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Human papillomavirus (HPV) mainly causes skin warts (verrucae); it is also associated with a number of lesions including oral papillomas, oral verrucous carcinomas and focal epithelial hyperplasia. Over 40% of healthy individuals have HPV in the normal oral mucosa, suggesting that this is a reservoir of the virus. These DNA viruses induce latent infections of the tonsils, adenoids and other lymphoid tissues of humans. Adenoviruses are ubiquitous, and human beings are the only known reservoir for the human strains.
There are a range of different human herpesviruses, currently numbered 1–8 (see Table 4.3).
Disease due to HSV can be either a primary infection, due to first encounter with the virus, or a reactivation or recurrent infection, due to activation of the latent virus. There is an incubation period of 2–20 days, depending upon the infected site and the infecting strain of virus.
Recurrence or reactivation of HSV entails activation of the non-infectious form of the latent virus residing in the neurons of either the trigeminal ganglion (Fig. Humans are the only known reservoir for HSV-1 and HSV-2; experimental infection can be induced in animals and cell cultures. As recurrent infection is common in the presence of high antibody titres, circulating antibodies appear to be unhelpful in controlling HSV infection. Diagnosis is usually achieved clinically; laboratory diagnosis is useful to confirm infection, especially in compromised patients. However, the foregoing traditional techniques are now supplanted by polymerase chain reaction-based rapid diagnostic methods.
The course of primary infection can be altered significantly with drugs that interfere with viral DNA synthesis, such as aciclovir and vidarabine, but these should be administered in the early prodromal phase of the disease for best results (see also Chapter 35). This organism causes both varicella (chickenpox) and herpes zoster (shingles) – two different diseases due to an identical organism. Occurs primarily as a reactivation of the virus in dorsal root or cranial nerve (usually trigeminal) ganglia (Fig. The virus remains latent in ganglionic nerve cells and, after activation, travels back along the nerve fibre to the skin. The trigeminal nerve is affected in about 15% of cases, with involvement of the ophthalmic, maxillary and mandibular divisions (in that order of precedence).
Ramsay Hunt syndrome is a rare manifestation of zoster, with a vesicular rash on the tympanic membrane and the external auditory canal, together with unilateral facial nerve palsy. Shingles is primarily a disease of older adults and immunocompromised persons; it is rare in children.
The clinical picture is pathognomonic, as the lesion distribution overlaps and accurately maps the distribution of the sensory nerve (Fig. Passive immunization with varicella-zoster immune globulin (VZIG) may be indicated for persons at high risk of severe infection. An acute infection affecting lymphoid tissue throughout the body, infectious mononucleosis is commonly seen in teenagers, with a peak incidence at 15–20 years of age. Low-grade fever with generalized lymphadenopathy and abnormal lymphocytes in the blood (note that a similar illness, glandular fever-like syndrome, develops during the first fortnight after infection with human immunodeficiency virus (HIV)). This may take many clinical forms and is less common than acute mononucleosis, described above. The CNS involvement in varicella zoster is primarily due to vasculitis and manifests with acute stroke, transient ischemic attack and progressive encephalopathy. 4 Herpes Simplex Diagnosis –Tzanck Smear: 60-90% accurate, 3-13 % false + Nonspecific (HSV and VZV) Used on acute vesicular lesions Multinucleated giant cells jig saw nucleus.


10 Herpetic Infections Herpetic Sycosis –blade shaving after facial herpes induces a slowly spreading folliculitis of the beard with few isolated vesicles. 13 Herpetic Infections Herpetic Keratoconjunctivitis –Punctate keratitis or as dendritic ulcers.
25 Intrauterine and Neonatal Herpes Prevention and management: –70% of mothers of HSV infected infants are asymptomatic at delivery and have no HX of infection.
30 Herpes Simplex in the Immunocompromised Any erosive mucocutaneous lesion should raise suspicion of herpes simples. 34 Varicella Presentation: Faint erythematous macules develop into teardrop vesicles in 24 hours.
38 Varicella Treatment: –Acyclovir for severe cases, high risk individuals and adults (>13 years). 39 Varicella Prevention: Varicella Vaccine –Live attenuated virus –95% effective Those who do contract varicella have mild case. 40 Varicella in Pregnancy Increased risk of spontaneous abortion (3% by 20 wks), congenital varicella syndrome and fetal death.
There are more than 70 serological types of HPV, some of which are more closely associated with lesions (both benign and cancerous) than others. Specific serological types of HPV are associated with anogenital warts (condylomata acuminata) and are seen in all cervical biopsies that show precancerous change. All of them are structurally similar (enveloped, icosahedral with double-stranded DNA) and infect both humans and animals.
They can be differentiated by serotyping, by DNA homology and, to some extent, by clinical disease pattern. As the virus is highly labile, most primary infections are acquired through direct contact with a lesion or contaminated secretions.
21.4 Predominant distribution of infection with herpes simplex virus types 1 and 2 (HSV-1 and HSV-2), in different age groups.
One reason for this may be the contiguous cell-to-cell spread of the virus, which cannot be prevented by antibody.
It is important to avoid contact with acute herpetic lesions and contaminated body fluid (e.g. Thoracic nerves supplying the chest wall are most often affected, and the lesion presents as a unilateral, painful vesicular rash, which extends in a horizontal strip from the middle of the back around the side of the chest wall (‘belt of roses from hell’). Severe localized oral pain precedes the rash and may be easily confused with toothache (see Chapter 35).
The virus persists in latent form within lymphocytes after primary infection (lymphotrophic, unlike HSV and varicella-zoster virus, which are neurotrophic). The organism is present in saliva and is postulated to be transmitted during kissing – hence, it is called the ‘kissing disease’. The syndrome is characterized by persistent fatigue, with or without physical or laboratory findings. After the primary infection, VZV remains dormant in ganglionic neurons along the entire neuraxis. Large vessel stroke is common in young and immune-competent (Fig 1) whereas small vessel disease (progressive encephalopathy) in elderly or immune-compromised patient (Fig 2). CSF oligoclonal band (IgG) against VZV is more sensitive than detection of VZV DNA by PCR. Oral valacyclovir 1gm 8 hrourly for 1-2 months may be given in small vessel vasculitis or in immunocompromised patients after iv acyclovir. Spread by Skin to Skin contact –Active lesions are infective –Asymptomatic shedding accounts for the majority of transmission.


HSV-2 facts: –20% truly asymptomatic, 20% recognize their lesions, 60% have lesion but don’t recognize them as HSV or don’t notice them at all. Herpes infection in pt with atopic dermatitis results in infection throughout the eczematous areas with hundreds of vesicles. In general, HSV-1 causes orofacial lesions or lesions ‘above the belt’, while HSV-2 causes lesions ‘below the belt’, i.e.
After a 2-week incubation period, fever develops, followed by a papular rash of the skin and mucous membranes, including the oral mucosa.
The disease usually affects adults, and the virus is reactivated despite circulating antibodies. Serology, if needed, entails detecting a fourfold rise in antibody titre in paired sera (compare herpes simplex reactivation, where antibody rise is not significant). The genome resides in a latent form in B cells; latent EBV infection is common in the population. Lymphocytosis is a characteristic feature, hence the term ‘mononucleosis’; some 10% of the lymphocytes are atypical, with enlarged misshapen nuclei and increased cytoplasm (Fig.
During immunosuppressed state or old age, VZV reactivates and produce zoster and rarely stroke which may involve large or small vessels, myelopathy, cerebellitis and retinal necrosis. Herpes zoster in the trigeminal and cervical area leads to large vessel disease and infection in the other areas though hematogenous spread leads to small vessel disease. Angiography reveals segmental narrowing, post stenotic dilatation or occlusion of vessel (Fig 1). Prior HSV-1 infection does not protect from HSV-2 infection but may lessen severity of first outbreak. Intrauterine infection (rare) –Primary lesions of mother –May cause fetal anomalies: skin lesions, scars, microcephally, microphthalamos, encephalitis, calcifications.
Although self-limiting, acute respiratory disease may be complicated by pneumonia in some cases.
All have the important property of remaining latent, with the ability to reinfect the host a variable period after the primary infection. The papules rapidly become vesicular and itchy but painless (in contrast to the rash in zoster). The rash may last for 2–4 weeks, with pain (post-herpetic neuralgia) persisting for weeks or months. Transmission occurs by direct contact with skin lesions or droplet infection from infectious saliva.
Other infections caused by these viruses include pharyngoconjunctival fever (a disease of infants and children), epidemic keratoconjunctivitis, pneumonia and gastroenteritis.
Important human pathogens include herpes simplex virus types 1 and 2 (HSV-1 and HSV-2), varicella-zoster virus (VZV), cytomegalovirus (CMV) and Epstein–Barr virus (EBV) (see Chapter 4). Systemic aciclovir may reduce the duration of the early infective phase and the associated pain. Students of dentistry should be thoroughly conversant with the herpes group of viruses as the majority of them either cause oral infection or are intimately associated with orofacial tissues and saliva. Herpetic Gingivostomatitis –1 % of infections –Erosions, ulcers in mouth with white base associated with fever, lymphadenopathy and malaise.



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