acid (either RNA or DNA), within a protein shell, the
capsid
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DNA virusesRNA viruses
? Herpes simplex
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? Retrovirus
? Varicel a-zoster
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? Togavirus? Human papil oma
? Flavivirus
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? Poxvirus
? Paramyxovirus
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? HHV 6,7 & 8? Hepatitis A, C & E
? Epstein Barr
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? Picornavirus
? Parvovirus
? Hepatitis B
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Aetiopathogenesis
? Cell lysis (Herpes)
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? Cell proliferation (Pox, HPV)? Carcinogenesis (Cervical Ca [HPV], hepatoma
[HCV, HBV])
?Exanthemata - Viraemia, type 3 hypersensitivity
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(Arthus) reaction, virus lodged in dermal capillaries &
replicate
?Persistent infection - Periods of latency & reactivation
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(HSV recurrence attacks of HSV labialis or genital
lesions; VZV herpes zoster)
Common Viral Infections of Skin
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?Human Papilloma Virus: Genital & extra-genital
warts
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? Pox Virus: Molluscum contagiosum? Varicella-zoster Virus: Varicella, Herpes zoster
? Herpes Simplex Virus 1 & 2: Herpes simplex
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? Viral Exanthemata
Human Papil oma Virus
?DNA virus, about > 200 types described til date
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?Carcinogenic ? anogenital, cervix?Incubation period: few weeks to about one year
?Transmission: direct or indirect contact (nail
biters, shaving, occupational, swimming pool)
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?Sexual transmission: genital / perianal wart
?Autoinoculation
Clinical Types
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Extra-genital (non-genital)
?Verruca vulgaris (Common warts)
?Verruca plana (Plane warts)
?Filiform
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?Digitate?Palmoplantar
?Periungual
Genital
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?Condyloma acuminataClinical features
Skin warts are benign tumours caused by infection
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of keratinocytes with HPV, visible as welldefinedhyperkeratotic protrusions
Verruca vulgaris:
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?Commonest type of warts?Children and young adults affected
?Asymptomatic, hyperkeratotic papular lesions
with warty excrescences
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?Common Sites: Extremities, dorsae of hands & feet?Koebner's phenomenon present
Clinical features
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Verruca plana?Juvenile/ flat warts
?Discrete flat skin colored or pigmented papules,
coalesce
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?Koebner's phenomenon +?Sites: face, neck, extremities
Filiform
?Finger like projection
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Digitate?Multiple finger like projections with a common base
?Sites: head, face and neck
Clinical features
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Palmoplantar
?Hyperkeratotic elevated or flat lesions, painful on
lateral pressure
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?Differential diagnosis: Corn, callosity
Periungual
?Commonly associated with palmoplantar warts
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?Invasion of nail bed?Recalcitrant to Rx
Genital Warts
Condyloma Acuminata
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?Protuberant moist, cauliflower like growths?Sites: frenulum, corona & glans in men &
posterior fourchette in women
?Anogenital warts in children: sexual or non-sexual
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transmission; may be sign of sexual abuseBowenoid Papulosis
?Multiple, grouped, warty lesions on genitalia
?Premalignant
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Complications?Secondary infection
?Pregnancy related:
Proliferative growth, obstruction of labour,
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laryngeal papillomas in infant / child
?Malignant change:
Buschke-Lowenstein tumor (verrucous
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carcinoma)
Cervical intraepithelial neoplasia (HPV 16, 18)
Investigations
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?Clinical diagnosis
?Histology: Papillomatosis, acanthosis with
inclusion bodies causing vacuolation in cells
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(Koilocytes)
?Immunohistochemistry: Type of HPV
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TreatmentNo treatment ? spontaneous clearing may occur
?Topical Keratolytics - Salicylic acid lotion; wart
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paints (lactic acid / salicylic Acid)
?Chemical cautery: TCA, liquified phenol
?Podophyllin / podophyllotoxin resin ?
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anogenital warts (CI ? pregnancy)?Cryotherapy (liquid N2 / CO2)
?Electrocautery / radiofrequency surgery
?Others: Imiquimod, 1% & 5% 5-FU creams,
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photodynamic therapyTreatment
Immnomodulators
? Levamisole, cimetidine, zinc
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Vaccines (immunotherapy)
? Mw vaccine, MMR vaccine, Trichophytin
Mol uscum Contagiosum
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?Pox Virus- Molluscum contagiosum virus
?MCV 1 & MCV 2
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?Incubation period: 2 weeks to 6 months?Transmission: contact, fomites, sexual
?Histology: Intracytoplasmic inclusion bodies (aka
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Henderson-Paterson bodies)
Clinical features
?Dome shaped, pearly white, discrete umbilicated
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papules
?Koebner's phenomenon present
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?Sites: Face, neck, trunk, around genitalia (more insexual transmission), eyelids
?Giant molluscum lesions / secondary infection
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Mol uscum Contagiosum in HIV
?Commonly on genitals, perianal region, eyelids
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?Refractory mollsca on face; disseminated lesionsmay be present
?D/D: Cryptococcosis, histoplasmosis, penicillinosis
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Treatment?Expression / Curettage
?Chemical cautery, electrodessication, cryotherapy.
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?Topical: Imiquimod, KOH, liquified phenol,
cantharidine, cidofovir cream
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?Systemic: Levamisole, cimetidineVaricella-Zoster Virus
?Chicken pox (varicella) & shingles (herpes zoster)
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?Transmission: Droplet infection - nasopharynx
?Varicella : Primary viraemia
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?Zoster: Reactivation of residual latent virus in thedorsal nerve root ganglia
Varicella - Clinical features
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?Incubation period: 2-3 weeks?Prodromal symptoms ? malaise, fever, sore throat,
bodyache etc.
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?Pleomorphic, centripetal distribution, dewdrops
on rose petal appearance
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?Vesicles, papulovesicles, crusting, haemorrhagic,umbilicated lesions
?Mucosal involvement +
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Complications
?Secondary infection
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?Encephalitis?Pneumonitis
?Hepatitis
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?Varicella in HIV- Progressive, haemorrhagic,
complicated
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?Chronic varicella- Hyperkeratotic lesions, acuteretinal necrosis
Treatment
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?SymptomaticRest, Antibiotics, NSAIDs, antihistamines
?Acyclovir
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Dose: 800 mg 5 times / day
Indicated in adult varicel a
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Reduces severity, duration & infectivity in childhoodchicken pox
?Prophylaxis
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Vaccine, Immunoglobulin (VZIg; IVIg), Acyclovir (IV)Herpes Zoster
Clinical Features
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?Reactivation of latent virus in the dorsal rootganglion of sensory nerve
?Older age group , diabetics, HIV infection / AIDS
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?Unilateral, dermatomal, grouped vesicles
?Cranial (V, VI commonly), spinal (thoracodorsal
commonly)
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?Pre-herpetic, herpetic and post-herpetic neuralgia
Herpes Zoster : Cranial nerve involvement
V Nerve
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?Ophthalmic division: Herpes zoster ophthalmicusHutchinsons sign (vesicles on nose tip)
Ocular complications: uveitis, keratitis,
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conjunctivitis, scleritis, ocular palsy
?Maxillary division: uvula / tonsils
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?Mandibular division : tongue / buccal mucosaHerpes Zoster : Cranial nerve involvement
VI nerve
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?Ramsay Hunt syndrome
?Earache, vesicles on pinna, facial palsy
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?Hearing loss, vertigo & taste sensation impairedComplications
?Secondary infection
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?Post herpetic neuralgia?Scarring
?Nerve Palsy
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?Encephalitis: in disseminated zoster
Herpes Zoster in HIV
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?Younger patient?Severe pre-, herpetic and post-herpetic neuralgia
?Multi-dermatomal, cranial nerve involvement
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?Haemorrhagic, disseminated
?Protracted course, verrucous lesions
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?Acute retinal necrosisTreatment
?Symptomatic
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?AntiviralsAcyclovir 800mg x 5times/day
Famciclovir 250-500 mg TDS
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Valaciclovir 1gm TDS
Duration: 1 week in immunocompetent
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2 weeks or more in immunosuppressedTreatment of post herpetic neuralgia
?Analgesics- NSAIDs- not much efficacy
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?TCAs- Amitryptiline, Nortryptiline?Sodium valproate
?Gabapentin
?Pregabalin
?Topical EMLA cream
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?Topical capsaicin ? causes irritationHerpes Simplex Virus
?HSV 1: Facial (above waist)
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?HSV 2: Genital (sexual)?Incubation Period : 3-7 days
?Primary infection
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?Persist in sensory ganglion - period of latency
?Reactivation
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Clinical features?Grouped vesicles on erythematous base followed
by erosions and healing
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?Primary attack: severe with lymphadenopathy and
systemic complaints
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?Recurrences: mild with shortened clinical course?Predisposing factors: trauma, sunburn, stress,
coitus, premenstrual, high grade fever, infections,
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surgery, dermabrasionHerpes Simplex- Clinical Types
?Herpes simplex virus 1
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Herpes labialis, herpetic gingivostomatitis,keratoconjunctivitis
?Herpes simplex virus 2
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Herpes genitalis, herpes vulvovaginitis?Complicated
Eczema herpeticum (Kaposi's varicelliform eruption),
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Disseminated HSV?Herpes simplex virus in HIV infection / AIDS
Chronic, recurrent, ulcers with eschar formation;
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dissemination can occurDifferential diagnosis
?Aphthosis
?Erythema multiforme
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?Behcet's syndrome?Pyodermas
?Genital ulcer disease e.g., chancroid
Investigations
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?Tzanck smear: Multinucleated giant cells
?Histopathology: Ballooning degeneration,
intraepithelial blisters, inclusion bodies
?HSV antibody titre: IgG / IgM ? not very reliable
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?Culture?Immunofluoroscence, PCR
?Electron microscopy
Treatment
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?Symptomatic?Topical - Acyclovir, penciclovir, cidofovir
?Systemic
Antiviral
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Primary
Recurrence
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Suppressive(10 days)
(5 days)
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6 months - 1yr or
longer
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Acyclovir 200 mg 5 times 400 mg TDS400 mg BD
/ day
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Valaciclovir
1 gm BD
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500 mg BD500 - 1000 mg BD
Famciclovir
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250 mg TDS
125 mg BD
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250 mg BDViral Exanthems
Macular
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?Rubel a
?EBV (infectious mononucleosis)
?Human herpesvirus 6 (roseola)
?Human herpesvirus 7
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Maculopapular
?Togavirus
?Measles
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?Human parvovirus B19 (erythema infectiosum)Viral Exanthems
Maculopapular - vesicular
? Coxsackie A (5, 9, 10, 16)
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? Echovirus (4, 9, 11)Maculopapular - petechial
? Togavirus (Chikungunya)
? Bunyavirus haemorrhagic fever (lassa)
Urticarial
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? Coxsackie A9? Hepatitis B
Uncommon Viral Infections of the Skin
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? Pox VirusesCowpox, orf, milker's nodule
? Epstein Barr Virus (EBV)
Infectious mononucleousis, oral hairy leukoplakia (OHL),
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Gianotti Crosti syndrome, lymphomas
? Viral (insect-borne & haemorrhagic) fevers
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(Toga, Flavi, Arena, Filo, Bunya)Chikungunya, dengue, Kyasanur forest disease (KFD), lassa
fever
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?Picorna Viruses
Herpangina
Hand, foot & mouth disease
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