HSV Flashcards
Types of Herpes Viruses
HHV-1: HSV-1-Herpes simplex virus type 1 HHV-2: HSV-2-Herpes simplex virus type 2 HHV-3: VZV-Varicella zoster virus HHV-4: EBV-Epstein Barr virus HHV-5: CMV-Cytomegalovirus HHV-6: Sixth disease/Roseola HHV-7: Roseola HHV-8: KSHV-Kaposi sarcoma-associated herpesvirus
HHV-1/HSV1 Cells of Latency
Sensory Ganglia
HHV-2/HSV2 Cells of Latency
Sensory Ganglia
HHV-3/VZV: Cells of Latency
Sensory ganglia (dorsal root ganglia)
HHV-4/EBV: Cells of Latency
B-Lymphocytes
HHV-5/CMV Cells of Latency
Myeloid cells, salivary gland cells, endothelium
HHV-6 Cells of Latency
CD4+ T-Lymphocytes
HHV-7 Cells of Latency
CD4+ T-Lymphocytes
HHV-8 Cells of Latency
B-lymphocytes (latency), endothelial cells (Kaposi sarcoma)
Primary Infection of Herpes
Acute (primary) herpetic gingivostomatitis
Recurrent Infection of Herpes
Herpes labialis
Intra-oral herpes
HSV-pathogenesis-Primary Infection
- Usually young age
- Often asymptomatic
- Symptomatic=Primary herpetic gingivostomatitis
- In adults is usually pharyngotonsillitis
- Spread through infected saliva or active lesions
- Incubation period=3-9 days
Primary Herpetic Gingivostomatitis Clinical Features
- Cervical lymphadenopathy
- Chills
- Fever
- Nausea
- Anorexia
- Irritability
- Sores in mouth
Primary Herpetic Gingivostomatitis Oral Lesions
- Ulcerations on fixed and movable mucosa
- Variable number of lesions
- Ulcers coalesce and form larger irregular ulcerations
- Gingiva enlarged and painful
- Resolution in 5-7 days (latency in trigeminal ganglion)
HSV- diagnosis
Clinical** Culture (may take 2 weeks) Tissue biopsy Cytologic smear (less invasive)** Serologic testing
HSV-Histopathology
Molding
Margination
Multinucleation
Also Tzanck cells
Lab Results
Positive IgM and Negative IgG = Acute/Recent Infection
Negative IgM and positive IgG = established infection
Treatment primary HSV
- Supportive/Palliative Treatment
- Fluids, nutrition, rest, avoid spreading to others
- Avoid touching eyes, genitals
- Possible referral to MD if infant is not drinking because of pain
**ACYCLOVIR NOT RECOMMENEDED ANYMORE
Medications:
- Topical anesthetic (OTC vs Rx)
- Mucosal coating (OTC)
- Analgesic (OTC vs Rx)
- Antiviral (Rx) (for immunocompromised or dehydrated pts)
Warning about Primary HSV Meds
Rinses may diminish the gag reflex therefore better suited for older patients, but remember serious side-effects of seizures and methemoglobinemia in pediatric population.
HSV-1 Recurrent infection
Secondary herpes Mild, self-limiting Latency in trigeminal ganglion Vermilion border Intraorally on fixed keratinized mucosa Prodrome> papules > vesicles > ulcer > crust > heals > no scar 7-10 days Unilateral
Recurrent HSV-Triggers
Old age UV light Physical/emotional stress Fatigue Heat Cold Pregnancy Allergy Trauma Dental treatment Respiratory illnesses Fever Menstruation Systemic Diseases Malignancy
Can you give someone Herpes if you’re asymptomatic?
Asymptomatic shedding can occur in seropositive patients
More common after surgical procedures and in immunocompromised patients
Universal precautions
What is the difference clinically between Recurrent HSV infection and Primary?
Intraoral colescing lesions are NOT ON MOVABLE MUCOSA FOR RECURRENT!! (palate and keratinized gingiva)
Recurrent HSV-Treatment
- Depends on severity/frequency
- Preventive/suppressive vs episodic/abortive strategies
- Antiviral agents/antiviral-steroid combination agents
- Remove precipitating factors
Recurrent Herpes Labialis-FDA approved topical treatments
Rx: Acyclovir cream 5% (Zovirax)
Disp: 5g tube
Label: dab on lesion every 2 hours for 4 days
Rx: Penciclovir cream 1% (Denavir)
Disp: 5g tube
Label: dab on lesion every 2 hours for 4 days
Rx: Docosanal cream (Abreva) OTC
Disp: 2g tube
Label: dab on lesion five times per day for 4 days
Rx: Acyclovir 5%/ hydrocortisone 1% cream (Xerese)
Disp: 5g tube
Label: dab on lesion 5 times a day for 5 days
Rx: Acyclovir buccal tablets 50mg
Disp: 2 dose pack
Label: apply to canine fossa within 1 hour of symptoms (single dose)
Recurrent Herpes Labialis-FDA approved systemic antivirals
Rx: Valacyclovir 1g tablets Disp: 4 tabs Label: 2 tabs stat PO, then again in 12 hours (ie 2 doses) Rx: Famciclovir 500mg tablets Disp: 3 tabs Label: 3 tabs stat PO
Recurrent Herpes Labialis-OTHER Topical AGENTS
Ice
L-lysine
Bioflavonoids
Evaporants-Dessicants
Emollients
Bioadhesives (Zilactin-benzyl alcohol, topical pain reliever)
Wound-healing modification/occlusive agents
Suppression of Dentally Induced recurrent HSV
2-day prophylactic course of valacyclovir
- 2g taken 1 hr before dental tx
- 2g taken same evening
- 1g taken bid the next day
**STUDY WAS FUNDED BY MANUFACTURER OF VALTREX
HSV-ATYPICAL PRESENTATION
Immunocompromised host
Location and extent of lesion
Usually do not see necrotic, large, lesions or lesions on movable mucosa
HSV Associated Erythema multiforme
HSV implicated in trigger for erythema multiforme
Skin immune reaction in response to infection
Rx antiviral prophylaxis
Varicella Zoster Virus Infection
- HHV3
- Primary infection is Varicella/Chicken pox
- Secondary infection is Zoster/Shingles
- May affect oral cavity/face if reactivation along distribution of V1/2/3
Cytomegalovirus Infection
-HHV-5
-Latency in myeloid cells, salivary gland cells and endothelium (“OWL EYES”)
-Disease states found predominantly in:
> pregnancy/neonates (congenital infection)
> immunocompromised patients, particularly transplant and HIV+ patients
Epstein-Barr Virus Infection
- HHV-4
- Latency in lymphocytes
-EBV-induced diseases with oral manifestations:
> Infectious mononucleosis
> Oral hairy leukoplakia
>Nasopharyngeal carcinoma
>EBV mucocutaneous ulceration
> Burkitt lymphoma
Burkitt lymphoma histology is
Sheets of diffuse B cells
“starry sky” is lymphocytes with center of macrophage
Kaposi sarcoma
-HHV-8, KSHV
-Vascular neoplasm of endothelium
-Associated with immunosuppression
-Usually evolves through 3 stages:
Patch-plaque-nodular
DOES NOT BLANCH ON PALPATION
