Viral Infections

Viral Infections
HUMAN HERPESVIRUSES
• The human herpesvirus (HHV) family (Herpetoviridae) constitutes a large family of double-stranded DNA viruses.
• The best-known member of this family is herpes simplex virus (HSV), which includes HSV type 1 (HSV-1 or HHV-1) and HSV
type 2 (HSV-2 or HHV-2). Other members of the HHV family include varicella-zoster virus (VZV or HHV-3), Epstein-Barr virus
(EBV or HHV-4), cytomegalovirus (CMV or HHV-5), and more recently discovered members, HHV-6, HHV-7, and HHV-8.
Humans are the only natural reservoir for these viruses
• All eight types cause a primary infection and remain latent within specific cell types for the life of the individual. On
reactivation, these viruses cause recurrent infections that may be symptomatic or asymptomatic. The viruses are shed in
saliva or genital secretions, providing an avenue for infection of new hosts.
• Human herpesvirus 8 (HHV-8) is involved in the pathogenesis of Kaposi sarcoma (KS) (Kaposi sarcoma–associated
herpesvirus (KSHV) ).
HERPES SIMPLEX VIRUS
• HSV-1 is spread predominantly through infected saliva or active perioral lesions and adapted best to
the oral, facial, and ocular areas. The pharynx, intraoral mucosa, lips, eyes, and skin above the waist
are involved most frequent
• HSV-2 is adapted best to the genital zones, is transmitted predominantly through sexual contact, and
typically involves the genitalia and skin below the waist
• The natural history of HSV infection includes primary infection, latency, and recurrent infection.
• Primary infection refers to initial exposure of an individual without antibodies to the virus. Primary
infection with HSV-1 typically occurs at a young age, often is asymptomatic, and usually does not
cause significant morbidity.
• For symptomatic cases, the usual incubation period is 3 to 9 days. After primary infection is
established, the virus is taken up by sensory nerves and transported to the associated sensory or,
less frequently, autonomic ganglia where the virus remains in a latent state. The most common site
of latency for HSV-1 is the trigeminal ganglion
• The virus uses the axons of the sensory neurons to travel back and forth to the skin or muco
• Recurrent (secondary or recrudescent) infection occurs with
reactivation of the virus. Old age, ultraviolet light, physical or
emotional stress, fatigue, heat, cold, pregnancy, allergy, trauma,
dental treatment, respiratory illnesses, fever, menstruation, systemic
diseases, and malignancy have been associated with reactivation.
Clinical Features
primary herpetic gingivostomatitis
• Gingivostomatitis is the most common manifestation of primary
herpes simplex virus (HSV) infection during childhood.
• Primary Herpes simplex virus (HSV) infection in children is usually
asymptomatic or non-specific.
• Primary herpetic gingivostomatitis is characterized by ulcerative
lesions of the gingiva and mucous membranes of the mouth , often
with perioral vesicular lesions
• HSV Gingivostomatitis is usually a self-limiting illness, which resolves
without complications
• Primary herpetic gingivostomatitis is characterized by ulcerative lesions of the
gingiva and mucous membranes of the mouth , often with perioral vesicular lesions
• Illness occurs approximately one week after contact with an infected person
• Generally, begins with a prodrome which may include fever, anorexia, malaise,
sleeplessness and headache
• The lesions heal in approximately 10-14 days (up to 3 weeks in severe cases)
• Refusal to drink may result in dehydration, which is the most common complication
• Lethargy, drowsiness or focal neurology and altered behaviour may indicate HSV
encephalitis
• Rarer complications are oesophagitis, epiglottitis, pneumonitis and keratitis
Examination
• Lesions involve the buccal mucosa, tongue, gingiva, hard palate,
pharynx, lips and perioral skin
• Rash is vesicular and can easily bleed. The vesicles appear yellow after
rupture and develop a red halo, while bleeding vesicles can develop a
black crust.
• Submandibular or cervical lymphadenitis may be presen
Treatment
• Care is mainly supportive (analgesia and hydration)
• Analgesia
Pain relief options include;
• Simple oral analgesia including paracetamol and ibuprofen
• Topical analgesics eg Xylocaine Viscous® or Lignocaine gel 2%®
• For severe pain, inpatient management and oral opiates may be required
• Hydration
Adequate fluid intake to avoid dehydration is essential
• Antiviral Treatment
• Treat immunocompromised children with Aciclovir 10 mg/kg (max 400 mg) IV 8 hourly until there are no new
lesions
• Topical aciclovir is not effective
• Immunocompetent children generally don’t require antivirals. However, if within 72 hr of onset of disease and in
cases of severe pain, dehydration, consider Aciclovir 10 mg/kg (max 400 mg) PO 5 times per day until there are no
new lesions
The varicella-zoster virus (VZV)
• causes two distinct clinical infectious diseases, chickenpox (varicella)
and shingles (zoster)
• Chickenpox is the primary infection caused by the varicella-zoster
virus. It is an acute, highly infectious disease most commonly seen in
children under 10 years old. Chickenpox is usually a mild, self-limiting
illness and most healthy children recover with no complications.
Adults tend to suffer more severe disease than children.
Transmission
Chickenpox is highly contagious, infecting up to 90% of non-immune people who are

exposed to the disease. The incubation period (the time from becoming infected
until symptoms appear) ranges from 10 to 21 days .
Chickenpox is transmitted by the following routes:-
1. Airborne respiratory droplets.
2. Direct contact with the vesicle fluid.
3. Indirect contact through contact with clothes/linen freshly soiled by vesicle fluid
4. Chickenpox can also be spread from people with shingles. A person with shingles
can spread the VZV virus to others who have never had chickenpox. The exposed
person would need to come in contact directly or indirectly with the vesicle fluid
of the person with shingles but would develop chickenpox and not shingles.
Signs and Symptoms
• Chickenpox develops in stages. Before the rash appears, there may be:
1. fatigue or a general feeling of being unwell (malaise)
2. fever that lasts 3-5 days and is usually less than 102 °F (39 °C ).
3. loss of appetite
4. Muscle or joint aches
5. cold-like symptoms such as a cough or runny nose
6. headache
• After these symptoms, the following will happen:
1. An itchy rash will present on the face, body, or inside the mouth. The rash will develop in spots and
sometimes can also appear on the eyelids or the genitals. The severity of the rash can vary.
2. The rash will develop into fluid-filled blisters that will turn cloudy. These blisters may take days to
heal. As there may be many blisters, some may heal sooner than others.
3. The blisters will become scabs. The scabs will fall off after about a week.
Chickenpox and a weakened immune system
• The risks of contracting chickenpox and the development of
complications are higher in a person with a weakened immune system.
• A weakened immune system can result if a person:
1. is taking certain medications
2. has cancer
3. is undergoing treatment such as radio- or chemotherapy
4. has certain chronic conditions, such as lupus or rheumatoid arthritis
5. has other chronic illnesses such as uncontrolled diabetes, or heart,
liver, or kidney failure
Complications
• The risk of complications varies with age and is higher in infants under 1 and in persons over 15 years.
• Among unvaccinated people who develop chickenpox, a few people may have more severe symptoms. Adults
are more susceptible to complications than children, but even in adults, they are rare.
• Pregnant women, newborns, and infants up to 4 weeks old, as well as those with weakened immune
systems, are more likely to experience complications.
1. Infection: If the skin around the spots and blisters becomes red and tender or sore, there may be a
bacterial infection in the skin.
2. Breathing problems: If a person experiences breathing difficulties, they may be developing pneumonia.
3. Encephalitis: A person can develop an inflammation of the brain. Symptoms include confusion, sleepiness,
behavior or personality changes, or seizures.
4. Reye’s syndrome: In rare cases, recovering children and teenagers will experience swelling of the liver and
brain.
5. Bleeding: A person can experience a hemmorhage, which is a loss of blood from a ruptured blood vessel.
6. Sepsis: A person can getTrusted Source an infection in the blood, which is a life-threatening condition.
Chickenpox and pregnancy
• People who are pregnant have a slightly higher risk of developing

pneumonia from chickenpox. There is also a danger of passing the
infection to the fetus.
• If infection occurs during the first 20 weeks of pregnancy, there is a higher
risk of congenital varicella syndrome. This can cause scarring in the fetus,
as well as eye problems, brain drainage, and shortened arms or legs.
• If the infection happens later in pregnancy, the virus can transmit directly
to the fetus and the baby can be born infected.
• If a person becomes exposed to varicella during pregnancy, it is important
to talk to a doctor right away.
Diagnosis
• Chickenpox may be diagnosed by clinical signs and symptoms. The
diagnostic feature of chickenpox is the vesicular rash which starts as
small papules, develop into clear vesicles which become pustules and
then dry into crusts. The rash usually appears first on the trunk and
successive crops of vesicles appear over several days although hands
and feet are relatively spared.
• Laboratory confirmation is rarely required but if necessary, is
available by sending a microscopy slide with vesicle fluid to the
National Reference Laboratory. Serology is also available and is used
to demonstrate immunity.
Treatment
• There is no specific treatment for chickenpox. It is a viral infection that will
therefore not respond to antibiotics.
• Treatment should be based on reducing symptoms such as fever and
itchiness
• People at higher risk of developing serious complications from chickenpox
may be given antiviral drugs such as acyclovir and/or immunoglobulin (a
specialised preparation of antibodies taken from the plasma of blood
donors), which may prevent severe illness developing. These people include
pregnant women who are not immune, neonates, immunosuppressed
people e.g. receiving chemotherapy or radiotherapy, received an organ
transplant and are receiving immunosuppressant therapy etc.
Shingles
• Shingles affects a person’s nerves. Usually, people will experience an intensely painful rash that
looks like a patch of raised dots and follows the path of a nerve on one side of the body. This
may be on the face or the trunk of the body, but may also occur in other areas.
• The rash may be itchy. In addition, a person may also feel stabbing pain. Later, the rash will turn
into fluid-filled blisters that crust over within several days.
• When a person gets shingles, they may also get a fever or a headache. Additional symptoms may
include nausea, diarrhea, upset stomach, and chills.
• Shingles can also cause postherpetic neuralgia, which is pain from shingles lasting for at least
three months after the blisters have gone. It can also cause neurological problems affecting the
brain, spinal cord, and facial nerves.
• A doctor may suspect a person has shingles instead of chickenpox if the person has had
chickenpox before, is over the age of 50, under a lot of stress, or if they are
immunocompromised. These are factors that may put a person at a higher risk for the condition.

Viral Infections

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Viral Infections

Chickenpox is highly contagious, infecting up to 90% of non-immune people who are

• People who are pregnant have a slightly higher risk of developing

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