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Viral Diseases of the Skin
Terms in this set (67)
What are viral exanthems?
Cutaneous manifestations of viral infections
What is an enanthem?
Internal rash, ex. mucous membranes
What forms do viral exanthems usually take?
Macular, papular, vesicular, pustular, petechial
What are the DNA viruses?
- Hepadna (Hep B)
Parvo: SS DNA
Which DNA viruses are single stranded?
What are the RNA viruses?
- Retrovirus: HIV and HTLV-1
- Paramyxovirus: Measles (Rubeola) and Mumps
- Picornavirus: Coxsackie, Hep A
- Flavivirus: Hep C, WNV, Yellow fever
- Togavirus: Rubella (German measles)
What are the common exanthems (names in order of time of discovery)?
First disease = Measles (Rubeola)
Second disease = Scarlet fever (bacterial)
Third disease = Rubella
Fourth disease = Duke's disease (likely a scarlet fever variant)
Fifth disease = Erythema infectiosum
Sixth disease = Roseola
What is first disease?
What is second disease?
What is third disease?
Rubella (German measles)
What is fifth disease?
What is sixth disease?
-Highly contagious via respiratory droplets
-Paramyxoviridae (RNA virus)
-Humans are only natural host and reservoir
-Prodrome: fever, cough, coryza, conjunctivitis, photophobia
-Enanthem: Koplik's spots on buccal mucosa occur 1-3 days before rash
-Exanthem: Rash begins on forehead and progresses down within 24 hours
What is the enanthem associated with measles?
What are the complications of measles?
-Pneumonia, myocarditis, otitis
When is the measles vaccine given?
Live, attenuated vaccine.
1st dose @ 12-18 months
Booster dose @4-6 years
-Togaviridae (RNA virus)
-Moderately contagious via respiratory droplets
-Humans are only host
-Incubation period of 2-3 weeks
-Prodrome (1-5 days): fever, headache, sore throat, malaise, rhinorrhea, eye pain, lymphadenopathy
Enanthem: Forchheimer's sign
What is the exanthem associated with rubella (aka German measles)?
Pale pink morbiliform macules (smaller than rubeola). Spreads cephalocaudad. Occasionally pruritic. Fades in 2-3 days.
What is Forchheimer's sign?
Pinhead size red macule or petechiae on the soft-palate and uvula.
The enanthem associated with rubella
Congenital Rubella Syndrome
-Occurs in pregnant women who are
* to virus
-Viremia --> placental infection --> fetal infection
-Most likely in 1st trimester
-Sensorineural deafness, cataracts, congenital heart disease, CNS abnormalities
Can you give the rubella vaccine during pregnancy to a woman who is rubella naïve?
No. It is a live, attenuated virus (MMR), therefore it is contraindicated in pregnancy.
What is Fourth's Disease?
Duke's disease. Due to enterovirus, echovirus, coxsackie.
Fever, nausea, vomiting, diarrhea, photophobia, lymphadenopathy, sore throat.
Erythema infectiosum (Fifth's disease)
-Parvovirus 19 (DNA)
- bright red macules with sparing of nasal ridge and perioral area
-Red macules/papules 1-4 days later
erythema that may last 1-3 weeks
-Rash intensifies with intensified temperature
-More common in winter and spring
-Spreads via resp droplets
-Most common in 4-10 year olds
-4-14 days incubation
-Arthralgias in 10%
For whom is Parvovirus 19 of specific concern?
Can lead to aplastic crisis in those with:
-Sickle cell anemia
What is the result of fetal infection with erythema infectiosum?
-Most common cause of
(other big cause is Alpha Thal Major)
-Miscarriage, stillbirth (8-10%)
-Highest risk in 2nd trimester (30% risk of transplacental infection
What are the live attenuated vaccines?
-Oral Polio (OPV)
What are the inactivated/killed vaccines?
-Polio (in US)
Papular Purpuric Gloves and Socks Syndrome
-Associated with coxsackie virus, HHV6, Hep B and EBV
-Common in young adults
-Mild prodrome: fever, anorexia, arthralgias
-Enanthem: petechiae of hard palate, pharynx and tongue
Exanthem: edema and erythema of both hands and feet with petechiae and purpura; well demarcated at wrists and ankles
Petechiae primarily on foot arch/instep likely due to Coxsackie virus
-Burning and pruritus
-Resolves of 1-2 weeks
-HHV6 or HHV7
-Spread via resp. droplets
-Common in spring
-Between 6 mos and 3 yoa
-Latency established in
of salivary glands and genital tract
-HHV6 latency in brain
-HHV6 integrates into human chromosomes (can be acquired from parents congenitally)
-9-10 days incubation
Prodrome (HHV6): very high fever for 4-5 days
Exanthem: Appears as the fever breaks.
Rose pink macule and papules that fade in 2-3 days
-May have mild URI and lymphadenopathy
What are Nagayama's spots?
Red papules on soft palate and uvula seen in associated with
When does the exanthem of roseola appear?
As the high fever dissipates
What are the human herpes virus subtypes?
HHV-1/HSV-1: usually oropharyngeal
HHV-2/HSV-2: usually genital
HHV-6 & HHV-7: Roseola
HHV-8: Kaposi's sarcoma, Primary Effusion Lymphoma, Castleman's
-Acute & self-limiting
Grouped vesicles on erythematous base
-Precipitating factors play a role in eruption
What are the primary signs of inoculation with HSV-1?
-Fever, sore throat, painful vesicles/erosions on tongues, palate, buccal mucosa and gingival mucosa
-Enanthem erosions covered in characteristic gray membrane
How is Recurrent Herpes Labialis differentiated from aphthous ulcers (canker sores)?
-Clustering of flat lesions
-Typically affects skin-mucosa junction
On non-keratinized mucosa
-Discrete, often singular lesions
Primary Genital Herpes
-Multiple painful erosions on anogenital mucosa
-Painful inguinal lymphadenopathy
-May have concomitant meningitis
-Severity peaks at 8-10 days
-Important to catch early and treat aggressively in first few days
Recurrent Genital Herpes
-Shorter duration than primary
-Greater recurrence with HSV-2
-Must be able to differentiate from folliculitis!
-Wrestlers and rugby players
-Most common on face, lateral neck and medial arms
Note to self: never let kids be wrestlers.
Eczema Herpeticum (Kapok's varicelliform eruption)
-Especially dangerous in infants and children with atopic dermatitis (can be fatal)
-Rapid, widespread cutaneous dissemination of HSV infection in areas of dermatitis/skin barrier disruption
Varicella Zoster (chicken pox)
-Highly contagious via resp droplets
-10-14 day incubation
-Exanthem: begins on head and torso and spreads outward (centripetal). Red macule evolve into vesicles over 12-14 hrs. Lesions can be seen in all stages. Dewdrops on a rose petal. Crusting and healing in 7-10 days. Pruritic.
Enanthem: Erythematous lesions in oropharynx
How is chickenpox differentiated from small pox?
Chicken pox: lesions in multiple stages
Smallpox: lesions all in the same stage
When is chickenpox no longer infectious?
When all the lesions have crusted over.
Intrauterine growth retardation, CNS, limb, ocular and skin abnormalities.
Maternal infection 5 days prior to 2 weeks after delivery --> very serious infection of neonate. Treat with acyclovir and VZIg
What is Ramsay-Hunt Syndrome?
VZV (herpes zoster) infection of geniculate ganglion. Zoster infects external ear. Ipsilateral facial paralysis. Tinnitus or auditory symptoms.
How are herpetic lesions diagnosed in the office?
Tzanck smear. Unroof blister and scrape the base. Multinucleate giant cells will be seen on the slide. Viral cultures are useful but take too long, since it's important to treat in the first few days of primary herpetic episodes.
When are oral antiviral agents useful?
Either used prophylactically (valacyclovir/Valtrex) or only if caught within in the first 48 hours of prodromal symptoms (acyclovir).
-Papular Acrodermatitis of Childhood -Super common
-Associated with EBC and CMV -Can be triggered by live/attenuated immunizations
-Most cases occur between 1-6 years old -Prodrome: URI, cough, fever
Symmetric, homogenous flat-topped brown-pink papules. Classically on cheeks, extensor extremities, buttocks. Spares the trunk!
Lasts 2-3 weeks.
Hand, Foot & Mouth Disease
-Enteroviruses and Coxsackie virus
-Highly contagious (spread fecal-oral or oral-oral), esp in daycare centers
-Prodrome: fever, malaise, anorexia, cough, sore mouth, abdominal pain
Painful, ulcerative lesions in oral cavity
-Exanthem: Appears after oral enanthem. Erythematous macules or papules with
central gray vesicle
-Gradually disappears after 5-10 days
-Benign skin infection
-Caused by HPV
1) Verruca vulgaris- common wart
2) Verruca planus- flat wart
3) Verruca plantaris- plantar wart
4) Condylomata accuminata- genital wart
What are the low risk HPV types?
What are the high risk HPV types?
16, 18, 31, 33, 34, 35, 45, 52, 58
What are the HPV subtypes that cause verruca vulgaris?
1, 2, 4, 7
What are the HPV subtypes that cause verruca plantaris?
1, 2, 4, 27, 57
What are the HPV subtypes that cause verruca planus?
3, 10, 28, 49
What are the HPV types that cause Butcher's warts?
What are the HPV types that cause Heck's Disease?
What are the HPV types that cause Buschke-Lowenstein (Giant Condylomata Accuminata)?
6, 11, 16, 18, 24
What are the HPV types that cause Epidermodysplasia Verruciformis?
5, 8, 9
HPV 1, 2, 4, 7
Fingers, dorsal hands, knees, elbows, nail folds (eponychium).
Punctate black dots representing thromboses capillaries.
Autoinnoculation by scratching results in linear arrangement of warts.
Palmar and Plantar warts
HPV 1, 2, 4, 27, 57
Thick, endophytic papules
Gently sloping sides and central depression, resembling an anthill (Myrmecia)
Painful on sole
Large plaques = mosaic warts
Verruca Planae (flat warts)
Flesh colored or spink, smooth-surfaced.
Slightly elevated and flat-topped papules.
HPV 3, 10, 28, 49
Common in meat-processing professionals.
Extensive verrucous papules or cauliflower-like lesions.
Hands and fingers of meat and fish handlers.
Anogenital and upper aerodigestive mucosa are target sites of infection.
subclinical infections more common than warts.
Discrete, sessile smooth surfaced exophytic papillomas or acuminate warts that may be flesh-colored, brown or white.
Lack of thick, horny scale seen on cutaneous warts.
Large, confluent plaques may form extending into vagina, urethra, or anal canal.
Condylomata plana = flat cervical warts
Affects mainly sexually-active young adults.
Multiple red-brown warty papules or confluent plaques on the external genitalia, perineum or perianal region.
Lesions may clinically resemble genital warts, but histologically represent a high-grade squamous intraepithelial lesion (HSIL) or squamous cell carcinoma in situ.
Predominantly high risk type 16.
Erythroplasia of Queyrat
Well-demarcated, velvety (ew) erythematous plaque of the glabrous skin of the penis and vulva. HSIL histologically. predominantly high risk type 16. May represent a precursor lesion of vulvar or penile cancer in younger patients.
Moral of the HPV story: No glove, no love.
Most common in children, especially those with atopic dermatitis. Predominant on trunk. Henderson-Patterson bodies seen histologically. Flesh-colored umbilicated papule. Spontaneous involution. Difficult to treat.
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