li></ul></ul></ul><ul><ul><ul><li>Replication seen in ductal epithelial cells. </li></ul></ul></ul><ul><ul><ul><li>Excretion in body fluids, Milk & Urine. </li></ul></ul></ul>
  28. 28. <ul><li>Modes of transmission </li></ul><ul><ul><ul><li>Transplacental. </li></ul></ul></ul><ul><ul><ul><li>Sexual contact. </li></ul></ul></ul><ul><ul><ul><li>Blood and its products. </li></ul></ul></ul><ul><ul><ul><li>Organ transplantation. </li></ul></ul></ul><ul><ul><ul><li>Urine, Saliva, Cervical secretions, </li></ul></ul></ul><ul><ul><ul><li>semen, breast milk. </li></ul></ul></ul><ul><ul><ul><li>Perinatal & Postnatal infections: </li></ul></ul></ul><ul><li> Infected birth canal,Breast milk. </li></ul>
  29. 29. <ul><li>1 . Transplacental route: </li></ul><ul><li>Condition severe if infection occurs during first </li></ul><ul><li>trimester of pregnancy. </li></ul><ul><li>Cytomegalic Inclusion disease of Newborn(10%) </li></ul><ul><li>c haracterised by varied type of clinical manifestations . </li></ul><ul><ul><ul><li>Hepatospleenomegaly </li></ul></ul></ul><ul><ul><ul><li>Jaundice </li></ul></ul></ul><ul><ul><ul><li>Thrombocytopenic purpura </li></ul></ul></ul><ul><ul><ul><li>Haemolytic anaemia </li></ul></ul></ul><ul><ul><ul><li>Microcephaly </li></ul></ul></ul><ul><ul><ul><li>Cerebral calcifications. </li></ul></ul></ul><ul><ul><ul><li>Mental retardation. </li></ul></ul></ul>
  30. 30. IMN like disease: Young adults. Hepatitis, fever, atypical lymphocytosis. (No pharyngitis, no lymphadenopathy, Negative for heterophile antibody) Respiratory tract infections: Pneumonitis in infants. Immunocompromised individuals: Pneumonia Fatal encephalitis Chorioretinitis
  31. 31. Lab. Diagnosis: Adults: Urine, Saliva, BAL, Semen & Cervical secretions. Neonate: Urine 1. Microscopy: Centrifuged deposits of secretions. Giemsa stain: Cytomegalic cells
  32. 32. 2.Isolation: “ Human diploid fibroblast cell” culture. Large retractile cells with cytoplasmic granules. 3.Serology: Anti CMV IgM Ab estimation by ELISA. Treatment: Ganciclovir & Foscarnet. Prophylaxis: Acyclovir.
  33. 33. <ul><li>Epstein – Barr (EB) Virus </li></ul><ul><ul><ul><li>Burkitt's lymphoma in 1964 . </li></ul></ul></ul><ul><ul><ul><li>Affinity for B – lymphocytes (CD 21 receptors.) </li></ul></ul></ul><ul><ul><ul><li>80 – 90% of children by three years of age. </li></ul></ul></ul><ul><ul><ul><li>Asymptomatic. </li></ul></ul></ul><ul><ul><ul><li>Not highly contagious. </li></ul></ul></ul><ul><ul><ul><li>Droplets are not infectious. </li></ul></ul></ul><ul><ul><ul><li>Source : Saliva, Oropharyngeal secretions </li></ul></ul></ul>
  34. 34. Pathogenesis Infected saliva. Pharyngeal epithelial cells (Multiplies locally). Persistence Shed in saliva Invades blood stream Infects B. lymphocytes . Liver Spleen Polyclonal activation cell death . Unchecked replication results in Lymphomas Neoantigen formation Atypical lymphocytosis .
  35. 35. <ul><li>Clinical Diseases </li></ul><ul><li>Incubation period : 4 – 7 weeks </li></ul><ul><li>1.Infectious Mononucleosis </li></ul><ul><li>(Glandular disease, Kissing disease) </li></ul><ul><ul><ul><li>Acute self limiting illness. </li></ul></ul></ul><ul><ul><ul><li>Fever, sore throat. </li></ul></ul></ul><ul><ul><ul><li>Lymphadenopathy. </li></ul></ul></ul><ul><ul><ul><li>Sub clinical Hepatitis, Tender spleenomegaly </li></ul></ul></ul><ul><ul><ul><li>Abnormal lymphocytes in PS </li></ul></ul></ul>
  36. 36. 2.Chronic fatigue syndrome. 3.Malignancies associated with EB. Burkitt’s lymphoma (Malignant B cell lymphoma of jaw) Nasopharyngeal carcinoma Lymphomas in HIV infected persons.
  37. 37. Lab diagnosis 1.Blood smear examination : Atypical Lymphocytosis. 2.Paul - Bunnel test: Heterophile antibody detection test. Inactivated serum + 1% sheep RBC suspension  37 0 C  4 hrs  Agglutination (>100) 3. EBV Specific antibodies: EBNA Ab EBNA Ig M VCA, Ig G VCA 4. PCR: More sensitive.
  38. 38. <ul><li>HHV – 6 </li></ul><ul><li>Isolated in 1986 from AIDS patient </li></ul><ul><li>T - lymphocytotropic (CD+) </li></ul><ul><li>Transmission through Oral secretions. </li></ul><ul><li>Roseola infantum (Exanthema subitum) </li></ul><ul><li>High fever with generalized rash. </li></ul><ul><li>Chronic fatigue syndrome . </li></ul>
  39. 39. <ul><li>HHV – 7 </li></ul><ul><li>Isolated from AIDS </li></ul><ul><li>patient in 1990. </li></ul><ul><li>No disease </li></ul><ul><li>association. </li></ul><ul><li>Remains as orphan </li></ul><ul><li>virus. </li></ul><ul><li>HHV – 8 </li></ul><ul><li>Kaposi's sarcoma related </li></ul><ul><li>herpes virus. </li></ul><ul><li>In 1994 : Association </li></ul><ul><li>with Kaposi's sarcoma . </li></ul><ul><li>(Rare type of “B cell </li></ul><ul><li>lymphoma” from </li></ul><ul><li>AIDS patients). </li></ul>
  40. 40. Alzheimer's disease atherosclerosis cholangiocarcinoma Crohn's disease chronic fatigue syndrome fibromyalgia Irritable bowel syndrome multiple sclerosis pancreatic cancer pityriasis rosea Type II Diabetes Research is currently ongoing into a variety of side-effect or co-conditions related to the herpesviruses.
  41. 41. Prepared for e -learning by Dr .P.SRINIVASULU REDDY , M D., Professor, Department of Microbiology Narayana Medical College NELLORE

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