Viruses Flashcards
What is the clinical name for HSV1?
Primary Herpetic Gingivostomatitis
What part of the body does HSV2 affect?
Genital
What sites does Primary Herpetic Gingivostomatitis present?
KERATINISED TISSUE (the gingiva + hard palate, dorsum of the tongue)
Lips
Labial Mucosa
State IO/EO presentation of HSV-1?
- herpetic mouth ulcers (initially 2-3mm vesicle that ruptures in 2-3 days + heals within 7-10 days)
- erythematous gingivitis (glossy gums)
- lips erosions
- cervical lymphadenopathy
- pharyngotonsillitis (severe)
If a pt presents with HSV1 on clinic, what do you do?
- only emergency tx
- avoid AGP
- Enforce standard precaution /Full PPE (eye protection for all)
- Extra care for child or immunocompromised
After recovery, how does HSV 1 present?
HSV1 lies dormant in the DORSAL ROOT GANGLION
Presenting as HERPES LABIALIS (cold sores) when reactivated by:
- intense sunlight/ UV
- trauma/ post op
- immunosuppression
- menstruation
How does herpes labialis present?
- vermilion border of the lips
- ruptures in 2-3 days + heals in 10 days
- if gold crust= s.aureus
- prodromal tingling 24hrs before
What is recurrent intraoral HSV?
= localised collection of vesicles that coalesce + ulcerate
- presents on keratinised surfaces (esp. hard palate near greater palatine + attached gingiva)
- prodromal tingling before
- happens after dental tx often
Often misdiagnosed as LA necrosis (differential)
What is the name of the condition when HSV1 affects the digits?
Herpetic whitlow
- affects skin of digits, saliva from pts is risk factor
What other condition is HSV1 associated with?
Erythema Multiforme
State the management of HSV1:
a) diagnosis?
diagnosis = normally CLINICAL
If unclear:
1. immunofluorescence
2. PCR
3. Viral culture (takes too long)
State the management of HSV1:
a) treatment ?
- Chlorhexidine (antiseptic m/w)
- Encourage fluid intake (A&E if severely dehydrated)
- Simple analgesics (paracetamol)
- Education (avoid close contact, not sharing formites)
- acyclovir 200mg tablets x5/day for 5 days
Prevention:
SPF 50
Topical acyclovir 5%/ penciclivor 1%
If severe/frequent, systemic acyclovir prophylaxis 200-400mg bd for 9months
List and describe the clinical features seen in primary herpetic gingivostomatitis? Name the organism responsible.
Primary herpetic gingivostomatitis
* Causative agent: herpes simplex virus 1
- Route of transmission: direct contact e.g., with sores, saliva
- Clinical features: multiple herpetic mouth ulcers, diffuse gingivitis, cervical lymphadenitis, fever, malaise, irritability and fever, anorexia
- Reactivation of HSV1 triggered by: sunlight, trauma, immunosuppression + others
- Management: antiseptic mouthwash to prevent secondary bacteria infection, fluid intake (dehydration risk), simple analgesics e.g. paracetamol/ibuprofen, prevention of spread by avoiding close contacts and aciclovir suspension
What does the Varicella Zoster Virus cause?
Chicken pox (primary)
Shingles (secondary reactivation)
What is the causative agent of Varicella Zoster Virus?
HHV3 (Human herpesvirus 3)
What is the presentation chickenpox?
Initial site: droplet infection in upper respiratory tract
General pres: itchy macopapular skin lesion. Site - back, cheek, face 2-3 weeks after initial infection, self-resolving
Oral presentation- ulceration in palate + fauces
What is the presentation shingles?
- underlying sign of malignancy or immunosuppresion (e.g. AIDs, Hodgkin’s lymphoma, organ transplant)
Affects one side:
- single dermatome trunk (back)
- predilection for CN5 + 7
- ORAL LESIONS ARE ALSO ON THE SAME SIDE AS TRUNK AFFECTED (unilateral)
What conditions are associated with shingles?
- Post-herpetic neuralgia
- Ramsay Hunt Syndrome
- Opthalmic herpes zoster (V1)
- Maxillary (V2) + Mandibular (V3) herpes zoster
What is post Herpetic Neuralgia and tx?
- Continuous pain on the same side as the shingle
- Re-activation from DRG or CN ganglia
Tx?
- Prevention: systemic acyclovir
- Tx: Gabapentin, tricyclic antidepressant
What is Ramsay Hunt Syndrome?
this is when VZV affects CN7 geniculate ganglion, leading to:
- lower motor neuron paralysis
- vesicular lesion on external auditory meatus (–> temp or perm deafness)
-altered taste
-dizziness
- palatal vesicles
What is ophthalmic herpes zoster?
Once VZV reaches CN5 V1, it leads to:
- corneal scarring
- loss of vision
- urgent referral to ophthalmology
What is Maxillary (V2) & mandibular (V3) herpes zoster?
VZV affecting branches V2 +V3 of trigeminal CN (V)
Presents as:
-Vesicles in face skin & mucosa
-Teeth & gingiva pain
-Lymphadenopathy (malaise & pyrexia)
What is the treatment for Shingles?
- Acyclovir or Famciclovir
- Tx w/in 72hrs before onset to reduce viral load + decrease severity + pain
- Increased risk if >50 yr old
- IV antivirals if immunocompromised
- Ophthalmic assessment + antivirals if V1 involvement
- Pain relief - analgesics, opioids (severe)
- Ear examination if Ramsay Hunt Syndrome
What is the name of the virus that causes infectious mononucleosis aka glandular fever?
Epstein- Barr Virus
How is Epstein Barr Virus (EBV) transmitted?
Saliva (“teenage kissing disease)
What conditions are associated with EBV?
Assoc w/ non-Hodgkin’s lymphoma
Burkitt’s lymphoma
Oral hairy leukoplakia
Nasopharyngeal carcinoma
What is the link between EBV + oral hairy leukoplakia?
(Not specifically indicative of HIV)
- Likely in immunocompromised/ transplant
- Rx w/ potent oral +inhaled corticosteroids
Appearance of oral hairy leukoplakia:
white vertical lines of hyperkeratosis on lateral border of tongue (rf to image)
What is the incubation period of EBV?
30-50days (after which symptoms present)
What is the clinical presentation of EBV?
- Fever
- Malaise
- Lymphadenopathy
- Anorexia
- Sore throat (soft palate, uvula, tonsils are red + swollen plus creamy tonsillar exudate)
- ORAL petechiae on the soft/hard palate junction
What is the treatment for EBV?
No specific tx (manage symptoms)
Maintain fluid intake
Antiseptic m/w
Analgesics
Note: Concurrent tx with penicillins whilst having EBV can cause erythematous skin rash (therefore, not a penicillin allergy)
What is Erythema Multiforme (EM)?
mucocutaneous blistering immune complex condition triggered by recurrent or occult HSV infection
What does EM typically affect?
Young males
What parts/components of the body does EM target?
Targets the skin with a rash/target lesions appearing on:
hands, arms
feet, legs
face
trunk
When affecting the mucous membranes of mouth (IO), lips, eyes + genitals, can see presentation on these sites
What is the aetiology of EM? (4)
Infections (HSV ~70%, hepatitis viruses, mycoplasma, HIV, bacterial, fungal + parasitic infections?
Drugs (NSAIDs, antimicrobials, barbiturates)
Systemics - SLE, malignancy, pregnancy
Idiopathic
What is the clinical presentation of EM? IO + EO
IO:
Oral lesions - bullae or erythematous base that breaks forming irregular ulcers, bleeds + forms crusts
Lips freq. involved (gingiva rarely affected)
EO:
Skin macules + papules- central pale area surrounded by oedema + bands erythema
i.e. iris or target type lesion or central bullae
What is the tx for EM?
acyclovir 5% topical cream as prophylaxis at beginning stage (cream doesn’t help with pain)
Penciclovir 1% (need to reapply every 2hrs + not well tolerated by pts)
Coffee grounds?
What is the tx for EM in pts w/ recurrence?
Continuous systemic antiviral therapy to suppress recurrence (Acyclovir 400mg bd)
What two viruses are caused by Paramyxovirus?
- Measles (aka rubeola) - acute contagious infection
- Mumps
What is the incubation period for Measles?
7-10days
What is the incubation period for Mumps and route of transmission?
14-25 days
Spread by close contact respiratory route
What is the EO clinical presentation of Measles?
Systemic:
Fever
Cough
Rhinitis
Conjunctivitis
Followed by maculopapular rash on forehead + ears + chest
What is the IO clinical presentation of Measles?
1-2 days prior to development of EO rash
there are KOPLIK’S SPOTS on buccal + labial mucosa + soft palate (pathognomonic of measles)
Appearance of these: small whitish lesions resembling grains of salt
Irregular patchy erythema w/ tiny central white specks
What is the management of Measles?
Vaccination
What is the EO presentation of Mumps?
Headache, nausea, loss of appetite
Fatigue
Pyrexia
Joint pain
Mid abdominal pain
Complications w/ older pts:
Orchitis (20-30% of adult men affected may cause sterility)
Oophritis
Pancreatitis
Meningitis
What is the oral presentation of Mumps?
Painful swelling of major salivary glands - often asymmetrical
Giveaway: inverted earlobes + salivary gland swelling
What is the management of Mumps?
Vaccination
Self-resolving
What virus causes Hand, foot + mouth disease (HFMD)?
Coxsackie Virus (subspecies A16)
Who does HFMD affect + what is the incubation period?
Highly infectious childhood infection (rarely affecting adults)
3-10days incubation period
What is the EO clinic presentation of HFMD?
Erythematous macular + vesicular eruptions involving hands, feet + oropharyngeal mucosa
–> lasting 1-3 days
What is the IO clinic presentation of HFMD?
- Multiple shallow but relatively painless, ORAL VESICLES/ULCERS
–> affecting the pharynx, soft palate, buccal mucosa + tongue (gingiva spared) - Rarely severe enough for a dental opinion
- No lymphadenopathy
What is a common differential diagnosis for HFMD?
Primary herpetic gingivostomatitis
What is the management of HFMD?
Diagnosis:
Serology needed for confirmation but normally not preformed as self-resolving
Tx:
- supportive tx
- antiseptic M/W
What virus causes Herpangina?
Coxsackie Virus (subspecies A2,4,5,6,8)
Who does Herpangina affect?
Children (childhood infection)
What is the EO presentation of Herpangina?
- sudden onset of pyrexia
- sore throat
(mild symptoms)
What is IO presentation for Herpangina?
Multiple papules, vesicles + ulcers on soft palate + sauces
Pain + swelling of salivary glands
What is treatment for Herpangina?
No tx
Self resolving within 10 days
What the causative agent of Cytomegaly virus (CMV)?
HHV5
Who does CMV affect? (2)
Immunocomprisied (esp HIV)
Newborns
What is the key oral symptom of CMV?
Sialadenitis
If pt has HIV –> then widespread shallow mucosal ulcers
What is the most common differential for CMV?
Glandular fever
What is the tx for CMV?
Ganciclovir
What is Human Papilloma Virus (HPV2 + HPV4) also known as?
‘Wart’ Virus
What is the oral presentation of HPV2 + 4?
Oral warts
Different types but often filementous warts (i.e. with strands of keratin)
What is the EO presentation of HPV2 + 4?
Lesions on hands + fingers (e.g. Butcher’s warts)
Genital mucosa (condyloma)
Skin
(often then transferred to oral cavity)
What is the link between HPV and HIV?
Massive outbreaks of HPV in HIV/AIDS pts
- When antiretrovirals used for a long period, warts disappear
What is the tx for HPV?
- can resolve spontaneously
- Important to tx all sites at same time
Possible tx:
- surgical excision
- Cryotherapy
- Laser tx
- Medical tx
What condition is Human Herpes Virus 8 (HHV8) responsible for causing?
Oral Kaposi Sarcoma
Who HHV8 aka Human Kaposi Sarcoma affect?
M>F
What HHV8 aka Human Kaposi Sarcoma affect?
Skin
Mucosa - eyes, mouth + nose
Systemic spread to lungs + GIT
Promotes angiogenesis
What is the clinical presentation of oral kaposi sarcoma (HHV8)?
Likely affecting PALATE + PERIODONTAL TISSUES
- Reddy-blue/purple macules or nodules that may ulcerate
Oral KS pathognomonic of AIDS-Mouth affected in 50% of pts w
mucocutaneous KS (seen in pt’s w CD4 count <200)
> reduced prevalence since introduction of antiretroviral therapy
What is tx forHHV8 aka Human Kaposi Sarcoma?
- antiretroviral therapy
- OR alitretinoin gel, liposomal
daunorubicin /oloxorubicin, paclitaxel,
IFN-α
Intralesional tx /
localised radiotherapy
How does HIV present orally?
Candidiasis
Linear Gingiva Erythema
Advanced Periodontal Disease
Oral Hairy Leukoplakia
Oral Kaposi Sarcoma
Oral Ulcers
Lymphoma
