Viral Infections
Prof Dr S L Rajbhandari
2079/8/8
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Outline
• Introduction
• Classification
• Pathogenesis
• Clinical features
• Diagnosis
• Investigations
• Differential diagnosis
• Treatment
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Introduction
• Characteristic skin lesions suggest a specific viral illness
• Virus induce alterations in cell function and host response to the
presence of viruses clinical features
• First attach to specific receptors on cell surface of host cell
• Enter cytoplasm of cell eclipse phase replicate new virions
• Viral proteins produced follow the genetic code of the specific virus.
nucleic acid proteins formed are characteristic of virus
• Assemble and release by lysis or budding
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Introduction
• Inclusion bodies occur at replication site
• Seen in 3 groups of viruses – herpes and papilloma v within nuclei of
cells
• In pox virus group within cytoplasm
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Introduction
• Tropism
• Eclipse
• Different viruses have different tissue tropism, some for mucosa other
for squamous cell
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Classification: Viruses of dermatological
importance
DNA Viruses RNA Viruses
• Herpes viruses: • Picorna Viruses
(Herpes simplex, Varicella, Coxackie, ECHO
Zoster, Epstein Barr )
• Pox Viruses:
MC
• Papova Viruses:
Warts
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Pathogenesis
• Cell lysis(herpes)
• Cell proliferation(HPV, Pox)
• Persistent infection: periods of latency and reactivation(HSV, VZV)
• Exanthemata –viremia (type 3 reaction) virus lodge in dermal
capillaries, replicate in epidermis
• Carcinogenesis(cervical ca, hepatoma)
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Common viral infections of skin
• Human papilloma virus: genital and nongenital warts
• Pox virus: molluscum contagiosum
• Varicella zoster virus: varicella, herpes zoster
• Herpes simplex virus I, II: herpes simplex
• Viral exanthems
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HPV
• DNA virus >200 types
• Anogenital warts: 6, 11,16,18,31,33,51-59,70
• Incubation period: few wk – 1 yr
• Transmission: direct, indirect contact (nail biters, shaving,
occupational, swimming pool)
• Sexual transmission: genital, perianal wart
• Auto inoculation
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Clinical types
• Non genital- verruca vulgaris
- verruca plana
- filiform
- digitate
- palmoplantar
- periungual
• Genital – condyloma acuminata
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Clinical features
Verruca Vulgaris
• Commonest type
• Children, young adults
• Asymptomatic, hyperkeratotic, papular, warty
• Common sites: extremities, dorsa hands, feet
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Verruca plana
• Discrete flat papules or coalesce
• Sites: face, neck, extremities
Others
Filiform: single finger like projection
Digitate: multiple finger like projections with wide base
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Palmoplantar
• Hyperkeratotic, elevated, flat, painful on lateral pressure
• Mosaic , Myrmecia
DD: corn, callosity
Periungual :
• commonly associated with palmoplantar warts, invasion of nail bed
• Recalcitrant to treatment
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Genital wart
• Condyloma acuminata: protuberant, moist, cauliflower like growth
Anogenital warts in children: sexual non sexual transmission
• Bowenoid papulosis: multiple, grouped, warty lesions on genitals,
premalignant
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Complications
• Secondary infections
• Pregnancy related: proliferative growth, obstruction of labour,
laryngeal papilloma in child
• Malignant change: cervical intra epithelial neoplasia(HPV 16, 18)
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Investigations
• Clinical diagnosis
• Histology
• Electron microscopy
• DNA hybridization
• Immunohistochemistry: type of HPV
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Treatment
• Topical keratolytics
Salicylic acid, urea, wart solution(lactic acid, salicylic acid)
• Chemical cautery: podophyllin, TCA
• Cryotherapy
• Electrocautery
Radiosurgery
Laser therapy
Others: Imiquimod, 5 FU, DNCB, Bleomycin, IFN
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Treatment …
• Systemic immunomodulators: levamisole, cimetidine, IFN,
photodynamic therapy
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Molluscum Contagiosum
• Pox virus: Molluscum Contagiosum Virus
• MCV 1, MCV 2
• Incubation period: 2 wk to 6 mth
• Transmission: contact, fomite, sexual
• Intra cytoplasmic inclusion bodies
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MC-clinical features
• Dome shaped pearly white discrete umbilicated papules
• Sites: face, neck, trunk, perigenitals, eyelids
• Giant MC/secondary infection
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Treatment
• Expression /curettage
• Chemical cautery/elctrodessication, cryotherapy
• Topical: Imiquimod, KOH, phenol
• Systemic: levamisole
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VZV
• Chickenpox, shingles
• Transmission: droplet infection – nasopharynx
• Varicella: primary viremia
• Zoster: reactivation of residual latent virus in the sensory nerve
ganglion
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Varicella: clinical features
• Incubation period: 2 – 3 wks
• Prodromal symptoms
• Pleomorphic, centripetal distribution, dew drop on rose petal
appearance
• Vesicles, papulovesicles , crusting, hemorrhagic , umbilicated lesions
• Mucosal involvement
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Complications: chickenpox
• Secondary infections
• Encephalitis
• Pneumonitis
• Hepatitis
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Treatment
• Symptomatic
Rest, antibiotic, anti-inflammatory, calamine
• Acyclovir
Dose 800 mg 5 times a day adult reduces severity, duration, infectivity
in childhood chickenpox(20 mg/kg) qds x 5 d
• Prophylaxis –
Vaccine, IG, acyclovir
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HZ—clinical features
• Reactivation of latent virus in the dorsal root ganglion of sensory
nerve
• Older age group
• Unilateral, dermatomal grouped vesicles
• Cranial, spinal
• Pre herpetic, herpetic, post herpetic neuralgia
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HZ - cranial nerve involvement Vth
• Ophthalmic – HZO, Hutchinson sign(vesicles on nose tip)
complications uveitis, keratitis, conjunctivitis, scleritis, ocular palsy
• Maxillary : uvula, tonsil
• Mandibular: tongue, buccal mucosa
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Cranial nerve VII – Ramsey Hunt syndrome
• Earache, vesicles on pinna facial palsy
• Hearing loss, vertigo, taste sensation impaired
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Complications : HZ
• Secondary infection
• PHN
• Scarring
• Nerve palsy
• Encephalitis disseminated hz
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Treatment
• Symptomatic
• Antiviral
Acyclovir 800mgx5times/day
Steroids in cranial nerve involvement
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Treatment of PHN
• Steroids
• Analgesics
• Amitriptyline
• Phenytoin, carbamazepine, sodium valproate
• Gabapentine
• Methylcobalamine
• Topical EMLA cream
• Topical capsaicin
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HSV
• HSV 1: facial(above waist)
• HSV2: genital (sexual)
• Incubation period: 3-7 days
• Primary infection
• Persists in sensory ganglion – period of latency
• Recurrent infection
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Clinical features -HSV
• Grouped vesicles on erythematous base followed by erosions healing
• Primary attack: severe with lymphadenopathy, systemic complaints
• Recurrences: mild with shortened clinical course
• Predisposing factors: trauma, sunburn, stress, coitus, premenstrual,
infections, surgery
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HS – clinical types
• HSV 1
Herpes labialis, gingivostomatitis, whitlow, gladiatorum,
keratoconjunctivitis
• HSV2
Progenitalis, vulvovaginitis
• Complicated
Eczema herpeticum, disseminated
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Investigations
• Tzanck smear: multinucleated giant cell
• Histopathology: ballooning degeneration, intraepithelial blisters,
inclusion bodies
• HSV antibody titer: IgG/IgM
• Culture
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