VIRAL DISEASES
part II
Andrews’
p501-525
Molluscum contagiosum
Poxvirus
 MCV-1 to -4 and variants
 MCV-2 in HIV
 Worldwide
 Children, sexually active adults and
immunosuppressed
 Direct contact

Lesions are smooth surfaced, firm and dome
shaped pearly papules
 A central umbilication is characteristic
 Clinical pattern depends on the group
affected
 When restricted to only the genital area in a
child the possibility of sexual abuse must be
considered
 Secondary infections may occur

Seen in 10-30 % of AIDS pts
 Helper T-cell count of less than 100
 Giant lesion may be confused with BCC
 Henderson-Patterson bodies – basophilic
inclusion bodies

treatment
Topical tretinoin or imiquimod
 Extraction
 Light cryotherapy
 Cantharadin
 Curettage
 podophyllotoxin

Human monkeypox
Rare
 More than 90% of cases occur in children
under 15
 Fatality rate of 11%
 Disease is clinically similar to smallpox
 Fever followed by vesiculopustular eruption
 Develop following contact with wildlife
sources


Human to human transmission may occur
Picornavirus group
RNA
 Only coxsackieviruses, the echoviruses, and
enterovirus type 71 are significant causes of
skin disease

Enterovirus infections
Person to person transmission occurs by the
intestinal-oral route and less commonly the
oral route
 Usually the diagnosis is by clinical
characteristics

herpangina
Disease of children worldwide
 Coxsackievirus and echovirus
 Acute onset of fever, ha, sore throat,
dysphagia, anorexia, and sometimes a stiff
neck
 Yellowish white, vesicles in the throat,
surrounded by an intense areola
 Most frequently on the anterior faucial
pillars, tonsils, uvula, or soft palate

Lesions coalesce and ulcerate leaving a
shallow crater
 Lesions disappear in 5-10 days
 Treatment is supportive
 Topical anesthetics or allopurinol mouthwash

Hand-Foot-and-Mouth Disease
Infection begins with a fever and sore mouth
 90% have oral involvement
 Lesions are small rapidly ulcerating vesicles
surrounded by a red areola
 Buccal mucosa, tongue, soft palate, and
gingiva
 Lesions on hands and feet
 Red papules that quickly turn to gray vesicles
 With a red halo

Typically lasts less than a week
 Treatment is again supportive
 Topical anesthetics
 Coxsackievirus A-16
 Distribution and presence of skin lesions
differentiates this from herpangina

Boston Exanthem Disease
Occurred as an epidemic in Boston
 Caused by echovirus 16
 Consisted of sparsely scattered pale red
macules and papules
 Chiefly on the face chest and back
 Now an uncommon cause of viral
exanthems

Eruptive pseudoangiomatosis
Young children during or immediately
following a viral illness develop red papules
that resemble angiomas
 Face trunk and extremities
 Resolve spontaneously within 10 days
 Echoviruses 25 and 32 have been
implicated

PARAMYXOVIRUS GROUP
RNA viruses
 Measles
 Rubella

Measles
(rubeola, morbilli)
Worldwide disease
 Commonly affects children under age of 15
months
 Respiratory spread with an incubation of 912 days
 Immunizations are highly effective
 Prodrome- fever, malaise, conjunctivitis and
prominent upper respiratory symptoms

A macular or maculopapular eruption
appears after 1-7 days
 Anterior scalp line and behind the ears
 Quickly spreads over the face and involves
the entire body by day 3
 Purpura may be present
 Koplik’s spots are pathognomonic, appear
during the prodrome


Erythematous lesions
of the measles
exanthem
Pink macules with minimally elevated papules
with confluence
Koplik’s Spots
 cluster of tiny bluish white papules with an
erythematous areola on buccal mucosa
opposite premolar teeth

complications
OM
 Pneumonia
 Encephalitis
 Thrombocytopenic purpura
 Infection in pregnant patients is associated
with fetal death


DX


Clinical- high fever, Koplik’s spots,
conjunctivitis, upper respiratory symptoms, rash
course and prognosis
maximum intensity of rash reached in 3 days
 rash fades 5-10 days
 self limited
 death 1 in 3000
 chronic complication, subacute sclerosing
panencephalitis

RUBEOLA
management

Acute
Vitamin A
 decreases morbidity and mortality
 given to severe measles even if no nutritional
deficit is suspected


vaccine

MMR given at 12-15 months, and 4-6 years
measles
Rubella
German measles, 3-day measles
 benign contagious viral disease
 etiology



transmission


Togavirus
inhalation of aerosolized respiratory droplets
incubation
12-23 days
 Vaccination gives lifelong immunity

RUBELLA
clinical manifestations

Prodrome- 1-5 days
mild symptoms of malaise, headache, sore
throat, eye pain, and moderate temperature
elevation
 Pain on lateral and upward eye movement is
characteristic
 precedes eruption by a few hours to a day
 children are usually asymptomatic

RUBELLA
clinical manifestations

Eruptive phase
begins on neck or face
 spreads to trunk and extremities in hours
 lesions are pinpoint to 1 cm, round or oval,
pinkish or rosy red, macules or maculopapules
(purplish lesions of measles and fine punctate
yellow-red lesions of scarlet fever)
 discrete, grouped or coalesced
 arthritis of phalangeal joints may be seen in
women

RUBELLA

Diagnosis



course and prognosis



Clinical, posterior cervical, suboccipital, and
postauricular lymphadenitis occurs in more than half
can be confirmed with serology
typically mild, requiring only symptomatic treatment
lesions last 24 -48 hours, followed by desquamation
prevention

MMR given at 12-15 months, and 4-6 years
rubella
RUBELLA


Forchheimer Spots
red palatal lesions start
with onset of rash
Congenital Rubella Syndrome




Infants born to mothers who have had rubella
during the first trimester of pregnancy
transplacental transmission as high as 80% in the
first trimester
Typical anomalies include IUGR, deafness, mental
retardation, cataracts, retinopathy, cardiac defects,
and “blueberry muffin” rash.
Prior to pregnancy antibody titer should be
verified. Immunization is contraindicated in
pregnancy.
Asymmetric Periflexural
Exanthem of Childhood (APEC)
AKA unilateral laterothoracic exanthem
 Children 8 mo to 10 yrs
 Cause is unknown
 Viral origin has been proposed
 Symptoms of mild upper respiratory or
gastrointestinal infection usually precede
the eruption



Erythematous macules
and papules involving
the axilla, lateral trunk
and flank.
In this patient the
exanthem progressed
to bilateral distribution
but maintained leftsided predominance
Erythematous papules coalesce to form
poorly marginated morbilliform plaques
 Mild pruritis
 Lesions begin unilaterally, close to a
flexural area, usually the axilla
 Centrifugal spread to adjacent trunk and
extremity
 The contralateral side is involved in 70% of
cases, asymmetrical nature is maintained

Lymphadenopathy is seen in 70%
 Last 2-6 weeks on average
 Resolves spontaneously
 Topical steroids or oral antibiotic are of no
benefit
 Oral antihistamines

PARVOVIRUS GROUP
Erythema Infectiosum
(Fifth Disease)
Worldwide benign infectious exanthem
 Parvovirus B19
 Spread by respiratory droplets
 Viral shedding has stopped by the time the
exanthem has appeared
 Incubation 4-14 days
 prodrome


pruritus, low-grade fever, sore throat, malaise
seen in 10% of cases
Three distinct overlapping stages
 facial erythema. Red papules on the
cheeks that rapidly coalesce. Resembles
erysipelas. “slapped cheek.”
 net pattern erythema. Fishnet like pattern,
begins on extremities then extends to trunk
 recurrent phase. Eruption may reappear
following emotional upset or sunlight
exposure over next 2-3 weeks.


Lacy, reticulated skin
eruption over the arm
during the second
stage of the exanthem
Papular Purpuric Stocking and
Glove Syndrome
Occurs in teenagers and young adults
 Pruritis, edema, and erythema of the hands
and feet, and a fever is present
 Lesions are sharply cut off at the wrists and
ankles
 Mild erythema of the cheeks, elbows, knees
and groin
 Syndrome resolves within 2 weeks

Erythematous patches with petechiae on
the palms
Serovonversion for parvovirus B19 has been
found
 Complications are uncommon and age
dependent
 Arthritis and arthralgias occur in 60% of
adult women
 Aplastic crises may result in the sickle cell pt
 In primarily infected pregnant women, fetal
death can result from hydrops fetalis as a
result of intrauterine anemia, esp. first 20
weeks

ARBOVIRUS GROUP

Comprise the numerous arthropod-borne
RNA viruses
West Nile Fever
A maculopapular eruption accompanied by
lymphadenopathy and fever characterize
this disease
 The Culex mosquito is the vector
 Disease seen in the Middle East

Sandfly Fever
AKA phlebotomus fever and pappataci fever
 Small pruritic papules appear after the bite of a
sandfly
 Fever, ha, malaise, nausea, conjunctival
injection, stiff neck, and abdominal pains
suddenly develop
 Recovery is slow, with recurring bouts of fever
 No specific treatment is available

Dengue
(break-bone fever)
A common disease of tropical regions
throughout the world
 Spread by Aedes aegypti mosquito
 Disease begins with a sudden high fever, ha,
back ache, retroorbital pain, bone and joint
pain, weakness, depression and malaise
 A scarlatiniform or morbilliform exanthem,
especially on the thorax and joint flexors
may be seen
 Patient may recover fully at this stage

In 1-7% of cases dengue hemorrhagic fever
develops, bleeding, thrombocytopenia, and
hemoconcentration develop
 Mortality 1-15%

Alphavirus
Sindbis virus infection
 Seen in Finland
 Transmitted by the mosquito
 Multiple erythematous papules with a
surrounding halo associated with a fever
and prominent arthralgias
 Symptoms resolve over a few weeks

PAPOVAVIRUS GROUP
DS, DNA viruses
 Slow growing
 Replicate within the nucleus

Verruca
Human papillomaviruses include more than
80 types
 Most types cause specific types of warts and
favor certain anatomic locations
 Infections are described as clinical,
subclinical and latent

Verruca vulgaris
Commonly HPV 2
 5% prevalence in children
 Frequent emersion of hands in water is a
risk factor
 Natural history is for spontaneous
resolution, half by 1 year and two thirds by
2 years
 Usually located on the hands
 Present as elevated, rough, grayish papules

Verruca vulgaris.
Note the characteristic
features of ‘church spire’ papillomatosis heaped with orthoand parakeratosis, acanthosis and koilocytosis.
Diagnostic clue- warts do not have
dermatoglyphics
 Occur anywhere on skin
 Spread by autoinnoculation
 Digitate or filiform warts on the face and
scalp

Verruca plana
HPV 3
 Children and young adults
 Flat-topped papules that are slightly
erythematous or brown
 Generally multiple and grouped
 Face, neck, dorsa of hands, wrists and knees
 Men who shave and women who shave their
legs
 Koebnerization
 Highest rate of spontaneous remission

Verruca plantaris
HPV type 1
 Appear at pressure points on the ball of the
foot
 Frequently several lesions are seen
 Mosaic wart
 May be confused with callous, no black dots
 Myrmecia type- occurs as smooth surfaced,
deep, often inflamed and tender papules or
plaques- may be confused with mucinous cyst


Myrmecial wart


Verrucae plantares
Photo after the
shaving of the
hyperkeratotic
surface
HPV-60
Ridged wart
 Persistence of dermatoglyphics
 This type also causes plantar verrucous
cysts

treatment
Depends on the type of wart and the age of
the patient
 Allow 2-3 months of therapy
 Do not abandon any treatment too quickly

TX-flat warts
Frequently undergo spontaneous remission
 Cryotherapy
 Topical salicylic acid preparations
 topical tretinoin
 5-FU
 anthralin

TX-common warts
Two basic approaches
 Destruction and Induction of local immune
reactions
 Cryotherapy, salicylic acid preparations,
canthrone, bleomycin, surgical ablation,
laser, high dose cimetidine, heat treatment,
isotretinoin, hypnotic suggestion, DNCB

TX-plantar warts
Salicylic acid preparations
 Cryotherapy
 Cantharadin
 Bleomycin, laser, and DNCB

Genital warts
The most common sexually transmitted
disease
 Lifetime risk in sexually active young
adults may be as high as 80%
 A large portion of genital HPV is either
subclinical or latent
 Infection is closely linked with cancer of the
cervix, glans penis, anus, vulvovaginal area,
and periungal skin
 Transition zones of cervix and anus

Numerous HPV types are associated with
genital warts
 Those producing benign lesions- low risk



Those associated with cancer- high risk or
oncogenic type


Most common are HPV-6 and HPV-11
most common HPV-16 and HPV-18
Virtually all condylomata are caused by
types –6 and –11
Condylomata acuminata
Appear as lobulated papules that are
frequently multifocal
 Intraurethral condylomata may present with
terminal hematuria, altered urinary stream,
or urethral bleeding
 Numerous genital warts may appear during
pregnancy
 Other sexually transmitted disease may be
present

Bowenoid papulosis and HPVinduced genital dysplasias
Characterized by flat, often hyperpigmented
papules
 Singly or in multiples
 HPV-16may behave similar to other genital
warts
 May progress to invasive SCC


Bowenoid papulosis
of the anus positive
for high-risk HPV
in a homosexual
male
Erythroplasia of Queyrat.
A well demarcated
velvety plaque of the prepuce positive for high-risk
HPV
Giant condyloma acuminatum
(Buschke-Löwenstein tumor)
A rare, aggressive wart-like growth that is a
verrucous carcinoma
 HPV-6
 Most often occurs on the glans penis or
prepuce of an uncircumcised male
 May invade deeply, and uncommonly
metastases
 Complete surgical excision

 Buschke-
Löwenstein
Tumor

Cauliflower-like
deeply infiltrating
giant condyloma
acuminata
Diagnosis of genital warts
Inspection
 Acetowhitening may help in the
differentiation of certain genital papules
 Bowenoid papulosis may require Bx

Treatment of genital warts
Recurrence is frequent
 Not proven to reduce transmission to sexual
partners nor to prevent progression to
dysplasia or cancer
 Subclinical of the external genitalia should
not be sought or treated
 Bleeding genital warts may increase the
sexual transmission of HIV and hepatitis B
and C

Treatment of genital warts
Podophyllin 4-8 hrs, weekly application
 Purified podophyllotoxin 0.5% sln
 Aldara, 3 alternate days per week
 TCA (safe in pregnancy)
 Cryotherapy (also safe in pregnancy)
 Electrofulgeration or electrocauterization
 CO2 laser

Any surgical method that generates a smoke
plume is potentially infectious to the
surgeon
 5-FU 5% cream, esp. bowenoid papulosis
 Systemic and intralesional interferon alfa


CDC no longer recommends
Genital warts in children
Children can acquire genital warts through
vertical transmission perinatally, digital
inoculation or autoinoculation, fomite or
social nonsexual contact, or through sexual
abuse
 HPV typing has demonstrated that most
warts in the genital area of children are
“genital” HPV type
 And most children with them have family
members with them as well

Finding of a nongenital type does not exclude
abuse
 The risk for sexual abuse is highest for
children older than 3 yrs of age
 Case-by-case management
 Should screen for other STDs
 Podophyllotoxin, imiquimod, light
cryotherapy

Recurrent respiratory (laryngeal)
papillomatosis
HPV associated papillomas may occur
throughout the respiratory tract, from the
nose to the lungs
 Bimodal distribution- children under 5 and
after 15
 Affected young children were born to
mothers with genital condylomata and
present with hoarseness
 HPV-6 HPV-11
 Carcinoma that is often fatal develops in 14%

Heck’s disease
Linked to HPV-13
 AKA focal epithelia hyperplasia
 Small white to pinkish papules occur
diffusely in the oral cavity

Epidermodysplasia verruciformis
A rare inherited disorder characterized by
widespread HPV infection and cutaneous
SCCs
 Most commonly inherited as and AR trait
 HPV-3, HPV-10 and many other “unique”
types
 Pathogenesis is unknown
 Presents in childhood and continues
throughout life

Skin lesions include flat, wartlike lesions of
the dorsal hands, extremities, and face
 SCCs develop in 30-60% of pts, most often
on sun exposed areas,-5,-8,-47
 Actinic background
 Surgery, radiation is contraindicated
 Strict sun avoidance

Warts in immunosuppressed
patients
Predisposing conditions include organ
transplantation, immunosuppressive
medication, congenital immunodeficiency
diseases, lymphoma and HIV infection
 By 5 yrs posttransplant 90% of pts have warts
 Regular dermatologic examinations
 Standard methods of treatment, efficacy is
reduced

RETROVIRUSES
Contain RNA which is converted by a
virally coded reverse transcriptase to DNA
in the host cell
 The target cell population is primarily
CD4+ lymphocytes
 Transmission by sexual intercourse, blood
products/intravenous drug use, and from
mother to child during childbirth or
breastfeeding

HTLV-1
Endemic in Japan, subSaharan Africa and
southeastern US
 Responsible for several clinical syndromes
 1% will develop adult T-cell leukemialymphoma
 Four forms: smoldering, chronic, acute, and
lymphomatous, usually progressing in that
order
 Skin lesions in ATLL include erythematous
papules or nodules

Infected patients may develop various forms
of dermatitis mimicking other skin diseases
 Infective dermatitis, children present with a
chronic eczema of the scalp, axilla, groin,
external auditory canal, retroauricular area,
eyelid margins, paranasal areas and neck
 Chronic nasal discharge
 Cultures positive for S. aureus

Human Immunodeficiency Virus
(HIV, HTLV III)
Cutaneous manifestations are prominent
 Affecting up to 90% of HIV-infected persons
 Many have multiple skin lesions of different
types
 Skin lesions can be classified into three broad
categories: infections, inflammatory
dermatoses, and neoplasms
 Skin lesions tend to appear at a specific stage
of disease, making them useful markers


Seborrheic dermatitis , pruritis ani,
psoriasis, Reiter’s syndrome, atopic
dermatitis, herpes zoster, acne rosacea, oral
hairy leukoplakia, onychomycosis, warts,
recurrent S. aureus folliculitis and
mucocutaneous candidiasis- helper T-cell
counts 200-500
With counts < 200, pt defined as AIDS
 Opportunistic infections: chronic herpes
simplex, MC, bacillary angiomatosis,
systemic fungal infections and
mycobacterial infections
 Hyperreactive skin is also seen: eosinophilic
folliculitis, GA, drug reactions,
photodermatitis


Eosinophilic
folliculitis (right)

Bacillary angiomatosis
(below)
T-cell count < 50 = advanced AIDS
 Unusual presentations of opportunistic
infection
 Treatment is difficult
 Combination cocktails, (HAART), highly
active antiretroviral therapy
 About half of HIV patients respond
 Opportunistic infections no longer occur and
mortality decreases
 Eosinophilic folliculitis and drug eruptions
may become more frequent and severe

Primary HIV infection
(Acute seroconversion syndrome)
An acute illness develops several weeks
after infection
 Clinical syndrome resembles Ebstein-Barr
infection
 Fever, sore throat, cervical adenopathy,
rash, and oral and genital and rectal
ulceration
 Dysphagia may be prominent

Oral candidiasis or Pneumocystis carinii may
develop
 Suspect DX in at risk individuals
 Direct measurement if HIV load will confirm
 Prompt combination antiviral therapy

HIV-Associated pruritis
Not caused by HIV disease itself but related to
its associated inflammatory dermatoses
 “papular pruritic eruption”- a wastebasket
diagnosis
 Follicular eruptions are more common
 Eosinophilic folliculitis is the most common
pruritic follicular eruption, helper T-cell <200
 Urticarial follicular papules on the upper
trunk, face, scalp, and neck
 90% of lesions occur above the nipple line

Disease wanes and wanes and may
spontaneously clear, only to flare
unpredictably
 Peripheral eosinophilia may be present
 Topical steroids and antihistamines
 Phototherapy or itraconazole
 isotretinoin

HIV-Associated Neoplasia
Kaposi’s sarcoma
 Superficial BCC
 SCC
 Genital HPV-induced SCC
 Extranodal B-cell and T-cell lymphoma
 BCC’s behave in the same manner, receive
standard management

SCC’s, standard management, excision is
recommended
 SCC in sun-exposed skin can be very
aggressive
 Genital SCC, associated with “high-risk”
HPV types (-16, -18)

Extranodal B-cell and T-cell
lymphoma
Associated with advanced
immunosuppression of AIDS
 Present as violaceous or plum-colored
papules, nodules or tumors
 MF can also be seen in patients with HIV
infection

Melanoma
Occasionally seen in HIV patients
 Prognosis is unknown
 It has been suggested that the risk of
metastasis is increased

AIDS and Kaposi’s Sarcoma
HHV-8
 Patients with AIDS present with
symmetrical widespread lesions, that are
often numerous
 Any mucocutaneous surface may be
involved
 Favors hard palate, trunk, penis, lower legs
and soles
 DX by biopsy

Red-violet papules on the palate
in addition to oral candidiasis
Treatment depends on the extent and
aggressiveness of the disease
 Effective HAART after about 6 months is
associated with involution of KS lesions
 Initial treatment for fewer than 50 lesions
 Intralesional vinblastine
 Cryotherapy
 Irradiation therapy

Systemic therapy in aggressive disease
 Interferon alfa
 Vinca alkaloids
 Bleomycin
 Liposomal doxyrubicin
