SSS Week 3

Herpes Simplex Virus infection (types, recurrence, complications, diagnosis, treatment

• clinical sign: grouped vesicles on an erythematous base

• spread via resp droplets or direct contact with an infected lesion or bodily fluids

• HSV enters host through abraded skin or intact mucous membranes

• targets epithelial cells initially but retrograde transport through adjacent neural tissue to sensory ganglia leads to lifelong latent infection

two types: HSV1 and HSV2

HSV1 is more associated with oral n facial infections (cold sores)

• often initial episode has no symptoms but can be severe if have systemic symptoms

• vesicles turn quickly into ulcers (red based)

HSV2 more associated with anogenital herpes

• presents after onset of sexual activity

• painful vesicles, ulcers, redness and swelling last for 2-3 weeks, often accompanied by fever and tender inguinal lymphadenopathy

minor injury helps inoculate HSV into skin

How can HSV recur

• can either be local or systemic stimuli

• UV light

• fever

• trauma

• mensturation

• sexual intercourse

• stress

• immunodeficiency

recurrence is often less severe 

Complications

• eye infection: dendritic ulcer

• throat infection

• eczema herpeticum (in patients with history of atopic dermatitis or darier disease)

• erythema multiforme (target lesions, symmetrical plaques on hands, forearms, feet and lower legs)

• cranial/facial nerve infections by HSV (bells palsy)

• widespread infection —> disseminated infection (eg. can occur in a HIV patient)

Diagnosis

• clinical diagnosis, culture and PCR

treatment

• mild uncomplicated eruptions of herpes simplex require no treatment

• sunscreen and other sun protection measures are crucial as sun exposure often triggers facial herpes simplex

for mild oral lesions: topical acyclovir

severe infection may require treatment with an oral antiviral agent

• acyclovir

• valaciclovir

• famciclovir

theyre suppressive not curative

How can HSV recur

can either be local or systemic stimuli

• UV light

• fever

• trauma

• mensturation

• sexual intercourse

• stress

• immunodeficiency

recurrence is often less severe 

Diagnosis for HSV

Clinical diagnosis, culture, PCR

Treatment for HSV

• mild uncomplicated eruptions of herpes simplex require no treatment

• sunscreen and other sun protection measures are crucial as sun exposure often triggers facial herpes simplex

for mild oral lesions: topical acyclovir

severe infection may require treatment with an oral antiviral agent

• acyclovir

• valaciclovir

• famciclovir

theyre suppressive not curative

Varicella (chickenpox) (rash, lesion characteristics, diagnosis, complications, treatment, vax?)

• caused by varicella-zoster virus

• remains in dorsal ganglia of the spinal cord —> can reappear later as shingles or herpes zoster infection

spread via inhalation of resp droplets or direct contact with the vesicles’ fluid.

RASH: begins on trunk and spreads to face and extremities (the opposite of rubella and measles)

LESIONS are: 2-4mm red papules —> become vesicular and umbilicated —> breaks and crusts over leaving an eroded red base 

diagnosis

• made clinically in typical cases

• can be confirmed by PCR on a viral swab from base of vesicle 

complications

• secondary bacterial infection from scratching

• dehydration from vomiting and diarrhoea

• systemic: 

~ viral pneumonia

~ encephalitis

~ thrombocytopenia

~ hepatitis 

~ scarring

pregnancy complications

• If a non-immune pregnant woman is infected:

◦ Maternal varicella pneumonia (serious).

◦ Congenital varicella syndrome (limb hypoplasia, eye/brain defects, skin scarring in fetus).

◦ Severe neonatal varicella if infection occurs just before or after delivery.

treatment

symptomatic eg. antipruritis lotions, antihistamines?

• antiviral therapy is indicated for patients with complications or who are immunocompromised 

antiviral agents include acyclovir, valacyclovir, famciclovir (same as HSV)

varicella-zoster immune globulin (VZIG) is indicated for immunocompromised and neonates exposed to varicella (must be given within 96 hours of exposure)

vaccination

• immunisation schedule in australia for infants aged 18 months and children 10-13 years who have not been previously immunised or previously had varicella infection

• zoster vax has also been introduced for patients over 60 and who are most at risk of this condition

Herpes Zoster (shingles) +diagnosis, clinical features, treatment

• reactivation of varicella virus localised to one or two dermatomes (what ur auntie had)

• virus remains in selected ?anterior? horn cells of spinal cord before it is reactivated and grows down the nerves to the skin

• predisposing factors apart from age are immunocompromised individuals eg. HIV

Diagnosis

• clinical

• viral PCR for herpes zoster virus

clinical features

• unitlateral

• dermatome (one or several)

first sign of shingles is usually pain, which may be severe, in areas of one or more sensory nerves. the patient may appear quite unwell with fever and headache, lymph nodes draining the affected area are often enlarged and tender

pain —> closely grouped lesions start as erythematous papules or plaques —> turn vesicular and become crusted —>over a course of 2-3 weeks clear vesicles appear in the affected dermatome

complications

• post-herpetic neuralgia (can last for years)

• corneal damage if CN V involved

• encephalitis

• myelitis causing contralateral hemiplegia

*Hutchinson’s sign - vesicle on side or tip of nose in ophthalmic zoster (WHAT UR AUNTIE HAD)

treatment 

• antiviral medication within 72 hours

• analgesia

• vaccination for patients over 60 

Viral exanthem

rash due to a virus

can be divided into

1. classic eg. measles rubella

2. non-specific (in children usually enteroviridae (coxsackie or echovirus))

whereas there are specific presentations with varicella, measles, rubella, hand, foot and mouth disease, parvovirus (slapped cheek), roseola, pityriasis rosea

What are the two non-specific presentations of viral exanthem in children

1. generalised, bilaterally symmetrical maculopapular rashes, often with confluence on the face

2. peripheral papular eruptions mainly on arms and leg

Measles (clinical presentation, diagnosis, complications)

• spread via resp droplets

clin presentation

• initially URTI symptoms of fever, malaise, cough and conjunctivitis

• characteristic KOPLIK spots (pinhead size white spots on buccal mucosa) in prodromal stage —> a widespread morbilliform (macular) rash appears HEAD then spreads to TRUNK and limbs

• non-pruritis rash

• macules may coalesce, esp on face

• when it fades —> purplish hue —> brown/coppery coloured lesions with fine scales

diagnosis

clinical n confirm with serology

complications (Did this in GH)

• diarrhoea

• otitis media

• pneumonia

• encephalitis

vax at 12 months of age

*notifiable disease

Rubella (german measles) = presentation, diagnosis, complications

• mild pink maculopapular rash and lymphadenopathy

• begins on FACE and spread to TRUNK and limbs (less widespread than measles)

• mild fever, sore throat and rhinitis

• adults have arthralgia and arthritis

• infected by direct contact with nasal or throat secretions of infected individuals, infected personcontagious 7 days prior to rash, until 7 days after

diagnosis

• clin and confirm with serology (same as measles)

complications

• first trimester of pregnancy has 50% risk of congenital rubella syndrome (sensorineural deafness, CNS dysfunction, cataracts, cardiac defects)

*notifiable disease (like measles)

rubella vax is on national schedule

Hand, foot and mouth disease (clin presentation + DDx + diagnosis)

most often affecting young children under 5

• due to coxsackie virus A16

children present with small red macules that rapidly evolve into cloud vesicles and surrounded by erythematous areola in the oral cavity

• there may be lesions distributed over plams and soles, and dorsal fingers or toes

• 20% of cases have submandibular / cervical lymphadenopathy

DDx for hand, foot and mouth disease

• enterovirus 71 infection

• herpetic stomatitis

• aphthous ulceration

• herpangina

• erythema multiforme

• scabies

(see the ppt for explanation on ddx)

diagnosis

clin and serology (same as measles and german measles (rubella))

DDx for hand, foot and mouth disease

• enterovirus 71 infection

• herpetic stomatitis

• aphthous ulceration

• herpangina

• erythema multiforme

• scabies

(see the ppt for explanation on ddx)

Parvovirus infection - slapped cheek - fifth disease (clin features, treatment, complications, DDx)

• parvovirus B19

transmitted via resp droplets

clin features

• firm red burning-hot cheeks

• rash follows with lace or network pattern on limbs and then trunk

treatment - supportive

complications

• in pregnant women may cause foetal anemia and cardiac failure and fetal loss

• arthralgia in adults

DDx

• enterovirus exanthemata

• rubella

• scarlet fever

Roseola (clin presentation and treatment?)

transmitted via resp droplets

• HHV-6B, HHV-7

clinical presentation

• high fever and upper resp symptoms

• rash appears as fever subsides (days 3-5)

• rash: small pink or red maculopapular rash that blanch when touched, may be surrounded by lighter halo of pale skin

• begins on TRUNK and may spread to neck, face, arms and legs (sort of like varicella)

• non-itchy, painless and does not blister

no treatment required

Pityriasis Rosea (presentation)

• rash of unknown cause (possible reactivation of Herpes 7 or 8 virus)

• most commonly affects teenagers or young adults

PRESENTATION

• single inner circlet of scaling, oval red or pink plaque (the HERALD patch) appears before general rash

• few days later, smaller plaques appear on chest n back, uncommon on face

• these lesions follow the relaxed skin tension lines (LANGER’S LINES) on both sides of upper trunk (so it looks like a fir tree?)

• can be very itchy and sometimes not at all. on darker skin they appear more pigmented or white due to scales

Monkey pox (MPox) - presentation, transmission, prevention, diagnosis, treatment and vax

• viral zoonotic disease

presentation

• general symptoms (fever, chills, headache, muscle aches, back aches, fatigue, swollen lymph nodes)

• USUAL symptoms: rashes, pimple-like lesions or sores, particularly in areas like genitals, anus or buttocks…. ulcers, lesions or sores in mouth… rectal pain (with or without rash)

• all lesions go crusted and fall off to reveal a fresh layer of skin

most people with MPox get better within a few weeks without needing any specific treatment

Mpox spread via

• direct contact w rashes, blisters or sores, or contact w bodily fluids also

• TOUCHING contaminated objects

who is at risk: men who have sex w men

prevention

• isolation

• hand hygiene

• keeping lesions covered and wear a face mask

diagnosis

• by lab testing

treatment

• supportive care —> pain relief

• antivirals for more severe disease

vaccine for at risk population!

Molluscum contagiosum - presentation, DDx, control spread, treatment

• poxvirus

• two peaks: in children (3-9) and young adults

spread from direct contact

the papules form a row —> known as pseudokoebnerised molluscum

presents as clusters of small pearly papules with a central umbilication, core can be expressed by firm pressure, occurs in warm moist areas like armpits, groin or behind knees in kids, in adults in groin

DDx

• verrucae (but have no central umbilication)

• herpes (rapid onset and vesicles)

treatment

• in children leave alone

• cryotherapy

• can use tape occlusion

• immune techniques such as imiquimod creme, topical retinoids

Viral warts - transmission, presentation, DDx, treatment

• common benign growths

• usually on hands, feet and extensor surfaces

• HPV

transmission

• direct contact w infected skin or contaminated surfaces (breaks in skin increase transmission)

presentation

• comon warts (verruca vulgaris)

• plane warts

• plantar warts

• digitate/filiform warts

• characterised by papillomatous surace, loss of skin lines and papillary capillaries

DDx

• Bowen’s disease

• seborrheic keratosis

• corns and callous

• penile pearly papules and equivalent papillomatosis of vulva

treatment

• spontaneous resolution usually 2 years

• topical salicylic acid, podophyllin or cryotherapy

• imiquimod topical treatment

• specialist referral if conservative fail

• HV vax 

reason we see viral warts as doctors

• cosmetic

• teasing from school mates

• exclusion from sport

• increasing number of warts

• pain in weight bearing

• distortion of structure

• concern of diagnosis

Scabies * presentation, diagnosis, complications, treatment

• scarcoptes sscabiei hominus

transmitted by body-to-body contact

• burrow through strateum corneum, produce 2-3 eggs a day which mature in 2-3 weeks 

presentation

• variable due to allergic reaction which is dependent on individual 

• generalised eruption and itchiness is thought to be caused by sensitisation to their products eg. faeces and eggs 

• pruritic excoriated nonspecific rash on trunk with scaly burrows on fingers and wrists

• papular or nodular lesions are often seen on genitals and nipples in adults and major flexor surfaces of children

in infancy, rash on face

diagnosis

• confirm with scrapping from burror and examine under microscope

• dermoscopy sometimes helps

• pracical method is positive response to anti-scabicide

complications

• secondary bacterial infection, rarely glomerulonepritis or RHD

• crusted scabies —> more on this

treatment

What are crusted scabies

• severe variant of scabies

• often seen in immunosuppressed

• numerous more mites

• widespread, scaly and hyperkeratotic rash

Head lice (transmission, presentation, complication, diagnosis, treatment, prevention)

head-to head contact

presentation

• itching

• may see excoriations or local lymphadenopathy

complication

secondary bacterial infection

Insect bites (presentation, treatment)

• bites present as persistent itchy, oedematous papules

• bullous reactions are common on legs of children

treatment

• preventative measures like with insect sprays

• treat fleas if present

• treat infection if present

• calamine lotion

• local potent topical steroids

• wet dressings for severe cases

Body and public lice

so yeah