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Viral infections

Viral infections. Asma El-Howati BDS, Mclin Oral Medicine. Objectives. Be aware of the viruses which can cause oral lesions Recognize the oral manifestations of viral infections Understand how to manage these infections. Introduction.

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Viral infections

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  1. Viral infections Asma El-Howati BDS, Mclin Oral Medicine

  2. Objectives • Be aware of the viruses which can cause oral lesions • Recognize the oral manifestations of viral infections • Understand how to manage these infections

  3. Introduction • Viruses are vey small (100-300nm) obligate intracellular parasites that require host cells protein synthesising components • Many viruses have property of latency and reside in host asymptomatically • 90% of adults have viruses acquired early in life

  4. Introduction • Oral mucosa frequent location for primary viral infection and subsequent reactivation • Reactivation occurs during periods of immuno-compromization

  5. Viral infections potentially involving oral mucosa • Herpes simplex type 1 (HSV1) • Herpes simplex type 2 (HSV2) • Varicella zoster virus (VZV) • Epstein-Barr virus (EBV) • Human Cytomegalovirus (HCMV) • Coxsackie viruses • Other human herpes viruses eg; HHV8 (HHV) • Human papilloma virus (HPV) • HIV

  6. HSV1 and HSV2 • HSV1: most herpetic infection above the belt • Primary herpetic gingivostomatitis • Virus lies dormant in dorsal root ganglion • reactivation –herpetic labialis • Reactivation triggered by: sunlight, trauma, immunosuppression • HSV2: herpetic infections below the belt are mainly caused by this type and cause ano-genital herpes

  7. HSV infection • Endemic • By age 12 years 40% of children have HSV1 antibody • By age 60 years, 90% have HSV 1 antibody • Decreasing numbers with increasing prosperity • Infection maybe sub clinical (teething) or florid (up 10%) • Maybe sign of immunosuppression

  8. Primary herpetic gingivostomatitis • Caused by HSV1 or 2 and spread by saliva • Clinical features • Incubation period 4-7 days • Primary infection; intra epithelial vesicles • Multiple herpetic mouth ulcers • Diffuse gingivitis • Cervical lympadenitis • Fever • Malaise, irritability and fever

  9. Natural history • Prodromal symptoms of fever and malaise • Vesicles 2-3 mm on keratinised tissue only • Rupture leaving painful ulcers which heal 7-10 days • Lip erosions, lymphadenopathy, pharyngotonsillitis present in severe cases • Infection usually in childhood, but an increasing number are being encountered in young adults

  10. How would you manage primary HSV? • Basic principles • Specific treatment

  11. Management of primary HSV • Usually clinical diagnosis • Large numbers of virions in ulcers and saliva • Viral culture, electron microscopy • serology • PCR- raising titre of antibody is confirmatory • Treatment largely supportive • Antiviral therapy if severe

  12. Management of primary HSV • Reassurance and advise on nature of disease • Limit contact with lips and mouth • Antiseptic mouthwash to prevent secondary bacterial infection(chlorahexidine MW) • Encourage fluid intake (dehydration state) • Simple analgesics, antipyretic (paracetamol, ibuprofen) • Admission sometimes required if dehydrated • Prevention of spread, avoid close contacts • Acyclovir suspension 200mg in 5ml five times a day for 5 days (or tablets, 200mg) – half dose for children <2yrs. Prescribed at early stage

  13. Recurrent herpes labialis • Cold sore or fever blisters • Mucocutaneous junction of the lip • 40% of infected persons have recurrence • Prodromal tingling or burning prior to appearance of lesion (~24) • 25% episodes have no prodromal symptoms

  14. Recurrent herpes labialis • Vesicular eruption, breaks down to crusting lesion • Vesicular enlarge, coalesce, weep, rupture (2-3 days), crust, heal (10 days)

  15. Reactivation of latent HSV1 • Breakdown in local or systemic immuno-surveillance • Previously accepted that HSV1 migrates from trigeminal ganglion to site of peripheral reactivation • HSV may also be found in local neural tissue • HSV1 may be asymptomatically shed periodically > once/ month by up to 70%

  16. HSV recurrence- trigger factors • Ultraviolet light exposre-snow, sea • Infection eg; pneumonia, upper respiratory tract infection • Menstruation • Reduced immunity eg; HIV, chemotherapy, transplants • Trauma, post operative

  17. Prevention • Sunscreen- reduces frequency of recurrence • Topical aciclovir- can reduce duration of attack • Severe or frequent recurrences systemic aciclovir prophylaxis

  18. treatment • Educate patients regarding infectivity of the lesion • Topical aciclovir will reduce duration and severity

  19. Additional topical agents for RHL • 1% penciclovir apply every 2 hours for 4 days • 5% idoxuridine; little value

  20. HSV recurrence (Herpetic whitlow) • Recurrence involving skin and digits • Health care workers at risk • HSV acquired from patients saliva • Highly infective • Intensely painful • Warn about shared utensils

  21. Recurrent herpes simplex-intraoral • Keratinised tissue • Often on hard palate near the greater palatine foramen • Attached gingiva • Usually after dental treatment • Preceded by prodromal tingling • Area appears as localised collection of vesicles which ulcerate • Differential is anesthetic necrosis

  22. Erythema multiforme • EM is mucocutaneous blistering condition • Mucosal erosions and lip blistering with skin lesions • Some cases triggered by recurrent HSV infection • Continuous systemic antiviral therapy to suppress recurrence eg; Aciclovir 400mg bd

  23. Erythema multiforme • Age <30 (50% <20) • Aetiology: drugs, infections (HSV, HIV, Hepatitis, mycoplasma), Idiopathic. • Immune mediated type III (immune complex) • Target/ iris lesions, erythematoys papules and blisters • Extremities (palma and soles) and mucous membranes

  24. EM features • Oral lesions; bullae or erythematous base break rapidly into irregular ulcers, bleed, form crusts • Lips more frequently involved, rare for gingiva to be affected • Skin macules and papules, central, pale area surrounded by oedema and bands of erythema; iris type but can be bullae • Varied appearance

  25. EM causes • Infection; HSV 70%, hepatitis viruses, mycoplasma, bacterial, fungal, parasites • Drugs; NSAIAs, antifungal, barbiturates • Systemic; SLE, malignancy, pregnancy • Idiopathic 50%

  26. Aciclovir • Topical agent; Aciclovir cream 5% • Limited evidence for its effectiveness in reduction of pain and limited effect on reducing time to resolution • Systemic aciclovir is effective both as prophylaxis and treatment and some evidence on decreased healing time; level evidence A

  27. Action of aciclovir • Nucleoside analogue drug active against herpes viruses particularly HSV • Aciclovir triphosphate is produced in HSV infected cell by viral enzymes • Acts by inhibiting viral DNA synthesis and blocking viral replication • Similar agents include valaciclovir (longer intracellular half life), penciclovir (topical) and famciclovir (oral prodrug of penciclovir) • Docosonal alters cell membranes preventing viral entry used for orofacial herpes

  28. Varicella zoster virus (HHV3) • Herpes virus causing chickenpox and shingles • Primary infection; chickenpox in nonimmune, may affect up to 90% of children • Recurrence; reactivation as shingles; maybe sign of underlying malignancy, immunosuppression

  29. Primary infection- chicken pox • Common childhood infection • Itchy maculopapular rash back, chest, face, 2-3 weeks after initial infection • Initial site upper respiratory tract- droplet infection • May have areas of oral vesicles, ulceration, palate and fauces • Usually present to GMP rather than GDP

  30. Complication of chicken pox • Complication more common in adults, smokers and those with chronic lung infection • Bacterial superinfection of vesicles (usually staphylococcal or streptococcal) occurs in 1-4%, can lead to cellulitis, toxic shock syndrome (TSS) or bacterial pneumonia • Varicella pneumonitis • Cerebellar ataxia in children • Bacterial pneumonia (more common in adults, smokers and those with pre-existing lung disease) • Rare: Encephalitis, iritis, thrombocytopenia, myocarditis, osteomyelitis, orchitis, reyes syndrome.

  31. Herpes zoster recurrence • Shingles; usually appears on trunk, affecting single dermatome • Occasionally underlying immunosuppression eg; AIDS, Hodgkins lymphoma, organ transplant • Often misdiagnosed in prodromal phase • Predilection for cranial nerves V and VII

  32. Shingles • Herpes zoster (shingles) affects 50% of patients who live to 85% • Recrudescence of latent varicella zoster virus from DRG or cranial nerve ganglia present since initial infection as chicken pox • Probably many reactivation during life time but controlled by competent immune system cmi • Incidence; 200.000 per year and expected to increase

  33. Complications of herpes zoster • Postherpetic neuralgia • Ophthalmic shingles • Ramsay-Hunt syndrome • Encephalitis • Secondary bacterial infection • Scarring • Muscular weakness

  34. VII- Ramsay-Hunt syndrome • Herpes zoster affecting geniculate ganglion • Lower motor neuron facial paralysis • Vesicular lesions on external auditory meatus, (pinna, fauces) • Altered taste • deafness

  35. What is this? And why do you need to recognise it quickly? • V1- ophthalmic herpes zoster • Corneal scarring with result lost of vision • Urgent referral to ophthalmology

  36. Herpes zoster • V2 &3; maxillary and mandibular divisions: • Vesicles affecting facial skin and mucosa up to midline affected • Maybe preceded pain in teeth and gingivae • Lymphadenopathy • Malaise and pyrexia

  37. Potential long term effects of herpes zoster affecting the trigeminal nerve? • Corneal scarring; impaired vision • Post herpetic neuralgia

  38. Management of herpes zoster • Treatment often suboptimal • >50 yrs greater risk of PHN; antiviral treatment with aciclovir/ famciclovir/ valaciclovir • Treatment ideally commenced within 72 hours of rash onset • Decrease duration of viral shedding, rash healing hastened, decrease severity and duration of acute pain • Reduction in neural damage should decrease PHN

  39. Management of herpes zoster • Immunocompromised patients IV antiviral • V1 (nasociliary) ophthalmic assessment and antivirals • Pain relief; follow analgesic ladder, opioids maybe required • Risk of complication increases with age, immuno-compromisation, lack of appropriate treatment

  40. Post-herpetic neuralgia • Highest risk in the elderly over 65 years • Occurs in zone of eruption • Burning continuous pain/ intervals sever shooting pain • Prevention: systemic aciclovir (800mg x5/ day 10/7), famciclovir used during an attack of zoster also TCA • Treatment: gabapentin, TCA

  41. Epstein-barr virus • Cause of infectious mononucleosis (glandular fever); gives positive Paul Bunnel and monospot tests. • Also involved in number of other conditions eg; Non Hodgkins and Burkitts lymphoma, oral hairy leukoplakia, nasopharyngeal carcinoma • 70% carry virus by 30 years • Spread through saliva; “teenage kissing disease” • Concurrent treatment with penicillin causes erythematous skin rash (not penicillin allergy)

  42. Infectious mononucleosis • Oral involvement in 30% of patients • Incubation of 30-50 days followed by; fever • Anorexia • Malaise and lassitude • Generalized tender lymphadenopathy • Sore throat, faucial oedema creamy tonsillar exudate • Oral petechiae; at hard and soft palate junction

  43. Glandular fever management • No specific treatment • Symptomatic management maintain fluid intake • Antiseptic mouthwashes • analgesics

  44. EBV and OHL • Not pathognomonic of HIV • Immunocompromised patients • Use of potent oral and inhaled corticosteroids • Transplant patients

  45. Measles (rubeola) • Acute contagious infection with paramyxovirus, rubella virus (droplet) • Incubation period: 7-10 days • Fever, sore throat, rhinitis, cough, conjunctivitis • Then maculopapular rash- forhead first then behind ears

  46. 1-2 days prior to onset of rash develop Koplik’s spots on buccal mucosa and soft palate (small whitish lesions resembling grains of salt)

  47. Mumps • Paramyxovirus • Painful swelling of major salivary glands- often asymmetrical • Spread: close contact respiratory route • Incubation period: 14-25 days • Other symptoms: headache, joint pain, nausea, dry mouth, mild abdominal pain, fatigue, loss of appetite, pyrexia of >38◦C • Complications: Orchitis (20-30% of adults men affected may cause sterility), Oophritis, pancreatitis, meningitis.

  48. Cytomegalovirus (CMV, HHV5) • ~80% adults serological evidence of exposure • Salivary inflammation/ sialadenitis- cytomegalic inclusion disease • Uncommon and limited to immuno-compromised and newborn • May cause a glandular fever-like illness • HIV- widespread, shallow mucosal ulcers responds to ganciclovir

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