Viral Lesions Question And Answers
Question 1. Write short note on measles.
Answer. It is also called as rubella or morbilli
It is an acute contagious dermatotropic viral infection which mainly affect children.
Transmission
It spreads by direct contact or via the droplet infection, portal of entry is respiratory tract.
Measles Clinical Features
- There is onset of fever, malaise, cough, conjunctivitis, photophobia, lacrimation and eruptive lesions of skin and oral mucosa.
- Skin eruption begins on face, in hair line and behind ear, and spread to neck, chest, back and extremities.
- It appears as tiny red macules or papules which enlarge and coalesce to form discolored irregular lesions, which blanch on pressure. Skin lesions fade in 4 to 5 days with fine desquamation.
Measles Oral Manifestations
- The most common site is buccal mucosa.
- Koplik’s spot: Intraoral lesions appear known as Koplik’s spots.
- Koplik’s spot appears as small, irregularly shaped flecks, which appear as bluish white specks surrounded by bright red margins. They are described as grains of salt on red background.
- There is generalized inflammation, congestion, swelling and focal ulceration of gingiva, palate and throat may occur.
Read And Learn More: Oral Medicine Question And Answers
Measles Diagnosis
- Clinical diagnosis: Koplik spots and history provides clue to the diagnosis.
- Laboratory diagnosis: This is carried out by virus isolation and increased antibody titers. Antibodies are seen after three days of the occurrence of rash.
Measles Differential Diagnosis
- Smallpox: Presence of high fever.
- Chickenpox: Exanthema is seen which follow intraoral lesions.
Measles Complications
- Bronchial asthma
- Encephalitis
- Otitis media
- Noma
- Hodgkin’s lymphoma.
Measles Management
- MMR vaccination is the best treatment. When child is of one year of age injection of live attenuated measles virus is administered subcutaneously. Second dose is given in next 12 to 15 months.
- I.M. Human immunoglobulin should be given to prevent and attenuation of measles mainly to patients of 18 months of age or in debilitated children. Its dosage is 250 mg for children under age of 1 year and 500 mg to those who are more than 1 year of age.
- Isolate the patient.
- For control of pain and fever, analgesic and antipyretic should be given to patient.
Question 2. Write short note on mumps.
Answer. It is an acute contagious viral infection characterized by unilateral or bilateral swelling of salivary gland. It effects major salivary glands but also affects testis, meninges, pancreas, heart and mammary glands.
Etiology of mumps
- It is endemic in most urban populations.
- It is caused by paramyxovirus.
- It usually spread from human reservoir, by airborne infection of infected saliva and urine.
Mumps Clinical Features
- It occurs at 5 to 15 years of age and boys are most commonly affected with incubation period of 2 to 3 weeks.
- The onset is by headache, chills, moderate fever, vomiting and pain below ear which last for one week.
- Parotid gland is most commonly involved and is bilateral.
- It is followed by onset of salivary gland swelling which is firm somewhat rubbery or elastic and without purulent discharge from salivary gland duct.
- The enlargement of parotid gland causes elevation of ear lobule and produces pain on mastication especially while eating sour food.
- Sublingual gland can also be involved bilaterally. It can produce swelling at the floor of mouth.
- Papilla at the opening of parotid duct is puffy and red.
Mumps Complications
- Orchitis: It is seen in adult males. It can cause sterility.
- Pancreatitis: Involvement of pancreas may lead to acute pancreatitis which leads to elevation in serum lipase.
- Meningitis
- Other complications: They are epididymitis, mastoiditis, myocarditis, deafness and meningoencephalitis.
Mumps Diagnosis
- Clinical diagnosis: Presence of parotitis and various signs of viral infections.
- Laboratory diagnosis: There is increase in the salivary amylase levels. Paramyxovirus can be isolated from saliva 6 days before and 99 days after appearance of salivary gland swelling.
Mumps Management
- Most of the cases are self-limiting, with salivary gland enlargement subsiding within a week.
- Prevention with live-attenuated vaccine is best method for controlling disease.
- Symptomatic treatment is given to control pain and swelling. Analgesic and anti-pyretic is given.
- Provide adequate bed rest to the patient to decrease the chances of orchitis.
- Sour foods and drinks should be restricted for patient to decrease salivary gland discomfort.
Question 3. Write short note on exanthema.
Answer. Any eruption or rash that appears on the skin, as opposed to one that appears on the mucus membrane. The term is often use to describe childhood infectious rashes.
Viral infections associated with skin lesions are known as viral exanthems.
Viral exanthems lead to maculopapular rashes sparing palms as well as soles.
Following are the viral exanthems:
- Measles
- Rubella
- Varicella-zoster infection, i.e. chickenpox and shingles
- Exanthem infectiosum
- Exanthem Subitum
- Enteroviruses
- Infectious mononucleosis
- Adenovirus
- Reovirus
- Arbovirus.
Exanthematous Stage in Measles
- In exanthematous stage on 5th day the red macules appear behind the ear, along hair line and on posterior parts of cheeks and spread rapidly in a few hours all over the body. Macules appear in the crops which by confluence from blotches with crescentic or thumbnail edge. Fully erupted rash deepens in color, petechiae may occur. In severe measles rash is confluent, the face is swollen and disfigured and together with photophobic eyes create typical measly appearance.
- Mucous membrane involvement: It consists of conjunctivitis, rhinitis, stomatitis, laryngitis, tracheitis and bronchitis.
Exanthema in Chicken Pox
- Evolution: In form of crops, first at back, then chest, abdomen, face and lastly limbs.
- Character: At first macule appear then in few hours dark pink papule which soon turn into vesicle. They also get collapsed if pierced and vesicles turn into pustules in 24 hours and to scabs in 2 to 5 days.
- Distribution: It is centripetal, i.e. more on upper arm and thighs, upper part of face and in concavities and flexures.
- Cropping: Rash mature quickly and most spots dry up within 48 hours of appearance. For 2 to 3 days new spots continue to appear on any area of body vesicles, pustules and scabs are found side by side.
Exanthema in Rubella
In exanthema rash occurs more often in older children and adults on first or second day of illness, first on face and behind the ears, and then spreads downwards to trunk and limbs. The rash is variable, but commonly starts as discrete, pink, punctate, erythematous, perifollicular macules that rapidly become confluent. Alternatively, there may be blotchy pink rash or confluent blush. Rash seldom persists for more than 4 days and is not followed by staining or desquamation. Rubella without rash is common in young children. In a dark skinned patient all that may be seen is prominence of hair follicles giving a goose pimpled appearance.
Question 4. Describe in detail prevalence, predisposing factors, age and sex distribution, prodromal symptoms, location of lesion laboratory findings (diagnosis) and treatment of primary acute herpes gingivostomatitis.
Or
Write short note on management of acute herpetic gingivostomatitis.
Answer. Acute herpes gingivostomatitis is called as herpes labialis, fever blister, cold sore and infectious stomatitis.
Primary Acute Herpes Gingivostomatitis Prevalence
Most prevalent in higher socioeconomical, especially medical, dental and nursing personnel are at higher risk of contact and infection due to lack of circulating HSV antibodies.
Primary Acute Herpes Gingivostomatitis Predisposing Factors
- Trauma to lips, fever, emotional upset and upper respiratory tract infection.
- Sun burn, fatigue, menstruation and pregnancy.
- Emotional upset, allergy and dental extraction.
Primary Acute Herpes Gingivostomatitis Age and Sex Distribution
It develops in both children and young adults. No sex predilection is present.
Prodromal Symptoms
They precede local lesion by 1 to 2 days and it include fever, headache, malaise, nausea, vomiting and within a few days mouth becomes painful. There is also irritability, pain on swallowing and regional lymphadenopathy.
Location of Lesion
- Lips: Excoriation involving lips may become hemorrhagic and matted with serosanguineous fibrin-like exudate and parting of lips during mastication and speech.
- Gingiva: Appearance of generalized marginal acute gingivitis.
- Pharynx: Examination of posterior pharynx reveal inflammation.
- Lymph nodes: Cervical and submandibular lymphadenopathy.
Laboratory Findings (Diagnosis)
- Negative past history of recurrent herpes labialis and positive history of close contact with patient with primary or recurrent herpes is helpful in making diagnosis.
- Patient is easily diagnosed as having primary herpetic gingivostomatitis; if he/she present with typical clinical features of generalized symptoms followed by eruption of oral vesicles and acute marginal gingivitis and does not have history of recurrent herpes.
- HSV isolation: Isolation and neutralization of virus in tissue culture is most positive methods of identification.
- Antibody titer: Antibodies to HSV appears in a week and react peak in 3 weeks.
Primary Acute Herpes Gingivostomatitis Treatment/Management
- Topical anesthetics such as 2% lignocaine, 0.1% dyclonine hydrochloride.
- Topical anti-infective agents to prevent secondary infection are 0.2 % chlorhexidine gluconate, tetracycline mouthwash.
- Fluid to maintain proper hydration and electrolyte balance. If fever is present antipyretics should be given.
- Maintenance of oral hygiene is necessary to avoid the secondary infection
- Acyclovir suspension 15mg/kg or Acyclovir 200mg orally 5 times a day for 5 days should be initiated in first 3 days of onset may decrease duration of lesions.
- Acyclovir 800 mg/day is used as prophylactic regimen in immunocompromised persons.
- Valacyclovir 500 mg or Famciclovir 250 mg orally twice a day for 5 days can be given as alternative drug.
Question 5. Enumerate various acute multiple ulcerative lesions of oral cavity. Describe clinical features and management of acute herpetic gingivostomatitis.
Answer. For ulcerative lesions refer to Ans 1 of chapter 9 of same section. For management, refer to Ans 4 of same chapter.
Acute Herpetic Gingivostomatitis Clinical Features
- It occurs in both children and young adults and its incubation period is of 5 to 7 days.
- Prodromal symptoms are fever, headache, malaise, nausea, vomiting and in some days mouth gets painful. Patient is irritable and also complaints of pain on swallowing.
- Lesions occur on hard palate, dorsum of tongue, attached gingiva, lips, buccal mucosa and can also be seen on the skin.
- After prodromal period, multiple small vesicles are seen which are usually thin walled and are surrounded by the inflammatory base.
- Vesicles rupture quickly by leaving multiple small, shallow and oval shaped ulcers which are 1 to 5 mm in diameter. Base of the ulcer is covered by grayish white or the yellow plaque.
- These ulcers can coalesce to form large irregular ulcers along with scalloped border and erythematous base.
- In severe cases, lips become hemorrhagic and get matted by serosanguinous fibrin like exudates along with the parting of lips at the time of mastication and speech become painful and difficult.
- There is presence of acute marginal gingivitis. Whole of the gingiva is swollen and ulcers are seen on gingiva.
- Presence of pharyngitis can lead to dysphagia.
Question 6. Discuss clinical features, differential diagnosis and management of herpes simplex infection.
Answer.
Herpes Simplex Infection Clinical Features
- 1. Herpes genitalis: This is caused mainly by herpes simplex 2 virus. It is common in cervix, vagina, vulva and penis. Lesion occurs on well keratinized areas mainly at shaft of penis but it can progress into superficial erosions which are painful. Urethra can also be involved.
- 2. Genital herpes in HIV patients: It occurs in immunocompromised and HIV infected patients.
- 3. Herpetic meningoencephalitis: It is characterized by sudden fever and there are symptoms of increased intracranial pressure. There is paralysis of various muscles along with convulsions and even death can occur.
- 4. Herpetic conjunctivitis: Presence of swelling as well as congestion of palpebral conjunctiva, keratitis along with corneal ulcerations. Recurrent lesions may lead to blindness.
- 5. Herpetic eczema: This is superimposed over pre-existing eczema and is characterized by diffuse vesicular lesion of skin, umbilicated vesicles with high fever.
- 6. Herpetic whitlow: This is the infection of fingers by herpes virus, dentist can experience primary lesions over fingers on contact with the lesions of mouth or saliva of asymptomatic patients.
- 7. Herpes gladiatorum: There is infection of skin via sport of wrestling.
- 8. Oral infection: There is presence of primary infection and recurrent infection.
Oral Manifestations of herpes simplex infection
Primary Herpetic Gingivostomatitis
- It occurs in both children and young adults and its incubation period is of 5 to 7 days.
- Prodromal symptoms are fever, headache, malaise, nausea, vomiting and in some days mouth gets painful. Patient is irritable and also complaints of pain on swallowing.
- Lesions occur on hard palate, dorsum of tongue, attached gingiva, lips, buccal mucosa and can also be seen on the skin.
- After prodromal period, multiple small vesicles are seen which are usually thin walled and are surrounded by the inflammatory base.
- Vesicles rupture quickly by leaving multiple small, shallow and oval shaped ulcers which are 1 to 5 mm in diameter. Base of the ulcer is covered by grayish white or the yellow plaque.
- These ulcers can coalesce to form large irregular ulcers along with scalloped border and erythematous base.
- In severe cases, lips become hemorrhagic and get matted by serosanguinous fibrin like exudates along with the parting of lips at the time of mastication and speech become painful and difficult.
- There is presence of acute marginal gingivitis. Whole of the gingiva is swollen and ulcers are seen on gingiva.
- Presence of pharyngitis can lead to dysphagia.
Recurrent Herpetic Labialis
- It occurs at widely varying intervals.
- Patient complains of tingling and burning sensation, feeling of tautness, swelling and soreness with development of vesicle.
- Edema is seen at the site of lesion and is followed by development of small multiple clusters of vesicles.
- In recurrent intraoral herpes lesions occur on hard palate, gingiva and at the dorsum of tongue. Lesions occur after few hours of prodromal phase. There is presence of multiple, fragile, short lived which appear and rupture to form ulcerative lesions sometimes with slight erythematous halo. Small vesicles or the ulcers are 1 to 2mm in diameter and coalesce to form superficial irregular ulcers.
- In recurrent herpes labialis lesions are seen on vermilion border of lip as well as the surrounding skin. These are grayish or whitish vesicles are seen which rupture and leave small red ulcers. There is presence of very slight erythematous halo over the lip which is covered by brown colored crust. Size of crust is 1 to 4 mm in diameter.
Diagnosis of herpes simplex infection
- Negative part history of recurrent herpes labialis and positive history of close contact with a patient with primary or recurrent herpes is helpful in making diagnosis.
- Typical clinical features of generalized symptoms followed by eruption of oral vesicles and acute marginal gingivitis and does not have history of recurrent herpes.
- HSV isolation: Isolation and neutralization of virus in tissue culture is most positive method of identification.
- Antibody titer: Antibodies to HSV appear in week and react peak in 3 weeks.
Differential Diagnosis of herpes simplex infection
- Hand, foot and mouth disease: Lesion presents on foot and hand also.
- Herpangina: Oropharyngeal and soft palate involvement. It affects children in late summer and early monsoon season on soft palate and facial area with fever and malaise.
- Chronic recurrent aphthae: No stomatitis, lesions are less numerous and found in adults.
- Herpes zoster: Segmental distribution along anatomical location of nerve.
- Bullous lichen planus: It is painful condition characterized by large blister on tongue and cheek with rupture and undergoes ulceration.
- Benign mucosa pemphigoid: Prodromal symptoms are absent with progression of erythema to swelling to chronic blisters in crusting lesion.
- Erythema multiforme: It mainly occurs in adults. Gingivitis is not severe and is generally limited to anterior region of mouth. Here typical target eye lesions are present.
Management of herpes simplex infection
- Topical anesthetics such as 2% lignocaine, 0.1% dyclonine hydrochloride.
- Topical anti-infective agents to prevent secondary infection are 0.2 % Chlorhexidine gluconate, tetracycline mouthwash.
- Fluid to maintain proper hydration and electrolyte balance. If fever is present antipyretics should be given.
- Maintenance of oral hygiene is necessary to avoid the secondary infection
- Acyclovir suspension 15mg/kg or Acyclovir 200 mg orally 5 times a day for 5 days should be initiated in first 3 days of onset may decrease duration of lesions.
- Acyclovir 800 mg/day is used as prophylactic regimen in immunocompromised persons.
- Valacyclovir 500 mg or Famciclovir 250 mg orally twice a day for 5 days can be given as alternative drug.
Question 7. Write short note on clinical features and complications of varicella zoster infection.
Answer. Varicella zoster virus leads to the chickenpox.
Varicella Zoster Infection Clinical Features
- The disease begins with fever, headache, anorexia, nausea, vomiting, myalgia, sore throat, malaise, lung congestion and headache, etc.
- These are followed by a papular rash first appearing over the trunk and then rapidly spreading to face and limbs.
- After 3 to 4 days, unusual sequences of macules, vesicles, ulcerations and scabbing of the skin and oral mucosa are seen.
- The individual vesicle appears as ’dew drop’ on rose petals and is often surrounded by a zone of erythema at the periphery.
- The oral lesions often precede the skin lesions and produce vesicles and ulcerations which are similar to those of the skin. The oral lesions mostly develop over the palate, buccal mucosa and gingiva, etc.
- Following rupture of the oral vesicles, there is often formation of aphthous-like ulcers in the oral mucosa which are not painful.
- Occasionally, skin lesions become secondarily infected and these lesions heal with formation of a depressed scar (pock).
Varicella Zoster Infection Complications
Following are the complications caused by Varicella zoster virus:
- Pneumonia
- Encephalitis
- Cerebellar ataxia
- Myocarditis
- Reye’s syndrome
- Hemolytic anemia
- Sickle cell crisis
- Hepatitis.
Question 8. Write short note on recurrent herpes labialis.
Answer. Recurrent herpes labialis is the secondary herpes infection.
Herpes Labialis Pathogenesis
As primary infection is over, virus can no longer recover from the ganglion and viral DNA is seen in ganglionic cells. Humoral and cell-mediated immunity is responsible for the recurrence of the disease.
Herpes Labialis Etiology/Trigger Factors
- Any surgery which involves trigeminal ganglion leads to recurrent herpes.
- Low immunity leads to recurrent herpes.
- Trauma as in exodontias can precipitate recurrent herpes.
- Upper respiratory infection can lead to recurrent herpes.
- Other factors which lead to recurrent herpes are fatigue, pregnancy, fever, menstruation, etc.
Herpes Labialis Clinical Features
- Recurrent herpes, occur at varying intervals.
- Patient complains of tingling and burning sensation, feeling of tautness and soreness before development of vesicle.
- Edema is seen at the site of lesion and is followed by development of multiple clusters of vesicles.
Herpes Labialis Oral Manifestations
- In recurrent intraoral herpes lesions occur on hard palate, gingiva and at the dorsum of tongue. Lesions occur after few hours of prodromal phase. There is presence of multiple, fragile, short lived which appear and rupture to form ulcerative lesions sometimes with slight erythematous halo. Small vesicles or the ulcers are 1 to 2 mm in diameter and coalesce to form superficial irregular ulcers.
- In recurrent herpes labialis lesions are seen on vermilion border of lip as well as the surrounding skin. These are grayish or whitish vesicles are seen which rupture and leave small red ulcers. There is presence of very slight erythematous halo over the lip which is covered by brown colored crust. Size of crust is 1 to 4 mm in diameter.
Herpes Labialis Treatment
- Recurrent infection should be suppressed by applying sunscreen lotion to lip.
- Topical anti-viral drugs such as 5% acyclovir is very effective. Topical paste should be applied over the lesion for 4 to 5 times a day.
- Systemic anti-viral drugs should be given, i.e. Valacyclovir can be given 500 mg to 1 g three times a day.
Question 9. Write short note on clinical features of herpes zoster.
Or
Write short answer on herpes zoster.
Answer. Herpes zoster is also known as Zona or Shingles.
This is an acute infectious viral disease of an extremely painful and incapacitating nature.
Herpes zoster affects sensory nerves with trigeminal nerve. Other sensory nerves involved are C3, T5, L1 and L2.
Herpes Zoster Clinical Features
- Most commonly the disease is seen in adults.
- Prodromal phase of the disease ranges from 2 to 4 days.
- Patient complaint of burning as well as shooting type of pain along with paresthesia and tenderness along the course of nerve.
- There is presence of vesicles over the erythematous base. Vesicles appear in clusters at the course of nerve. This is known as zosteriform pattern. It is typically unilateral and dermatomic in distribution.
- Acute phase of the disease begins as involved skin develops cluster of vesicles over an erythematous base. In 3 to 4 days vesicle becomes pustular and ulcerate.
- Within the period of one week, the vesicles convert into scabs and complete healing occurs in 2 to 4 weeks. After healing, there is presence of scarring as well as hypopigmentation.
- Zoster infection of skin on side of the face is known as and Hutchinson’s sign.
- Chronic phase of herpes zoster is characterized by pain which persists for longer than 3 months after initial presentation of acute rash
Herpes Zoster Oral Manifestations
- The viral infection most commonly produces lesion in midface, upper lip, lower face, lower lip, mandibular gingiva and tongue.
- Patient usually complaint of pain, burning sensation and tenderness over palate on affected side.
- After some days of arising of symptoms vesicle appear over affected side which get rupture and leave erosions or ulcers of size 1 to 5 mm.
- At times exfoliation of teeth is also seen.
- Lesions heal within 15 days period.
Herpes Zoster Differential Diagnosis
Herpangina: It is basically an acute infection, posterior part of oral cavity become affected. It occurs in seasonal epidemics.
Herpes Zoster Diagnosis
- Clinical diagnosis: Lesions occur at the sites of distribution of nerve provide the diagnosis.
- Fluorescent antibody testing: Here, scraping of lesion is done and smear is obtained, smear is stained with fluorescent monoclonal antibody. If antibody is present, it gives positive staining.
- PCR: Polymerase chain reaction detects the viral antigen.
- Biopsy: On histological examination, it show multinucleated giant cells.
Herpes Zoster Management
Antiviral therapy is the first line of treatment. Acyclovir 800 mg five times/day or famciclovir 250 mg three times a day should be given. Therapy should be initiated under 72 hours of symptom onset for maximum effectiveness.
Question 10. Write short note on Ramsay-Hunt syndrome.
Answer. It is also known as James Ramsay-Hunt syndrome.
Ramsay-Hunt syndrome consists of zoster infection of the geniculate ganglion which involves external ear and oral mucosa.
- There is presence of facial paralysis.
- Presence of pain in pinna and external auditory meatus.
- Presence of vesicles in mouth and oropharynx along with vertigo, tinnitus and hoarseness of voice.
Question 11. Distinguishing features between herpangina and primary herpes virus infection.
Answer
Question 12. Write short note on Tzanck test.
Answer. Tzanck test involves the direct examination of cells which may indicate herpes simplex virus infection. The test is done by scrapping the lesion which can be a vesicle, ulcer or crust and the debris is smeared over the slide. Slide is now stained and examined by a microscope for virally infected cells, which show multinucleation and ground glass nuclei. This is known as Tzanck test.
Question 13. Write short note on clinical features of herpangina and its management.
Answer. Herpangina is also known as aphthous pharyngitis or vascular pharyngitis.
Herpangina Clinical Features
- If affects young children from 3 to 10 years of age and its incubation period is of 2 to 10 days.
- Most commonly involved sites are posterior pharynx, tonsil, faucial pillars and soft palate.
- Generalized symptoms are fever with chills, malaise, headache, anorexia, prostration, abdominal pain and sometimes vomiting. There is also presence of sore throat and dysphagia.
- Lesion begins as punctuate macule which evolve to papule and vesicles. Under 24 to 48 hours vesicle rupture to form crop of ulcers which are 1 to 2 mm in size. These ulcers have grey base and inflamed periphery.
- Ulcers do not tend to be extremely painful although patients complaints of dysphagia.
Herpangina Management
No treatment or management is required as the disease is self limiting in a period of one week.
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