Chris Hixon DO, PGY4Megan Joint DO, PGY 4

Lewis Gale Hospital Montgomery / VCOMProgram Director: Daniel S. Hurd DO, FAOCD

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

Classification Lytic Infection Latent Infection

Herpes Simplex Virus type 1

Alphaherpesvirinae Epithelial cells Neuron

Herpes Simplex Virus type 2

Alphaherpesvirinae Epithelial cells Neuron

HHV 3 – Varicella Zoster virus

Alphaherpesvirinae Epithelial cells Neuron

HHV 4 - EBV Gammaherpesvirinae Epithelial cells and B – cells

B Lymphocytes

HHV 5 - CMV Betaherpesvirinae Lymphocytes, Macrophages and Endothelial cells

Macrophages, Lymphocytes

HHV 6 Betaherpesvirinae CD4 T cells Lymphocytes

HHV 7 Betaherpesvirinae T cells T Lymphocytes

HHV8 Gammaherpesvirinae Lymphocytes Lymphocytes and Endothelial cells

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

Eczema herpeticum (Kaposi’s varicelliform eruption) Infection in areas of

dermatitis/skin barrier disruption

Herpetic whitlow

Ocular infections branching dendritic corneal lesions

Herpes Gladiatorum

Chronic enlarging ulcers

Neonatal HSV infection

Herpes Folliculitis

Encephalitis Temporal lobe

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 acyclovir-resistant HSV is present

Chronic suppression in those with > 6 outbreaks per year

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

• 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

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

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

PCR Use increasing, highly sensitive and rapid test

TREATMENT

Symptomatic treatment

Oral Antiviral medications within 24-72 hrs

Vaccine recommended for all immunocompetent individuals >60

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

“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

Nasopharyngeal carcinoma

Burkitt’s lymphoma

EBV found as latent infection in 97% of endemic, 15-85% of sporadic and 30-40% of AIDS-linked Burkitt's lymphoma cases

Common African manifestation

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 purpuraDeafness, retardation

AIDS patients:CMV retinitis blindness

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

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

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”

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

HISTOLOGY

Spindle cells forming slit-like vascular spaces

“Promentory sign”

Other associations: Castleman’s disease

Primary effusion lymphoma

TREATMENT

HAART IF AIDS-related Topical retinoids Surgery Radiation Systemic chemotherapy

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

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

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

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

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

Common – 1,2,4 Plantar – 1 Flat – 3, 10 Butcher’s – 7

Condylomma accuminata – 6, 11 Verrucous carcinoma – 6,11

Heck’s disease – 13,32 Epidermodysplasia

verruciformis – 5, 8 Bowenoid papulosis – 16,18 Digital SCC – 16 Cervical cancer – 16,18

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

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

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

Ecthyma contagiosum dsDNA virus, Parapox Transmitted via contact with

goats/sheep Clinically:

Fever and lymphadenitis

Stages: maculopapular, targetoid, acute, regenerative, papillomatous, regressive

dsDNA orthopox virus Local reaction to site of

smallpox vaccination with live virus

Clinically:

Erythema or pruritic papule

Heals with pitted scarring

Eczema vaccinatum

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

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

Saunders, Philadelphia; 2012.