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Board Review • Barnhill, R Viruses, Bacteria, and Fungi Infections of The Skin Chrissy Mitchell, MD University of Florida Viruses Human Herpes Viruses • HHV1- HSV 1 • HHV2- HSV 2 • HHV3- Varicella Zoster Virus • HHV4- EBV • HHV5- CMV • HHV6- Roseola • HHV7- Roseola • HHV8- Kaposi’s, Castleman’s, primary effusion lymphoma 4 HSV-1 • Primary infection is usually oral gingivostomatitis • HSV-1 may be triggered by fever, sunburn, trauma (peel/laser), or stress • Usually preceded by a prodrome of pain or tingling hours before eruption 6 HSV-1 • Usually affects the vermillion border but may also involve other areas of skin 7 Herpes Gladiatorum • Herpes Gladiatorum is a sports related infection usually affecting wrestlers • HSV1 primary infection that involves extramucosal sites • Usually affects the face, neck, upper body Neonatal herpes Courtesy of Dermatlas.org Neonatal Herpes • Neonatal Herpes results from infection acquired during vaginal birth • Most mothers have subclinical shedding of virus • Treatment is suppressive therapy for the mother or C-section in women with genital HSV • Associated with increased morbidity and mortality for the newborn • Treatment is IV acyclovir Herpes associated EM Courtesy of Dermatlas.org Herpes Associated EM • Presents 7-10 days after HSV infection with typical EM lesions on extremities that may spread centripetally • Self-limited disease • Treat with suppressive antiviral therapy to decrease recurrent disease Herpes vegetans as a sign of HIV infection Anisha B Patel MD, Ted Rosen MD Dermatology Online Journal 14 (4): 6 Verrucous HSV • Chronic ulcerative herpes infections are more common in HIV/immunocompromised patients • May appear verrucous and cancerous • Has been noted on the digits, genitalia, and buttocks • The treatment in acyclovir resistant cases due to mutant viral thymidine kinase of HSV is foscarnet or cidofovir courtesy of dermatlas.org Eczema Herpeticum • Eczema herpeticum (Kaposi varicelliform eruption) • Disseminated HSV: upregulated IL-4 downregulates anti-viral response • Seen in patients with skin barrier dysfunction (AD, Darier’s, ichthyosis, Hailey-Hailey, Pemphigus foliaceus) • May be life threatening Dewdrop on a rose petal 18 19 Varicella • Varicella is the initial infection • Virus lies dormant in dorsal root ganglion • 7-21 day incubation period • Rash has a truncal predominance • May result in pneumonitis particularly in cases of immunocompromised patients and adults 20 21 VZV • 75% of cases have a prodrome of pain or paresthesia • Almost always dermatomal • Macules to papules to vesicles to hemorrhagic crusts • Lesions are infectious until crusted and healing 22 23 VZV • Treatment is oral or IV antivirals • IV acyclovir is warranted if patients have HIV, immunosuppression, widespread disease or visceral involvement • Visceral involvement is more common in immunocompromised patients and may manifest with encephalitis, hepatitis, pneumonitis • Antivirals require renal dosing • Systemic steroids do not alter the development of PHN 24 Hutchinson Sign Courtesy of Medscape.com • Zoster of the V1 dermatome may cause keratitis and blindness. • Hutchinson’s sign: Involvement of the nasociliary branch of opthalmic nerve (V1) may cause vesicles at the tip of the nose Hutchinson’s sign 27 Courtesy of Dermatlas.org 28 Courtesy of Dermatlas.org Ramsay-Hunt Syndrome Archive of Neuro. 2005;62(11) 1774-1775 Ramsay-Hunt Syndrome • Infection involving the geniculate ganglion • Zoster involved the ear canal, auricle, and TM • Vesicles, facial hemiparesis, and ipsilateral hearing loss Post-herpetic hyperhidrosis in HIV patient Fig. 1 Hemorrhagic vesicles along distribution of the 8th cranial nerve on the left hand. Komal F. Chopra , Tanya Evans , Jessica Severson , Stephen K. Tyring Acute varicella zoster with postherpetic hyperhidrosis as the initial presentation of HIV infection Journal of the American Academy of Dermatology Volume 41, Issue 1 1999 119 - 121 http://dx.doi.org/10.1016/S0190-9622(99)70419-6 Fig. 2 Moist, glistening areas of hyperhidrosis along the distribution of the 8th cranial nerve on the left hand. Komal F. Chopra , Tanya Evans , Jessica Severson , Stephen K. Tyring Acute varicella zoster with postherpetic hyperhidrosis as the initial presentation of HIV infection Journal of the American Academy of Dermatology Volume 41, Issue 1 1999 119 - 121 http://dx.doi.org/10.1016/S0190-9622(99)70419-6 What is the common thread? Courtesy of Dermatlas.org EBV (HHV-4) • Epstein-Barr Virus (HHV-4) • Virus is dormant in B-cells and mucosal epithelial cells • EBV causes mononucleosis, OHL, and is implicated in neoplasms such as (Hodgkin’s lymphoms, Burkitt’s lymphoma, PTLD, NK T-cell lymphoma) • HHV-4 is a cause of Gianotti-Crosti syndrome and Kikuchi’s disease • Mono treated with ampicillin may result in an impressive morbiliform eruption (not a true drug allergy) courtesy of dermatlas.org • Oral hairy leukoplakia is seen on the lateral tongue of HIV patients Atypical Hydroa Vacciniforme-Like Epstein-Barr Virus Associated T/NK-Cell Lymphoproliferative Disorderr. Lee, Hye; Baek, Jin; Lee, Jong; Park, Sang; Jeon, In; Roh, Joo American Journal of Dermatopathology. 34(8):e119-e124, December 2012. DOI: 10.1097/DAD.0b013e3181c036de FIGURE 1 . Clinical features. A, Erythematous ulceronecrotic papules with a puffy face; B, Identical lesions on the trunk; C, Identical lesions on both legs; D, Crusted varioliform atrophic scar. © 2012 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc. 2 CMV “Blueberry muffin baby” Extramedullary hematopoesis courtesy of dermatlas.org • Subclinical infection in healthy people • Severe infection in fetuses and in immunocompromised patients • CMV is the #1 cause of severe birth defects • A cause of the “buleberry muffin baby” From: Mucocutaneous Presence of Cytomegalovirus Associated With Human Immunodeficiency Virus Infection: Discussion Regarding Its Pathogenetic Role Arch Dermatol. 2001;137(4):443-448. doi:10-1001/pubs.Arch Dermatol.-ISSN-0003-987x-137-4-dst00030 Figure Legend: Perianal condylomata acuminata and chronic ulcers (case 14). A 38-year-old man with condylomata and chronic HSV ulcers of 45 days' duration: CD4 cell count, 6 cells/µL; herpes simplex virus 2 was isolated on culture of the ulcer and exudate. Cytomegalovirus was found in the ulcer. Copyright © 2012 American Medical Date of download: 2/10/2013 Association. All rights reserved. CMV • HIV infected patients may have • CMV retinitis • Chronic GI and perianal ulcerations • Treatment of choice is ganciclovir, foscarnet, or cidofovir Roseola-Berliner’s sign Palpebral edema seen during roseola infection Roseola • HHV-6 • The etiologic agent of roseola infantum/sixth disease • Causes a high fever, malaise, irritability (a cause of febrile seizures in infants and toddlers) • Rose pink macules appear after fever breaks • Most children are infected by age 2 45 HHV-8 Kaposi Sarcoma-Associated Herpesvirus • Classic: • AIDS-related • Immunosuppression-associated • African endemic courtesy of dermatlas.org Classic KS • Classic KS- • The most indolent type, slowly growing • Seen in elderly men>>>>>>women from Mediterranean European decent • Predilection for lower extremities, rarely involves GI or oral mucosa courtesy of dermatlas.org AIDS Associated KS • AIDS-Related • Widespread • Seen as macules to plaques on skin and mucosa • Visceral involvement is common • Treatment is HAART Courtesy of Dermatlas.org African Endemic KS • African endemic • Aggressive. • Seen in young African (equatorial) patients • Unrelated to HIV Human Papilloma Virus Type of Lesion Frequent HPV Type Common Wart 1,2,4 Plantar Wart 1 Flat Wart 3,10 Butcher’s wart 2,7 Epidermodysplasia verruciformis 2,3,5,8,9,10,12,14,15,17 Focal Epithelial hyperplasia (Heck’s) 13,32 Verrucous carcinoma 6,11 Condyloma acuminata 6,11 Bowenoid papulosis 16,18 Subungual SCC 16 EDV associated SCC 5, 8 Cervical/penile/anal SCC 16,18 HPV • HPV is non-enveloped dsDNA virus • More than 100 HPV types • Genome encodes E (early) and L (late) proteins • Viral oncogenes include E6-p53 and E7-pRB • Transmission is from direct skin contact • Gardasil was FDA approved for prevention of cervical cancer (and condyloma) • Quadrivalent Vaccine composed of L1 capsid protiens with recombinant HPV 6, 11, 16, 18 • Intended for females between ages 9 and 26 • Series of 3 injections at month 0, 2, and 6 55 Courtesy of Dermatlas.org • Subungual SCC- HPV 16 Courtesy of Dermatlas.org • Bowenoid Papulosis • HPV 16>>>18 • Look like genital warts but are histopathologically consistent with SCCIS Courtesy of Dermatlas.org Verrucous carcinoma “Akerman tumor” • 3 types: – Oral Florid Papillomatosis: oral cavity carcinoma – Buschke-Lowenstein tumor: anorectal external genital carcinoma – Epithelioma cunniculatum: mass on sole of foot Courtesy of Dermatlas.org Courtesy of Dermatlas.org • Epidermodysplasia verruciformis • Inherited or acquired susceptibility to HPV • Looks like flat warts • Malignant transformation in 50% of patients Heck’s Disease •Focal epithelial hyperplasia •HPV -13,-32 •Multiple circumscribed papules on gingival, buccal, lingual or labial mucosa resembling flat warts or condyloma •Common in South American Indians, Greenlander Eskimos or South Africans •Primarily in children Common Disease? Courtesy of Dermatlas.org Erythema Infectiosum or FifthCourtesy of Dermatlas.org disease Parvovirus B19 • ssDNA virus • Infects RBCs via blood group P antigen • Risk of aplastic crisis in immunocompromised patients or sickle cell dx • Infection in young children manifests
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