HHV3 (VARICELLA ZOSTER INFECTIONS)

- cause: HHV3 or Varicella zoster virus (is a herpes virus) VZV

- primary infection: chickenpox (Thela, Hade)

- assumes latency in nerve root ganglion

- later in life: herpes zoster (Janai Khatera)

Varicella (Chickenpox)

- Cause: VZV
- Infection: highly contagious
- Virus spread by: droplet route
- IP: about a fortnight (15 days)
- A typical pt infectious 1-2 days before exanthema appears & for 4-5 days
thereafter i.e. till the last crop of vesicle has crusted

Clinical features

- Prodrome: low grade fever, malaise

- Morphology: lesions appear in crops of itchy papules----rapidly turn into------
clear superficial vesicle-----then into pustules ---at any given time, lesions at
different stages of evolution are present called as pleomorphic eruption
Typical vesicle of varicella: superficial, thin walled, looks like a drop of
water lying on skin, called a dew drop on a rose petal appearance due to
surrounding perivesicular erythema
Eventually lesions crust in a few days & heal-----usually healing without
scarring but sometimes depressed scar & hypopigmentation may develop
Sites of predilection: centripetal in distribution; lesions are most profuse on
the trunks & least on limbs

Diagnosis based on

- Clinical picture
- Investigations:
a) Tzanck smear for multinucleated giant cells
b) Immunofluorescent staining for the virus
c) Isolation of the virus in a suitable tissue culture
d) ELISA (Enzyme linked immunosorbent assay)

Differential diagnosis

- Viral infections:
a) coxsackie virus
b) vaccinia virus
c) variola virus
Course of chickenpox

- children: benign course

- adults: severe disease with residual scarring
- immunocompromised: hemorrhagic & lethal chickenpox
- occasionally pneumonitis

Treatment

- Children (mild cases): calamine lotion, antihistamines

- Adults, HIV (severe cases): Acyclovir 800mg X 5 times a day for 7-10 days
(Alternatives: famciclovir, valacyclovir)
- Prophylaxis:
a) live attenuated vaccine: in susceptible patients
b) immunoglobulins: immunocompromised individuals exposed to
chickenpox, within 24-48hrs of exposure

KEY FEATURES (MUST KNOW)

Chicken pox
Caused by Varicella zoster virus.
Transmitted by droplet route, with the infective period being 2 days prior
and 5 days after the appearance of rash.
Appears after a prodrome of fever as crops of erythematous papules
which rapidly become vesicular (dew drops on rose petal) then pustular.
Has a pleomorphic eruption with eruption of various stages being present
at a given time.
Centripetal in distribution.
Prophylaxis available as live attenuated vaccine.
Treatment is symptomatic in children. Adults and immunocompromised
require antiviral
therapy.

HERPES ZOSTER HZ (SHINGLES)

- an acute viral infection of skin

- cause: VZV
- an attack of chickenpox-----followed by ----latent infection in nerve root
ganglions----reactivation of latent VZV infection---leads to-----blistering d/s
limited to a single or adjacent dermatomes

Etiology & Pathogenesis:

- During an attack of chickenpox----VZV(varicella-zooster virus)-----travels along

sensory nerve fiber centripetally to spinal & cranial sensory ganglia where
the virus establishes a life-long latent infection
- reactivation of virus occurs in ganglia where virus is most numerous;
reactivation is triggered by diminished immunity associated with
a) advancing age
 b) immunosuppression due to drugs or radiation or trauma or diseases (DM,
HIV infection, lymphoma)
- viral proliferation -----virus travels down along nerve fibers to skin & mucosa
----- causes degenerative & inflammatory changes-----produces characteristic
lesions at corresponding dermatome

Clinical features

- affects both sexes equally

- people of all ages affected: frequency increases with advancing age; 2/3 rd of
them >40yrs of age
- occurrence: sporadic, no seasonal variation
- 10-20% people develop HZ in their lifetime
- Prodromal phase: constitutional symptoms like headache, photophobia, fever,
pain
- pre-eruptive pain: varying severity; deep aching sharp neuralgic pain or
theremay be allodynia (pain produced by minor stimuli like touching); pain
mimic acute abdomen, migraine or myocardial ischemia; pain soon followed
by a rash limited to one side of the body of a single or 2-3 adjacent
dermatomes; redness, papules, plaques may appear associated with itching
or burning sensation
- grouped vesicles on the area----umbilication----pustulation follows-----lesions
get crusted & heal over 2-4 weeks
 - common sites involved: thoracic (>50%); followed by cervical, trigeminal,
lumbosacral dermatomes; mucosa in the affected dermatomes are also
involved
- tender , regional lymph node enlargement is common
- Ophthalmic zoster: involvement of the tip & side of nose (Hutchinson's sign)
protends severe ocular involvement (conjunctivitis, keratitis, uveitis, lid
edema & severe pain)
- Herpes zoster in HIV infection: HZ is a sign of early immunosuppression in
HIV; affected nonadjacent multiple dermatomes; lesions may be severe,
hemorrhagic or ulcerative & long-lasting
- Ramsay-Hunt syndrome: infection of the geniculate ganglion leads to
involvement of motor & sensory portion of facial nerve; may be unilateral loss
of sensation in anterior 2/3rd of tongue, facial palsy, vesicles in tympanic
membrane, external ear or ear canal
- Complications of Herpes zoster:
a) Post-herpetic neuralgia (PHN): dominant cause of morbidity in HZ; defined
as pain persisting 90 days after onset of rash; incidence of PHN increases
with advancing age (about 75% pts above 70 yrs have PHN)
b) secondary bacterial infection
c) cutaneous dissemination
d) pigmentary changes, scarring, keloids
e) visceral involvement
f) motor palsies
g) encephalitis, myelitis
h) blindness

Diagnosis

- Typical clinical features: grouped vesicles on an erythematous base in a

dermatomal distribution is highly diagnostic
- Tzanck smear from the base of ruptured vesicle stained with Giemsa: reveals
multinucleated giant cells
- direct immunofluorescence of cellular material to detect viral antigen
- culture
- PCR for viral DNA

Differential Diagnosis

- prodromal pain: acute abdomen, myocardial ischemia, migraine, pleurisy

- rash: herpes simplex, phytophotodematitis, contact dermatitis, impetigo,
erysipelas

Course & Prognosis

- HZ: self-limiting d/s; complete spontaneous recovery within 2-4 weeks is the
rule; some residual sensory change & post-inflammatory dyspigmentation
may remain in some
- immunocompromised: severe, prolonged d/s course; scarring may occur
 - 2nd attack of HZ is rare but in HIV pts, recurrence is frequent

Treatment

Infection Supportive Definitive

Acute attack Cool compresses Systemic Antiviral
therapy (best if started
within 48 hrs of onset);
no role of topical
antiviral therapy in t/t
of HZ
Analgesics & sedatives Acyclovir 800mg X 5
times a day for 7-10
days; Valacyclovir 1000
mg X tid for 7 days;
Famciclovir 500 mg X
tid for 7 days
Concurrent therapy Antiviral therapy:
with systemic steroids: - reduce acute pain
- reduce acute pain & inflammation
& inflammation - reduce duration
- no role in of d/s & viral
prevention of shedding
PHN - reduce freq of
PHN

Infection Treatment
PHN (Post-herpetic neuralgia) Analgesics
Topical lidocaine patch, capsaicin
Tricyclic antidepressants
Amitryptiline 75 mg/day
Gabapentin 300mg tid; pregabalin
75mg bid

KEY FEATURES (MUST KNOW)

Herpes zoster (shingles)

HZ represents reactivation of the dormant varicella-zoster virus from the sensory
root ganglia. Its incidence increases with age.
The most commonly involved sites include the thoracic (50%), head (15%), neck
(20%), and lumbosacral (15%) nerves.
After a variable prodrome, clustered, red papulovesicles appear in a unilateral
dermatomal pattern, reach their full extent during first week and desquamate
during the second.
 Associated feature may be:
- Some scattered vesicles resembling chickenpox
- Motor involvement
- Ocular involvement, if facial HZ
- Regional lymphadenopathy
Patients with HZ must be isolated from individuals who are susceptible to
chickenpox because of the risk of acquiring infection from direct contact with skin
lesions.
PO (acyclovir, valacyclovir or famciclovir) antiviral therapy to lessen the chances
and severity of post-herpetic neuralgia, prevent further disease progression/
dissemination is indicated for the
following patients:
- Older than 50 years of age
- Immunocompromised
- With disseminated HZ
- Eye involvement.
Immunocompetent patients below 50 years may be given symptomatic therapy
only; however,
acyclovir may be given

HERPES VIRUSES CAUSING CUTANEOUS INVOLVEMENT

HHV-1 (HSV-1) Orofacial herpes or herpes labialis

HHV-2 (HSV-2) Genital herpes or herpes genitalis
HHV-3 (VZV): Varicella zoster virus Chickenpox (Varicella); Herpes zoster
(Shingles)
HHV-4 (EBV): Epstein Barr Virus Infectious mononucleosis
HHV-5 (CMV): Cytomegalovirus Illness in neonates or
immunocompromised; cutaneous
involvement (maculopapular eruption,
petechiae, vesicles, nodules)
HHV-6 Cause of Roseola infantum (6th disease,
common febrile d/s of early childhood)
HHV-7 Exanthem subitum, pityriasis rosea
associated virus
HHV-8 Kaposi sarcoma associated herpes virus