ODS-836_LECTURE_02-Agut_15-2024-Part_1-PDF.pdf

ODS 836 Oral Pathology II Diseases of the Oral Mucosa Dr. Jose Luis Tapia Lecture 2 Part 1 08/15/2024 Vesiculo-Bullous Diseases  Vesiculo-Bullous Diseases Viral Diseases Herpes Simplex Virus Varicella Zoster Hand, Foot and Mouth Disease Herpangina...

ODS 836 Oral Pathology II Diseases of the Oral Mucosa Dr. Jose Luis Tapia Lecture 2 Part 1 08/15/2024 Vesiculo-Bullous Diseases  Vesiculo-Bullous Diseases Viral Diseases Herpes Simplex Virus Varicella Zoster Hand, Foot and Mouth Disease Herpangina Measles (This is not a vesiculo-bullous disease) Conditions Associated with Immunologic Defects Pemphigus vulgaris Cicatricial Pemphigoid Bullous Pemphigoid Dermatitis Herpetiformis Linear IgA Disease Epidermolysis bullosa acquisita Hereditary Diseases Epidermolysis Bullosa  Viral Diseases Virus Family Virus Disease Herpesvirus DNA HSV-I Primary herpetic gingivostomatitis Secondary herpes Herpetic whitlow Occasional genital HSV-2 Genital herpes Occasional oral VZV (HHV-3) Varicella, HZ Picornavirus RNA Coxsackie Hand-foot-mouth (enteroviruses) Herpangina Paramyxovirus Measles Measles RNA  Human herpesvirus family Virus Family Virus Disease Herpesvirus HSV-I (HHV-1) Primary herpetic gingivostomatitis Secondary herpes DNA Herpetic whitlow Occasional genital HSV-2 (HHV-2) Genital herpes Occasional oral VZV (HHV-3) Varicella, HZ Epstein-Barr virus (HHV-4) Infectious mononucleosis Burkitt’s lymphoma Nasopharyngeal carcinoma “Hairy” leukoplakia Cytomegalovirus (HHV-5) Salivary gland disease, Systemic disease (immunocompromised patients) HSV: Herpes Simplex virus HHV: Human Herpesvirus HHV-8 Kaposi Sarcoma  Herpes simplex infection HSV infections: vesicular eruption of the skin and mucosa Primary (initial infection) and secondary (reactivation) - self-limited HSV-1 and HSV-2 Pathogenesis: HSV-1 - spread through infected saliva or active perioral lesions - Pharynx, intraoral mucosa, lips, eyes and skin above the waist Incubation: several HSV-2 – Transmitted predominantly days to two weeks through sexual contact - Genitalia and skin below the waist HSV-1 Primary infection Incubation (days-2 wks.) oral/perioral tissues, usually subclinical or gingivostomatitis - neural latency (trigeminal ganglion) Secondary infection - Reactivation of the virus: old age, sunlight, cold, trauma, menstrual cycle, pregnancy, stress, dental treatment, fever respiratory illnesses, systemic diseases, malignancies, immunosuppression. - From trigeminal nerve to epithelium - Carcinogenic potential? No! https://www.verywellhealth.com  Herpetic Simplex Infection Primary infection (Acute herpetic gingivostomatitis) Mainly children / occasional adults. Vesicular eruption on perioral skin, vermilion, oral mucous membranes Vesicles rupture forming ulcers – pain Painful, enlarged and erythematous swelling of the gingiva – erosions Fever, arthralgia, malaise, headache, cervical lymphadenopathy Course of 7-10 days Healing without scarring In adults may cause pharyngotonsillitis Cytology smear or viral culture for the diagnosis if needed Primary Herpetic Stomatitis (Gingivostomatitis) 90% of cases are caused by HSV-1  Herpetic Simplex Infection Primary Pharyngotonsillitis in adults that closely resemble pharyngitis secondary to streptococci or infection mononucleosis Figure1.com  Herpetic Simplex Infection Secondary 15 to 45% of the USA population Prodromal symptoms: tingling, burning or pain (6 to 24 hrs. before) Within hours, vesicles - small ulcers - large ulcers Perioral skin, lips (herpes labialis), gingiva, palate. Self-limited!! Healing without scarring 2 wks. later Secondary Herpes Balasubramaniam R, Kuperstein AS, Stoopler ET. Update on oral herpes virus infec>ons. Dent Clin North Am. 2014 Apr;58(2):265-80. Immunocompromised patients may develop severe secondary disease  Herpetic Simplex Infection Herpetic Whitlow Primary or secondary HSV infection in fingers 4-6 weeks duration Primary or secondary HSV-1 or HSV-2  Primary and Secondary HSV Infection Cytology and Histopathology Lymphocytes Vesicle Keratinocytes (Cytology) Virally-induced cytopathic effect (multinucleation) Primary HSV Infection Vesicles!!!!!!! Differential Diagnosis: Primary herpetic stomatitis (usually apparent from clinical features) - Aphthous stomatitis - Streptococcal pharyngitis or infectious mononucleosis (adults) - Erythema multiforme - Herpes zoster - Acute necrotizing ulcerative gingivitis (ANUG-Vincent’s infection) - Leukemia Secondary herpes - Aphthous stomatitis (oral mucosa) - Herpes zoster - Impetigo (perioral) - Vesiculo-Bullous Diseases Associated with Immunologic Defects - Erythema multiforme - Contact allergy  Treatment of HSV Infection Primary herpetic stomatitis (gingivostomatitis) Fluids, rest, oral lavage, antipyretics No later than 48 to 72 hours from onset of symptoms (start therapeutic measures) Acyclovir caps. (400mg 3 times daily for 7 days) Acyclovir suspension - rinse and swallow (children: 15mg/kg up to the adult dose of 200 mg) Valacyclovir caplets (1000 mg daily for 5 days) Secondary herpes Topical treatment (5% acyclovir or analog/5 times a day) but its effectiveness is limited. Other topical: penciclovir cream 1%, every two hours during waking hours for 4 days. Systemic antiviral (Acyclovir or analog) American Academy of Oral Medicine. Clinical’s Guide to treatment of Common Oral Conditions Eighth ed. Siegel MA et al. 2017  Varicella-Zoster Infections Etiology and Pathogenesis: VZV (HHV-3) Primary: -Varicella (chickenpox) Latent in sensory ganglia Secondary: -Herpes Zoster (shingles)  Varicella - Mainly in childhood - Direct contact with contaminated droplets from skin lesions or air droplets - 2 wks. incubation period - Fever, malaise, pharyngitis and rhinitis pruritic exanthema (face, truck and extremities) vesicles, pustule, ulcer and crust. - Crops of vesicles with surrounding erythema -“a dewdrop on a rose petal” - Recovery in 2-3 weeks (self-limited) - Complications are pneumonitis, encephalitis Aspirin Reye’s syndrome (acute encephalopathy, liver failure) Infection during pregnancy: congenital defects Latent in sensory ganglia  Varicella Oral lesions: vermilion border palate and buccal mucosa Vesicles ulcers Relatively painless Oral lesions may precede Tx: symptomatic or antiviral the skin lesions Varicella After primary infection with VZV (Chickenpox), the virus is transported up the sensory nerves (dorsal root, cranial nerve or autonomic ganglia)  Herpes Zoster - Reactivation of latent VZV with involvement of the distribution of the affected sensory nerve. - Single rather than multiple recurrences - Predisposing factors: Immunosuppression in malignancies, drug administration, radiation, surgery of spinal cord, HIV, alcohol abuse, stress and dental manipulation. - Older population (decline in cell-mediated immunity) - Self-limited Prodromal, acute and chronic phases - Prodromal symptoms - burning, tingling, itching, or knifelike pain and/or paresthesia (prickly pain) of the involved area (dermatome), – thoracic 2/3 - Acute develops vesicle - pustule - ulcer (3 to 4 days) - crust after 7 or 10 days Lasts several weeks, cutaneous hyper or hypopigmentation - Chronic – 15% of patients, postherpetic neuralgia, months Ramsay Hunt syndrome: facial palsy, vesicles in ear, tinnitus, deafness, vertigo Herpes Zoster Hamid Ehsani-Nia, BS, MS* and Robert Rowe, MD  Ramsay Hunt syndrome http://www.cmaj.ca/content/189/8/E320 https://www.verywellhealth.com Ramsay Hunt syndrome Reactivation of VZV in the geniculate ganglion (CNVII) facial palsy, vesicles in ear, tinnitus, deafness, vertigo  Herpes Zoster Oral lesion – trigeminal nerve – vesicles, pustules, ulcerations The teeth in affected areas may develop pulpitis, pulpar necrosis, pulpar calcification, root resorption and tooth loss (osteonecrosis) https://www.verywellhealth.com Lee, CK, Baek, BJ. Images in clinical medicine: lingual zoster. N Engl J Med 2011;365(18):1726 Joel J. Napeñas Herpes Zoster Hutchinson sign (Nasociliary branch of the trigeminal nerve) https://www.nejm.org/  Varicella-Zoster Infections Histopathology: Same as HSV (vesicles)  Differential Diagnosis of VZ Varicella - Primary HSV - Hand-foot-mouth disease Herpes Zoster - HSV  Treatment of Herpes Zoster Acyclovir caps (800 mg/5x/day) for 7 days Velacyclovir caplets (1000 mg/3x/day) for 7 days American Academy of Oral Medicine. Clinical’s Guide to treatment of Common Oral Conditions Eighth ed. Siegel MA et al. 2017  Herpes Zoster 71-year-old man with a “shooting pain” for five days. Maxillary right canine was diagnosed as pulpar necrosis. Paquitin R et al., 2017  Herpes Zoster aaaaaaaaa 3 days after root canal treatment Paquitin R et al., 2017 Herpes Zoster “Toothache” during the prodromal stage aaaaaac aaaaaac aaaaaac Paquitin R et al., 2017 Enteroviruses Hand–foot-and-mouth disease Herpangina Acute lymphonodular pharyngitis  Hand-Foot and Mouth Disease Etiology and Pathogenesis Coxsackie virus A16, sometimes A5, A9, A10, B2, and B5. Enterovirus 71 Transfer by direct contact with fluids (saliva, nasal) or fecal-oral Clinical Features Children younger than 5 Lasts 1-2 weeks Flulike symptoms (sore throat, dysphagia and fever) lymphadenopathy Vesicles - ulcers anywhere in the mouth Concomitant multiple maculo-papular lesions on feet, hands, toes and fingers that eventually progress to vesicles and ulcers. Most cases are mild to self limiting. Hand-Foot and Mouth Disease Oral lesions typically heal within 1 week  Differential Diagnosis Hand-Foot-Mouth Disease - Primary HSV - Varicella The diagnosis HFM disease is usually made clinically without the need for special tests. If needed viral culture. Treatment is symptomatic  Herpangina Etiology and Pathogenesis Coxsackie virus A1-6, A8, A-10, A22, B3 Transfer by saliva or fecal-oral Clinical Features More often in children than adults in summer/early fall Mild to moderate fever, dysphagia, sore throat for less than a week Vesicles - ulcers soft palate, faucial pillars, tonsils Diffuse erythematous pharyngitis Most cases are mild to self limiting Herpangina Vesicles ulcers 7 to 10 days to heal The diagnosis is usually made clinically without the need for special tests. If needed viral culture.  Differential Diagnosis of Herpangina Primary HSV HFM disease Varicella Streptoccocal pharyngitis Aphthous stomatitis Treatment is not required  Measles This is not a vesiculo-bullous disease Etiology and Pathogenesis Measles virus (paramyxovirus) Airborne droplets Clinical Features Children Incubation of 14 days average 3 stages - 3 days - 9 day measles First stage: three Cs – coryza, cough and conjunctivitis (photophobia) - fever - Koplik’s spots (initial stage) – buccal and labial mucosa, soft palate Second stage: skin rash, fever continues, lymphatic involvement Third stage: fever ends and rash begins to fade – desquamation. Infectious period – 4 days before and 4 after appearance Complications are encephalitis, thrombocytopenic purpura  Measles (Rubeola) Maculopapular and erythematous rash Severe measles Pitted enamel hypoplasia Stephen Foley Koplik spots Blue-white macules (grain of salt)  Measles Histopathology Warthin-Finkeldey giant cells – pharyngeal tonsils Treatment Bed rest, fluids, analgesics  Viral Diseases Herpes simplex Virus Varicella Zoster Hand, Foot and Mouth Disease Herpangina Measles