VIRAL INFECTIONS

INTRODUCTION• Cutaneous manifestations – common in viral

infections

• Characterized by definite morphology and

distribution - clinically diagnosed

• Light microscope - visualized only when

aggregated into inclusion bodies

Intranuclear inclusion bodies are seen in the

herpes virus group and papilloma virus group

Intracytoplasmic inclusion bodies are seen in

the poxvirus group

COMMON VIRAL INFECTIONS OF SKIN DNA VIRUSES:

Papova virus - Human Papilloma Virus - Genital & Non-genital warts

Pox virus - Molluscum Contagiosum, small pox, milker’s

nodules, Orf

Herpes virus - Varicella Zoster Virus - Varicella, Herpes

Zoster; Herpes Simplex Virus I & I I- Herpes Simplex

RNA VIRUSES:

Picornavirus – Coxsackie virus – Hand foot mouth disease

Retrovirus - HIV

MANIFESTATIONS DUE TO VIREMIA AND HYPERSENSITIVITY

• Viral exanthems

First disease - Measles (Rubeola)

Third disease - Rubella (German Measles)

Fifth disease - Erythema Infectiousum

Sixth disease - Roseola Infantum

• Hypersensitivity reactions

Pityriasis rosea

Gianotti crosti syndrome

ETIOPATHOGENESIS

Cell lysis - Herpes

Cell proliferation - Pox, HPV

Carcinogenesis - Cervical Ca, Hepatoma

Exanthemata - Viraemia, Type 3 hypersensitivity

(Arthus) reaction, virus lodged in dermal

capillaries and replicate in epidermis

Persistent infection: Periods of latency and

reactivation (HSV, VZV)

HUMAN PAPILLOMA VIRUS INFECTION - WARTS Most common mucocutaneous viral infection

Incubation period: few weeks to about one year

Asymptomatic latent infection to warts to squamous

cell carcinoma

Direct or indirect contact (nail biters, shaving,

occupational, swimming pool); sexual transmission;

autoinoculation

Koebnerization – pseudo Koebner phenomenon

CLINICAL TYPESNon genital: Verruca vulgaris (Common warts) – HPV

2

Verruca Plana (Plane warts) - HPV 3, 10

Filiform

Digitate

Palmoplantar

Periungual

Genital: Condyloma Acuminata – HPV 6,11, 16,18

Bowenoid papulosis – HPV 16

Buschke-Lowenstein tumor – HPV 6,11

Epidermodysplasia verruciformis

HISTOPATHOLOGY

Hyperkeratosis

Papillomatosis

Acanthosis

Vacuolation in the stratum granulosum and stratum spinosum

- koilocytes

TREATMENT

Topical Keratolytics : Salicylic Acid, Urea, Wart solution (Lactic

acid/Salicylic Acid)

Chemical cautery: Podophyllin, TCA

Cryotherapy

Electrocautery

Radiosurgery

Laser therapy

Photodynamic Therapy

Others: Formalin soaks, Imiquimod, 5FU, retinoids, immunotherapy,

Bleomycin, Interferon

Systemic Immunomodulators: Levamisole, Cimetidine

SMALL POX

• Eradicated in 1977. Only humans, no carriers

• Eosinophilic inclusions - Guarnieri’s bodies

• IP=12-14 days

• Fever, chills, myalgia, rash 3-4 days later

• Firm papulovesicles, pustular in 10-12 day

• All in the same stage of evolution

• Edward Jenner - vaccinia virus

MOLLUSCUM CONTAGIOSUM

• MCV-1 to – 4 ; MCV 1 – children, MCV 4 – HIV infected

• Incubation period: 2 weeks to 6 weeks

Transmission: contact, fomites, sexual

Dome shaped, pearly white, discrete umbilicated papules - Face,

neck, trunk, peri-genitals (sexual transmission), eyelids (HIV).

Pseudo Koebner’s phenomenon

Giant Molluscum Contagiosum (1.5 cm) – HIV infected

Differential – cryptococccosis, histoplasmosis, penicilliosis

Tzanck – Henderson Patterson bodies

TREATMENT

Expression / Curettage

Chemical cautery, Electrodessication, Cryotherapy.

Topical: Imiquimod, KOH, Phenol, Cantharidine,

Cidofovir.

Systemic: Levamisole, Cimetidine, cidofovir

HERPES SIMPLEX VIRUS

HSV 1: Facial (above waist)

HSV 2: Genital (sexual)

Incubation Period : 3-7 days

First clinical episode - true primary infection or non primary

Persist in sensory ganglion - period of latency

Recurrent infection

CLINICAL FEATURES Grouped vesicles on erythematous base followed by

erosions and healing

Primary attack: severe with lymphadenopathy and systemic

complaints

Non primary : lower frequencies of systemic symptoms,

shorter duration of pain, fewer lesions, shorter healing time

Recurrences: mild with shortened clinical course, smaller

size of the vesicles, close grouping and absence of systemic

symptoms

Predisposing factors: trauma, sunburn, stress, coitus,

premenstrual, high grade fever, infections, surgery,

dermabrasion

HERPES SIMPLEX- CLINICAL TYPES

Herpes Simplex Virus I :

Herpes Labialis, Herpetic Gingivostomatitis, Herpetic

whitlow, Herpetic gladiatorum, Herpes sycosis,

Keratoconjunctivitis

Herpes Simplex Virus II:

Herpes progenitalis, Herpetic vulvovaginitis, recurrent

lumbosacral herpes, HSV infection in newborn

Complicated:

Eczema herpeticum, Disseminated HSV

Herpes Simplex Virus in HIV:

Chronic, recurrent, ulcer, eschar formation and

dissemination

Chronic HSV more than 1 month – AIDS defining

COMPLICATIONS

Radiculoneuropathy

Dissemination

Meningitis / encephalitis

Erythema multiforme

Eczema herpeticum

Ocular complications

INVESTIGATIONS

Tzanck smear : Multinucleated giant cells

Histopathology : Ballooning degeneration,

intraepithelial blisters, inclusion bodies

HSV antibody titre : IgG/IgM

Culture

Immunofluoroscence, PCR

Electron microscopy

TREATMENT

Symptomatic

Topical: Acyclovir, Penciclovir, Cidofovir

Systemic:

Resistant – foscarnet, cidofovir

Antiviral Primary

(10 days)

Recurrence

(5 days)

Suppressive

6months-1yr

Acyclovir 200mg

5times/day

400mg tid 400 mg bd

Valaciclovir 1gm bd 500mg bd 500-1000 mg bd

Famciclovir 250mg tid 125mg bd 250mg bd

VARICELLA ZOSTER VIRUS

Chicken pox and zoster (shingles)

Transmission: Droplet infection - nasopharynx

Varicella : primary viraemia

Zoster: Reactivation of residual latent virus in

the sensory nerve ganglion

VARICELLA - CLINICAL FEATURES

Incubation period: 2-3 weeks

2-10 years

Prodromal symptoms

Pleomorphic, centripetal distribution, dewdrops on rose petal

appearance

Vesicles, papulovesicles, crusting, haemorrhagic, umbilicated

lesions

COMPLICATIONS

Secondary infection

Encephalitis

Pneumonitis

Hepatitis

Varicella in HIV- Progressive, haemorrhagic, complicated

Chronic varicella- Hyperkeratotic lesions, Acute retinal

necrosis

Reye syndrome

Congenital varicella syndrome

TREATMENT

Symptomatic:

Rest, Antibiotics, Anti-inflammatory, Calamine lotion

Antivirals - Indicated in adult varicella; reduces severity, duration &

infectivity in childhood chicken pox

Acyclovir : 800 mg 5 times/day

Valcyclovir : 1gm tds - contraindicated in immunosuppresed

individuals - Thrombotic thrombocytopenic purpura and hemolytic

uremic syndrome

Prophylaxis:

Vaccine, Immunoglobulin, Acyclovir

HERPES ZOSTER

Reactivation of latent virus in the dorsal root ganglion of

sensory nerve

Older age group >50 years

Unilateral, dermatomal, grouped vesicles

Cranial (V, VII commonly), spinal (thoracic commonly)

Pre-herpetic, herpetic and post-herpetic neuralgia

HERPES ZOSTER : CRANIAL NERVE

INVOLVEMENT

V Nerve:

Ophthalmic division: Herpes Zoster Ophthalmicus

Hutchinsons sign (vesicles on nose tip)

Ocular complications: uveitis, keratitis, conjunctivitis,

scleritis, ocular palsy

Maxillary division: uvula / tonsils

Mandibular division : tongue / buccal mucosa

HERPES ZOSTER : CRANIAL NERVE

INVOLVEMENT

VII nerve :

Ramsay Hunt syndrome:

Earache, vesicles on pinna, facial palsy

Hearing loss, vertigo and taste sensation impaired

COMPLICATIONS

Secondary infection

Post herpetic neuralgia

Scarring

Nerve Palsy

Encephalitis : in disseminated zoster

HERPES ZOSTER IN HIV

Younger patient

Severe pre, herpetic and post-herpetic neuralgia

Multi-dermatomal, cranial nerve involvement

Haemorrhagic, disseminated

Protracted course, verrucous lesions

Acute retinal necrosis

TREATMENT

Symptomatic

Antivirals:

Acyclovir 800mg x 5times/day

Famciclovir 500 mg tds

Valaciclovir 1gm tds

Duration : 1week in immunocompetent

2weeks in immunosuppressed

Steroids : in cranial nerve involvement

TREATMENT OF POST HERPETIC NEURALGIA

Steroids

Analgesics

Amitryptilline, Doxepine

Phenytoin, Carbamazapine, Sodium valproate

Gabapentine

Methylcobalamine

Topical EMLA cream

Topical capsaicin

Intralesional Steroids

HAND-FOOT-AND-MOUTH DISEASE

• Coxsackie virus A16, A5, A7, A9, and B 1, 2, 3; enterovirus 71

• IP - 4-6 days

• Vesicles painful erosions and ulcers on an erythematous base on buccal mucosa, tongue, palate, uvula.

• Gray-white vesiculopustules on palms, soles, dorsal or lateral surfaces of hands and feet., buttocks, thighs, and external genitalia

• Cervical and submandibular lymphadenopathy

• Encephalitis, aseptic meningitis, and myocarditis

• Hand hygiene

VIRAL EXANTHEMS

MEASLES (RUBEOLA/ MORBILLI)

• Preschool children; IP - 10-12 days

• 3 C’s —cough, coryza and conjunctivitis

• Koplik’s spots - blue white spots with a red halo on

buccal mucosa opposite the premolar teeth

• Maculopapular rash begins on the 4th day; face,

behind the ears trunk and extremities in 24-36

hrs maximum intensity in 3 days fades after 5-

10 days with desquamation

• Pneumonia, bronchitis, otitis media, gastroenteritis,

myocarditis, encephalitis

• Vitamin A supplementation; Vaccination at 9 -15

months

RUBELLA (GERMAN MEASLES/ 3 DAY MEASLES)

• > 15 years ; IP-12 to 25 days

• Posterior auricular Lymphadenopathy 4 to 7 days

before; maximal at onset; resolve in a week

• Forcheimer spots - petechiae of soft plate

• Maculopapular rash begins on neck or facetrunk

and extremities in a dayconfluent on face 2nd

day confluent on trunk, fades in face3rd day fully

fades

• Arthralgia, arthritis, encephalitis, thrombocytopenia

• Congenital rubella syndrome

• Vaccination at 15 months or older; 3 months

contraception

ERYTHEMA INFECTIOSUM

• 2-15 years

• 3 overlapping stages - facial erythema (slapped

cheek); Fades in 4 days 2 days laternet

pattern erythema – on extremities ; extends to

trunk and buttocks for 6-14 daysrecurrent

phase - fades and reappears in the next 2 to 3

weeks

• Papular-purpuric gloves and socks syndrome;

petechial exanthems

• Arthritis, transient aplastic crisis, chronic anemia

• In utero infection- hydrops fetalis, congenital

anemia

ROSEOLA INFANTUM EXANTHEM SUBITUM, “SUDDEN RASH”, 3 DAY FEVER

• 6 months- 2 years of age

• IP - 5-15 days

• Inappropriately well for the degree of fever

• Mild to moderate lymphadenopathy

• Seizures

• Rash begins as the fever subsides

• Pale-pink, almond-shaped confluent macules on

trunk and neckfade in a few hours to 2 days

without scaling or pigmentation

PAPULAR ACRODERMATITIS OF CHILDHOODGIANOTTI-CROSTI SYNDROME

• Hepatitis B (ayw), EBV (commonest), CMV, coxsackie, respiratory virus, parvoviruses, rotavirus, and HHV 6

• Vaccination –MMR, oral polio, DPT, hepatitis B.

• 2-6 yrs, males common

• Asymptomatic, symmetrical, edematous, erythematous, monomorphous, papules and papulovesicles, on face, extensors of upper and lower extremities

• Lymphadenopathy, hepatomegaly and anicteric hepatitis

• Self limited, lasts for 2-8 weeks.