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Infectious Disease: Viral Infections

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Chris Hixon DO, PGY4 Megan Joint DO, PGY 4 Lewis Gale Hospital Montgomery / VCOM Program Director: Daniel S. Hurd DO, FAOCD Human Herpes Virus 1-8 Parvo Virus Molluscum Contagiousum Milker’s Nodule Human Papilloma Virus Measles Rubella Hand-Foot-Mouth Disease Orf Vaccinia Cowpox Classification Lytic Infection Latent Infection Herpes Simplex Virus Alphaherpesvirinae Epithelial cells Neuron type 1 Herpes SimplexVirus Alphaherpesvirinae Epithelial cells Neuron type 2 HHV 3 – Varicella Alphaherpesvirinae Epithelial cells Neuron Zoster virus HHV 4 - EBV Gammaherpesvirinae Epithelial cells B Lymphocytes and B – cells HHV 5 - CMV Betaherpesvirinae Lymphocytes, Macrophages, Macrophages Lymphocytes and Endothelial cells HHV 6 Betaherpesvirinae CD4 T cells Lymphocytes HHV 7 Betaherpesvirinae T cells T Lymphocytes HHV8 Gammaherpesvirinae Lymphocytes Lymphocytes and Endothelial cells HSV - 1 HSV 2 Initial presentation: . Prodrome Initial presentation: . Gingivostomatitis . Frequently asymptomatic . Painful, erosive balanitis, vulvitis or vaginitis Recurrent lesions: . Herpetiform vesicles on the vermilion border of lip Usually mild recurrence with resolution within 1 week Herpetic whitlow Eczema herpeticum (Kaposi’s varicelliform eruption) Ocular infections . Infection in areas of . branching dendritic corneal lesions dermatitis/skin barrier disruption Herpes Folliculitis Herpes Gladiatorum Chronic enlarging ulcers Encephalitis Temporal lobe Neonatal HSV infection DIAGNOSIS TREATMENT Tzanck smear Oral Antiviral medications . Multinucleated giant cells . Orolabial Herpes and Genital Herpes (initiate within 24-48hrs of onset) Direct Fluorescent antibody assay (DFA) Foscarnet is used when acyclovir- resistant HSV is present Viral Culture Chronic suppression in those with > 6 Western Blot outbreaks per year VARICELLA Prodrome Clinically: pruritic, erythematous macules, papules and vesicles with a surrounding red halo (“dew drop on a rose petal”) lesions in all stages of development Patient is infectious from 1-2 days prior to presentation of skin lesions until all of the vesicles have crusted over • Dormant in the dorsal root ganglion and appears upon reactivation Prodrome of pruritus, tingling, tenderness, hyperesthesia and/or intense pain Development of painful grouped vesicles on an erythematous base in a dermatomal distribution . Can involve more than one dermatome and cross midline RAMSAY HUNT SYNDROME HUTCHINSON SIGN Reactivation involving the geniculate Zoster affecting the nasal tip can lead to ganglion of the facial nerve blindness due to direct effects on ophthalmic Can cause ear pain, hearing loss, facial division of CN V1 via nasociliary nerve paralysis and loss of taste to anterior 2/3 of the tongue DIAGNOSIS TREATMENT Diagnosis is usually made clinically Symptomatic treatment Tzanck smear and/or DFA . DFA used to differentiate between HSV and Oral Antiviral medications within 24- VZV 72 hrs Viral culture Serology Vaccine recommended for all . Requires fourfold increase in VZV titer to reveal positive test immunocompetent individuals >60 PCR . Use increasing, highly sensitive and rapid test Infectious Mononucleosis: Prodrome Triad: fever, pharyngitis and lymphadenopathy . Nonspecific erythematous, morbilliform rash on trunk and proximal extremities with spread to face and forearms . Palatal petechiae . Hepatosplenomegaly Ampicillin-induced eruption Hypersensitivity reaction Diagnosis: Monospot Test (specific), PCR, EBV titers Treatment: Supportive “Infantile Papular Acrodermatitis” Self limited infection of young children EBV and HBV likely causes Clinically: ▪ Abrupt onset of flesh-colored to pink-red papules on the cheeks, buttocks and extremities Treatment: supportive Nasopharyngeal carcinoma Burkitt’s lymphoma . EBV found as latent infection in 97% of endemic, 15-85% of sporadic and 30-40% of AIDS- linked Burkitt's lymphoma cases . Common African manifestation MONONUCLEOSIS-LIKE SYNDROME CONGENITAL INFECTION . Mononucleosis-like syndrome Congenital Infections: “Blueberry muffin” lesions ▪ Morbilliform eruption (Extramedullary erythropoiesis) ▪ Petechiae and purpura Petechiae and purpura ▪ Urticaria Deafness, retardation ▪ Erythema nodosum ▪ Ampicillin-induced eruption AIDS patients: CMV retinitis blindness Diagnosis: Treatment: Serology, PCR, Cultures, Uncomplicated CMV CMV Antigenemia assay . Supportive Biopsy of cutaneous lesions Immunocompromised . Intranuclear inclusions pts or complicated (“owl’s eyes”) infections . Systemic therapy ▪ Ganciclovir Intravenous ▪ Valganciclovir Oral ▪ Cidofovir ▪ Foscarnet ROSEOLA “Exanthem Subitum”, “Sixth Disease” Clinically . Abrupt onset of high fever lasting 3-5 days followed by elliptical rose colored macules or papules on the trunk . Nagayma spots – red papules on the soft palate . Berliners sign – palpebral edema Complications . Febrile seizures Treatment: supportive PITYRIASIS ROSEA Association with HHV-6 / 7 Self limited papulosquamous eruption along Langer’s lines of cleavage (Christmas tree pattern). Initial sign is a larger annular salmon colored plaque, “Herald Patch” KAPOSI’S SARCOMA Classic . Red-purple plaques on lower extremities in older pts of Mediterranean descent. AIDS-related . Widely distributed: skin, oral and genital mucosa, GI tract Immunosuppression-associated . Exogenous immunosuppression African endemic . Aggressive form seen in young pts in Africa HISTOLOGY TREATMENT Spindle cells forming slit-like vascular HAART IF AIDS-related spaces Topical retinoids “Promentory sign” Surgery Radiation Systemic chemotherapy Other associations: . Castleman’s disease . Primary effusion lymphoma Erythema Infectiousum “Slapped Cheek”, “Fifth Disease” Self-limited course Clinically: . Bright red macular erythema over the cheeks and lacy reticulated eruption on the extremities following cessation of fever PAPULAR PURPURIC GLOVES AND SOCKS SYNDROME Parvo B19 Self-limited Clinically: . Erythema, edema, petechial and purpura involving the palms and soles . +/- associated burning and pruritus MOLLUSCIPOX VIRUS Self-limited condition Clinically: . Pink umbilicated papules . Larger lesions in AIDS pts Diagnosis: . Clinical, histology showing Henderson Patterson Bodies Treatment: . Cantharidin, Curretage, Cryotherapy, Zymaderm, Tretinoin, Imiquimod PSUEDOCOWPOX / PARAVACCINA Parapox virus Self limited condition due to direct contact with infected cows or calves Clinically: . Slow growing solitary red-violaceous nodule on the finger Treatment: . supportive Non-enveloped dsDNA virus Infects basal keratinocytes in epithelium/mucosa Transmitted via direct skin contact Many subtypes and variable clinical presentation Common – 1,2,4 Plantar – 1 Flat – 3, 10 Butcher’s – 7 Condylomma accuminata – 6, 11 Verrucous carcinoma – 6,11 Heck’s disease – 13,32 Epidermodysplasia verruciformis – 5, 8 Bowenoid papulosis – 16,18 Digital SCC – 16 Cervical cancer – 16,18 Rubeola or “First disease” RNA virus, Paramyxovirus Clinically: . Prodrome . Koplik spots – buccal mucosa . Erythematous macules/papules on forehead, hairline, behind ears that spreads caudad Encephalitis (SSPE), otitis media, pneumonia, myocarditis German measles or “Third disease” ssRNA virus, togavirus Clinically: . Mild prodrome with tender lymphadenopathy . Erythematous macules and papules on the face then spreads Soft palate petechiae = Forschheimer spots Arthritis/arthralgias, hepatitis, myocarditis, pneumonia RNA enteroviruses . Coxsackievirus A16 . Enterovirus 71 Clinically: . Fever, anorexia, abdominal pain . Elliptical grayish vesicles, pustules, erosions on hands, feet and buttocks . Vesicles, erosions on a red base in the mouth Myocarditis, pneumonia, meningoencephalitis Ecthyma contagiosum dsDNA virus, Parapox Transmitted via contact with goats/sheep Clinically: . Fever and lymphadenitis . Stages: maculopapular, targetoid, acute, regenerative, papillomatous, regressive dsDNA orthopox virus Local reaction to site of smallpox vaccination with live virus Clinically: . Erythema or pruritic papule . Heals with pitted scarring Eczema vaccinatum dsDNA orthopox virus Transmitted via an infected cow Clinically: . Site of contact with painful inflamed macule or papule that becomes vesicular then pustular with ulceration . Deep seated black eschar with erythema . Heals with scarring Jain, Sima. Dermatology. Springer, NY; 2012. Bologna, JL. et al. Dermatology 3rd Edition. Elsevier Saunders, Philadelphia; 2012. .
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