Transcript Herpes simplex

Viral Diseases
 Herpes viruses
 Human papiloma viruses
 Pox viruses
 Viral exanthemas
Herpes Viruses
 the herpesviruses (DNA) are some of the most
widespread viruses throughout the world
 they are known for the ability to persist in the host
organism for lifetime with subsequent reactivation
Human Herpes Viruses (HHV)
cause a wide range of clinical disorders
HHV-1 (oral, labial, cerebral herpes simplex, EEH…)
HHV-2 (genital, neonatal herpes simplex)
HHV-3 = VZV (chicken pox, herpes zoster)
HHV-5 = CMV (chorioretinitis in AIDS,
atyp. inf.mononucleosis…)
HHV-6 a HHV-7 (exanth. subitum, pityriasis rosea,
hepatitis…)
HHV-4 = EBV (inf.mononucleosis, Burkit lymphoma,
nasopharyngeal ca, lymphoprolifer. disease in AIDS,
m. Hodgkin…),
HHV-8 (Kaposi sarkoma in AIDS)
Herpes Viruses
 HHV are neurotrophic and epidermotrophic
(multiplies in skin, mucosa, cornea, CNS)
and persist in cells of nerve ganglia for a lifetime.
 HHV cause a wide range of clinical disorders
(skin, mucosa, internal organs) depending on the age,
immune status of the patient, and wheather
the infection is primary or secondary.
 Both initial and recurrent infections proceed
asymptomatically in most cases.
 Howewer where immunity is deficient, herpetic infections
tend to have a more serious course.
Herpes Simplex (HHV1, 2)
 HSV type 1 is typically found above waistline (neck, head
oral mucosa, lips…).
 HSV type 2 occurs most often on the genital.
 Incidence: worldwide, 30-90% of populace.
 Clinical findings:
▪ herpes labialis (cold sore), h.facialis, herpes corneae,
h.digitalis,, herpes gladiatorum, herpes glutealis (HSV-1)
▪ herpes genitalis (HSV-2, 30% HSV-1)
Herpes Simplex (HHV1, 2)
 Human Herpetic Viruses - source = only human - secretions from mouth and genital contain HHV
in diseased and asymptomatic carriers too!
 Transfer via mucosa or skin: saliva, venereal fluids, direct
contact (tiny abrasions), indirect contact (stained things,
by means of sexual contact, from mother to child
(during delivery from the cervical canal or external genital, less
through placenta).
 Incubation period: 2 – 14 days, 1 week on an average.
The patient´s immune response plays
a key role in HSV infections.
Herpes Simplex – Primary Infection
 HSV-1 in childhood (1-5 years of age) by direct contact.
 HSV-2 in period of sexual activity, during delivery.
 …primary infections usually proceed asymptomatically…
 … antibodies develop, but not lead to viral elimination
(90% of population have positive antibodies)…
 … 1% of cases: grouped blisters, lymphadenopathy,
in children gingivo-stomatitis, in young adults herpetic
vulvovaginalis, keratoconjuctivitis,
in newborn HSV may cause encephalitis or sepsis…
Herpes Simplex – recurrent infections
(20 – 40% of populace)
 Recurrences come from reactivation of latent viruses
(in nerve ganglia).
 Triggers:
sunlight, bacterial or viral infection, fever, trauma
(shaving, medical intervention – dentistry, laser…),
stress, menstruation, gravidity, bad health condition…
 Clinical appearance:
 lokalized changes in site of primary infection
 antibodies prevent from generalization,
not from recurrence of infection
 sometimes without symptomps,
 always risk of transfer to others!
Eradication of virus is impossible!
Herpes Simplex Recidivans
COMPLICATIONS
 secondary bacterial infection,
genital ulceration, risk of other STDs
 dissemination on the skin (in CNS) in patients with
immunodeficiency (atopic dermatitis, AIDS, oncological
patients…)
 very seldom lymfatic obstruction
 genital herpes before delivery = indication
for Ceasarean section
 HSV-2 can be co-carcinogen for cervical carcinoma
Diagnostics
 Clinical findings
…sometimes co-operation with ophtalmologists,
neurologists…
 Viral identification
PCR, culture HSV
 Serology
…in case of latent HSV infections
(recurrent inf. – detection of antibodies isn´t significant)
Herpes Simplex
Differencial diagnosis:
 Herpes labialis (cold sore)
…incipient herpes zoster, anguli infectiosi, impetigo,
contact dermatitis…
 Herpes genitalis
…syphilis, mycotic infection, contact dermatitis,
genital warts, small lesion of psoriasis,
lichen planus…
Herpes Simplex
TOPICAL Therapy
 Antiviral ointment - in first days of infection
reduce replication and multiplication of HSV
 For healing (10-14 days) – zinc ointment, soft laser,
antibiotic ointment, antiseptic liquid
(prevent to secondary bacterial infection)
 Generally – observe hygiena rules, don´t touch lesion,
improve immunity…
Herpes Simplex
SYSTEMIC Therapy (tbl, infusion)
 dissemination - eczema herpeticatum, onkological
patients…(e.g. acyclovir, famcyclovir, valacyclovir…)
 prevention – recurrent infections, before laser or surgical
intervention on the face (days, month - low dose)
 pregnant women (if is any risk for child)
 newborn - infection with clinical findings
(e.g. acyclovir i.v. 20-60 mg/kg 14-21 dnů)
VARICELLA-HERPES ZOSTER
 varicella-zoster virus (HHV-3, α-herpesvirus)
 Primo-infection: varicella (chickenpox) in childhood.
 Source: person with chicken pox (highly infectious from
incubation period to development of crusts), very seldom
person with herpes zoster.
 Incubation period: 7 - 21 days
 Transmission: direct contact, seldom indirect contact
by stained things, respiratory droplet → through
respiratory mucosa → spreading to lymphatic vessels,
multiplication in RES → hematogenous dissemination –
clinical findings of chicken pox
Varicella – Course
 In adults: more serious, with complications - fever,
headache, encephalitis, bronchopneumonie, bacterial
infection.
 Longtime immunity persists, but repeated infetion can be
in case of immunodeficiency.
 VZV persists after primo-infection in organism
– in paravertebral or head ganglia (95% of adults).
 Reactivation of VZV (weakening of organism)
leads to herpes zoster (shingles).
Herpes zoster - Complication
 h.z.haemorrhagicus, gangrenosus
 dissemination in weaken persons, seldom
herpes zoster billateralis or multiplex
 secondary bacterial infection
 damage of cornea, iridocyklitida,,
postherpetic paresis (e.g. n. facialis)…
 postherpetic neuralgia
(persist a few months after healing
of skin changes)
 recurrence - very seldom
Diagnostics a diff.dg.
 Diagnostics: clinical findings, viral identification
(PCR, culture, IF), serology (antibodies),
co-operation with neurologists, ophthalmologists…
 Diff.dg.:
varicella – drug rash, prurigo simplex, dermatitis
herpetiformis Duhring…
herpes zoster - herpes simplex (incipient), contact
dermatitis, erysipel (bullous form)…
Varicella-herpes zoster
Therapy
 varicella
 symptomatically - antiseptics, zinc ointment…
 complications, adults: systemic antiviral therapy
(acyclovir, famcyclovir, valacyclovir, brivudin…)
 herpes zoster – topical therapy (e.g. antibacterial),
vitamin B, analgesics…
▪ prevention of complication (immunodeficiency, older
weaken person, head area…): systemic antiviral therapy
(in first five days of manifestation!)
HHV-7 (β-herpesvir)
pityriasis rosea (Gibert)
 viral etiology is suggested, but HHV-7 is frequently found
in healthy persons
 frequent disease - in otherwise fit children or young
adults, lasts about 6 weeks, is not contagious…
Clinical findigs: …starts with a single oval, pink, scaly plaque
(herald, mother patch), 2-3 cm, appears on the trunk or on a
limb … in 4 – 14 days later appears rash on the trunk –
macular exanthema - a lot of smaller lesions („Christmas
tree“ pattern).
Therapy: symptomatic, usually disappears spontaneously
Human Papilloma Viruses (HPV)
• Over 120 HPV types have been identified.
• HPVs infect and multiply in keratinocytes
(skin) or mucous membranes.
• They are transmitted by contact.
• Most people with HPV have NO symptomps.
Human Papilloma Viruses (HPV)
• The majority of the known types of HPV can cause:
warts (verrucae) and genital warts.
• Incubation time is highly variable – from weeks to
years (average about 2 years).
• Some of them (in a minority of cases) lead to cancers
of oropharynx, cervix and anogenital area.
• Different types of HPV are found in different clinical
settings, different HPVs cause the same clinical
lesions.
HPV – clinical findings
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Common warts (verruca vulgaris)
Plantar warts
Plane warts
Genital warts (condylomata acuminata,
flat genital w.)
• Mucosal warts (papillomas…)
• Squamous cell carcinoma
Common Warts (HPV)
- can occur on the fingers, palm, dorsum of
the hand, soles, eyelids…
- usually are multiple, but can be only one
for many years (it depends on immunity condition)
Common Warts (HPV)
 An initial wart is a firm, skin colored (or brown),
small papule,
with smooth surface, a few mm in diameter….
…it interrupts normal skin lines
(usually can be distinguished from adjacent skin)
As wart grows, it tend to have a rougher surface
(it reflects papillomatosis and hyperkeratosis) and
black pin point dots on the surface (this reflects
punctate bleeding into stratum corneum)
Common Warts (HPV)
Multiple warts
- usually on fingers, palms, back of hands…
Filiform (long thin) warts
- eyelids, face, beard area
(often large numbers spread through shaving)…
Plantar Warts (HPV)
- can be either solitary or widespread (mosaic warts)
- the tends to be pushed into the skin, presumably
through the pressure and weight from walking
Plane Warts (HPV)
- small flat papule, usually multiple
- they are typically seen in children and young adults
- most commonly on the face, back of hands,
less comon on arms and trunk
Genital Warts (HPV)
- they are highly infectious
- small papules or small finger-like prominences,
skin colored
- they grow best in a warm moist environment,
such as under foreskin, on the labia minora,
about the anus…
Warts – THERAPY
 cryotherapy with liquid nitrogen leads to devastation
of the skin
 keratolytic agents under plaster
(e.g. salicyl acid 10%-20%)
• Cytostatic agents - 1%podophylotoxin is applied by
doctor (once a week), patient washes it off after 6 hrs,
lengthy treatment period is a few weeks
• Immunologic therapy - imiquimod 5% cream
(modification of immune response by inducing
production of INFα) is applied three times weekly,
treatment period is up to 16 weeks
Warts – THERAPY
• surgery - under local anesthesia using
curettage, scalpel or electrosurgical device
• lasers
LA, ablative lasers (erbium, CO2) evaporate tissue
+ vascular lasers (Nd:YAG, DYE laser) destroy
vessels on the base
Viral Exanthemas
• Varicela (chickenpox) - VZV
• Morbilli (measles, in English rubeola) paramyxovirus
• Rubella (German measles, in German rubeola) Toga virus
• Erythema Infectiosium (fifth disease, slapped
cheek disease)
Molluscum Contagiosum
Pox virus
• Epidermotrophic infection producing papular lesions
with a central dell. Children are usually affected.
• The child may have a fever, but very often they are
without symptoms.
• Clinical findings: small 1-5 mm, white or pink
umbilicated papules are found anywhere on the skin
(a few or many papules).
• They can become inflamed, last about 6-9 months
and then can disappear spontaneously.
• Therapy: any destructive measure (a sharp curette or
scalpel)
Hand, foot and mouth disease
(Enteroviral vesicular stomatitis with exanthema)
Coxackie virus
• The virus is spread through respiratory secretions,
so infection tends to appear in small epidemics
(incubation period is 3-5 days)
• The child may have a fever, but very often they are
without symptoms.
• Clinical findings: a mild infection where a few
round erosions with a red margin are seen in the
mouth (look like small aphthous ulcers)
• They are associated with small grey blisters with red
halo on the fingers and toes.