Viral Infections of the Orofacial Tissues Flashcards
What is a virus?
An obligate parasite that invades host cells to hijack the internal machinery in order to replicate its DNA/RNA and multiply
How does Varicella Zoster spread?
Via nasopharyngeal secretions (sneezes/coughs) or fluid from vesicles containing the virus
How does HSV1/2 spread?
Via direct contact e.g. of mucous membranes (oral/genital) or through broken skin
List the 8 types of Human Herpes Virus
HSV1 (oral herpes)
HSV2 (genital herpes)
HHV3 (Varicella Zoster Virus)
HHV4 (Epstein Barr Virus)
HHV5 (Cytomegalovirus)
HHV6, 7, 8
What is the management protocol for a patient who presents with primary herpetic gingivostomatitis?
Reassure and explain the aetiology of the disease to the patient.
Advise the patient to keep well hydrated, choosing nice soft, bland diet for a few days until the inflammation wears off.
Reinforce good OH, keeping everything as clean as possible to help the area heal.
Suggest topical anaesthetics/sprays (e.g., 0.15% benzydamine hydrochloride for comfort/analgesia where lesions are painful)
Advise Paracetamol for pyrexia (and secondarily analgesia).
Suggest Gelclair, Gengigel or other mucosal coating agents (to protect the mucosa whilst it heals/for comfort)
Encourage avoidance of SLS toothpaste/mouthwash (which are extremely irritant with oral inflammatory conditions)
Suggest 0.2% chlorhexidine digluconate (which is useful due to its broad anti microbial properties however needs dilution (1:1) as it is an astringent).
NOTE-
Anti-retrovirals not routinely given as infection is self-limiting (<2 weeks) unless patient is immunocompromised or the infection is picked up really early.
May require A&E referral due to inability to maintain oral intake. Admissions are usually short or unnecessary however.
Define neurotrophic viruses
With certain viruses, once infected, they will live on forever in the sensory neurones of the host (e.g. trigeminal ganglion with oral HSV)
Briefly describe the phases of a HSV1 infection
Natural clinical course is a primary infection
To a period of latency where the patient may not be symptomatic in displaying evidence of the disease, or a period of latency where there may be viral shedding (where infective particles are still released by the host or the time where the host remains infective)
Followed by a period of reactivation later down the line in some cases (following triggers e.g. UV exposure, stress, steroids, fever, surgery, menstruation etc.)
Describe the evolution of the lesions found in a primary HSV1 infection
The HSV1 targets deep epithelial cells in the skin/mucous membranes during the primary infection.
Results in some sessile lesions (i.e. lesions that are firmly attached to the underlying skin, broad based, red and raised lesions that are fluid filled). These are vesicles, small fluid filled sacs, typically under 5mm of maximal diameter.
Also observe some small lesions known as pustules (red based lesion, with a head on it that is a creamy white colour indicating that it is filled with pus i.e. dead or dying macrophages amongst other materials)
Final evolution of this virus leaves a crusted lesion. This forms when a vesicle ruptures, leaving a raw base to the lesion with some weeping of tissue fluid and shedding of viral particles. At this stage, the patient is in their most infective state
Describe the pathophysiology of a HSV1 primary infection
Direct contact with infected HSV1 secretions lead to deep epithelial cells of the skin/mucous membranes becoming infected.
The infected cells undergo lysis allowing HSV1 to spread
The resulting inflammation leads to oedema which produces thin walled vesicles full of virus particles
These are very fragile and rupture easily as a result to leave an erythematous base that crusts over and then heals
What is HHV
A DNA virus (obligate parasite)
A 7 year old patient presents with a sore throat, fever, small and painful blisters/vesicles on the lateral surfaces of the tongue, the labial surfaces and the lower gingiva. These vesicles/blisters have a erythematous periphery with a pale pink/cream centre. In some areas you can see multiple small ulcers and the gingivae appear generally inflamed. On E/O examination you notice cervical lymphadenopathy. On inquiry, the mother states that the child is struggling to speak and eat. What is the likely diagnosis and management protocol for this patient?
Primary herpetic gingivostomatitis
Reassure and explain the aetiology of the disease to the patient.
Advise the patient to keep well hydrated, choosing nice soft, bland diet for a few days until the inflammation wears off.
Reinforce good OH, keeping everything as clean as possible to help the area heal.
Suggest topical anaesthetics/sprays (e.g., 0.15% benzydamine hydrochloride for comfort/analgesia where lesions are painful)
Advise Paracetamol for pyrexia (and secondarily analgesia).
Suggest Gelclair, Gengigel or other mucosal coating agents (to protect the mucosa whilst it heals/for comfort)
Encourage avoidance of SLS toothpaste/mouthwash (which are extremely irritant with oral inflammatory conditions)
Suggest 0.2% chlorhexidine digluconate (which is useful due to its broad anti microbial properties however needs dilution (1:1) as it is an astringent).
NOTE-
Anti-retrovirals not routinely given as infection is self-limiting (<2 weeks) unless patient is immunocompromised or the infection is picked up really early.
May require A&E referral due to inability to maintain oral intake. Admissions are usually short or unnecessary however.
How does primary herpetic gingivostomatitis appear in adults?
Can vary from the occasional one or two aphthous like ulcers to numerous ulcers grouped in close proximity to one another
Will affect areas like the soft palate, labial mucosa etc.
Usually each ulcer will have a very wide band of perilesional erythema (redness surrounding the lesion)
In certain areas, the ulcers may join together to coalesce and form larger ulcers.
Depending on the point at which the patient is examined, we may find numerous tiny isolated ulcers or lots of tiny ulcers having grouped together making the ulcers appear larger
Describe the features of ocular herpes
Scarring
Keratitis (inflammation of the cornea i.e. the protective transparent outer layer of the eye)
Can lead to blindness in the eye (requires an urgent same day ophthalmological opinion, patient should be directed to the local A&E department if indicated)
A patient presents with a visible cold sore on the left commissure of the lip. On further examination, you notice the patient appears to have some scarring in the eye with visible keratitis. What is the likely diagnosis and management protocol for this patient?
Reactivation of HSV1 infection (herpes labialis)
Ocular herpes
Urgent same day ophthalmological opinion is indicated as ocular herpes can lead to blindness. Patient should be directed to the local A&E department
What are the different ways in which a HSV1 infection can present?
Primary herpetic gingivostomatitis
Cold sores/herpes labialis
Intra-oral herpes lesions
Ocular herpes
Herpetic Whitlow
Eczema herpeticum
Describe the features of herpetic whitlow
Historically common, herpes infection of the skin on the hands
Extremely painful
Highly infectious
Now rare
Describe the features of Eczema herpeticum
HSV infection of eczematous skin
Can be rapidly spreading
Risk of bacterial superinfection and sepsis
Requires aggressive and urgent management (referral to A&E)
What is a primary infection?
The first presentation of an infection after the patient has acquired a virus
Describe the features of cold sores/herpes labialis
Viral reactivation of HSV1
Often following triggers such as-
UV light exposure
Wind
Stress
Steroids
Menstruation
Fever
Other illness
Surgery
Often present as vesicular crusted lesions at the mucocutaneous borders of the lip or the alars of the nose.
Affected patients tend to report a short prodrome phase with itching or tingling and then the lesions appear within hours to days, usually starting with oedema, turning into fluid filled blisters, then rapidly ulcerating at which point, the vesicles burst, the virus is released and infection may occur.
Healing tends to occur within 7-10 days.
Once the lesions have thoroughly dried out and crusted over, they are no longer capable of transmitting the virus.
Self-resolving condition
A patient presents with a vesicular crusted lesion on the upper lip. On inquiry, the patient reports the area first began to itch and tingle before forming a fluid filled blister that popped after a few days. The patient reports associated pain and says he struggles to open his mouth properly. He also reports a history of similar lesions affecting the lip. What is the likely diagnosis and management protocol for this patient?
Viral reactivation of HSV1 (herpes labialis/cold sores
Reassure and explain the aetiology of the disease to the patient.
Advise identification and avoidance of triggers to prevent subsequent attacks
Prescription of Acyclovir (Zivirax) which can be bought OTC but this topical is typically ineffective in stopping the lesions from propagating, only useful in prodrome phase. Advise patient that if they want to avoid the formation of the cold sore, the ointment should be applied as soon as the prodrome phase begins i.e., the tingling burning sensation and application should be repeated every 4 hours whilst awake. Penicyclovir can also be used, but applied every 2 hours whilst awake and not to be used <12 years
Advise the patient to keep well hydrated, choosing nice soft, bland diet for a few days until the inflammation wears off.
Reinforce good OH, keeping everything as clean as possible to help the area heal.
Suggest topical anaesthetics/sprays (e.g., 0.15% benzydamine hydrochloride for comfort/analgesia where lesions are painful
Suggest Gelclair, Gengigel or other mucosal coating agents (to protect the mucosa whilst it heals/for comfort)
Encourage avoidance of SLS toothpaste/mouthwash (which are extremely irritant with oral inflammatory conditions)
Suggest 0.2% chlorhexidine digluconate (which is useful due to its broad anti microbial properties however needs to dilution (1:1) as it is an astringent).
What is the treatment protocol for cold sores?
Reassure and explain the aetiology of the disease to the patient.
Advise identification and avoidance of triggers to prevent subsequent attacks
Prescription of Acyclovir (Zivirax) which can be bought OTC but this topical is typically ineffective in stopping the lesions from propagating, only useful in prodrome phase. Advise patient that if they want to avoid the formation of the cold sore, the ointment should be applied as soon as the prodrome phase begins (i.e., the tingling burning sensation) and application should be repeated every 4 hours whilst awake. Penicyclovir can also be used, but applied every 2 hours whilst awake and not to be used <12 years
Advise the patient to keep well hydrated, choosing nice soft, bland diet for a few days until the inflammation wears off.
Reinforce good OH, keeping everything as clean as possible to help the area heal.
Suggest topical anaesthetics/sprays (e.g., 0.15% benzydamine hydrochloride for comfort/analgesia where lesions are painful
Suggest Gelclair, Gengigel or other mucosal coating agents (to protect the mucosa whilst it heals/for comfort)
Encourage avoidance of SLS toothpaste/mouthwash (which are extremely irritant with oral inflammatory conditions)
Suggest 0.2% chlorhexidine digluconate (which is useful due to its broad anti microbial properties however needs to dilution (1:1) as it is an astringent).
Which topical antiviral ointments may be used to treat cold sores? What instructions should be given to patients prior to their use?
Prescription of Acyclovir (Zivirax) which can be bought OTC but this topical is typically ineffective in stopping the lesions from propagating, only useful in prodrome phase.
Advise patient that if they want to avoid the formation of the cold sore, the ointment should be applied as soon as the prodrome phase begins (i.e., the tingling burning sensation) and application should be repeated every 4 hours whilst awake.
Penicyclovir can also be used, but applied every 2 hours whilst awake and not to be used <12 years
Whilst cold sores are very common, reactivation of latent HSV via their presentation as intra-oral herpes lesions is rare but can be seen in the following:
In those who are immunocompetent (typically will see crops of tiny ulcers with a predilection for the hard palate or attached gingiva)
In those who are immunocompromised (uncontrolled diabetes, cancer, HIV etc. Can be very severe and much more widespread affecting more of the oral mucosa)
What is the management protocol for intra-oral herpes lesions during a reactivation of HSV1?
Explanation and reassurance to patient
Prescription if Chlorhexidine mouthwash or spray
If symptoms are unacceptable, prescribe systemic (not topical) aciclovir 200mg 2/daily as a prophylactic dose
Describe the phases of a Varicella Zoster infection
Primary infection (which presents as chicken pox)
Latency (at this point, the virus lives in the trigeminal neuronal ganglions of sensory nerves and later in life could be reactivated)
Reactivation (which presents as herpes zoster or shingles)
Not all patients who have had chicken pox will go on to develop shingles in later life. Certain risk factors will make it more likely e.g., immunocompromise
Describe the features of adult chicken pox
Extremely rare to get chicken pox more than once.
But if an adult was to develop chicken pox a second time, it would be much more severe, complicated with greater fatality than the childhood form. 20x risk of fatality in adulthood than childhood.
Greater risk of disseminated disease e.g., encephalitis, pneumonia, thrombocytopenia.
An 11 year old patient presents with a widespread maculo-papular rash affecting the scalp, trunk, skin and arms. On examination of his skin, you can see some crusty spots and red fluid filled sacs. The patient reports intense itching. Intra-orally, there is evidence of painful ulcers on the hard palate with a very erythematous base. What is the likely diagnosis and management protocol for this patient?
Chicken pox
Education and reassurance
Topical symptomatic relief (Gelclair, Gengigel etc.)
Anti-pyretics (paracetamol)
Advise soft bland diet and plenty of fluid for several days
What areas can be affected by chicken pox?
Trunk, arms, scalp, skin
Mucosa
Describe the features of mucosal chicken pox
Less common than chicken pox affecting the skin.
Typically, see lesions on an erythematous base that rupture to give painful ulcers.
Will resolve with little intervention other than topical symptomatic relief, anti-pyretics, and a soft, bland diet with plenty of fluid for a few days or so.
