VIRAL INFECTIONS on Skin and Mucosa

by Dr. Maria Dwikarya SpKK

UNTAR Medical Faculty in Jakarta

MUCOCUTANEOUS LESIONS CAUSED BY VIRUSES

VIRUS LESION
COMMON WART PLANTAR WART GENITAL WART FLESHY PAPULE PAPULOVESICULAR + VESICULAR (NEURAL SPREAD AND LATENCY VESICULAR IN MOUTH (HEPARNGINA) VESICULAR (HAND, FOOT AND MOUTH DISEASE) FACIAL MACULOPAPULAR (ERYTHEMA INFECTIOSUM) EXANTHEM SUBITUM (ROSEOLA INFANTUM) MACULOPAPULAR SKIN RASH MACULOPAPULAR NOT DISTINGUISHABLE CLINICALLY MACULOPAPULAR + + + -

VIRUS SHEDDING FROM LESION

+

NO SYSTEMIC SPREAD SYSTEMIC SPREAD

PAPILLOMA (WART)

MOLUSCUM CONTAGIOSUM (POXVIRUS) ORF (POXVIRUS FROM SHEEP, GOATS) HERPES SIMPLEX, VARICELLA-ZOSTER COXSACKIEVIRUS A (9,16,23) COXSACKIEVIRUS A16 ERYTHROVIRUS (FORMERLY HUMAN PARVOVIRUS) B19

MEASLES RUBELLA, ECHOVIRUS (4,6,9,16) DENGUE AND OTHER ARTHROPOD TRANSMITTED VIRUSES

DIAGNOSIS OF VIRAL INFECTION BASED ON RASH APPEARANCE (VIRAL TYPE)

MACULAR/MACULOPAPULAR MEASLES, RUBELLA, ENTEROVIRUSES, PARVOVIRUS B-19, MONONUCLEOSIS, CYTOMEGALOVIRUS, HEPATITIS B, ROSEOLA, HIV VESICLES HERPES SIMPLEX, VARICELLA-ZOSTER, ECZEMA HERPETICUM, HAND-FOOT AND MOUTH DISEASE PETECHIAE, PURPURA OR PUSTULES VIRAL HAEMORRHAGIC FEVERS, ENTEROVIRUS

THE DIFFERENTIATION OF MACULES, PAPULES, VESICLES AND PUSTULES

Viral infection wide spectrum clinical manifestations

HPV and MCV

Healthy
Colonize Without Lesions

Children
Benign Proliferation Transient

Immundeff
Extensive Persistent Refractory

HPV = Human Papiloma Virus , MCV = Moluscum Contagiosum Virus

MOLUSCUM CONTAGIOSUM
Self limited, multiple skin colored papules Age Children & Sexually active adults Males > females ; colonize follikel no lesion Transmission: Skin to skin, exposed area Incubation : several weeks Etiology : MCV 1 (child) + MCV 2 ( adult ) Morphology : papul or nodul with DELLE, contain white mass, multiple, diskret,mozaik

Spektrum Klinis Moluscum Contagiosum sesuai tingginya imunitas tubuh Hospes

MC

MC + ATOPY

MC+H I V

MOLUSCUM CONTAGIOSUM widespreading

ATOPIK

HIV infection

Terapi

Imunosupressif

Multiple facial MC and Trunk widespreading suggest HIV infection

MANAGEMENT for Moluscum

Differensial Diagnoses :
Multiple small Mol. = Flat warts, Condyloma Syringoma , Hiperplasi sebasea Large Solitary Mol. = Keratoacanthoma, Basalioma, Kista Epidermal

LABORATORY

EXAMINATIONS:

Giemsa stain: moluscum inclusion bodies Hb , Leucocyte counts, Diff count, anti HIV Elisa

Xantelasma & Syringoma

DD/
Flat Wart & Moluscum contagiosum

 PREVENTION: Avoid skin to skin contact

Minimized shaving hair

SUPPORTIVE Therapy : Regress spontaneouslly

Immunomodulator : Echinacea, Phylanti niruri

TREATMENT of lesions : Topical :

Yodium tincture 10 % 1x/day1 month Currettage or Enucleation with anatomic pincet. Electrodessication : anest EMLA cream 1 hour Cryotherapy: N2 spray 10 scnd not so painful

HUMAN PAPILOMA VIRUS

HPV subclinical or wide variety lesions 150 types HPV infect skin and mucosa by trauma

Cutaneus Infection
Common warts
70 % Children >>

Plantar warts
20 30 % Adult >>

Flat warts
4% Child & Adult

Mucosal infection Sexually Transmitted Disease CONDYLOMA Maternal transmitted to neonate baby

Some HPV types Can cause SCC in situ

Clavus/ Mata Ikan dg Kemoterapi AsSal 30%

Veruka vulgaris berbagai tempat

Human Papilloma Virus

Cutaneus warts = Verucca vulgaris
Discret , Confluence Mosaic Benign, epidermal hyperplasia & hyperkeratosis Morphology: minute papules to large plaques Occur on site of Trauma : fingers, hands , knees Vegetation & Brown dots bleeding after shaving Extent of lesion = Immune states of the Host Persist for years Cosmetic disfigurement

Veruka Vulgaris

Human Papilloma Virus

PLANTAR WARTS
Disrupt N dermatoglyphic Return N after resolutions Confluence lesion Mosaics Pressure Points : heels, toes Kissing lesions Opposing DD/ Callus & Corns/Clavus KAPALAN & MATA IKAN

FLAT WARTS
Thickness 1 2 mm 1- 5 mm flat lesions Skin coloured or light brown Scratching linear lesions On Face, beard, hands, shins DD/ Syringoma , Moluscum

CONDYLOMA intra URETHRA

M C + CONDYLOMA

CONDYLOMA peri ANAL

Management
Plantar Warts

Aggressive Th/

Conservative Imunomodulator Therapy

Common Warts

Flat Warts

Patient initiated therapy:

Small Lesion : 10 20 % salycilic acid and lactic acid in collodion,(Collomack) daily for 1 week Large lesion : 40 % salycylic acid plaster for 1 week followed by Necrotomy in Hospital.

Clinician initiated therapy :

Cryosurgery : N2, 30 sec, painful, freezing tissue not Virus Electrosurgery : more effective, Scarring Risk Laser CO2 surgery : for recalcitrant Warts Surgery : Non plantar warts, now rarely indicated.

HUMAN HERPES VIRUS

8 groups of HHV : HHV 1 & 2 = HSV ( Herpes Simplex Virus 1 + 2) HHV 3 = VZV ( Varicella Zoster Virus ) HHV 4 = EBV ( Eipstein Barr Virus ) HHV 5 = CMV ( Cyto Megalo Virus ) HHV 6-7-8 = Kaposi sarcoma ascociated Virus

3 groups HHV HumanHerpesVirus

ALPHA BETA GAMMA

HSV 1 + 2 VZV
Variable host Rapid destruction Latent infection Sensory ganglia

CMV
Restricted host Spread slowly Retina Pulmo & Colon

EBV HHV 6+7+8

Lymphotropic Specific Either T or B lymphocyte

HHV in immuno
competent & compromised individuals
HHV In Immuno
Competent Idvd
HSV-1 Prime Inf symp
Herpes labialis Herpetic whitlow

In Immuno Compromise
Widespread Chronic ulcer Disseminated Skin& viscera

Management
Immunisasi Anti Viral : Acy/Valacyclovir Foscarnet

HSV-2 Prime Inf symp

Herpes Genitalis Herpetic whitlow

IDEM
ChronicEctyma Varicella Disseminated Herpes Zoster

IDEM

VZV

PrimeInf Symp + Varicella latent Herpes Zoster

IDEM

HHV EBV
HHV -4

Disease in ImunCompetent
PrimInf Asymp MonoNucleosis PrimInf Asymp MonoNucleosis

Disease in ImCompromised Management

Lymphoma Burkitt Retinitis Pneumonitis Colitis Oral HairyPlakia Kaposi Sarcoma AntiViral Acyclovir Ganciclovir Immunization AntiViral Ganci/Cidofovir Foscarnet

CMV
HHV -5 HHV-6 HHV-7 HHV-8

PrimInf Asymp ExantemSubitum Fever morbiliform

Lymphoma of
Body cavity

NONE

HERPES SIMPLEX VIRUS

Age of onset : Infancy Young adult Senescence Etiology : HSV-1 and HSV-2 LABIALIS
HSV-1 80% HSV-2 20%

UROGENITALIS
HSV-1 20 % HSV-2 80 % < 20 yr HSV-1 > 20 yr HSV-2

HERPETIC WHITLOW

NEONATAL
HSV-2 =70 % HSV-1 =30%:

HERPES SIMPLEX VIRUS

Acute muco-cutaneus infection Herpetiform group : Erythemal based vesicles Constitutional state : fever, malaise, anorexia Bacterial secondary Infection : Lesions soon
become purulent & crusted & ulcerated

Latent episode Recurrent periodically with Precipitating factors.

HERPES SIMPLEX VIRUS INFECTION

Transmission: Skin- skin & Skin-mucosa
Incubation: average 6 days Crowded living & Low SocioEconomy Wrestler Herpetic whitlow.

Precipitating factor of Recurrence:

UV radiation Hormonal : Menstruation Fever & Influenza Altered Immunity : HIV infection, ChemoTherapy, Radiotherapy, Steroid therapy, Malignancy: Leucemia

Herpetic Gladiatorum/ Herpes zoster

PATHOGENESIS
ViralShedding person
Periodically HSV

reactivate

Travel along sensory nerve To skin or mucosa viral shedding

Ascend perypheral nerve

Inoculation onto
susceptible skin or mucosa

Enter sensory nerve ganglia to be LATENT

Viruses replicate in parabasal

epitelial cell Lysis Vesicles & Local Inflammation

CLINICAL MANIFESTATIONS
Primary infection: gingivostomatitis, genital, neonatal Recurrent infection : milder symptoms Disseminated infection : muco-cutan & visceral Complication : Eczema Herpeticum , Erytema Multiform
Meningitis & Encephalitis . HSV infection of peripheral sensory nerve system : 1. 5th = Trigeminal nerve :Gingivostomatitis, Corneal lesi 2. 7th = Facialis nerve : Facial paralysis 3. Cervical & Thoracic nerve : HSV gladiatorum, Nipple lesi 4. Lumbosacral nerve: Genital Herpes

Herpes Nipple & Labialis

Herpes Simplex Labialis

Herpes Labialis Rekurens

Herpes Labialis Serangan Awal

DD/ Herpes Labialis & Impetigo

Dermato Pathology
Tzanck smear & Giems stained : Ballooning & Reticular Epidermal degeneration, Acantholysis, IntraEpidermal vesicles Intranuclear Inclusion bodies Multinuclear giant Keratinocytes = Datia Langhans cell

Serology : Anti HSV-1 and -2 : IgM & IgG (+) PCR : polymerase chain reaction: determined the HSV-DNA in tissue, smears and secretion

HERPES GENITALIS INFEKSI Sekunder + ULCUS Durum

Hepes simplex Genital + Infeksi sekunder & Phymosis

Differential DIAGNOSIS

REGIO UROGENITAL :

Ulcus durum, ulcus molle, Ulcus mixtum Primary infection LGV

MANAGEMENT
PREVENTION : avoid skin to skin contact TOPICAL THERAPY : Acyclovir cream ( early state)
Antibiotic oinment ( after secondary infected ) Vulva Hygiene : Shaving + Normal Saline wash

ORAL THERAPY :
1st Episode : Acyclovir 400mg 3 dd for 7-10 days ( Valaciclovir 1000mg 2 dd for 7-10 days) Antibiotics : Broadspectrum or for Gram-Negative Anti Fungal : Itraconzole : 2 dd 100mg 5 days Analgetics and anti Inflammation, Recurrence : Acyclovir 400mg 3dd for 5 days Valaciclovir 500mg 2dd for 5 days Chronic suppression : Acyclovir 400 mg/day 1 year

VARICELLA ZOSTER VIRUS

Age of onset : 90% in children<10 yrs Etiology : DNA virus 150-200 nm Transmission : airborne droplet & direct contact.
Very contagious several days before exantem until last crops of vesicles, Crusts are not infectious. Epidemics occur in Winter and Spring.

VZV can be aerosolized from H.Zoster skin Varicella.

VARICELLA
Incubation period : 14 days ( 10-23 d) Prodrome : More common in adults ,
Headache, malaise, Exanthem quite pruritic

Synonims : Chicken Pox ( = cacar air ) Laboratory Examination: Tsanck smear :

cytology of fluid show : Giant & multinucleated acantholytic epidermal cells = HSV infections

Viral Cultures : on Human fibroblast monolayer

VARICELLA

Travel sensory nerve to SensoryGanglia Latent infection

Reactivate VZV

HERPES ZOSTER

VZV enter mucosa

LOCAL REPLICATION

VZV replication inBasal layer Ballooning degeneration Epithelial cells vacuol formation

Dissemination to

Skin & Mucosa

PATHOGENESIS
Primary VIREMIA

VARICELLA
VZV replicates in ReticuloEndothelial System

Secondary VIREMIA

VARICELLA
& VARIASI KLINIS

VARICELLA & Herpes ZOSTER

Prodrome : Flu synd Age onset: >>Children No immunity to VZV Generalize lesion Dewdrops on Rose petal discret lesions vesicles umbilicated pustules and crusts 812 days Sites: Centripetal FaceTrunkExtremity Complication: Scar , Encephalitis,Pneumonitis Prodrome: Neuralgia Age onset: 66% >55 yrs Partial immunity to VZV Unilateral & Dermatomal Papul vesicopustul bullae herpetiformis lesion even Necrotic Gangrens Crusts 7-10 days Sites: Thoracic 50 %, Trigeminal 10 20 % Lumbosacral 10-20 % Complication : Scar, PostHerpetic Neuralgia

Herpes Zoster pada berbagai predileksi & stadium

DIAGNOSIS : made on clinical findings

PROGNOSIS : self limited COMPLICATION :
< 5 yrs : Bacterial infection ( Staphylococc & Streptococcal) 5-11 yrs : Varicella Encephalitis Adults: 4 % Pneumonitis , Arthritis, Orchitis, Nephritis, Carditis , Uveitis and Conyunctivitis.( immunsupressi & steroid therapy, HIV)

Maternal Varicella :
Trimester 1 : fetal varicella syndrom, (limb hypoplasia, eye & brain damage & skin lesions ). Neonatus : pneumonitis & encephalitis.

VARICELLA MANAGEMENT
Immunization ( Varivax - Varilrix) 80 % effective Symptomatic : Calamine lotion antippruritic
Oral antiHistamines & antipiretic Agents

AntiViral : Acyclovir 4 dd 800 mg oral for 5 days

Valaciclovir&Penciclovir effective but not approved used. Imunocompromised : Acyclovir 10mg/kg IV q8h 7 days for Acyclovir resistant Foscarnet 40mg/kg IV q8h 7 days

Anti Biotics: Oral Broad Spectrum Antibiotics

Topical : Mupirocin 2 % , Neomycin yelly

HERPES ZOSTER
Physical Exam : Unilateral >2 dermatomes,

10% hematogenous to other site . Skin & Mucous Membranes involved Lymphadenopathy regional tender Sensory defects & motor paralysis Eyes defects: Keratitis, Uveitis, Retinitis, Neuritis Delayed Contra lateral Hemiparesis: direct
invasion of cerebral arteries to intracranial nerve branch

DIFFERENSIAL DIAGNOSIS
Prodromal pain : mimic MIGRAINE, CARDIAC & PLEURAL disease, AcuteAbdomen, HNP vertebral . Dermatomal Eruption : mimic Poison Ivy Erysipelas,Contact dermatitis, Impetigo

MANA HERPES ZOSTER ? Poison IVY ?

COMPLICATION
H. ZOSTER on Face

SKIN
HAEMORRHAGE BACTERIAL INFC GANGREN SCARRING COSMETIC BADLY

NERVE
NERVE INFECTION INFLAMATION SCARRING PARALYSIS NEURALGIA

RAMSAY HUNT SYNDROME N. TRIGEMINAL ramus 2

>60YRS 40 % PHN + 60 % 1 month+ 24 % 2months +13 % 3months

H. Zoster Facial Komplikata

MANAGEMENT
AntiViral < 72 hrs Acyclovir 800mg qid 7 10 days Valaciclovir 3dd 1 g

ANTI VIRAL

Sedation NSAID Steroid

BedRest, Doxepin 10-100mg Prednisone 2dd10mg (old age)

HerpesZoster
PHN

Wet Dressing Antibiotic

Gabapentin 300 mg tid Capsaicin & EMLAcream

Normal Saline dressing& Antibiotics oral / topical

BOOK REFFERENCES
1. Wolff,K ; Johnson, RA : Fitzpatrick`s Color Atlas & Synopsis of Clinical Dermatology (USA Mc Graw Hill 2005)5th ed.pp 760-831 Handoko R Dr. ; Djuanda, A Proff.DR. cs : Ilmu Peny. Kulit & Kelamin, Balai Penerbit FKUI Jakarta 5th ed. Pp 110-118 Barakbah J, cs : Atlas Penyakit Kulit & Kelamin 2nd ed. Surabaya: Airlangga University Press pp. 11-23

2.

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