1. Viral Skin Infections Ziad Elnasser, MD, Ph.D

2. Skin rashes World wide, Nonimmune, human reservoirs, respiratory tract. World wide, Nonimmune, human reservoirs, respiratory tract. Mumps, Measles, Rubella. Mumps, Measles, Rubella. Erythema infectiosum and Parvovirus B19. Erythema infectiosum and Parvovirus B19. Roseola Infantum (Exantheme Subitum) and HHV6 and HHV7. Roseola Infantum (Exantheme Subitum) and HHV6 and HHV7. Poxviruses. Poxviruses. Herpes viruses. Herpes viruses.

3. Mumps

4. Mumps Paramyxovirus one antigenic type. Paramyxovirus one antigenic type. NA, HA on envelope. NA, HA on envelope. Parotitis, aseptic meningitis in children. Parotitis, aseptic meningitis in children. Acute orchitis in adults. Acute orchitis in adults. Communicable 7days before to 9 days after. Communicable 7days before to 9 days after. Late winter to spring. Late winter to spring.

5. Local replication, viremia, salivary glands and CNS, second viremia then organs. Local replication, viremia, salivary glands and CNS, second viremia then organs. Kidneys. Kidneys. Cell necrosis and inflamation. Cell necrosis and inflamation. IgM, then IgG, CMI might contribute. IgM, then IgG, CMI might contribute. Permanent immunity. Permanent immunity. IP=12 to 29 days ave. 16-18 days. IP=12 to 29 days ave. 16-18 days. Unilateral or Bilateral. Unilateral or Bilateral. Meningitis, encephalitis, transverse myelitis, Pancreatitis, orchitis, Oophoritis. Meningitis, encephalitis, transverse myelitis, Pancreatitis, orchitis, Oophoritis. Myocarditis, nephritis, arthritis, thyroiditis, sensorineural deafness. Myocarditis, nephritis, arthritis, thyroiditis, sensorineural deafness.

6. Saliva, CSF, Pharynx. Saliva, CSF, Pharynx. Primary monolayer of Monkey kidney cell culture. Primary monolayer of Monkey kidney cell culture. Cyncytial giant cells, viral agglutination. Cyncytial giant cells, viral agglutination. Serology. Serology. No specific therapy, only MMR one or two doses. No specific therapy, only MMR one or two doses.

7. Measles (Rubeola) Paramyxovirus (Mobillivirus). Paramyxovirus (Mobillivirus). H, F proteins, CD46 receptor. H, F proteins, CD46 receptor. Fever, rash and immunesuppression. Fever, rash and immunesuppression. More than 6 months of age. More than 6 months of age. Late winter and early spring. Late winter and early spring. 95% infectivity, 3-5 days before to 4 days after the disappearance of the rash. 95% infectivity, 3-5 days before to 4 days after the disappearance of the rash.

8. Exanthemes and enanthemes

10. Pathogenesis URT, intense infection, inclusion bodies in the nucleus and the cytoplasm. URT, intense infection, inclusion bodies in the nucleus and the cytoplasm. Viremia. Viremia. B and T cells, PMN’s, CMI and humoral immunity effect, superinfection. B and T cells, PMN’s, CMI and humoral immunity effect, superinfection. Warthin-Finkeldey cells. Warthin-Finkeldey cells. Vasculitis and skin rash, exantheme and enantheme (Koplik’s spots). Vasculitis and skin rash, exantheme and enantheme (Koplik’s spots). CNS involvement. CNS involvement.

12. CMI suppression. CMI suppression. Humoral peaks in 2-3 weeks, persist at low level. Humoral peaks in 2-3 weeks, persist at low level. Life long immunity. Life long immunity. 5 day measles, IP=7-18 days, URT symptoms, conjunctivitis, fever, Kopkik’s spots, skin rash, LNs. 5 day measles, IP=7-18 days, URT symptoms, conjunctivitis, fever, Kopkik’s spots, skin rash, LNs. Mortality could reach 15-25%. Mortality could reach 15-25%. Bacterial superinfection in 5-15% (URT, pneumonia, encephalitis, thrombocytopenic purpora, Bacterial superinfection in 5-15% (URT, pneumonia, encephalitis, thrombocytopenic purpora, SSPE and evidence. SSPE and evidence.

13. Clinical Diagnosis. Clinical Diagnosis. Viral isolation from oropharynx or urine. Viral isolation from oropharynx or urine. Multinucleated giant cells. Multinucleated giant cells. Serology. Serology. Treat complications. Treat complications. MMR, once (12 to 15 months)or twice (4-6 years or 10-12 years), contraindications. MMR, once (12 to 15 months)or twice (4-6 years or 10-12 years), contraindications.

14. Rubella (German measles) Mild benign childhood exantheme. Mild benign childhood exantheme. Profound effects on developing fetuses. Profound effects on developing fetuses. Togavirus, only in humans. Togavirus, only in humans. Agglutinates chicks RBC’s, Trypsin treated O RBC’s. Agglutinates chicks RBC’s, Trypsin treated O RBC’s. Winter and spring, only 30-60% develop clinical apparent disease. Winter and spring, only 30-60% develop clinical apparent disease. Contagious 7 days before to 7 days after. Contagious 7 days before to 7 days after. Infected babies spread the virus 6 M after birth. Infected babies spread the virus 6 M after birth.

15. Rubella Virus

17. URT, LNs, Viremia up to 8 days before rash to 2 days after. URT, LNs, Viremia up to 8 days before rash to 2 days after. CMI and Immune complexes, rash, arthritis. CMI and Immune complexes, rash, arthritis. Maternal viremia, placenta, fetus and congenital infection, vasculitis, impaired oxygenation and chromosomal breakage. Maternal viremia, placenta, fetus and congenital infection, vasculitis, impaired oxygenation and chromosomal breakage. Shedding prolonged, IgM and IgG for 4 Y. Shedding prolonged, IgM and IgG for 4 Y. Mononuclear cell infiltration, Ca++ deposition is delayed (Celery stalk). Mononuclear cell infiltration, Ca++ deposition is delayed (Celery stalk). Life long immunity. Life long immunity.

18. Three day measles. Three day measles. IP=14 – 21 days (16 average), fever, URT symptoms, LNs. IP=14 – 21 days (16 average), fever, URT symptoms, LNs. Macular rash, faint, arthralgia, arthritis. Macular rash, faint, arthralgia, arthritis. Risk for fetal damage is up to 80% in 2w, 6 – 10% by 14 th, 20-30% over all. Risk for fetal damage is up to 80% in 2w, 6 – 10% by 14 th, 20-30% over all. Cardiac: PDA, Pulmonary valvular stenosis. Cardiac: PDA, Pulmonary valvular stenosis. Eye: Cataract, chorioretinitis, Glucoma, Coloboma, cloudy cornea, microophthalmia. Eye: Cataract, chorioretinitis, Glucoma, Coloboma, cloudy cornea, microophthalmia. Sensorineural deafness, Liver, Spleen. Sensorineural deafness, Liver, Spleen.

20. Thrombocytopenia, intrauterine growth. Thrombocytopenia, intrauterine growth. CNS defects. CNS defects. Late including DM, chronic thyroiditis, Subacute panencephalitis (SPE). Late including DM, chronic thyroiditis, Subacute panencephalitis (SPE). Diagnosis: Clinically is not enough. Diagnosis: Clinically is not enough. Respiratory secretions, Urine. Respiratory secretions, Urine. Cell culture. Cell culture. PCR. PCR. Serology, IgM significance. Serology, IgM significance. MMR: RA 27/3 human diploid fibroblast cell culture, female adults, hospital staff at risk, contraindications. MMR: RA 27/3 human diploid fibroblast cell culture, female adults, hospital staff at risk, contraindications.

21. Erythema infectiosum Parvovirus B19. Parvovirus B19. SSDNA, cultured in BM cells, fetal liver cells. SSDNA, cultured in BM cells, fetal liver cells. Blood group P as a receptor. Blood group P as a receptor. Anemia, and aplastic crises. Anemia, and aplastic crises. Indurated rash on the face (slapped- cheek), LNs, spleen, liver. Indurated rash on the face (slapped- cheek), LNs, spleen, liver. Thrombocytopenia, nephritis, encephalitis. Thrombocytopenia, nephritis, encephalitis. PCR, and serology. PCR, and serology.

22. Parvovirus B19

23. Roseola Infantum (Exanthem Subitum). Roseola Infantum (Exanthem Subitum). Sudden rash. Sudden rash. HHV6, HHV7. HHV6, HHV7. EBV, Adenovirus, coxsakieviruses and echoviruses cause similar manifestations. EBV, Adenovirus, coxsakieviruses and echoviruses cause similar manifestations. Faint macular rash. Faint macular rash.

24. Roseola infantum

25. Poxviruses Birds, mammals, and insects. Birds, mammals, and insects. DsDNA brick shaped, enveloped multiply in the cytoplasm, 100x200x300 nm. DsDNA brick shaped, enveloped multiply in the cytoplasm, 100x200x300 nm. Variola, Vaccinia, Moluscum contagiosum, orf, cowpox, and pseudocowpox. Variola, Vaccinia, Moluscum contagiosum, orf, cowpox, and pseudocowpox. Variola major (smallpox), V. minor (alastrim). Variola major (smallpox), V. minor (alastrim). Uniform papulovesicular rash, pustules with significant mortality. Uniform papulovesicular rash, pustules with significant mortality.

26. poxviruses

27. Survives well in the extracellular milieu. Survives well in the extracellular milieu. Highly contagious, saliva, skin, articles and fomites. Highly contagious, saliva, skin, articles and fomites. Eradicated in 1977. Only humans, no carriers. Eradicated in 1977. Only humans, no carriers. Concern for recurrence? Concern for recurrence? Cell lysis, eosinophilic inclusions Guarnieri’s bodies. Cell lysis, eosinophilic inclusions Guarnieri’s bodies. IP=12-14 days, can be short to 4-5 days. IP=12-14 days, can be short to 4-5 days. Fever, chills, myalgia, rash 3-4 days later. Fever, chills, myalgia, rash 3-4 days later. Firm papulovesicles, pustular in 10-12 day Firm papulovesicles, pustular in 10-12 day All in the same stage of evolution All in the same stage of evolution

29. Hemorrhagic rash (sledge hammer). Hemorrhagic rash (sledge hammer). Diagnosis by taking vesicular scraping, culture, electron microscopy, PCR. Diagnosis by taking vesicular scraping, culture, electron microscopy, PCR. Bacterial superinfection leads to death. Bacterial superinfection leads to death. Edward Jenner, Vaccinia virus, combination, Edward Jenner, Vaccinia virus, combination, Vaccination resembles real infection. Vaccination resembles real infection. Vaccinia virus is used as a vector for vaccines Vaccinia virus is used as a vector for vaccines Molluscum contagiosum: Direct contact, IP=2- 8w, pearl-like cheesy painless nodule, curettage, eosinophilic inclusions (molluscum bodies). Molluscum contagiosum: Direct contact, IP=2- 8w, pearl-like cheesy painless nodule, curettage, eosinophilic inclusions (molluscum bodies). Orf, milkers nodules and cowpox. Orf, milkers nodules and cowpox.

31. Herpesviruses Enveloped, DsDNA, painfull skin ulcers, chickenpox, and encephalitis. Enveloped, DsDNA, painfull skin ulcers, chickenpox, and encephalitis. 8 types:HSV1,2, CMV, VZV, EBV, HHV6, HHV7, HHV8, alpha, beta and gamma. 8 types:HSV1,2, CMV, VZV, EBV, HHV6, HHV7, HHV8, alpha, beta and gamma. Icosahedral capsid, large genome, cross similarity. Icosahedral capsid, large genome, cross similarity. Latency and reactivation. Latency and reactivation. Replication, IE, E, and L, role of TK, polymerase, in antiviral effect. Replication, IE, E, and L, role of TK, polymerase, in antiviral effect.

32. Herpes simplex dsDNA, linear, 50% similarity. dsDNA, linear, 50% similarity. Recurrent ulcers in skin and mm, above and below the waist, latency. Recurrent ulcers in skin and mm, above and below the waist, latency. Humans only, 90% +ve abs for type1, type 2 sexual 15-30%. Cervix in 5-12%. Humans only, 90% +ve abs for type1, type 2 sexual 15-30%. Cervix in 5-12%. Acute infection, multinucleated giant cells, latent infection of sensory and autonomic nerve ganglion. Acute infection, multinucleated giant cells, latent infection of sensory and autonomic nerve ganglion. Latent infection, trigeminal, superior cervical and vagal nerve ganglion, S2,S3 for HSV-2, antivirals doesn,t work. Latent infection, trigeminal, superior cervical and vagal nerve ganglion, S2,S3 for HSV-2, antivirals doesn,t work.

34. Herpes simplex type 2

35. Asymptomatic or mild illness in secondary infection. Asymptomatic or mild illness in secondary infection. Both Humoral and CMI are important, ADCC mechanism. Both Humoral and CMI are important, ADCC mechanism. Single vesicular legions, pustular, coalese then ulcerate, ectoderm origin. Single vesicular legions, pustular, coalese then ulcerate, ectoderm origin. Cold sores, fever blisters, herpetic whitlow, Cold sores, fever blisters, herpetic whitlow, Corneal damage and blindness. Corneal damage and blindness. Encephalitis. Encephalitis. Primary and recurrent genital herpes infection. Primary and recurrent genital herpes infection. Neonatal herpes. Neonatal herpes.

36. Tissue culture and CPE. Tissue culture and CPE. Tzanck test. Tzanck test. PCR. PCR. Serology is of less value. Serology is of less value. Acyclovir is used Foscarnet if R. Acyclovir is used Foscarnet if R. Valacyclovir, and Famciclovir. Valacyclovir, and Famciclovir. Safe sex. Safe sex. C-section. C-section.

37. Varicella-Zoster Similar to HSV differ in the glycoproteins. Similar to HSV differ in the glycoproteins. Human diploid cell culture. Human diploid cell culture. Chickenpox and shingles. Chickenpox and shingles. 90% get the disease before 10. 90% get the disease before 10. Spread via the respiratory tract, highly contagious, winter and spring, 1-2 days before the rash to 3-4 days into the rash. Spread via the respiratory tract, highly contagious, winter and spring, 1-2 days before the rash to 3-4 days into the rash. URTI, LNs, viremia, RES, viremia, skin. URTI, LNs, viremia, RES, viremia, skin. Chickenpox and zoster sensory Nerve root Chickenpox and zoster sensory Nerve root ganglion. Dermatomes. ganglion. Dermatomes.

39. CMI and humoral are important. Reactivation is more severe in Immunesuppressed. CMI and humoral are important. Reactivation is more severe in Immunesuppressed. Generalized vesicular rash, different stage of evolution. Generalized vesicular rash, different stage of evolution. Progressive varicella and high mortality (20%) Progressive varicella and high mortality (20%) CNS, pneumonia, hepatitis, nephritis. CNS, pneumonia, hepatitis, nephritis. Post herpetic neuralgia. Post herpetic neuralgia. Fetal embryopathy in pregnant women, microcephaly, cataract, chorioretinitis, microphthalmia. Fetal embryopathy in pregnant women, microcephaly, cataract, chorioretinitis, microphthalmia. Diagnosis: clinical, IF, serological, PCR. Diagnosis: clinical, IF, serological, PCR. Treatment: Acyclovir, Famciclovir, valacyclovir Treatment: Acyclovir, Famciclovir, valacyclovir

40. High titer Immunoglobulins within 96hrs. High titer Immunoglobulins within 96hrs. Not effective in shingles, or if rash has evolved. Not effective in shingles, or if rash has evolved. Alive attenuated vaccine after 12 M, health care workers. Alive attenuated vaccine after 12 M, health care workers.