Viral Infections

Eman Elmorsy, M.D.

A. Professor of Dermatology & Andrology
Viral infections

Papular Vesicular
1. Warts Herpes Simple Varicella
2. Molluscum • Primary • Herpes zoster
• Recurrent • Chicken pox
Herpes Virus Infections
Taxonomy

Virus Code. 31.1.1.0.001. Virus Accession number

31110001.
Synonym(s): human (alpha) herpes virus 1; herpes
simplex virus 1.
Approved acronym: HHV-1. Virus infects vertebrates.
Description is on taxonomic level of species. Virus is
the type species of the genus. Virus belongs to the
genus Simplex virus (VC 31.1.1. ); subfamily Alpha
herpes virinae (VC 31.1. ); family Herpes viridae (VC
31. ).
Herpes simplex

Organism
Herpes virus hominis type 1 (mainly face
non-genital areas) or type 2 (ano-genital).
Herpes simplex

Pathogenesis
Primary infection: in infants and children where
no immunity against the virus. The virus
ascend the peripheral nerves to the dorsal root
ganglion. After healing the virus remains latent
in the dorsal root ganglion.
Secondary infection: latent virus particles
descent from the dorsal root ganglion along
the nerves  skin recurrent infection.
Herpes simplex

Pathogenesis
Primary infection: in infants and children where
no immunity against the virus. The virus
ascend the peripheral nerves to the dorsal root
ganglion. After healing the virus remains latent
in the dorsal root ganglion.
Secondary infection: latent virus particles
descent from the dorsal root ganglion along
the nerves  skin recurrent infection.
Herpes simplex

Pathology:
Ballooning and reticular degeneration of
the epidermis with giant cells.
Derma cellular infiltration and vasculitis.
A- Primary Herpes simplex

Constitutional symptoms and usually wide

spread.
Morphology
Grouped painful vesicles on erythematous
base rupture erosions, crustation or
plaque formation.
Course
2-6 weeks.
A- Primary Herpes simplex

Localization
Primary gingivostomatitis:
Erosions on the mouth interfere with
feeding. May coalesce  yellowish
plaque.
A- Primary Herpes simplex

Localization
Keratoconjunctivitis:
Dentritic painful keratitis and conjunctivitis
 corneal opacity.
A- Primary Herpes simplex

Localization
Vulvovaginitis:
Pain dysuria  vesicles  vagina  cervix.
Urtheritis and cystitis.
Groin skin may be affected
A- Primary Herpes simplex

Localization
Primary genital in the male
The vesicles and erosions on the penis and
pubic area with tender lymphadenopathy.
A- Primary Herpes simplex

Localization
Primary inoculation herpes (whitlow):
In dentists and surgeons.
At the site of trauma (fingers with
supratrochlear or axillary lymph nodes.)
A- Primary Herpes simplex

Localization
Kaposi varicellifom eruption:
In children suffering of atopic dermatitis,
and Dareir’s disease.
Generalized vaccinator eruption with
umblicated bullae.
B- Recurrent Herpes simplex
B- Recurrent Herpes simplex

Precipitating factors:
Common cold, influenza and other
febrile condition.
Sun exposure.
Gastro-intestinal troubles
Septic focus
Psychological stress or anxiety.
Drug or food allergy.
B- Recurrent Herpes simplex
B- Recurrent Herpes simplex
B- Recurrent Herpes simplex
B- Recurrent Herpes simplex

Localization
Face:
Orificial, periorifcial: lips, nostrils, ears and
eyes and cheeks.
Mucous membrane:
Buccal mucosa, tongue, pharynx, larynx and
conjunctiva
Genitalia:
Glans penis, clitoris, labia, cervix and urethra.
B- Recurrent Herpes simplex

Morphology
Grouped vesicles on an erythematous
base.
Vesicles contain clear fluid  purulent
 rupture (few days) crust formation
under which epitheliazation occurs.
Or leave erosion within 4-12 hours and
heal spontaneously within 5-7 days.
B- Recurrent Herpes simplex

Diagnosis
Clinical picture
Tzank test: scrapping the vesicle base  Giemsa 
giant multinucleated cells
Viral culture
Immunofluorescence
PCR
Electron microscopy.
Differential diagnosis: other cause of bullous
eruption.
B- Recurrent Herpes simplex

Treatment
General measures
Avoid predisposing factors.
In severe cases hospitalization and
immuno-stimulant .
B- Recurrent Herpes simplex

Treatment
Local measures:
Compresses: remove crust
(K permengnate/saline).
Local antiviral: (acyclovir, iodoxurdidine).
Drying agent: gentian violet in oozing
lesions.
Local antibiotics: in secondary infection.
Local analgesic creams.
B- Recurrent Herpes simplex

Treatment
Systemic:
Usually needed in the first attack and
severe recurrent cases:
Acyclovir (Zovirax®): 200 mg 5 times daily
for 5-10 days; 200 x 5 x 5
Famcyclovir (Famvir®) 125 twice daily for 5
days.
C- Herpes zoster (Shingles)

Organism:
Varicella zoster virus.
Pathogenesis:
Droplet viral infection  olfactory bulb 
nervous system  dorsal root ganglion
 skin along the peripheral nerves.
Some-times spread to anterior horn cells
 paralysis.
C- Herpes zoster (Shingles)

Predisposing factors:
Trauma.
Acute inflammation.
Debilitating diseases.
Immunosupression.
C- Herpes zoster (Shingles)
C- Herpes zoster (Shingles)
C- Herpes zoster (Shingles)
C- Herpes zoster (Shingles)
C- Herpes zoster (Shingles)
C- Herpes zoster (Shingles)
C- Herpes zoster (Shingles)
C- Herpes zoster (Shingles)
C- Herpes zoster (Shingles)

Pathology:
Ballooning degeneration of basal cell
layer by marked acantholysis due to
damage of intercellular bridges 
separation  formation of unilocular
vesicle with the presence of
multinucleated cells (characteristic).
C- Herpes zoster (Shingles)

Pathology:
Reticular degeneration due to increased
intracellular edema  cell distension 
rupture  coalescence of nearby cells
 multilocular vesicles.
Dermal changes: inflammatory cellular
infiltrate, damage of capillary
endothelium (haemorrahgic).
C- Herpes zoster (Shingles)

Clinical Picture:
Symptoms:
Pain (mild to severe) usually at the site of eruption. I
may precede, associate or follow eruption.
Localizations:
Usually unilateral along the course of a nerve or
nerves.
Pectoral region: commonest
Head: along facial, trigeminal nerve
Abdomen: intercostals or lumbar nerves
Lower limbs
Genitals
C- Herpes zoster (Shingles)

Clinical Picture:
Morphology:
Grouped vesicles on erythematous base,
which contains clear fluid  purulent
contents  some vesicles rupture 
crustation the others may dry up.
C- Herpes zoster (Shingles)

Clinical Types:
A. According to the site:
Herpes zoster pectoralis:
Involve one of the intercostals nerves  eruptions
in one side of the chest and back.
Pain may be mistaken as chest pain.
HZ cervicalis:
Along the cervical nerves.
HZ abdomenalis:
Abdominal nerves may be mistaken as renal or gall
bladder or even appendicitis.
HZ lumbosacral:
In genitals, groin and sacral regions.
Sine-herpetes  urinary manifestation without
cutaneous lesions.
C- Herpes zoster (Shingles)

Clinical Types:
HZ cranialis:
Frontalis:
Involvement of supra-orbital nerve (trigeminal TG branch)
 forehead and scalp.
Ophthalimicus:
ophthalimic division of TG  eye (conjunctivitis or keratitis)
may be affected if nasociliary branch affected  vesicles at
the side of the nose.
Maxillary branch of TG  vesicles on uvula and tonsillar
area.
Mandibular branch of TG  vesicles on posterior
tongue, buccal mucosa.
Facial:
Ramsy Hunt syndrome due to involvement of geniculate
ganglion  ear pain and vesicles on external ear+ facial
palsy and loss of hearing (auditory nerve).
C- Herpes zoster (Shingles)

Clinical Types:
Bilateral:
Rare associated with constitutional
manifestation in debilitating diseases and
immunocompromised patients.
C- Herpes zoster (Shingles)

Clinical Types:
B. According to morphology:
Classical
Abortive
Grouped papular  healing
Haemorrahgic
Vesicles filled with blood in debilitating &
immunocompromised.
Gangenerous
Gangrene develops at the site of infection due
to thrombosis of derma vessels.
C- Herpes zoster (Shingles)

Complications
Secondary bacterial infections.
Eczematization.
Gangrene.
Post hereptic neuralgia.
Systemic affection
Ocular
Keratitis
Neurological
Facial palsy, meningitis& myelitis.
Urinary bladder
Cystitis
C- Herpes zoster (Shingles)

Treatment
Systemic:
Analgesic to relief pain and as anti-inflammatory in
some case you may give corticosteroid or ACTH.
Vitamin B1&12 to support the nerve.
Acyclovir (Zovirax®) 800 mg 5 times daily for 7-10
days.
Famcyclovir (Famvir®) 500mg daily for 5 days help
to decrease post herpetic neuralgia (antiviral).
Antibiotics: for secondary bacterial infections.
C- Herpes zoster (Shingles)

Treatment
Local treatment
Analgesic creams.
Anesthestic cream.
Antibiotics if secondary infected
Antiviral acyclovir in early lesions.
Drying agents.
Chicken pox (varicella)

Organism
Varicella zoster virus primary infection
Incubation period
2 weeks.
Clinical picture:
Mild constitutional manifestation
Localization
On the trunk, scalp, face, mucous membrane and
extremities
Chicken pox (varicella)

Morphology
Papules or macules  vesicles or
bullae  pustules  crust. All the
lesions are present at the same time
(polymorphism)  usually heal within 7-
10 days with normal skin.
Chicken pox (varicella)
Chicken pox (varicella)

Differential diagnosis
Complication
Secondary infection
Systemic involvement ( pneumonia).
Chicken pox (varicella)

Treatment
Bed rest
Systemic antibiotics
Local drying agents or antibiotic
In severe cases:
Acyclovir or gammaglobulins.
Thank you
Eman El Morsy