1. BY
DR. ABHISHEK SOLANKI

2. VIRAL INFECTION
 HERPES SIMPLEX VIRUS  ENTEROVIRUS
 VARICELLA  RUBEOLA
 HERPES ZOSTER  RUBELLA
 INFECTIOUS  MUMPS
MONONUCLEOSIS
 HIV
 CYTOMEGAVIRUS

3. HERPES SIMPLEX VIRUS
 Members of the Herpes Virus Family which are some of the
most common human viruses
 The Type 1 virus causes cold sores. Most people get Type 1
infections during infancy or childhood.
 The Type 2 virus causes genital sores. Most people get Type
2 infections following sexual contact with an infected
person.

4. Acute Herpetic Gingivostomatitis
 6 mon – 5 yrs (peak 2-3 yrs)
 before 6 months rare because of protection by
maternal anti- HSV antibodies.
 Onset is abrupt & accompanied
by anterior cervical
lymphadenopathy, chills,
fever ( 103 to 105 F).

5. Pharyngotonsillitis
 Sore throat, Fever, Malaise & Headache.
 Numerous vesicles develops
on the tonsils & posterior
pharynx.
 Vesicles ruptures to form
ulcers which coalsce.

6. Herpes Labialis
 "labia" = "lip”
 Age: Adults
 Sex: No predilection
 Most common recurrent site for HSV-1 is vermilion
border & adjacent skin of lip.

7.  In some pt UV light & trauma trigger recurrence.
 Pain, Burning, Itching, tingling, Localized
warmth, erythema of involved epithelium.
 Multiple small, erythematous
papules develop & form clusters
of fluid filled vesicles.
 Persistent herpes labialis is indicative of
immunocompromised status, including HIV infection.

8. DIFFERENTIAL DIAGNOSIS
 Impetigo
 Contact dermatitis

9. HERPETIC WHITLOW
 A/k/a herpetic paronychia
 Medical & Dental personnel infect their digits by
contact with infected patients.
 Can cause permanent scarring

10. Herpes gladiaotorum
 a/k/a scrumpox
 Ocular involvement may occur
 d/t self inoculation
 Pt with diffuse chronic skin disease, such as
eczema, pemphigus and Darier’s disease may develop
life threatening HSV infection ka ECZEMA
HERPETICUM (KAPOSI’s VARICELLIFORM
ERUPTION).

11. COMPLICATIONS
 Meningitis
 Encephalitis
 Eczema herpetiform-- widespread herpes
across the skin)

12.  Keratoconjunctivitis-- Infection of the eye
 Pneumonia
 Infection of the trachea
 Keratitis-- Corneal infection, irritations, and
inflammations

13. H/P
 Infected epithelial cells exhibit acantholysis, nuclear
clearing, nuclear enlargement which has been termed
ballooning degeneration.
 Tzanck cells (multinucleated giant
cells) Multinucleated, infected
epithelial cells, infected cells are
formed when fusion occurs between
adjacent cells.

14.  Intra-epithelial vesicles.

15. Diagnosis
 Clinical presentation
 Viral isolation from tissue culture
 HSV antigens.
 Serologic test for HSV antibodies (4-8 wks after
infection)

16. TREATMENT & PROGNOSIS
 Acyclovir suspensions
 Viscous lidocaine (not in pediatrics)
 NSAIDS
 Anti-viral vaccines (studies)

17. VARICELLA
 VZV or HHV – 3
 DNA virus
 Two clinically distinct syndromes
 Chickenpox
 Shingles.
 Acquired by inhalation or contact, with primary
infection of conjunctiva or upper airway mucosa

19. Primary Varicella (Chicken Pox)
 Age: Children
 Sex: No predilection
 Dermal vesicular exanthem
 incubation period lasts 2 to 3 weeks

20.  Early onset of vesicles that rapidly rupture & leave
erosions with a surface pseudomembrane
 lesions located on the trunk and face, are vesicular
with an erythematous boundary, and are extremely
pruritic.
 Fever, malaise
 mild generalized lymphadenopathy
 lesions resolve within 5 to 8 days.

21. H/P
 Superficial intraepithelial vesicle formation.
 vesicular contents contain eosinophilic exudate, inflammatory
cells and epithelial cells.
 Nuclear ballooning
 Superficial submucosal inflammatory cell infiltrate
DIFFERENTIAL DIAGNOSIS
 Herpes
 Coxsackieviruses
 Aphthae.

22. Herpes zoster
 Age: Adults and elderly people
 Sex: Slight male predilection
 VZV spreads from skin/mucosa into sensory nerve
endings

23.  Virus travels to dorsal root ganglion and becomes
latent
 Reactivation occurs with decreased cell-mediated
immunity
 Initial replication occurs in affected ganglion after
reactivation

24. Clinical Features
Prodrome:
Headache
photophobia
malaise
fever
abnormal skin sensations
pain

25. Rash:
 Vesicular eruption follows the
distribution of sensory nerves,
being segmental and unilateral.
 Thoracic , cervical, ophthalmic involvement most common
 Initially erythematous, maculopapular
 Vesicles form over several days, then crust over
 Full resolution in 2-4 weeks

26. Complications of Herpes Zoster
 Postherpetic Neuralgia (PHN)
 Herpes Zoster Ophthalmicus
 VZV viremia
 Dermatologic complications

27. Histopathologic Features
 Same as HSV
Treatment and prevention
 Vaccination
 Acyclovir
 VZIG as post-exposure prophylaxis in individuals at high
risk
 Exclude kids from school until sixth day of rash

28. Infectious Mononucleosis
 Aka Glandular Fever & Kissing Disease because adult
contract the virus through direct salivary transfer like
straws or kissing
 7-10 days incubation period.
 Acute self-limiting infection
 Epstein-Barr Virus

29. Clinical Features
 Age : Young Adults
 Sex : no prediliction
 Petechiae on hard palate
 Lymphadenopathy, Pharyngitis, Tonsillitis.
 Sore throat, fever, rash

30.  NUG is common.
 Malaise, lethargy, extreme tiredness
 Liver and spleen involvement and enlargement
 Hematology: High WBC, over 20% atypical reactive
lymphocytes also known as Downey cells.

31. Histopathologic feature
 Downey cells – atypical lymphocytes diagnostic feature
DIFFERENTIAL DIAGNOSIS
 Platelet disorders
 Hereditary hemorrhagic telangiectasia.

32. T/t
 Supportive
 Bed rest and high liquid intake.
 Mild analgesic and antipyretic

33. Cytomegalovirus
 HHV-5
 Transmission occurs from person to person.
 Close intimate contact
 Sexual contact
 During delivery
 Breast milk
 Organ transplant
 Blood transfusion

34. Clinical features
 Symptoms resemble IM
 In babies may cause life threatening illness
 Patients with deficient immune systems
 AIDS patients
 Transplant patients
 Common in AIDS pt.

35.  90 % of CMV are infections are assymptomatic
 Typical Features
 Hepatosplenomegaly
 Thrombocytopenia
• Fever
• Malaise
• Myalgia

36. H/P
 Scattered infected cells are extremely
swollen, showing both intracytoplasmic and
intranuclear inclusions and prominent nuclioli - Owl
Eye

37. Diagnosis
 Clinical Features
 Viral Antigen
Treatment
 CMV infection resolve spontaneously
 Gancyclovir in immunocompromised patient

38. Enteroviruses
 Genus of the picornavirus family which replicate
mainly in the gut.
 Single stranded RNA virus

39.  Divided into 5 groups
 Polioviruses
 Coxsackie A viruses & Coxsackie B viruses
 Echoviruses
 Enteroviruses
 Herpanginia, Hand-foot-and-mouth
disease, Acute lymphonodular pharyngiitis

40. Herpangina
 Caused by Coxakievirus A 1 to 6, 8, 10, 22 Coxakievirus
A7, 9 or 16; Coxakievirus B 2 to 6; Echovirus 9,16,17;
enetrovirus 71.
 Age: Children
 Sex: No predilection

41.  Most cases arise in summer with crowding & poor oral
hygiene.
 Fecal-oral route : major path of transmission

42. Clinical Features
 Sore throat
 Dysphagia
 Fever, cough
 Rhinorrhea
 Anorexia.

43.  Vomiting, diarrhea and headache.
 Mostly soft palate or tonsillar pillars involved
 affected areas begin as red macules which form fragile
vesicles that rapidly ulcerate.

44. H/P
 Intraepithelial vesicles contain eosinophilic exudate.
 Nuclear ballooning degeneration of epithelial cells.
DIFFERENTIAL DIAGNOSIS
 Infection by Herpes virus & Varicella zoster

45. Hand-Foot-and-Mouth Disease
 Coxsakievirus A 5,9,10,16
 Age: Children and young adults
 Sex: No predilection

46.  Like herpangina skin rash & oral lesions with flu like
symptoms like fever, dysphagia, sore throat associated
with cough, anorexia, vomiting, diarrhea, headache.
 Without prodomal symptoms

47.  Buccal mucosa, labial mucosa and tongue most
affected.
 after a short incubation period, vesicles with an
erythematous halo appear in the oral cavity, on the
hands, and on the feet

48. H/P
 Intraepithelial vesicles – early stages with intra-
cytoplasmic eosinophilic inclusion bodies.
 Later stages - shallow ulcerations and erosions with
regeneration of the marginal epithelium.
 Superficial inflammatory cell
infiltrate in submucosa.

49. DIFFERENTIAL DIAGNOSIS
 Herpetic gingivostomatitis,
 Herpangina,
 Varicella, and
 Aphthous stomatitis

50. Acute Lymphonodular pharyngitis
Clinical Features
 Coxsakievirus A 10
 Sore throat, fever, mild headache
 Yellow to dark pink nodules
on soft palate and tonsillar
pillars

51. H/P
 Affected epithelium exhibit intracellular &
intercellular edema leads to intraepithelial vesicle.
 Vesicle enlarges and ruptures through the epithelial
basal cell layer which leads to subepithelial vesicle.
Diagnosis
 Virus Isolation
 Serology

52. Treatment
 Most cases self limited
 Symptomatic relief
Topical anaesthetics
Nonaspirin antipyretics

53. Rubeola (Measles)
 Paramyxo RNA virus
 Highly contagious
 Primarily respiratory infection
 Incubation approximately 10
days, ranges from 8-13.
 Rash appears at about day 14.

54. Prodromal Symptoms
 irritability,
 runny nose,
 eyes that are red and sensitive to light,
 cough, and
 high fever
 Koplik’s spot- small, red, irregular with blue white
centres on mouth and conjunctiva
 Rash on forhead, face, neck, limbs

55. Complications
 bronchitis
 bronchiolitis
 pneumonia
 conjunctivitis
 myocarditis
 Hepatitis
 encephalitis

56. T/t
 Self limiting
 vaccines

57. Rubella (Germen Measles)
 RNA virus – Toga virus
 Incubation 2- 3 weeks
 Highly contagious, spread
through respiratory tract.
 Rubella vaccine has resulted in 99% decline in
infections.

58. Mumps(Endemic Parotitis)
 Age: Children
 Sex: No predilection
 Single stranded RNA virus.
 Mumps is transmitted by direct contact with saliva and
discharges from the nose and throat
 incubation 16-18 days.

59.  Virus can infect many parts of body, especially parotid
salivary glands & Submandibular also common.
 Glands usually become increasingly swollen & painful
over a period of 1 to 3 days
 Pain is moderate to severe
 Both left & right parotid glands may
affected

60. DIFFERENTIAL DIAGNOSIS
 Bacterial or occlusive salivary inflammatory disease
 Sjögren’s syndrome
Complications
 Inflammation and swelling of the brain
 Orchitis
 Oophoritis
 Infection in pregnant women may result in increased risk
for fetal death

61. Laboratory Testing
 Complement fixation
 Hemagglutination inhibition
 ELISA

62. T/t
 MMR vaccine
 No specific therapy exists for mumps.
 Warm or cold packs for the parotid gland tenderness
and swelling is helpful.
 Pain relievers acetaminophen
, ibuprofen are also helpful.

64. Introduction
 Human Immuno Deficiency Virus
 Etiologic agent of Acquired Immunodeficiency
Syndrome (AIDS).
 Characterized by severe depletion of CD4 cells.

65. MODES OF TRANSMISSION
 SEXUAL TRANSMISSION
 BLOOD OR BLOOD PRODUCTS
 MATERNAL-FETAL TRANSMISSION
 INFECTED NEEDLES

66. CDC CLASSIFICATION FOR HIV
INFECTED PATIENTS
CD4 Cell
Clinical Categories
Categories
A B C
Asymptomatic, Acute HIV, or Symptomatic Conditions, AIDS-Indicator
PGL not A or C Conditions
≥500 cells/µL A1 B1 C1
200-499 A2 B2 C2
cells/µL
<200 cells/µL A3 B3 C3

67. CLASSIFICATION OF CLINICAL
MANIFESTATIONS
 GROUP I : ACUTE INFECTION
 GROUP II : CHRONIC ASYMPTOMATIC
INFECTIONS
 GROUP III : PERSISTENT GENERALIZED
LYMPHADENOPATHY
 GROUP IV : AIDS RELATED COMPLEX

68. Acute Infections
 IM
 HEPATITIS
 MENINGITIS
 MENINGOCEPHALITIS

69. CHRONIC ASYMPTOMATIC
INFECTIONS
 MOST DANGEROUS GROUP
 SEROPOSITIVE PT WHO IS APARENTLY HEALTHY
CAPABLE OF INFECTION
 ENLARGED AXILLARY GLANDS
 HEMATOLOGICAL & IMMUNOLOGICAL
ABNORMILITIES

70. PERSISTENT GENERALISED
LYMPHADENOPATHY
 LYMPHADENOPATHY in 2 or more extrainguinal
sites persisting for more than 3 months in the absence
of disease

71. AIDS RELATED COMPLEX
 OPPORTUNISTIC INFECTIONS
-
Pneumonia, Cryptococcosis,
Viral Infections, Toxoplasmosis, TB etc.
 NEOPLASMS
- KS, Lymphoma, SCC

72.  NEUROLOGIC DISEASES
- Meningocephalitis
 OTHERS
- Encephalopathy, Purpura, Thrombocytopenia

73. Oral Manifestations of AIDS
INFECTION ORAL DISEASE
FUNGAL CANDIDIASIS
HISTOPLASMOSIS
CRYPTOCOCCOSIS
VIRAL HERPES SIMPLEX
HERPES ZOSTER
CMV
EBV(HAIRY LEUKOPLAKIA)
HHV-8 (KS)
ORAL WARTS(HUMAN PAPILOMA VIRUS)
BACTERIAL LINEAR GINGIVAL ERYTHMA
NUP
TUBERCULOSIS

74. Oral Manifestations of AIDS Contd..
TYPE OF LESION DISEASE
NEOPLASTIC KAPOSI SARCOMA
LYMPHOMA
SCC
LYMHADENOPATHY CERVICAL
OTHERS HIV- Necrotizing Ulceration
HIV-Salivary Gland Disease / Xerostomia
Thrombocytopenic Purpura
Abnormal Mucosal Pigmentation
APHTHOUS ULCERS

75. CANDIDIASIS

76. PSEUDOMEMBRANOUS ERYTHEMATOUS
ANGULAR CHEILITIS

77. HISTOPLASMOSIS
 Histoplasma capsulatum
Nodules over the mucosa which undergoes ulceration
Gingiva, tongue, palate, buccal mucosa

78. LINEAR GINGIVAL ERYTHMA
Very fine red band along gingival margin and attached gingiva with profuse bleeding

79. NECROTIZING ULCERATIVE
PERIODONTITIS
Advanced destruction of peridontium, rapid bone loss, loss of PDL

80. HAIRY LEUKOPLAKIA
Soft painless plaque on the tongue

81. WART (HPV)
Painless papule or nodule with papillary projections or rough surface
Pedunculated or Sessile

82. APHTHOUS ULCER (MINOR)
Single or multiple recurrent ulcers with whitish pseudomembrane & surrounded by
Erythamatous halo mostly seen on cheek, tongue, soft palate, tonsils.

83. APHTHOUS ULCER (MAJOR)

84. KAPOSI’S SARCOMA
 Predominantly in homosexuals.
 lesions are vascular, angiomatous neoplasms that begin
as red macule & progress to large tumefactive red &
purple lesions.
 Oral lesions: multifocal &
typically seen on palate & gingiva

85. LYMPHOMA
 Most are of B cell origin and Epstein-Barr virus occurs in
cells from several cases.
 Lymphoma can occur anywhere in the oral cavity & there
may be soft tissue involvement with or without
involvement of underlying bone.

86. DIAGNOSIS
 CLINICAL FEATURES
 WESTERN BLOT ANALYSIS
 ELISA
 PCR
 IMMUNOLOGICAL TEST
 VIRAL CULTURE

87. TREATMENT
 HAART -
ZIDOVUDINE, STAVUDINE, LAMIVUDINE, DIDAN
OSINE
 SYMPTOMATIC TREATMENT
 PRECAUTIONS