VESICULOBULLOUS LESIONS (VIRAL)

Question 1

CONCEPT

Answer 1

• INFECTION ARE COMMON VESICULAR ERUPTIONS SKIN/MUCOSA
• 2 FORMS: PRIMARY (SYSTEMIC): EXPOSURE WITHOUT ANTIBODIES TO HSV-1 VIRUS (YOUNG AGE)
  : SECONDARY (LOCALIZED): INFECTION PER REACTIVATION OF THE VIRUS
• NATURAL HISTORY: PRIMARY INFECTION/LATENCY/RECURRENT INFECTION

Question 2

CAUSE

Answer 2

HSV1: SPREAD INFECTED SALIVA OR ACTIVE PERIORAL LESIONS

Question 3

AREAS

Answer 3

• HSV1: PHARNYX/INTRAORAL MUCOSA/EYES/SKIN ABOVE WAIST
• HSV2: GENITAL ZONE (TRANSMITTED SEXUAL CONTACT) AND SKIN BELOW WAIST

Question 4

MECHANISM

Answer 4

EXPOSURE HSV-1 VIRUS - VIRUS TAKEN UP BY SENSORY NERVES AND TRANSPORTED TO THE ASSOCIATED SENSORY (REMAINS LATENT - TRIGEMINAL GANGLION)

Question 5

REACTIVATION FACTORS

Answer 5

OLD AGE/ULTRAVIOLET LIGHT/PHYSICAL OR EMOTIONAL STRESS/RESPIRATORY ILLNESSES/FEVER/MENSTRUATION/SYSTEMIC DISEASES/MALIGNANCY

Question 6

ACUTE HERPETIC GINGIVOSTOMATITIS (PRIMARY HERPES)

Answer 6

• MORE 90% CAUSED BY HSV-1
• CHILDREN (6 MONTHS-5 YEARS) AND YOUNG ADULTS
  90% CASES SUBCLINICAL
• PRODROMAL SIGNS/SYMPTOMS: SIMILAR GENERAL FLU (FEVER, IRRITABILITY, CERVICAL LYMPHADENOPATHY, NAUSEA, ANOREXIA, SORE MOUTH LESIONS
• AFFECTED MUCOSA: DEVELOPS NUMEROUS PINHEAD VESICLES (RAPIDLY COLLAPSE TO FORM NUMEROUS SMALL RED LESIONS - ENLARGE SLIGHTLY AND DEVELOP CENTRAL SHALLOW, IRREGULAR ULCERATION COVERED BY YELLOW FIBRIN IN BOTH MOVABLE AND ATTACHED ORAL MUCOSA
• GINGIVA: ENLARGED, PAINFUL, EXTREMELY ERYTHEMATOUS
• SELF INOCULATION OF THE FINGERS “HERPETIC WHITLOW” EYES AND GENITAL AREAS
• MILD CASES: RESOLVE 5-7 DAYS
• SEVERE CASES: MAY LAST 2 WEEKS
• TREATMENT (SUPPORTIVE): FLUID INTAKE, GOOD ORAL HYGIENE, ANALGESICS, TOPICAL ANAESTHETICS
• SYSTEMIC ANTIVIRAL BENEFICAL FIRST 3 DAYS

Question 7

RECURRENT HERPES SIMPLEX INFECTIONS (SECONDARY HERPES)

Answer 7

• MOST COMMON SITE RECURRENCE HSV-1: VERMILION BORDER/ADJACENT SKIN LIPS
• HERPES LABIALIS = “COLD SORE” OR “ FEVER BLISTER”
• PRODROMAL SIGNS/SYMPTOMES: PAIN, BURNING, ICHING, TINGLING ARISE 6-24 HOUR BEFORE THE LESIONS DEVELOP
• MULTIPLE SMALL, ERYTHEMATOUS PAPULES DEVELOP AND FORM CLUSTERS OF FLUID-FILLED VESICLES
• VESICLES RUPTURE AND ULCERATE AND HEA: 7-10 DAYS
• NO SCAR FORMATION
• RECURRENT INTRAORAL MUCOSA = RECURRENT HERPETIC STOMATITIS
• IMMUNOCOMPETENT PATIENT: KERATINIZED MUCOSA BOUND TO BONE (ATTACHED GINGIVA/HARD PALATE)
• LESIONS: BEGIN 1-3 MM VESICLES/COLLAPSE TO CLUSTER OF ERYTHEMATOUS MACULES
• DAMAGED EPITHELIUM LOST/CENTRAL YELLOWISH ULCERATION DEVELOPS
• HEALING: 7-10 DAYS
• TREATMENT: ANTIVIRALS (ACYCLOVIR/VELACYCLOVIR)

Question 8

HISTOPATHOLOGIC FEATURES

Answer 8

• HSV INFECTED EPITHELIAL CELLS EXHIBIT ACANTHOLYSIS (TZANCK CELLS), NUCLEAR CLEARING, NUCLEAR ENLARGEMENT BALLOONING DEGENERATION
• EPITHELIAL CELLS: CONTAIN DARK SPOTS (INCLUSIONS - LIPSCHÜTZ BODIES)
• THESE ARE AGGREGATES OF CYTOPLASMIC OR NUCLEAR SUBSTANCE STAINED
• GENERALLY FOUND IN SITES OF VIRAL REPLICATION (HIGH IN PROTEIN)
• DIAGNOSIS: CYTOLOGIC SMEAR AND TISSUE BIOPSY