Viral Infections

CONTENTS

 Classification  Epstein Barr virus infection

 Etiopathogenesis  Other herpes infection
 Molluscum contagiosum  Viral exanthem
 Human papilloma virus infection  Uncommon viral infection of skin
 Herpes simplex infection  MCQs
 Herpes zoster infection  Photo quiz
 Classification of virus

 DNA VIRUS  RNA Virus

 Enveloped (double stranded) • Flaviviridae
• Herpesviridae • Togaviridae
• Hepadnaviridae • Retroviridae
 Non-enveloped (double • Coronaviridae
stranded) • Picornaviridae
• Papillomaviridae • Calciviridae
• Polyomaviridae • Orthomyxoviridae
• Adenoviridae • Paramyxoviridae
 Single stranded (non-enveloped) • Rhabdoviridae
• Arenaviridae
• Parvoviridae
• Reoviridae
• Poxviridae
 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)
 Molluscum Contagiosum

 Caused by molluscum contagiosum virus , a DNA virus of Poxviridae

family.
 Commonly affects children and sexually active adults.
 Most easily transmitted by direct skin to skin contact.
 Incubation period varies from 2 weeks to 6 months.
 Typical lesions are discrete, dome shaped, umbilicated papules.
 D/D: Cryptococcosis, Histoplasmosis, Penicillinosis
Molluscum Contagiosum Molluscum In HIV
 Diagnosis and treatment

 Direct examination of expressed material when clinical diagnosis is doubtful.

 On histopathology-Henderson-Paterson bodies (molluscum bodies).
 Enucleation, Cryotherapy using liquid nitrogen, Curettage or diathermy
 Pulsed dye laser.
 Application of phenol or 40 % silver nitrate.
 10 % KOH, 0.5 % podophyllotoxin, Imiquimod cream.
 1 -3 % cidofovir ointment or cream, 0.9 % cantharidin.
 Povidone iodine with 15 – 20 % salicylic acid.
 Systemic : Levamisole, Cimetidine.
 Human Papilloma Virus

 More than 100 types of HPV

 Genome of HPV-Early genes (E1-E7), Late genes (L1-L2)
 Transmission : direct or indirect contact (nail biters, shaving,
occupational, swimming pool)
 Sexual transmission : genital / perianal wart
 Autoinoculation
 Clinical Types

 Non genital :
• Verruca vulgaris (Common warts)
• Verruca Plana (Plane warts)
• Filiform
• Digitate
• Palmoplantar
• Periungual
 Genital :
• Condyloma Acuminata
 Common Wart
 HPV types-1,2,4,27 and 57
 Commonly seen in young
children and adults.
 Meat butchers, frequent
immersion of hand in water are
risk factors
 Papules with verrucous surface.
 Commonest site-Hands
 (Fingers and palms)
 Warts do not have
dermatoglyphics
 Verruca Plana
HPV types-3,10,28 and 41
 Risk factors-sun exposure,
swimmers
 Common sites-Face, lower legs
 Few milimetres brown or skin
coloured flat topped papules
 Koebnerisation seen
 Palmo-Plantar warts
 HPV types-1, 2, 4, 27
 Seen at pressure points
 If paring is done-multiple small
black points seen (dilated
capillary loops)
 Myrmecia
 Mosaic type
 Differentiate from corn and
callosity
 Filiform and digitate warts  Periungual warts
• Finger like projection • Seen in nail biters
• Recalcitrant to treatment
 Genital Warts

 Low risk genital HPV types-6 and 11

 High risk genital HPV types-16 and 18
 Condyloma acuminata
• Few mm to cms in size
• Lobulated papules usually multifocal, cauliflower like mass may be
seen in moist occluded areas
• Sites- intraurethral in men, mucosal surface of cervix or vulva,
perianal skin, vulva
 Giant Condyloma acuminata (Buschke Lowenstein tumor)
• Verrucous carcinoma, may invade and metastasize to LN
 Genital Warts

 Bowenoid paulosis
• Hyperpigmented papules or flat surface
• HPV types-16,18
• Sites- Penis, Perianal area, vulva
 Diagnosis
• Clinically
• Histopathology-Papillomatosis, acanthosis
• DNA hybridisation, Immunohistochemistry
Genital Wart
 Treatment

 Salicylic Acid, Lactic acid / Salicylic Acid combination

 Chemical cautery : Podophyllin, TCA (35%-85%)
 Imiquimod, Green Tea Extract (Sinecatechins), 5FU
 Cryotherapy
 Electrocautery
 Radiosurgery
 CO2 Laser
 Newer therapies - Mycobacterium W vaccine, MMR vaccine
 Human Herpes Virus

 Human Herpes virus 1 (Herpes simplex virus 1 (HSV 1))

 Human Herpes virus 2 (Herpes simplex virus 2 (HSV 2))
 Human Herpes virus 3 (Varicella-Zoster virus (VZV))
 Human Herpes virus 4 (Epstein Barr virus (EBV))
 Human Herpes virus 5 (Cytomegalovirus (CMV))
 Human Herpes virus 6 (HHV 6)
 Human Herpes virus 7 (HHV 7)
 Human Herpes virus 8 ( Kaposi’s sarcoma associated Herpes Virus (KSV)
(HHV 8))
 Herpes Virus

 Herpes Simplex Virus I :

Herpes Labialis, Herpetic Gingivostomatitis, Herpetic whitlow, Herpetic
gladiatorum, Herpes sycosis, Keratoconjunctivitis
 Herpes Simplex Virus II :
Herpes progenitalis, Herpetic vulvovaginitis
 Complicated :
Eczema herpeticum, Disseminated HSV
 Herpes Simplex Virus in HIV :
Chronic, recurrent, ulcer, eschar formation and dissemination
 Herpes simplex infections

 Primarily involve the skin and mucous surfaces

 Can be disseminated in neonates and immunocompromised hosts
 Produces primary infection - enters a latent or dormant stage, residing in
the sensory ganglia - can be reactivated at any time
 HSV-1 : >90% of primary infections caused by HSV-1 are subclinical;
more common
 HSV-2- usually the genital pathogen and usual pathogen of neonatal
herpes
 Orolabial Herpes
 95 % HSV – 1
 Presentation :
 Grouped vesicles on an
erythematous base.
• Often prodrome of tingling or
itching.
• Variable severity of recurrent
lesions.
• Mild flu like symptoms may
be present.
 Herpetic Gingivostomatitis
• High fever, irritability, anorexia, mouth pain, drooling
• Gingivae becomes intensely erythematous, edematous, friable and
tends to bleed
• Symptoms last 5-14 days, but virus can be shed for weeks following
resolution
 Differential diagnosis
 Aphthous ulcer
 Herpangina
 Stevens Johnson Syndrome
 Syphilis
 Diagnosis

 Tzanck smear-
• Method-scraping base of freshly ruptured vesicle
• Staining with Giemsa or Wright stain
• Look for multinucleated giant cells
 HSV antibody titre : IgG/IgM
 Immunofluoroscence, PCR-most sensitive
 Herpetic Infections ( contd)

 Herpetic Sycosis
• Shaving after facial herpes induces a slowly spreading folliculitis
of the beard with few isolated vesicles.
 Herpes Gladiatorum
 Herpetic whitlow
• Herpetic infection of the fingers.
• Children (thumb sucking)
• Adults : 2/3 cases HSV-2, Children nearly 100% HSV-1
 Genital Herpes

 Infection of HSV-2 in majority of cases.

 Spread by Skin to Skin contact
 Active lesions are infective
 Asymptomatic shedding accounts for the majority of transmission.
 Prior HSV-1 infection does not protect from HSV-2 infection but may
lessen severity of first outbreak.
 Primary infection:
 Grouped vesicles which appear for 7-14 days.
 Fever, Flu like symptoms, inguinal lymphadenopathy, proctitis if rectal
involvement.
 Recurrent lesions with typical prodrome of burning/itching followed by
outbreak which is less severe than the primary infection healing in 6-10
days.
Genital Herpes simplex infection
 Treatment

 Symptomatic
 Topical : Acyclovir, Penciclovir, Cidofovir
 Systemic :

Primary Recurrence Suppressive

Antiviral
(10 days) (5 days) 6 months - 1yr

Acyclovir 200 mg 5 400 mg tid 400 mg bd

times / day

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

Famciclovir 250 mg tid 125 mg bd 250 mg bd

 Intrauterine and Neonatal Herpes

 Extent of initial involvement predicts outcome:

• Localized : rarely fatal
• Disseminated disease fatal
 Presentations in newborns
• Majority present with vesicles.
• Disseminated herpes with CNS involvement may occur without skin
involvement.
• Few cases never have vesicles.
• Treatment: Acyclovir 250 mg/(m)2 q8 hours x7 days
 Eczema herpeticum
(Kaposi’s varicelliform eruption)
 Multiple crops can appear over 7-10 days (like varicella)
 Can be mild or fulminant,
 If area of involvement is large, can be lots of fluid loss and potentially fatal
 Onset of high fever, irritability, and discomfort
 Lesions appear in crops in areas of currently or recently affected skin (for
those with atopic eczema or chronic dermatitis)
 Lesions begin as pustules, then rupture and crust over the course of a
couple of days
 Lesions can become hemorrhagic.
 Risk of secondary bacterial infections
 Varicella (chicken pox)

 Acute and highly contagious exanthem that occurs mostly in children.

 Rash begins on face, scalp and spreads to trunk.

 Lesions scattered than clustered and progress from rose colored
macules to papules, vesicles, pustules and crust.
 Individuals are infectious 4 days before and 5 days after exanthem
appears.
 Varicella

 Secondary bacterial infection may result in scarring.

 Other complications :
• Pneumonia : neonates and adults (1/400)
• Reyes syndrome: encephalitis, hepatitis with aspirin use.
• Thrombocytopenia
• Purpura Fulminans : DIC with low proteins C and S
 Treatment :
• Acyclovir (800mg 5 times a day/1week) for severe cases, high risk
individuals and adults (>13 years).
• No Aspirin
• Isolate from immunocompromised.
Varicella
 Prevention

 Varicella Vaccine
• Live attenuated virus
• At present immunity appears to be lasting.
• Modified Varicella-like syndrome (MLSV)
– 15 days after exposure to varicella virus.
– 35-50 macules and papules, few vesicles.
– Mild, afebrile course lasting 5 days
 Varicella in Pregnancy

 Increased risk of spontaneous abortion (3% by 20 wks), congenital

varicella syndrome and fetal death. Possible increase in pre-term
labor.
 Mother at increased risk for varicella pneumonia.
 Congenital Varicella Syndrome
• Hypoplastic limbs, scars, ocular and CNS disease.
• F>M
• 1-2% risk, highest between weeks 13 and 20.
 Herpes Zoster

 Reactivation of latent herpes zoster infection from the dorsal root

ganglia
• Over 1-5 days new lesions develop, these become pustular and
crust.
• Typically along a dermatome at times involving adjacent
dermatomes.
• Preceded by pain, itching
 Duration of the lesion is dependent on age
 Young 2-3weeks, Elderly 5-6 weeks
• Severity of lesions, immunosuppression
 Incidence of H.Z. increases with age (>50 yrs) and immunosuppression.
 Herpes Zoster

 Heals without scaring in young.

 Increased incidence of scarring in elderly and severe eruptions.

Disseminated Zoster
 Defined as >20 vesicles outside dermatome.
 Chiefly elderly or Immunocompromised
 Hemorrhagic/gangrenous lesions with outlying vesicles or bullae.
 Systemic symptoms include fever, meningeal irritation.
Herpes Zoster
 Herpes Zoster Ophthalmicus

 Involvement of fifth cranial nerve, ophthalmic branch

 Lesion location on tip/side of nose- ‘Hutchinson’s sign’
 Ocular complications
• Uveitis , Keratitis
• Less common: glaucoma, optic neuritis
 Encephalitis
Herpes Zoster Ophthalmicus
 Ramsay Hunt syndrome

 Facial and auditory nerve involvement with inflammation of geniculate

ganglion
 Zoster of external ear or TM, herpes auricularis, with ipsilateral facial
paralysis
 Herpes auricularis, facial paralysis and auditory symptoms.
 Diagnosis and Treatment

 Diagnosis : Tzanck, direct fluorescent antibody, culture, PCR.

 Symptomatic treatment
 Antivirals :

Acyclovir 800mg x 5times/day for 1 week (may lessen severity of

symptoms in acute outbreak. May lessen incidence of PHN).
Famciclovir 250-500 mg TDS
Valaciclovir 1gm TDS
Duration : 1week in immunocompetent
2 weeks in immunosuppressed
 Post Herpetic Neuralgia

 Postherpetic neuralgia- nerve pain due to damage caused by VZ virus.

 Constant burning pain, intermittent stabbing pain or shooting pain,
stimulus evoked pain including Allodynia.
 Risk factors : prodromal pain, severe pain during acute phase, greater
rash severity, opthalmic zoster.
Treatment
 Topical : Capsaicin, topical lidocaine.
 Oral :analgesics ( NSAIDS), tricyclic antidepressants (amitryptiline),
anticonvulsants : gabapentin
 Injectable : lidocaine / steroids
 Epstein Barr Virus

Infectious mononucleosis
 After 3-7 wk incubation period
 Bilateral enlargement of cervical and other lymph glands
 High grade fever, malaise, splenomegaly.
 Pharyngitis with hyperplasia of lymphoid tissue are the most frequent
signs.
 Ampicillin triggers maculopapular eruption.
 Macular or morbilliform rash.
 Mucous membranes with 5-20 pinhead sized petechiae at junction of
soft palate with hard. (Forscheimer spots)
 Atypical lymphocytosis with more than 10 % atypical cells.
 Epstein Barr Virus

 Lab findings :
• WBC count 10,000 to 40,000.
• Abnormal large lymphocytes (Downey cells) are 10% of total
leukocyte count.
• Heterophile antibodies 1:160 of higher
 EBV is associated with lymphoma esp. Hodgkin's disease.
 Treatment : supportive.
 Oral Hairy Leukoplakia

 Associated with chronic shedding of EBV in the oral cavity.

 Presentation: Poorly demarcated, corrugated, white plaques on
lateral aspect of tongue.
 Unlike thrush, cannot be removed by scraping.
 Occurs with immunosuppression (esp AIDS) and warrants HIV
workup.
 Treatment
• Not required
• Podophyllin and tretinoin are used but lesions recur
 Human Herpes virus 6

 HHV 6A causes multiple sclerosis and HHV 6B causes Exanthem

subitum or Roseola Infantum.
 Roseola Infantum (sixth disease) presents as abrupt fever, inflammed
tympanic membrane, periorbital edema, hematuria and
maculopapular rash.
 Complications : seizures, thrombocytopenia, intussusception,
hemophagocytic syndrome and fatal hepatitis.
 Human Herpesvirus 7

 HHV 7 has been associated with febrile illness in children, exanthem

subitum and questionably pityriais rosea.
 There is persistent infection in salivary glands and is believed to be
the mode of infection.
 HHV 7 infection can reactivate HHV6 from latency.
 Human Herpesvirus 8

 Three proliferative diseases are associated with HHV 8:

Kaposi sarcoma, Primary effusion lymphoma and Castelman’s
disease.
 Kaposi’s Sarcoma
• Includes AIDs, African and Mediterranean cases.
• Seroprevalence correlates with prevalence of KS in a given
population.
• Infection predicts and precedes subsequent development of KS.
• HHV 8 is found in KS lesions, saliva, blood and semen of infected
individuals.
 Viral Exanthems

 Macular :
• Rubella
• EBV (infectious mononucleosis)
• Human herpesvirus 6 (roseola)
• Human herpesvirus 7
 Maculopapular :
• Togavirus
• Measles
• Human parvovirus B19 (erythema infectiosum)
 Viral Exanthems

 Maculopapular - vesicular :
• Coxsackie A (5, 9, 10,16)
• Echovirus (4, 9, 11)
 Maculopapular – petechial :
• Togavirus (Chikungunya)
• Bunyavirus haemorrhagic fever (Lassa)
 Urticarial :
• Coxsackie A9 and Hepatitis B
 Uncommon Viral Infections of the Skin

 Pox Viruses :
• Cowpox, Orf, Milker’s nodule
 Epstein Barr Virus :
• Infectious Mononucleousis, OHL, Gianotti Crosti,
• Lymphomas
 Viral insect-borne and haemorrhagic fevers:
(Toga, Flavi, Arena, Filo, Bunya)
• Chikungunya, Dengue, Kyasanur Forest Disease, Lassa
 Picorna Viruses :
• Herpangina, hand, foot and mouth disease.
 MCQ’S

Q.1) Henderson-Paterson bodies is seen in

A. Wart
B. Herpes simplex
C. Molluscum Contagiosum
D. EBV

Q.2) The following diseases are associated with Epstein-Barr virus infection,
except :
E. Infectious mononucleosis
F. Bowenoid papulosis
G. Nasopharyngeal carcinoma
H. Oral hairy leukoplakia
 MCQ’S

Q.3) Kaposi’s Sarcoma is associated with

A. HHV 6
B. HHV 7
C. HHV 8
D. HHV 3

Q.4) All are differential diagnosis of plantar wart except -

E. Corn
F. Callosities
G. Punctate Keratoderma
H. Plantar psoriasis
 MCQ’S

Q.5) HPV is responsible for cancer of

A. Brain
B. Lung
C. Cervix
D. Prostate
 Photo Quiz

Q. Diagnose and describe the lesions

 Photo Quiz

Q. Identify the Phenomenon and describe the condition

where it is seen
 Photo Quiz

Q. Identify the condition and the causative

organism?
Thank You!