Herpes Virus Infections PDF

Herpes virus infections Prof. A. Kelati Dermatology Academic year: 2024-2025 www.um6ss.ma The course plan I-Introduction II-Herpes group 1. Herpes simplex 2. Varicella III-conclusion...

Herpes virus infections Prof. A. Kelati Dermatology Academic year: 2024-2025 www.um6ss.ma The course plan I-Introduction II-Herpes group 1. Herpes simplex 2. Varicella III-conclusion 2 I Learning objectives - 1. To diagnose Herpes infection with HSV-1, HSV-2 2. To recognize the varicella infection 3. Recognize the treatment modalities for these infections FACULTY OF MEDICINE – UM6SS – CASABLANCA 3  Introduction Group: Herpes Viridae About a hundred viruses: 8 strictly human HSV and VZV (Varicella-zoster virus ) +++ Widespread infections that are usually mild Recurrent Sometimes severe Latency state  Virology Hundred viruses: 8 strictly human: Herpes simplex: HSV1 & HSV2 Varicelle-zona: VZV Cytomegalovirus: CMV EPSTEIN-BARR: EBV HHV6: Roseolovirus ( Dress syndrom) HHV7 : Pityriasis rosea HHV8: Rhadinovirus (Kaposi)  Virology Common structure: High molecular weight double-stranded DNA virus Capsid: a protein cage surrounding the genetic material Replication requires DNA polymerase Target of antivirals HERPES SIMPLEX 7  Introduction Mucocutaneous herpes = All mucocutaneous manifestations due to HSV1 and HSV2 Chronic, contagious disease Characteristic sequence: primary infection, latency, recurrences  Epidemiology Human reservoir 2 types: HSV1 and HSV2 HSV1: Upper half of the body: Cephalic region 90% case Transmission: direct contact: Lesions or saliva Very common,can be contracted as early as childhood Infected adult population: 80% of the population  Epidemiology HSV2 : HSV2 =Sexually transmitted disease Lower half of the body Genital herpes: 80% HSV2 / 20% HSV1 Transmission : by genital contact, sometimes oral-genital or ano-genital Risk factors: early sexuality, multiple partners, History of other STIs  Natural history 1st contact with HSV: Primary infection, sometimes symptomatic but often asymptomatic Latency phase: a lifelong carrier! Trigeminal lymph node: orolabial herpes Sacral lymph nodes: genital herpes Endogenous reactivation : Recurrences Fever, sun Infections, stress, trauma, hormonal factors Immunosuppression (HIV, corticosteroid therapy, immunosuppressants, chemotherapy)  Histoire naturelle Primary infection often recurrence asymptomatic latence  Clinical aspects Orofacial Herpes Primo-infection Recurrences Genital herpes Primo-infection Recurrences Severe forms and complications  Orofacial herpes Primo-infection 1st contact with the virus: childhood +++ HSV1 +++++ Seroconversion : IgM ++ Often asymptomatic (90%) rarely symptomatic (10%)  Orofacial herpes Primo-infection a- Asymptomatic forms: +++ 90% cases, childhood b- Symptomatic forms: Rare 10% More symptomatic than the recurrences Acute Gingivostatitis….  Acute herpes gingivostomatitis (90% HSV1) Child: 6 months- 4 years Incubation = average 6 days (2 to 12 days) primo-infections Onset: Pain, Dysphagia, hypersiallorhea, fever 39-40° Sometimes subangillomaxillary lymphadenopathy Acute gingivostomatitis: Swollen and bleeding gums. Oral mucosa red haemorrhagic with greyish aphthoid erosions, with a peripheral red border, coalescing into polycyclic ulcerations covered with a whitish coating Erosive and crusty erythematous vesicular lesions on the lips + chin. Location: Gums, palate, inner side of the cheeks, tongue, even the pharynx Sometimes subangillomaxillary LADP Evolution = reduction of pain in 7 days, disappearance of L* without scars in 10-15 days.  Oral mucosa red Haemorrhagic with greyish aphthoid erosions, set with a red border, Herpes gingivostomatitis coalescing into polycyclic ulcerations covered with a whitish coating  Orofacial herpes Recurrences 80% of the adult population have latent HSV Only 20% have clinical recurrences Triggering factors: Febrile systemic infection UV Menstruation Stress Trauma; Regional Surgery Immunosuppression  Orofacial herpes Recurrences Particularities of recurrences: Less intense clinical signs, + short duration Location at the same site of the PI. General signs are minimal or absent Prodromes = pruritus, burning sensation, tingling Then: blisters are usually in clusters → erosions→ crusts Orofacial herpes Recurrences  Genital Herpes HSV2>>>>HSV1 STI+++ Adolescent and young adult Symptomatic or not  Genital Herpes Primary infection a- Asymptomatic forms: 40 to 80% of cases b – Symptomatic forms : Incubation = average 6 days (2- 20days ) Onset: tingling, pain, burning, paresthesia, pruritus Vesicles grouped in clusters evolving into polycyclic erosions if you’re in emergency you might have ladies w/ urine retention due to the pain associated signs: dysuria, vaginal or urethral discharge, fever, asthenia, LADP.....  Acute vulvovaginitis Acute balanitis  Genital Herpes Recurrences Same clinical appearance with: Less symptomatic Shorter duration Minimal or absent general signs  Virological diagnosis Diagnosis = essentially clinical +++ Sometimes: severe or atypical forms: Tzank's cytodiagnosis: Ballooning giant cells PCR: Sensitive, costly. Interest: Dg herpes meningoencephalitis (CSF) Serology: has value only in primary infection → seroconversion (IgM) NB: Positive IgG: no value because positive in a large majority of the population and signify previous contact with the virus +++  Treatment: ❖Curative treatment: Not really curative Primo-infection : Aciclovir : 200 mg ×5 times/day for 10 days Valaciclovir : 500 mg ×2 times/day for 10 days Recurrence: Aciclovir: 200 mg ×5 times/day for 5 days Valaciclovir : 500 mg ×2 fois/j pd 5 jours Severe forms: Intravenous aciclovir ❖Preventive treatment: If oral or genital recurrent herpes > 6 recurrences per year Varicella-Zona 34  Introduction Virus varicelle-Zona Varicella = primo-infection Shingles = viral reactivation a.k.a zona Benign disease, sometimes severe forms  Epidemiology Reservoir = strictly human Age : Varicella (Chickenpox) : 1 to 14 years (peak: 5 and 9 years) sometimes infant or adult (severity) Zona (shingles) : - after age 50 - Rare dans l'enfance (chickenpox in utero) - In young adults: should be investigated for HIV infection Transmission of VZV : Airborne ++++ Direct by contact with skin lesions Transplacental , hematogenous  Physiopathology After primary infection (chickenpox): migration of virions through the sensory axons to the sensory ganglia → Latent infection at this level Years later : reactivation of the infection in one of these lymph nodes → zona  Clinical Diagnosis a- Common Varicelle : A highly contagious disease with an average incubation period of 2 weeks (10 to 21 days) An exanthema: lesions of different ages+ pruritus Pink macules only itchy viral infection An acute vesicular eruption at different stages of development: papules, vesicles, pustules, crusted lesions, and healing lesions may all be present Then vesicles with clear contents and then the fluid becomes purulent umbilicated vesicles that dries out, forming a crust then depigmented or atrophic scar The site: beginning of the face and scalp, then: extension to the trunk and limbs, then mucous membranes, respect for the palms and soles An enanthema - Vesicles Erosions of the Oral Cavity - Sometimes: genital conjunctivae and mucous membranes General signs: fever, asthenia  Complications A- Superinfections of the skin and soft tissues: - Favoured by pruritus, lack of hygiene, taking NSAIDs (risk of necrotizing fasceitis) - Staph aureus , Strep B hemolytic A B- Mucosal complications: - Conjunctivitis, keratitis or keratoconjunctivitis C- Lung: Varicella Pneumonitis - Adult (pregnancy, smoking, immunocompromised), newborn - - 30% of deaths during adult chickenpox  Complications D- Neurological: Meningoencephalitis Peripheral involvement Sd de Reye: Encephalopathy and fatty liver disease Promoted by taking salicylates (aspirin) Fatal: 80%  Treatment General principles: No salicylates (REYE) or NSAIDs (necrotizing fasciitis) ++++ Hygiene rules: daily shower, nail clipping, clean laundry Symptomatic treatment: mild forms Local antiseptics: Chlorhexidine Antipyretics: Paracetamol, no NSAIDs Antihistamine: for pruritus ATB if superinfection  Zona Acute posterior ganglioriculitis, especially in adults Reactivation of a latent VZV limited to one lymph node (metameric characteristic) like following 1 dermatome Common in Immunodepressed patients (ID) In a young adult >> seek ID (HIV) Severity and complications with age Postherpetic pain: difficulty of management Reactivation:Zona  Positive diagnosis A - Clinique : TDD : Intercostal zona Most frequent + location: 50% of cases (D5 to D12) Onset: 3 to 4 days Unilateral radicular chest pain, such as burning before rash Eruption: Metameric unilateral topography Vesicles, grouped in a cluster, sometimes confluent in bubbles on Erythematous patches then crusts Extension over the entire metamer of the hemithorax Intercostal herpes zoster: vesicles grouped in a cluster of metameric arrangement B – Other clinical forms: Ophthalmic Zona : Visual prognosis ++++: ophtalmologic examination +++  Other locations: Zona of the upper limb Zona inguino-crural Zona of the leg Immunocompromised herpes zoster: HIV Necrotic herpes zoster, multi-metameric, visceral involvement possible Systematic HIV serology if zoster in young subjects  Complications : Postherpetic pain ++++: Rebellious, difficult specific managemnent (psychiatrist) General: rare Neurological: encephalitis, meningitis, myelitis, radiculitis Pulmonary or hepatic Ophthalmological: only for ophthalmic zona Keratitis > Blindness ++ Conjunctivitis, uveitis, retinitis, retinal necrosis, eyelid ulceration, glaucoma  Treatment: Symptomatic TRT: always No salicylates (REYE) or NSAIDs (necrotizing fasciitis)+++++. Local antiseptic care No systematic antibiotic therapy unless superinfection occurs Healing creams Vitamin Therapy (Vitamin B) Treatment of acute pain: in a step-up  Traitement antiviral : Local antivirals (creams): no interest Decreased acute pain and reduced the risk of postherpetic pain Interest within 72 hours. Oral: VALACICLOVIR: 3 g/day ACICLOGIR: 4 g/d Duration: 7 to 10 days Injectable: severe forms of immunocompromised patients  Conclusion Herpes: HSV = Mild condition that can be serious Recurrence Problem ++ HSV2: STIs: search for other STIs++ Varicella : - Highly contagious childhood viral disease, often mild - Adult over 50: risk of varicella pneumonia - Pregnant women: risk of fetopathy or neonatal varicella Zona : child with varicella -> tell the parents to avoid their kid being in contact w/ pregnant women - more common in the elderly - Postherpetic pain +++ - Ophtalmic Zona ++++ - Young subject>> HIV serology