Subject: Microbiology Topic: Viral Exanthems & Other Viruses Associated with Skin Infections Lecturer: Dr.

Barzaga Date of Lecture: July 2011 Transcriptionist: Angry Birds Pages: 9

I. HERPES VIRIDAE A. Alpha Herpesviridae Subfamily HERPES SIMPLEX VIRUS Worldwide distribution Humans: only natural reservoir Transmission: promoted by direct exposure to secretions containing the virus Virus remains infectious in moist secretions and inanimate objects for a few hours Person w/ active lesion: most significant source of infection Asymptomatic carriers: can shed small numbers of virus Age specificity of primary infections: o HSV 1: frequently in infancy and early childhood o HSV 2: most frequently in ages 14 -29 (reflects sexual route of infection) o HSV 1 genital infections and HSV 2 oral infections are caused by autoinoculation with contaminated hands or by oral sexual contact Transmission: o Mucocutaneous herpes Person to person when active lesions are present (fever blisters are contagious) Thru contact with contaminated objects o Genital herpes Active lesions Asymptomatic intravaginal lesions Pathogenesis: exposure to HSV at mucosal surfaces or abraded skin entry of virus replication in cells of epidermis or dermis inflammatory response (edema, cell lysis, fusion, cell degeneration, ballooning effect) produces characteristic thin-walled vesicle resolves o Presence of viral DNA: 10 50% of ganglion cells in anatomic region of initial reaction may cause reactivation o Associated stimulus for reactivation: UV light, fever, local trauma, trigeminal nerve manipulation, menstruation, emotional stress o Recurrences are secondary to the endogenous reactivation of virus rather than exogenous reinfection Diagnosis: o Giemsa/Wright/PAP stain of scrapings from base of lesions (TZANCK SMEAR)

Presence of multinucleated giant cells and intranuclear eosinophil inclusion bodies Indicative but not diagnostic o Culture Uses primary cell line such as monkey kidney cell observe for CPE in 24 -48 hours Specimens: from lesions throat washings, CSF, stool o Confirmatory test: Fluorescent antibody or DNA probe o Serology: useful only for primary infections and those w/ asymptomatic HSV 2 infections, since in recurrent infections, there is 10% increase in titers Prevention: o Avoid contact with individuals w/ lesions. Asymptomatic shedding may occur and be transmitted from saliva, urethra, and cervix by individuals w/ no evident lesions o Safe sex practices o Caesarian section for infected pregnant females A. HSV 1 DISEASES Herpes labialis o fever blisters or cold sores o most common recurrent HSV 1 infection o vesicles on mucocutaneous junction of lips or adjacent skin crust in 2-3 days heals in 1 week Gingivostomatitis o Infection of the oropharynx o By HSV 1 o Can involve the gums, tongue, soft palate, lips (sometimes with ulceration and bleeding) o Frequently occurs in children o Common complication in adolescents: pharyngitis (sore throat, fever, chills, headache, swollen lymph nodes, difficulty in swallowing) Herpetic keratitis o ocular herpes o Caused by latent virus that has traveled into the ocular branch of trigeminal nerve o Symptoms: gritty feeling; sharp pain; conjunctivitis; sensitivity of light

SY 2011-2012

o 25-50% of cases: recurrent and chronic visual loss

Persons with immunity- dont acquire chickenpox or shingles when re-xposed to an exogenous source of VZV. Clinical manifestations A. Chickenpox Symptoms : rash, low grade fever, malaise, pruritus, anorexia **rash maculopapules, vesicles and scabs in varying stages **immunocompromised children (leukemia) : more lesion, often more hemorrhagic base **complication 1. Cerebellar ataxia: benign in children 2. Encephalitis (0.1- 0.2%) 3. Varicella pneumonitis: adults and immunocompromised Association with Reyes syndrome : in latter stages of varicella with vomiting , restlessness, irritability and decreasing level of consciousness Perinatal varicella : high death rate when maternal disease develops 5 days before delivery or 48 hours post-partum Congenital varicella : commonly manifested at birth Characterize by skin scarring , hypoplastic extremities eye abnormalities and evidence of CNS impairment B. Herpes Zoster Unilateral vesicular eruption with dermatomal distribution (thoracic and lumbar) Pain in sensory nerve distribution heralds onset of eruption Vesicular eruption: usually unilateral Results from the VZV that has migrated towards the CNS and has becomed establish in the sensory ganglia in latent form reactivated (stimuli: xray treatment, immunosuppressive and other drug therapy, surgery or developing malignancy) virus migrates down the ganglion to the skin multipliesproduces vesicles Diagnosis 1. Clinical hx and physical examination 2. Labnoratory a. Isolation in cell culture

Encephalitis o Most common cause of sporadic fatal disease in US o High mortality rate o Half of patients have primary infections; other half have recurrent infections B. HSV 2 DISEASES Genital herpes o herpes genitalis o Symptoms: vesicles on genitalia, perineum and buttocks with urethritis, painful urination, cervicitis, itching, CNS involvement Herpes of the newborn o Due to retrograde spread secondary to maternal genital infection or passage through an infected birth canal VARICELLA ZOSTER VIRUS Varicella (CHICKENPOX) Herpes Zoster (Shingles)

EPIDEMIOLOGY Humans only natural host Mode of transmission: A. Respiratory droplets(airborne) : MAJOR B. Virus-filled fluid of skin (direct contact) Chickenpox Primary infection Disease of the childhood which is 90% occur in <13 years of age Incubation period is 10-20 days Lesions spread centrifugally to the face , neck and trunk Period of infectivity is 48 hours before vesicles formation and 4-5 days after until all the vesicles are crusted Herpes Zoster It is the reactivation of VZV which become latent within the dorsal root ganglia It occurs in all ages and in person who are sero positive in VZV Reactivation is dependent on a balance between virus and host factors Patient with Shingles- source of infection for non0immune children (attack rate is lower than with exposure to chickenpox)

b. Tzanck smear: multinucleated giant cells in scrapping from base of lesion c. Direct fluorocent antibody stains scarppings from lesion d. Serology and convalescent serum samples **immune adherence hemagglutination; FAMA (fluorescent antibody to membrane antigen)ELISA Prevention 1. Higher titer immune globulin given within 96 hours of exposure : useful in preventing infection or ameliorating disease in those at risk for primary infections (immunosuppressed children who are household or play contacts of ptt with varicella or zoster 2. Live vaccine: for routine use after 12 months of age 3. Rigid precaution for hospitalized cases

Higher mean antibody titers of HHV6 in patients with lymphoma, chronic fatigue syndrome, HIV Up to 70% of infants acquire HHV6 during 1st year of life (6-12mos) Transmission 1. Saliva virus replicated in the salivary glands and secreted in saliva is epidemiologically proven source of transmission 2. Suggested routes that need to be proven a. HHV6 was recovered from cervical tissues and secretions b. Intrauterine transmission c. Genetic Clinical Manifestations A. Exanthem Subitum (Roseola Infantum) Generally benign rash of infants and young children characterized by: a. 3-5 days fever with or without mild upper respiratory tract infection and cervical lymphadenopathy b. Maculopapular rash on trunk and neck within 48 hours B. HHV6 infection in adults Spectrum of diseases: Mild mononucleosislike illness to severe cases of pneumonitis and fulminant hepatitis Important pathogen in organ transplant recipients (seen as serologic reactivation) Diagnosis 1. Serology a. 4-fold or greater rise in IgG titers b.Development of anti-HHV6 IgM 2. Cultures: isolation from saliva and blood 3. DNA detection in blood by PCR

B. BETA HERPESVIRIDAE SUBFAMILY 1. Human Herpes Virus Type 6 First identified in culture of a peripheral blood lymphocytes from patients with lymphoproliferative diseases Occupies the 6th position in the herpes virus family hence called HHV 6 Particles mature in the nucleus and released either by exocytosis or cytosis In vitro, it infects T and B lymphocytes, monocytes, macrophage cell lines, megakaryocytes and gliosbastoma cells Replicates in lymphoid tissues especially in CD4 T lymphocytes Genetically distinct but morphologically similar to other herpes viruses Can be distinguished from other herpes viruses by: o DNA Hybridization o PCR o IF testing with antibodies HHV6 genome persists in host cells in a latent state after resolution of a primary infection o Latent infection occurs in T cells It has 2 subtypes which differ in predilection to cause disease in children as compared to adults Epidemiology 20-40% of the population = seropositive

2. Human Herpes Virus Type 7 Originally isolated from CD4 T lymphocytes (receptor for virus attachment) Closely related to HHV6 and Cytomegalovirus Usually does not infect children after infancy Nearly 90% of children are seropositive by age 3 Transmission Close and personal contact (frequently isolated from saliva)

Clinical Manifestation May cause exanthema subitum Diagnosis - By seroconversion II. PAPILLOMAVIRUSES HUMAN PAPILLOMA VIRUS -Small -Unenveloped -Double stranded DNA viruses -exhibits cubic symmetry -have not been grown in tissue culture -high affinity for epithelial cells of the skin and mucous membranes Epidemiology and Pathology has 40 different strains of HPV causing wart or verruca benign squamous epithelial growth maybe virus-specific for mucous membranes or skin associated with premalignant (cervical intraepithelial neoplasia) and malignant disease (cervical cancer) a. Plantar warts -painful, deep, papillomas on the soles of the feet b. Common or seed warts -painless, elevated, rough growths on the fingers c. Flat warts -smooth, skin colored lesions on the face, trunk, elbows, knees d. Genital warts -a prevalent STD linked to some types of cancer GENUS SYMPTOMS in Papillomavirus HUMANS (host) HPV 1, 4 plantar warts HPV 2, 4 common warts ( verruca vulgaris) HPV 3, 10 flat warts (verruca plana) epidermoplasia verruciforms HPV 6, 11 anogenital warts (condyloma acuminata) otolaryngeal warts HPV 7 meat-handler warts HPV 13 oral focal hyperplasia HPV 16, 18, genital tract cancers 31, 33, 34 invasive carcinomas of cervix Transmission 1. Direct contact with wart 2. Indirect contact with fomites 3. Autoinoculation INCUBATION PERIOD: 2 weeks to more than a year

common among all sexes, races, and geographical regions*

Diagnosis: Clinical diagnosis possible due to distinctive character of warts Biopsy and histologic examination may be needed in some ambiguous cases Does not grow in routine tissue culture IMMUNOASSAYS detection of viral antigen In situ HYBRIDIZATION and PCR detection of specific viral DNA in cervical swabs or tissue *** Probes can detect HPV type and assess risk of developing cervical cancer Treatment and Prevention 1. Chemical application of cytotoxins (podophyllin,5 FU, Trichloroacetic acid) 2. ELECTROCAUTERY for cervical lesions *recurrences common after cessation of treatment because of survival of virus in basal layers of epidermis 3. HPV vaccine recombinant vaccine produced in yeast and contains virus-like particles Composed of HPV proteins of types 6, 11, 16 and 18 III. POX VIRUS Largest and most complex of the animal viruses Brick-shaped or ovoid; enveloped; dsDNA viruses Multiply in the cytoplasm in well-defined sites called FACTORY SITES as inclusion bodies (GUARNIERIS BODIES) Produce eruptive skin pustules called POX or POCKS, which leaves small depressed scars Common feature: Specificity for the cytoplasm of epidermal cells and subcutaneous connective tissue

A. SMALL POX (Variola) Considered to be a disease of the past One of the deadliest infectious diseases Now presently exist in research labs Exposure is usually direct inhalation of droplets or skin crusts from an active case Potential to be used for biological warfare Pathogenesis: virus enters the mucous epithelium of the respiratory tract moves into the circulation multiplies in the local lymph nodes viremia ( fever, malaise, prostration ) Rash begins in the pharynx, spreads to face, then to extremities 4

Rash is initially macular, evolving into popular, vesicular and pustular before eventually crusting over, leaving nonpigmented sites pitted with scar Two principal forms of small pox: Variola minor Variola major: 25 times more virulent, death occurs early in illness ( toxemia, shock, and intravascular coagulation ) Recovery from infection confers a lifelong immunity Laboratory Diagnosis: Must be differentiated from chicken pox, disseminated herpes, vaccinia, monkeypox, and certain non-viral lesions mimicking smallpox Scanning stained smears of vesicle fluid for typical elementary bodies + other cytopathic effects Isolation of virus by inoculating the chorioallantoic membrane of chicks eggs with specimen Prevention: Puncturing a single drop of vaccinia virus into the skin with a double-pronged needle or jetgun Successful take = appearance of a large, scablike pustule with a reddened periphery permanent scar Vaccine protection last up to 10 years Vaccine no longer given and not required for travel because it is no longer a threat and due to vaccinia complications especially in the immunocompromised and allergic person

IV. RNA ENVELOPED A. MEASLES VIRUS An enveloped RNA virus (rubeola virus) Belongs to the genus Morbillivirus of the family Paramyxoviridae Are transmitted thru respiratory droplets Also known as red measles and rubeola Entirely unrelated to rubella (German Measles) Morphology: pleomorphic spheres with diameter of 10250nm virion: nucleocapsid (RNA) + envelope envelope has HN (conical shape) spikes and F (dumbbell-shape) glycoprotein spikes that allow the virus to infect neighboring cells very labile agent: sensitive to acid, drying, strong light, proteolytic enzymes remains infective in droplet form in air for several hours (esp. under conditions of low humidity) virus composed of 6 structural proteins: 1. Complexed with RNA a. nucleoprotein (N) b. polymerase protein (P) c. large protein (L) 2. Associated with the viral envelope a. M protein: non-glycosylated protein b. H glycoprotein: responsible for the absorption of virus to receptors on the host cell; makes up the antigen that mediates hemagglutination c. F glycoprotein: responsible for the membrane fusion virus and host cell, penetration into host cell and hemolysis Mechanism of Action cell membrane of infected cell modified by insertion of spikes HN spikes immediately bind an uninfected neighboring cell in the presence of F spikes the two cells permanently fuse chain reaction of multiple cell fusions produce a syncytium or a multinucleate giant cell (with cytoplasmic inclusion bodies)

B. MOLLUSCUM CONTAGIOSUM Distributed throughout the world, with highest incidence in certain Pacific islands Primarily an infection of children transmitted by direct skin to skin contact and fomites ( sharing of towels ) Infection can be spread by sexual intercourse in adults with lesions occurring on the pubic and genital region Nodular, pale, firm (pearl-like), painless, umbilicated lesions Cheesy material may be expressed from the pore at the center of each lesion Lesions may disappear in 2-12 months without treatment

Epidemiology one of the most contagious infectious diseases rare under 6 months of age; transplacental IgG transmitted principally by direct contact with respirator aerosols epidemic spread favored by crowding, a prevalence of non-immune children, malnutrition 1986 measles epidemic linked to lack of immunization in children or the failure of a single dose of vaccine in many children no reservoir other than humans person considered infectious during period of incubation, prodrome and skin rash single attack confers lifelong immunity Infection and Disease characterized by maculopapular eruption, URTI, conjunctivitis incubation period: 2weeks invasion of mucosal lining of respiratory tract, followed by viremia Symptoms sore throat, dry cough, headache, conjunctivitis, lymphadenitis and fever Signs: Kopliks spots (on lateral buccal mucosa) appear as a prelude to the red maculopapular exanthema that erupts on the head which progresses to the trunk and extremities rash gradually coalesce into red patches that fade to brown Complications in most instances, a self-limited infection may be severe enough to cause death in about 1 in 500 children respiratory: laryngitis, bronchopneumonia, bronchitis, pneumonitis, bacterial secondary infections, otitis media and sinusitis children with leukemia predisposed to pneumonia due to lack of natural T-cell defense CNS: SSPE (subacute sclerosing panencephalitis) manifests 5-7 years after initial infection due to failure of viral replication which is related to mutations of the gene encoding the M protein

Diagnosis 1. Clinical -age, history of recent exposure to measles (useful clues to diagnosis) -cough, coryza, conjunctivitis, Kopliks spots, a maculopapular rash beginning on the face 2. Laboratory a. virus isolation b. identification of measles antigen in infected tissues (if from nasal exudates/urine sediments and RT-PRC) c. demonstration of specific serologic response (ELISA, HI on paired serum samples) Treatment symptomatic treatment for most cases antibiotics may be given for bacterial complications large doses of immune globulin may be therapeutic Prevention vaccination is the most practical, economical and enduring strategy to combat measles Measles vaccine attenuated virus given subcutaneously immunity persists for about 20 years any person who receive vaccine prior to 1980 or whose immunization history is in doubt should be revaccinated may cause atypical infection recommended for all healthy children at the age of 15 months (MMR vaccine, with mumps and rubella) and booster prior to entering school RUBELLA VIRUS Classified in the Togaviridae based on RNA genome, icosahedral capsid and lipoprotein envelope Only one known serotype; no extra human reservoirs Rubella virus is relatively unstable and inactivated by lipid solvents trypsin, formalin, and extremes of pH and heat and is inhibited by amantadine Epidemiology Incidence highest in the spring Common in ages 5 to 9 years old

 Now being seen with increasing frequency in an older age group because of the widespread use of rubella vaccine Compared to measles: a moderately contagious disease

Complications of Postnatal Rubella o Complications of postnatal rubella are uncommon (unlike measles) o Bacterial super infection after rubella is rare o Arthritis, or arthralgia: reported in as many as 1/3 of women with rubella (tends to involve the fingers, wrists and knees) o Hemorrhagic manifestations I 1 out of 3,000 cases (more common in children), may be secondary to thrombocytopenia or vascular damage o Encephalitis 1. Extremely uncommon (1 out of 5,000 cases) 2. Usually occurs in adults 3. Associated with a mortality of 20 to 30%

Transmission Spreads in droplets shed from respiratory secretions of infected persons Patients are most contagious when rash is erupting May shed virus from the throat from 10 days before the onset of the rash to 15 days after its onset Patients with subclinical illness may transmit the disease Infants with congenital rubella shed large quantities of virus from body secretions for many months and may transmit the infection to those who care for them Persons who have received rubella vaccine do not transmit rubella to others

Laboratory Diagnosis o Usually made serologically (IgM or IgG antibodies) 1. HAI was once the preferred means of measuring antibody titers 2. ELISA 3. Passive latex agglutination test a. In the latex agglutination test, latex particles are coated with the rubella antigens that are then reacted with the serum being tested; agglutination indicates the presence of rubella antibodies b. Acute rubella infection may be diagnosed either by a demonstration of specific IgM in one serum sample or by a fourfold greater increase in rubella antibody titer in acute and convalescent specimens assayed in the same test

Immunity to Rubella Lifelong immunity for most persons but reinfections with rubella can occur Viremia is rare in reinfections

Clinical Manifestations I. POSTNATAL RUBELLA Many if not most cases are subclinical Children: may not have a prodromal phase adults: may have a prodrome of malaise, fever, and anorexia for several days; may be accompanied by mild coryza and conjunctivitis Rashes last 3 to 5 days

Major clinical manifestations: 1. Adenopathy posterior auricular, posterior cervical and sub-occipital 2. Rash begins on the face and moves down the body, maculopapular but not confluent and may be absent in some

II. CONGENITAL RUBELLA Rubella can be disastrous in early gestation

*Can lead to: - Fetal death - Premature delivery - An array of congenital defects *Occasionally fetal damage (deafness alone) is seen if rubella occurs up to the 20th week of gestation

*Forscheimer spots petechial lesions on the soft palate but is not diagnostic of rubella unlike Kopliks spots

THE YOUNGER THE FETUS, THE MORE SEVERE THE ILLNESS 1st two months of gestation o 65-85% chance of either being spontaneously aborted or developing multiple congenital defects 3rd month of fetal life o 30-35% chance of developing a single defect such as deafness or congenital heart disease th 4 month of gestation o 10% risk of a single congenital defect

Laboratory Diagnosis Neonatal period Antibody to rubella virus should be measured in both infant and maternal sera 1. Serial antibody determination in a neonate a. A falling rubella antibody titer indicates passively acquired maternal antibody b. A rising rubella antibody titer suggests rubella infection 2. Rubella IgM newborn infants serum: transplacental infection 3. Congenital rubella infection a. Placental biopsy at 12 weeks b. demonstration of rubella antigen with monoclonal antibodies, cordocentesis and detection of RNA by in situ hybridization, and PCR c. Demonstration of specific IgM in fetal blood (22 weeks AOG)

Common manifestations a. b. c. d. e. Low birth weight (temporary) Deafness Cataract or glaucoma Congenital heart disease Mental retardation

Pathologic mechanisms to explain manifestations a. Persistent infection with rubella virus leads to mitotic arrest of cell leading to inhibition of cell growth retarded organ growth b. Increased frequency of chromosomal breakage in cultured cell from children with congenital rubella c. Infection of various types of cells during gestation interferes with normal balance of growth and differentiation defective organogenesis d. Lymphocytic abnormalities in patients with congenital rubella syndrome may predispose them to organ-specific autoimmunity

Treatment Postnatal rubella, a mild infection needs no treatment most of the time Ig was once advocated for the prevention or modification of rubella in susceptible pregnant women exposed to the infection *Ig might suppress symptoms but would not prevent viremia Indications for use of Ig for rubella prophylaxis are few With the advent of the rubella vaccine, it is now possible to immunize susceptible women of childbearing age before they get pregnant Vaccination against rubella Live attenuated vaccine, used since 1969: o Rationale for use of the vaccine to prevent congenital rubella by controlling postnatal rubella o More recently, there has been emphasis on immunizing rubella-

Diagnosis o Virus isolation: from throat swabs, urine, synovial fluid and other body secretions are acceptable methods for diagnosis o Virus can also be isolated from amniotic fluid drawback of isolation method: Time-consuming and expensive hence, reserved only for special circumstances (e.g. investigation of arthritis, and complications of postnatal rubella)

susceptible women of childbearing age who are not pregnant (usually done just after delivery of an infant) In some other countries, the approach has been to vaccinate girls against rubella as they approach puberty

Complications of vaccination Rubella vaccine may cause viremia: fever, adenopathy, arthritis and arthralgia More common in adult females over 25 years 40% of vaccines may develop this complication but they are transient

Efficacy of Vaccination Vaccine has caused a decline in the number of reported cases of clinical rubella Seroconversion rate is 95% Seroconversion in response to the vaccine is not impaired in children with upper respiratory infections

Effects of Rubella Vaccine on Fetus Of the 812 women who were inadvertently immunized against rubella during early pregnancy, no cases of congenital rubella syndrome were not noted