Chris Hixon DO, PGY4 Megan Joint DO, PGY 4. Lewis Gale Hospital Montgomery / VCOM Program Director: Daniel S. Hurd DO, FAOCD

Transcription

1 Chris Hixon DO, PGY4 Megan Joint DO, PGY 4 Lewis Gale Hospital Montgomery / VCOM Program Director: Daniel S. Hurd DO, FAOCD

2 Human Herpes Virus 1-8 Parvo Virus Molluscum Contagiousum Milker s Nodule Human Papilloma Virus Measles Rubella Hand-Foot-Mouth Disease Orf Vaccinia Cowpox

3 Herpes Simplex Virus type 1 Herpes Simplex Virus type 2 HHV 3 Varicella Zoster virus Classification Lytic Infection Latent Infection Alphaherpesvirinae Epithelial cells Neuron Alphaherpesvirinae Epithelial cells Neuron Alphaherpesvirinae Epithelial cells Neuron HHV 4 - EBV Gammaherpesvirinae Epithelial cells and B cells HHV 5 - CMV Betaherpesvirinae Lymphocytes, Macrophages and Endothelial cells B Lymphocytes Macrophages, Lymphocytes HHV 6 Betaherpesvirinae CD4 T cells Lymphocytes HHV 7 Betaherpesvirinae T cells T Lymphocytes HHV8 Gammaherpesvirinae Lymphocytes Lymphocytes and

4 HSV - 1 Initial presentation: Prodrome Gingivostomatitis Recurrent lesions: Herpetiform vesicles on the vermilion border of lip HSV 2 Initial presentation: Frequently asymptomatic Painful, erosive balanitis, vulvitis or vaginitis Usually mild recurrence with resolution within 1 week

5 Eczema herpeticum (Kaposi s varicelliform eruption) Infection in areas of dermatitis/skin barrier disruption Herpes Folliculitis Encephalitis Temporal lobe Herpetic whitlow Ocular infections branching dendritic corneal lesions Herpes Gladiatorum Chronic enlarging ulcers Neonatal HSV infection

6 DIAGNOSIS Tzanck smear Multinucleated giant cells Direct Fluorescent antibody assay (DFA) Viral Culture Western Blot TREATMENT Oral Antiviral medications Orolabial Herpes and Genital Herpes (initiate within 24-48hrs of onset) Foscarnet is used when acyclovirresistant HSV is present Chronic suppression in those with > 6 outbreaks per year

7 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

8 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

9 RAMSAY HUNT SYNDROME Reactivation involving the geniculate ganglion of the facial nerve Can cause ear pain, hearing loss, facial paralysis and loss of taste to anterior 2/3 of the tongue HUTCHINSON SIGN Zoster affecting the nasal tip can lead to blindness due to direct effects on ophthalmic division of CN V1 via nasociliary nerve

10 DIAGNOSIS Diagnosis is usually made clinically Tzanck smear and/or DFA DFA used to differentiate between HSV and VZV Viral culture Serology Requires fourfold increase in VZV titer to reveal positive test TREATMENT Symptomatic treatment Oral Antiviral medications within hrs Vaccine recommended for all immunocompetent individuals >60 PCR Use increasing, highly sensitive and rapid test

11 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

12 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

13 Nasopharyngeal carcinoma Burkitt s lymphoma EBV found as latent infection in 97% of endemic, 15-85% of sporadic and 30-40% of AIDSlinked Burkitt's lymphoma cases Common African manifestation

14 MONONUCLEOSIS-LIKE SYNDROME Mononucleosis-like syndrome Morbilliform eruption Petechiae and purpura Urticaria Erythema nodosum Ampicillin-induced eruption CONGENITAL INFECTION Congenital Infections: Blueberry muffin lesions (Extramedullary erythropoiesis) Petechiae and purpura Deafness, retardation AIDS patients: CMV retinitis blindness

15 Diagnosis: Serology, PCR, Cultures, CMV Antigenemia assay Biopsy of cutaneous lesions Intranuclear inclusions ( owl s eyes ) Treatment: Uncomplicated CMV Supportive Immunocompromised pts or complicated infections Systemic therapy Ganciclovir Intravenous Valganciclovir Oral Cidofovir Foscarnet

16 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

17 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

18 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

19 HISTOLOGY Spindle cells forming slit-like vascular spaces Promentory sign TREATMENT HAART IF AIDS-related Topical retinoids Surgery Radiation Systemic chemotherapy Other associations: Castleman s disease Primary effusion lymphoma

20 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

21 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

22 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

23 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

24 Non-enveloped dsdna virus Infects basal keratinocytes in epithelium/mucosa Transmitted via direct skin contact Many subtypes and variable clinical presentation

25 Common 1,2,4 Plantar 1 Flat 3, 10 Butcher s 7 Condylomma accuminata 6, 11 Verrucous carcinoma 6,11

26 Heck s disease 13,32 Epidermodysplasia verruciformis 5, 8 Bowenoid papulosis 16,18 Digital SCC 16 Cervical cancer 16,18

27 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

28 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

29 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

30 Ecthyma contagiosum dsdna virus, Parapox Transmitted via contact with goats/sheep Clinically: Fever and lymphadenitis Stages: maculopapular, targetoid, acute, regenerative, papillomatous, regressive

31 dsdna orthopox virus Local reaction to site of smallpox vaccination with live virus Clinically: Erythema or pruritic papule Heals with pitted scarring Eczema vaccinatum

32 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

33 Jain, Sima. Dermatology. Springer, NY; Bologna, JL. et al. Dermatology 3 rd Edition. Elsevier Saunders, Philadelphia; 2012.