11. Clinical Manifestations of Herpes Flashcards
(35 cards)
Herpes simplex virus infection
HSV Type 1
• ____, facial and ocular areas
• Infected ____ or active lesion
HSV Type 2
• Mainly affects ____ area
• ____ contact / birth canal
There are 8 types of Herpes viruses (all ____ stranded viruses)
◦ Herpes Simplex Type 1 and Type 2
◦ Herpes Type 3 (____ and Varicella)
◦ Herpes Type 4 (____ which causes mononucleosis)
◦ Herpes Type 5 (____)
◦ Herpes Type 8 (____)
These 6 herpes viruses causes evidence in oral cavity, Type 6 and 7 are mostly associated with ____ reactions, and very rare. We don’t see them in the ____ cavity.
oral
saliva
genital
sexual
double chicken pox eppstein-bar CMV kaposi sarcoma hypersensitivity oral
Most common infection - Herpes Simplex Infection
◦ Herpes Type 1 and Type 2 give rise to exactly same type of ____
◦ But Type 1 manifests itself in the ____ area, whereas Type 2 is in ____.
‣ However, Type 1 can cause genital herpes, and Type 2 can cause oral-facial herpes.
‣ Wherever the lesions are, infections manifest the same way.
‣ They produces ____, vesicles (small) and bullae (large).
◦ Type 1,2,3 produce blisters initially before they ____.
◦ Herpes Type 1 is contracted via infected ____. This manifests early in life or in college years. Kissing etc.
◦ Herpes Type 2 is mostly seen as ____ transmitted disease. But this can also happen due to Type 1 with oral-genitalia contact.
diseases head and neck genitalia blisters ulcerate saliva sexually
How do these viruses manifest?
◦ Manifest as ____. Patient experiences ____ signs of symptoms
‣ (headache, nausea, malaise, fatigue, diarrhea, stomach ache - we call them ____ signs of symptoms which are common to many diseases)
◦ Contract this as a little child, and have these symptoms, the doctor might have just attribbuted them to a cold/flu virus, whereas it was Herpes.
◦ Non-specific, transient, acute = during this time frame, you are ____.
◦ Only in subset of lesions will produce these lesions.
blisters
non-specific
B
contagious
Primary herpetic gingivostomatitis \_\_\_\_ age of onset Mode of transmission is usually infected \_\_\_\_ \_\_\_\_ disease Abrupt \_\_\_\_
Only SMALL subset of people manifest these lesions. But when they manifest these lesions they are very characteristics.
‣ ____ symptoms
‣ Lesions are papular, erythematous, itchy and painful
‣ After a few days, they become blisters
‣ Then the blisters ruptures, it becomes an ____
If these blisters in the patient ruptures –> get ulcers –> also heals ____
‣ So these are spontaneously healing lesions
Once you are infected, you are infected for ____. It sits latent/dormant then gets reactivated at some time of person’s life.
Initial infection: bimodal (very young age or college age)
‣ Very rare for a patient to be diagnose with primary Herpes who is over ____+ years old
‣ Third world countries - 80% DNA have Herpes
Can contract this via infected ____, kissing - and manifest itself as blisters and leave an ulcer and then heal.
Referring to the image: 13 yr old boy - acute onset - non specific signs of symptoms were seen and then 2 days later he woke up like that. Dr. Alawi asked the boy if he came into contact with someone who had a cold sore. He kissed a girl in his school dance and got Herpes.
bimodal
saliva
vesiculobullous
onset
non-specific
ulcer
spontaneously
life
30
saliva
Primary herpetic gingivostomatitis
- constitutional signs and symptoms
- ____ and non-____ mucosa
- acute disease lasts about one ____
- symptoms subside ____
These lesions affect both keratinized and non-keratinized tissue (IMPORTANT)
◦ Why it’s important?
‣ ____ sores - a common oral condition manifests as ulcerations . These happen in the non-____ lesions.
‣ Keratinized surfaces in oral cavity: ____ tongue, ____, ____ gingiva (everything else is non-keratinized)
◦ Primary Herpes - no restriction to which tissue, both keratinized and non-keratinized can happen
◦ Secondary Herpes - only in ____ tissue
◦ Canker sores - ____ tissue
Keratinized: for ____
Non-keratinized: for ____ sores
But ____ patients are in disadvantage, and can have prolonged disease. It can be an opportunistic infection with immunosuppresed patient (you’ll get it worse than for someone who is healthy)
keratinized
keratinized
week
spontaneously
canker keratinized dorsum hard palate attached
keratinized
non-keratinized
herpes
canker
immunosuppressed
Desquamative gingivitis • Erosive lichen planus • Lichenoid mucositis • Mucous membrane pemphigoid • Pemphigus vulgaris • Graft vs host disease • Lupus erythematosus • Primary herpetic gingivostomatitis
Don’t need to worry about the list of diseases.
Know that ____ can manifest itself as Desquamative Gingivitis (separating and peeling). The image: college kid who has Desquamative Gingivitis (part of differential diagnosis)
primary herpes
• Adult onset
– Pharyngitis and tonsillitis
• Supportive and symptomatic therapy only
ADULT patients who contract Herpes for the first time
• Manifest with a severe ____ throat (you can palpate it on the neck)
• Diffuse disease that affects the oropharyngeal area
• Most patients with this don’t manifest actual lesions as we saw before
• Either way, it is an ____ disease (10-14 days)
◦ No ____ necessary during this time, nothing you can do to accelerate healing process
◦ Make sure they maintain their nutrition and ____ (can drink milk, water and recommend drink over the
counter milkshakes - which will help them maintain nutrition. You should avoid ____ and soft drink, with any irritation)
If you are going to prescribe medicine - recommend viscous ____ if they want to eat soemthing solid
• will numb their mouth and will help them eat and the numbness will resolve in minutes
• But this is ____ NOT curative.
sore acute treatment hydration citrus
lidocaine
palliative
Herpes simplex
• After primary infection, the virus establishes ____
– HSV-1 infection - ____
– HSV-2 infection - ____
• Reactivation induced by variety of stimuli
– More common and severe in ____ patients
Once you contract this, you are infected for ____.
Once it is dormant, the DNA is incorporated into your ____ but its not active. It can get activated later on life.
Herpes simplex - acute ____ exposure reactivates the virus into it’s ____ phase. Other potential foods and things can also trigger the virus (____, lemon, hormones - but no common link with them for sure)
If you are immunocompromised reactivation happens more ____ and you will get the disease for ____ period of time.
latency
trigeminal ganglia
sacral nerve root ganglia (S2-S5)
immunocompromised
LIFE
genome
UV lytic menstruation frequently longer
Secondary herpes
- at site of primary ____
- most common on ____ (herpes labialis)
- ____ signs and symptoms
‣ Before cold sores, patients will report ____ signs of symptoms (itchy, sore, few days later a
papule - blister - ulcer)
◦ Before lesion manifests - we call this ____
‣ No amount of ____ treatment will get this lesion away
‣ But this phase of disease is ____
‣ If you always experience cold sores, and before getting the lesion (during prodrom phase) if you take
an anti-viral drug (orally or topically) that will preempt the lesion and will minimize it’s duration or size.
‣ ____ cycle - once someone does something, they know they will get the cold sore
‣ ____ - medication for these cold sores (more helpful)
inoculation
vermilion
prodromal
non-specific prodromal anti-viral preventable routine acyclovir
Secondary herpes
- ____ papules > vesicles > ____
- ____ recurrence
- continuous ____ shedding
Secondary Herpes
◦ Just like primary lesions, lesions are the same just this one is more limited
◦ If more than one vesicles, ulceration will coalesce and form a bigger ____
◦ Recurrence changes from patient to patient
‣ If recurrence is frequent -> only those patients benefit from the ____ therapy
◦ Once lesion is present, that patient is actively ____ virus.
‣ Lesion is active, infective and ____ locally (not systemically) - contract it via ____ contact.
Once the ulcer dries, the virus is not ____ and the patient is not ____.
erythematous
ulceration
variable
viral
ulceration medicinal shedding contagious direct
active
contagious
Secondary herpes
These patients are ____ so their lesions are more ____. This kind of lesions won’t happen in normal patients
immunocompromised
aggravated
These happened due to sharing ____ and eye ____. Developed secondary herpes of the eyelid.
mascard
makeup
A dentist treated someone without gloves, and developed a ____. This is ____ herpes.
herpetic whitlow
primary
High school Wrestling - direct contact with kids who are infected ____
herpes gladiatorum
A young kid who is infected via ____ from a mother who was infected. Developed very severe Herpes.
____ (happened in a neonate because the immune system is very weak)
Secondary herpes will be at the site where it got initially ____ and it will be small.
birth canal
eczema herpeticum
infected
- Intraoral - restricted to ____ surfaces
- ____ healing
- NO ____
- Tx: ____ and prophylaxis
Some patients might get intraoral herpes. When they reoccur later on in secondary form, they are restricted to ____ tissue. Almost always ____ palate or ____ gingiva, not really on dorsum of tongue.
These lesions will heal over a few days,
Both patients got dental treatment and it led to recurrence of Herpes (trigger for Herpes).
If you are going to treat, you need to treat with ____ phase and ____ treatment. If the lesion is already present, you can’t treat it. You just give it ____ treatment.
• ____ - for patients who have no recurrences
◦ HIV+ patients who have more severe recurrences and disease –> so give ____ + prophylaxis
• DO NOT GIVE STEROIDS
◦ ____ act on the virus
◦ Steroids suppress ____, so you are suppressing the immune response that suppress the virus. If you give steroids, it can make the disease state worse
keratinized
spontaneous
steroids
antivirals
keratinized hard attached prodrom anti-viral palliative
prophylaxis
anitvirals
lymphocytes
lymphocytes
Herpes identification • PCR • Biopsy – \_\_\_\_ – Multinucleated giant cells – \_\_\_\_ inclusion bodies • Smear – see \_\_\_\_ cells
How do you identify? • PCR (gold standard) ◦ Get a swab and run Herpes test ◦ Problem: very \_\_\_\_ not everyone can afford ◦ Easier and painless than biopsy
• Biopsy
◦ Less expensive (instead of using PCR)
◦ What you see in Biopsy of Herpes:
‣ ____, ____ cells, ____ stoning, ____ giant cells and ____ bodies
Biopsy of Herpes mimics features in ____
◦ Tomb stonings, Tzanck cells and acantholysis
What you don’t see in Pemphigus, but see in Herpes are large ____ epithelial cells.
◦ The nuclei are smushed together (____ for Herpes infection - specifically for Herpes Simplex Type
1, Type 2 and Herpes Zoster all show similar biopsy structures.
◦ Problem with Biopsy: you can’t differentiate between different ____ of Herpes bc they all look the same
acantholysis
eosinophilic intranuclear
Tzanck
expensive acantholysis tzanck tomb multi-nucleated eosinophilic
pemphigus vulgaris
multi-nucleated
pathoneumonic
types
SMEAR • Equally painless as PCR • Scrape a lesion and put it in a slide • Stain the slide with \_\_\_\_ stain and we look for \_\_\_\_ cells that are pathognomonic for Herpes infection
• Problem:
◦ Also can’t tell the ____ of Herpes virus this is because they all show the same structures under microscope
PAP
multi-nucleated giant
type
FYI - Cutting edge medicine
• October 2015 FDA approved modified HSV-1 for melanoma treatment
– Kills ____ cells
– Triggers ____ system
Because Herpes is so prevalent and evokes a potent immune response,
FDA approved using ____ for chemotherapy specifically for ____.
This modified virus binds to malignant cancerous ____ and when it binds to the cell, it evokes a very potent immune reponse and the immune cells target those cells with ____
Used as therapy for ____.
cancer
immune
herpes simplex type 1
melanoma
melanocytes
NK cells
malignant melanoma
Chicken pox
• ____ virus
• Highly ____
• ____ very effective
◦ As an adult, if you contract Chicken Pox, it will be ____ than getting it while you are young.
◦ Chicken Pox is a ____ disease
‣ Varicella zoster virus
‣ It’s Herpes ____ (different than Herpes Simplex Type 3)
◦ When one kid has chicken pox, families bring the kids with the other kid and have chicken pox parties.
‣ But not a good thing to do because it can be fatal to the kid (very unusual reactions)
◦ This disease is preventable with ____
Robust decrease of chicken pox incident rates with the introduction of vaccine.
varicella zoster
contagious
immunization
worse
type 3
vaccination
Lesions are almost identical to____ infections.
First ____ –> ____ –> rupture –> ____
Chicken Pox is an acute disease and can last ____ than Herpes Simplex (at most 2-3 weeks). During their disease state, they are highly ____. Unlike Herpes Simplex, chicken pox is a ____ disease.
herpes simplex papular vesicles ulcer longer contagious diffuse
Herpes zoster
• ____ of VZ virus
• Prodromal pain and lesions involving ____
– Area of mucosa/skin innervated by ____ nerve
Like Herpes Simplex, the chicken pox virus is sitting in the ganglion still. You are infected for ____. It sits at the location (lie dormant at the trigeminal ganglion) where you initially got the disease.
But unlike Herpes Simplex, reactivation of the virus will lead to a debilitating and a ____ disease. In healthy person, when chicken pox is reactivated, leads to whole array of lesions that follow the distribution of the nerve coming from the ____.
In Trigeminal Ganglion, V1, V2 or V3 can be affected. Part of a nerve, or multiple nerves can be effected. This is called a ____ (represents the tissues innervated by the nerves where the virus is lying dormant).
Dermatomes - Represents the areas where the lesions will occur.
reactivation
dermatome
single spinal
life
diffuse
ganglia
dermatome
Shoulder - affected by the ____
◦ This patients lesion stop at the ____ and same thing happens down at the hip also
◦ The lesion is confined to a ____ (innervated by the nerve where the ____ was lying dormant)
◦ ____
shingles midline dermatome virus defined
Shingles at ____ branch - only one ____ is infected. The kid also has ____ involvement.
V1
side
V1
