Viral and bacterial infections of mucosal tissue Flashcards
How many human herpes viruses are there?
8 (HHV 1-8)
What viruses have oral manifestations?
Human Herpes Virus Coxsackie Human papillomavirus Human Immunodeficiency Virus (HIV) Measles Mumps
List the human herpes viruses
HHV1 - Herpes simplex 1 (HSV1) HHV2 - Herpes simplex 2 (HSV2) HHV3 - Varicella Zoster virus (VZV) HHV4 - Epstein Barr Virus (EBV) HHV5 - Cytomelagovirus HHV6 and HHV7 HHV8 - Kaposi's sarcoma-associated Herpes virus
Which herpes simplex virus has a predilection for the oral cavity, and which has a predilection for genitals?
HSV1 oral
HSV2 genital
Describe clinical features of intra-oral herpes
- Dozens of small ulcers that may coalesce or appear punched out
- Gingival lesions - gingivostomatitis
Describe the clinical features of primary herpetic stomatitis
- Dome-shaped ulcers, around 2-3mm dia
- Rupture may lead to sharply defined shallow ulcers with yellow/gray floor and red margins
- Common on the hard palate and dorsal tongue
- Gingival lesions
- Halitosis and impeded function
- Systemic symptoms
What is the management of primary herpetic stomatitis
- OTC analgesics, CHX, fluid intake and soft diet for symptomatic relief
- Aciclovir if immunocompromised
Where does herpes simplex remain latent?
In the trigeminal ganglion
What is another term for herpes labialis
Cold sore
What is recurrent herpes labialis?
Reactivation of latent HSV due to a trigger
What may trigger recurrent herpes labialis
common cold, UV, menstruation, local irritation, emotional upset
Describe clinical features of recurrent herpes labialis
- Vesicles along the mucocutaneous junction of the lips +/- adjacent skin
- Vesicles may enlarge, coalesce and weep exudate
- Rupture of vesicles occurs after 2-3 days and it crusts over, or it may ulcerate
What may cause secondary infection of recureent herpes labialis
Staphylococcus or streptococcus
Management of herpes labialis
- Symptomatic relief - OTC analgesics
- Topical penciclovir, aciclovir or hydrocolloid film
- Systemic aciclovir if immunocomp
What infections occur with HHV3 - Herpes varicella zoster virus
- Primary infection = chickenpox (varicella)
- Reactivation = shingles (zoster)
Where does varicella zoster virus remain latent?
In the sensory nerve ganglia
Intraoral cinical features of chickenpox (varicella)
Vesicles which may rupture and form painful, round/ovoid ulcers with inflammatory halos
Common on the palate
Extraoral clinical features of chickenpox (varicella)
Centripetal (trunk, head, neck) itchy rash which goes through macular, papular, vesicular and pustular stages and may crust over
Systemic - fever, malaise, irritability, anorexia
Management of chickenpox
- Analgesics
- Antihistamines or calamine lotion for itching
- Aciclovir systemically if pregnant, neonates or immunocompromised
When may complications of chickenpox arise
- If primary infection in adulthood
- Reactivation as shingles (main complication)
- Pregnancy or non-immune
Define shingles
Painful, unilateral rash in a dermatome due to reactivation of latent VZV in the sensory nerve ganglion
Epidemiology of zoster
- Middle aged and over
- Underlying immunodeficiency
- Children if there was maternal varicella during pregnancy
Intraoral features of shingles
- Unilateral, severe pain or paraesthesia before, during or after (PHN)
- Maxilla = rash over cheek and ulcers on palate
- Mandible - rash lower face and lip, ulcer on tongue and soft tissues
What are extraoral features of shingles
- Unilateral rash in the dermatome, may crust over and heal +/- scarring
- Suppraration and scaring if lesions infected with bacteria
What is post-herpetic neuralgia
Complication of shingles, resulting in burning pain after the shingles disappears
When may Ramsay Hunt Syndrome occur?
If zoster involves the geniculate ganglion of the facial nerve
What are the signs of ramsay hunt syndrome
Facial paralysis, rash, tinnitus, nausea, vertigo
Management of shingles
- OTC analgesics for ulcers
- Systemic aciclovir for symptomatic relief and prevent PHN
- Early treatment indicated to reduce risk of PHN
What treatment is indicated for post-herpetic neuralgia
Antidepressant and an anti-epileptic
What intraoral lesions may arise due to EBV
- Oral hairy leukoplakia
- Hodgkin lymphoma
- Burkitt lymphoma
- Petechial haemorrhage at the junction of hard and of palate
What does coxsackie virus lead to?
- Herpangina
- Hand-foot and mouth disease
Describe features of herpangina
- Young children
- Sudden onset of fever, sore throat, anorexia and dysphagia
- Vesicles on the tonsils, soft palate and uvula which break down into ulcers
Describe features of hand-foot and mouth disease
- Children
- Shallow ulcers with vesicles orally, and ulcers on the hands and feet
Describe oral manifestation of measles
Koplik spots on the oral mucosa - these are pin-point blue/white spots on an erythematous base
Found particularly on the BM
Describe oral manifestations of cytomegalovirus
- Common ulcer on the hard or soft palate, tongue or FOM
- May be mistaken for aphthous ulcer
Describe oral manifestations of HPV
- Oral warts
- Verruca vulgaris
- Focal epithelial hyperplasia
- HPV related dysplasia
- HPV related SCC
Describe the clinical appearance of oral warts
- singular or multiple raised masses resembling focal epithelial hyperplasia
- or small cauliflower like projections
Describe oral manifestations of hepatitis
- Lichen planus
- Xerostomia / Sjogrens
- Sialdenitis
What oral lesions occur with the treatment of hepatitis infections
- Gingival bleeding or swelling
- Periodontal changes
- Oral pain
- Lichen planus
- Discolouration of the tongue
What is HIV
Retrovirus that affects humans and eventually leads to acquired immunodeficiency syndrome
What is the pathology of HIV
Destroys T helper cells, macrophages and dendritic cells - thus impairs cell mediated immunity, leaving progressive susceptibility to opportunistic infections and AIDS
Why does CD4 count decline in HIV
Proptosis
Apoptosis
Direct viral killing
CD8 cytotoxic lymphocytes
How is HIV transmitted
- Sexual intercourse
- Infected needles and syringes w drugs
- Vertically mother to baby
- Blood transfusions
- Occupational exposure
Describe the replication cycle of HIV
- Binding, fusion and entry
- Reverse transcriptase from viral RNA to DNA
- Integration of DNA to host DNA
- Transcription, translation and assembly then release of viral proteins
What is the diagnostic feature of HIV
Reduced CD4 count
What are the common oral manifestations of HIV
Candida Hairy leukoplakia Periodontal changes Kaposi's sarcoma Non-hodgkin's lymphoma
What are additional, less common oral manifestations of HIV
- Ulcers
- Salivary gland disease or xerostomia
- Thrombocytopenia purpura
- Manifestations of other viruses
What is the clinical presentation of hairy leukoplakia
Corrugated or ‘hairy’ white lesion typically on the lateral border of the tongue
What is the cause of oral hairy leukoplakia
EBV
What periodontal changes occur with HIV
- Linear gingival erythema
- Necrotising gingival conditions
When to be suspicious for HIV with periodontal changes
- Disproportionate to OH
- Rapid bone loss
- Advanced disease for age
What is Kaposi’s sarcoma
HIV-associated vascular malignancy
Presentation of Kaposi’s sarcoma
Red or purple macules, which progress to papules, nodules or plaques
Predilection for head, back, neck, trunk and MUCOUS MEMBRANES (bruises in the mouth)
What is the theory behind pathology of Kaposis
Cancer of lymphatic endothelium, forming vascular channels that fill with blood cells (giving rise to the bruise like appearance)
What are the clinical features of NHL
Rapidly enlarging mass with bone destruction and ulceration
Common on fauces, gingiva and palate
Systemic symptoms typical of cancer
How is HIV diagnosed
Antibody test via blood test
What are the drug classes for HIV
- Entry inhibitors
- Reverse transcriptase inhibitors (nuceloside and non-nucleosite)
- Integrade inhibitors
- Protease inhibitors
What is HART?
Highly active anti-retroviral treatment
What HIV treatment is recommended for all therapy naive HIV patients
2 nuceloside reverse transcriptase inhibitors
1 other HIV drug
Protease inhibitor
Non-nucleoside RT inhibitor
What is PREP
Pre-exposure prophylaxis, used in high risk groups in advance to having diagnosis to prevent it
What oral lesions are persistent even with HART
- HPV related papilloma
- HIV related salivary gland disease
List orofacial adverse effects of HART
- Lipodystrophy
- Hyperpigmentation
- Oral ulceration
- Xerostomia
- Hypersensitivity reaction (SJS/TENS)
What is lipodstrophy?
Changes in fat distribution which hollow out the face
Which bacterial infections can cause oral ulceration?
Tuberculosis
Syphilis
What types of TB can cause oral manifestations
- Oral TB (however this is rare)
- Secondary infections from pulmonary TB
Describe oral ulcerations in TB
Chronic, painless, undermined ulcer on the dorsal tongue, covered in a yellow slough
What are the oral manifestations of primary syphilis
Shallow, painful ulcer with indurated base on the lips, tongue or other mucosal site
What are the oral manifestations of secondary syphilis
2-3 months after initial infection
Flat ulcerations common on the tongue and forming snail track ulcers
What are the oral manifestations of tertiary syphilis
Years after exposure
Necrotic granulomas called gummas which are destructive (Esp on the palate where they may perforate the nasal cavity)
What other lesions may be associated with tertiary syphilis
White pigmented lesions - these are OPML
