Week 2 - E(2) - Microbiology - Herpes/Shingles, Ramsay Hunt, H.P.V, Molluscum, Herpaingina/H.F.M, Slapped-cheek, Syphilis

Question 1

What viruses causes both chicken pox and shingles?

Answer 1

Both caused by varicella zoster virus - human herpes virus 3

Chicken pox is also known as varicella

Shingles is also known as zoster

Question 2

State the common names which you know for the different human herpes viruses

Answer 2

HHV1 - herpes simplex virus 1

HHV2 - herpes simplex virus 2

HHV3 - varicella zoster virus

HHV4 - epstein barr virus

HHV5 - cytomegalovrus

HHV8 - kaposi’s sarcoma

Question 3

What age does chicken pox generally present and what is the progression of the presentation? What is its site of latency?

Answer 3

Chicken pox generally presents in childhood with a generalized rash, itch and fever -

usually the rash begins as macules–>papules–>vesicles with a red surround

The virus establishes latency usually in the sensory nerve roots

Question 4

Describe a macule, papule and vesicle?

Answer 4

Macule - flat lesion with less than 1cm width (>1cm - patch)

Papule - raised skin lesion less than 0.5cm height

Vesicle - small blister - lesion less than 0.5cm in diameter

Question 5

Chicken pox usually is a clinical diagnosis How can it be diagnosed if uncertain?

Answer 5

Taking a swab in a viral medium and sending to he microbiologists for PCR

Question 6

What is the latent reactivation of chicken pox known as and what is the presentation?

Answer 6

Latent reactivation of chicken pox is shingles - aka zoster aka herpes zoster

Results in a dermatomal vesicular rash which can begin to crust - tingling pain initially to erythema to vesicles to crusts

Question 7

What is the word used to describe the type of pain experienced in shingles? What is this pain known as when it lasts longer than 4 weeks? - who does this usually occur in

Answer 7

Shingles pain is described as a neuralgic pain in character

Long term complication of the nerve damage due to VZV is prolonged pain (beyond 4 weeks) and this is known as post-herpetic neuralgia It is more common in elderly patients and those with trigeminal distribution zoster

Question 8

Is scarring of the skin common in shingles? What is the treatment of shingles or severe chicken pox?

Answer 8

Scarring of the skin due to shingles is not common

Treatment of shingles or severe chicken pox is acyclovir

Question 9

What is chicken pox in a neonate known as? What can cause this? What is the syndrome this can cause?

Answer 9

Neonatal varicella voster virus - occurs secondary due to mother contracting chicken pox in late pregnancy

Can cause foetal varicella syndrome

Question 10

What can you prescribe to woman who are exposed to somebody with chicken pox whilst late in pregnancy?

Answer 10

Varicella Zoster Immune Globulin or acyclovir can be given to the mother

Give the baby zoster immunoglobulin

Question 11

What is it known as when shingles affects the ophthalmic division of the trigeminal nerve? What division is the ophthalmic? What it is the sign known as where it has affected the tip of the nose? - why is this important?

Answer 11

Shingles affecting the ophthalmic division is known as ophthalmic zoster (CN V1)

Hutchinson’s sign is when there is nose tip involvement - this means involvement of the nasociliary branch of CN V1 which also supplies the globe and therefore makes it likely that the eye will be infected

Question 12

Where should patients with ophthalmic zoster be referred to and why? What is the treatment?

Answer 12

Refer to ophthalmology to exclude inflammation and ulceration of the cornea of the eye

Treat with acicylovir + lubricating eye drops if near eyelid

Question 13

Is there a vaccine for chickenpox? If so, what type of vaccine is it and who is it used in?

Answer 13

There is a live attenuated vaccine available for chicken pox - it is only used in susceptible health care workers in the UK

Not used in children in UK

Question 14

How is the live attenuated vaccine used in chickenpox used to vaccinate against shingles and when is it given?

Answer 14

The live attenuated VZV used in chickenpox vaccine can be used in a high titre preparation in the elderly - to both reduce the incidence of shingles and reduce incidence of post-herpetic neuralgia

Routinely given to patients aged 70 years old

Question 15

What is often the initial presentation of herpes simplex known as primary gingivostomatitis?

Answer 15

Primary gingivostomatitis is often a presentation of herpes simplex virus - causing extensive ulceration in and around the corner of the mouth - lasts around 1 week

Question 16

Is HSV type 1 or 2 the main cause of oral lesions? Which causes genital lesions?

Answer 16

HSV type 1 is the main cause of oral lesions, causes half of genital lesions can lead to encephalitis

HSV type 2 - rarely causes oral lesions, causes half of genital lesions, can lead to encephalitis

Question 17

What is acyclovir an analogue of? How does it inhibit replication of a viral pathogen? Does it elimate latent virus?

Answer 17

Acyclovir is an anlogue of the nucleoside guanosine

It is incorporated into the viral DNA inhibiting DNA replication It does not eliminate latent virus

Question 18

What is it known as when the herpes simplex virus causes a lesion on the finger or thumb? What does it look like? What is it known as when herpes simplx virus affects an area of eczema?

Answer 18

HSV in finger or thumb - herpetic whitlow - vesicles/rash on the digit

HSV affecting an area of previous eczema - eczema herpeticum (may be confused with impetigo however eczema herpteicum usually child will also feel unwell/fever which is unusal in impetigo)

Question 19

peripheral facial nerve palsy accompanied by an erythematous vesicular rash on the ear or in the mouth What is this? What causes it? What is it called if it is just the peripheral facial palsy with no rash?

Answer 19

This is Ramsay Hunt syndrome - caused by latent varicella zoster virus reactivating in the geniculate ganglion of the 7th nerve

The condition where there is an idiopathic 7th nerve palsy with no rash is Bell’s palsy

Question 20

Apart from the facial nerve palsy seen in ramsay hunt syndrome, what other symptoms are seen? What is the treatment of both Bell’s pay and Ramsay Hunt syndrome?

Answer 20

irritation of the 8th cranial nerve may also occur in ramsay hunt syndrome causing vertigo, deafness, tinnitus

Bell’s palsy - treat with steroids

Ramsay Hunt syndrome - treat with steroids and acicylovir

Question 21

What is the skin reaction showing target lesions what may occur as an adverse reaction to drugs or some infections? Give two infection examples

Answer 21

Erythema multiforme can also be desribed as target lesions as they have a red erythematic circle with a central blister

Many triggers including drug reactions and Herpes simplex

Mycoplasma pneumoniae

Question 22

How long does erythema multiforme tend to persist?

Answer 22

Erythema multiforme is usually mild and goes away in a few weeks

Question 23

Which HPV is most common in warts/verucas? Which is most common in genital warts? Which is most common in cervical cancers? What is the HPV vaccine available known as and which age groups is it given to?

Answer 23

HPV 1-4 - most common in warts/verucas

HPV 6 and 8 - most common in genital warts

HPV 16 and 18 - most common in cervical cancers (account for about 70%)

HPV Vaccine known as Gardasil - Available

• * All females and males aged 12-13 years old
• * All MSM up to the age of 45 years old
• * 2 injections given 6 months apart

Question 24

What cells in the skin does HPV infect? What is the treatment of warts/verucas? (HPV types 1-4)

Answer 24

HPV infects the keratinocytes in the skin

Treatment of HPV types 1-4

Often resolve spontaneously

Can use topical salicylic acid or liquid nitogen (cryotherapy)

Question 25

What is the viral infection of the skin that results in small, raised, pink lesions with a dimple in the center? How would you describe them medically?

Answer 25

Molluscum contagiosum is a viral disease of the skin that results in small fleshy, pink firm, papules that have an umbilicated (depressed) central punctum

Question 26

Who is molluscum contagiosum most common in? How is it treated?

Answer 26

Molloscum contagiosum is most common in chidlren however can be sexually transmitted in adults

Treatment is self limiting as they resolve spontaneously although it can take months

Can use local application of cryo treatment (liquid nitrogen)

Question 27

What is herpangina and what causes it? What does it look like?

Answer 27

Herpangina is a common childhood illness caused usually by enteroviruses - eg coxsackie virus or echovirus

It’s characterized by small, blister-like ulcers at the back of the mouth and the throat

Question 28

How is herpangina usually confirmed? What is the treatment?

Answer 28

Swab of lesion and a sample of stool for entorovirus PCR

It is self-limiting and does not require treatment

Question 29

What is another enterovirus conditon (especially coxsackie viruses) that typically affects children and affects the hands, feet and mouth? How are the mouth symptoms different from that of herpangina?

Answer 29

Hand, foot and mouth disease is caused by enteroviruses (mainly coxsackie viruses) and cause vesicle/ulcers to develop on palms, soles and mouth

Differs from herpangina

Ulcers in herpangina at back of mouth

Ulcers in hand,foot and mouth disease at front of mouth

Question 30

What is the erythema infectiosum better known as? What causes it? How does it present?

Answer 30

Erythema infectiosum aka erythrovirus aka fifth disease is better known as slapped cheek disease It is caused by erythrovirus B19 aka parvovirus B19

It presents typically in childhood with a rash on the cheeks - looking like a slap then this fades and a macular rash appears on the body/limbs

Question 31

What are the complications of erythrovirus other than the red cheeks and macular rash?

Answer 31

Erythrovirus can cause acute arthritis - especially in adults as the rash fades

Also can lead to chronic anaemia or aplastic crisus - marrow stops making RBCs

Also linked to foetal loss if pregnant when infected

Question 32

How is erythrovirus diagnosed?

Answer 32

Diagnosis via lab confirmation of the IgM antibody in the blood - parvovirus B19 IgM test

Question 33

What is the virus of sheep causing firm fleshy nodules on the hands of eg farmers known as? How is it treated?

Answer 33

Orf - self limiting

Question 34

What sexually transmitted infection causes syphilis? What is the primary infection symptoms? What are the secondary and tertiary stage symptoms?

Answer 34

Treponema pallidum causes syphilis -

Primary infection shows a chancre at the entry site - painless ulcer

Secondary stage - dissemination - red rash over body, prominent on soles of feet and palsm

Tertiary stage - neurosyphilis

Question 35

What is the type of pupil that is seen in neurosyphilis?

Answer 35

Argyll Robertson pupil - pupil is constricted and unreactive to direct and consensual light reflexes

However the accommodation-convergence reaction remains intact

(prostitutes pupil - accomodates but doesnt react)

Question 36

Why is Argyll-Robertson pupil sometimes referred to as prostitute’s pupils?

Answer 36

Argyll Robertson pupils are also sometimes called “prostitute’s pupils” because of their association with late neurosyphilis.

A popular mnemonic to remember Argyll Robertson pupils is that, just like prostitutes, they “accommodate but do not react”.

Question 37

What is the treatment of syphilis?

Answer 37

Treat with IM benzylpenicillin - duration depends on stage