HUMAN HERPES VIRUSES 1 Dr D Kalita Associate

HUMAN HERPES VIRUSES -1 Dr. D Kalita, Associate professor, Department of Microbiology, AIIMS Rishikesh Date of Class: 26/4/2017 (4 PM to 5 PM, LT-4)

DNA Viruses Members causing disease in Humans Herpesviridae Herpes simplex 1&2, CMv, EBV, Varicella zoster, HSV 6, 7, 8 Hepadnaviridae Hepatitis B virus Adenovirus Human Adenoviruses A-F Poxviridae Variola, Vaccinia, Cow pox, Monkey pox Papovaviridae Papilloma, Polyoma, Vacuolating viruses Parvoviridae Parvovirus 2/25/2021 2

HERPES VIRUS 2/25/2021 3

Introduction to HERPES VIRUS • About 100 Enveloped DNA viruses affecting Humans and animals • Can cause Latent infections – enabling virus to persist within infected hosts and to undergo periodic reactivation. 2/25/2021 4

Herpes virus morphology • Icosahedral capsid - 162 capsomers - Enclosing the core with ds. DNA • Nucleocapsid covered by a lipid envelope (derived from modified host cell membrane) • Envelope carries surface spikes • Tegument (amorphous): between envelope and capsid 2/25/2021 5

Herpes virus morphology • Enveloped virion 200 nm • Naked virion 100 nm • Replication takes place in the host cell nucleus • Cowdry type A inclusion bodies which is also called Lipschutz bodies 2/25/2021 6

CLASSIFICATION 2/25/2021 7

Herpes simplex

HHV 1 & HHV 2 - Morphology 2/25/2021 9

HHV 1 & HHV 2 - Pathogenesis 2/25/2021 10

Differentiation of HSV 1 and HSV 2 • • • Monoclonal antibodies Pocks in CAM (HSV 2 > HSV 1) HSV 2 more neurovirulent in lab animals HSV 2 is more resistant in vitro to antivirals (e. g. Cytarabine & IUDR) DNA RE studies differentiates (upto strain level) Etc. ……………. Ref to a textbook 2/25/2021 11

Infections • HSV 1 • • • Acute gingivostomatitis Herpes labialis (cold sore) Keratoconjunctivitis Eczema herpericum Encephalitis Dendritic keratitis (above waist…………………but…) 2/25/2021 12

• HSV 2 • Genital herpes (Penile, Urethral, Cervix, Vulval, Vaginal) • Neonatal herpes • Aseptic meningitis (Below waist…. . but…………. ) 2/25/2021 13

ACUTE GINGIVOSTOMATITIS • Acute gingivostomatitis is the commonest manifestation of primary herpetic infection. • Pain and bleeding of the gums • Ulcers with necrotic bases • Neck glands are commonly enlarged accompanied by fever. • Usually a self limiting disease lasting around 13 days.

HERPES LABIALIS (COLD SORE) • Recurrence of oral HSV. • 45% of orally infected individuals will experience reactivation. • Tingling, warmth or itching at the site initially 12 hours later, redness appears followed by papules and then vesicles.

SYMPTOMS Mild or severe and may include: • Sores on the inside of the cheeks or gums • Fever • General discomfort, uneasiness, or ill feeling • Very sore mouth with no desire to eat • Halitosis

HSV – Cold Sore

HHV 1 - Clinical manifestations EM of Herpes virus 1 2/25/2021 19

OCULAR HERPES Cause of corneal blindness. Include the following: • Primary HSV keratitis Keratoconjunctivitis • Dendritic ulcers • Recurrent HSV keratitis • HSV conjunctivitis • Acute necrotising retinitis, chorioretinitis –

KERATOCONJUNCTIVITIS • Inflammation of the cornea and conjunctiva. • Minor damage to the epithelium (superficial punctate keratitis) to formation of dendritic ulcers.

Keratoconjunctivitis

HERPES SIMPLEX ENCEPHALITIS • One of the most serious complications of herpes simplex disease. • There are two forms:

1. Neonatal – global involvement and the brain is almost liquefied mortality rate approaches 100%. 2. Focal disease – • Temporal lobe is most commonly affected. • In children and adults • Many arise from reactivation of virus. • Mortality rate is high (70%) in untreated

• Early diagnosis and treatment of HSE is very essential. • IV acyclovir is recommended in all cases of suspected HSE before laboratory results are available. 2/25/2021 25

Herpes Simplex Encephalitis CT Scan Autopsy

MENINGITIS • Most commonly with primary HSV-2 infection; less likely with recurrences of genital herpes • Benign, self-limited (contrast with encephalitis) • Usually affects sexually active young adults • No neurologic sequelae

GENITAL HERPES • Genital lesions may be primary, recurrent • Sites: penis, vagina, cervix, anus, vulva, bladder, the sacral nerve routes, the spinal and the meninges. • Prone to secondary infection eg. Staphylococcus aureus, Streptococcus group, Trichomonas and Candida albicans.

GENITAL HERPES • Dysuria is a common complaint, • Recurrences in 60%. • Recurrent lesions in the perianal area more numerous and persists longer.

HSV – CONGENITAL/PERINATAL • Perinatal infection: • ¾ th are due to HSV 2 acquired during delivery • Post natal infection • HSV-1 acquired from maternal genital, oral or breast lesions or nosocomial infection from other infected babies

HERPETIC WHITLOW • A lesion (whitlow) on a finger or thumb caused by the herpes simplex virus. • HSV-1 or HSV-2. • HSV-1 whitlow is often contracted by health care workers dental workers and medical workers exposed to oral secretions.

Laboratory Diagnosis • Direct Detection § Electron microscopy of vesicle fluid - rapid result § Immunofluorescence of skin scrappings distinguish between HSV and VZV

HHV 1& 2 Diagnosis • Multinucleate Giant cells – Tzanck’s smear 2/25/2021 35

Laboratory Diagnosis • Viral culture (gold standard) • Preferred test in genital ulcers or mucocutaneous lesions Highly specific (>99%) • Sensitivity declines rapidly as lesions begin to heal • Positive more in primary infection (80%– 90%) than with recurrences (30%)

CPE of HSV in cell culture: ballooning of cells. IF test for HSV antigen in epithelial cell.

Laboratory Diagnosis…cntd Polymerase Chain Reaction (PCR) • More sensitive than viral culture; has been used instead of culture in some settings not widely available • Preferred test for detecting HSV in spinal fluid (Routinely used in HSE)

Serology • Type-specific and nonspecific antibodies • Anti HSV-2 antibody indicates anogenital infection • Anti HSV-1 antibody does not distinguish anogenital from orolabial infection • Ig. G, Ig. M - ELISA 39

ANTIVIRAL Several antivirals available for treatment of the conditions: • Aciclovir (acyclovir), • Valaciclovir (valacyclovir), • Famciclovir, • Penciclovir.

Varicella zoster

VARICELLA • Primary infection results in varicella (chickenpox) • Incubation period : 14 -21 days • Presents fever, lymphadadenopathy. a widespread vesicular rash. • Diagnosis can be made on clinical grounds alone.

• Complications are rare occurs more frequently and with greater severity in • Adults • Immunocompromised persons • MC complication is secondary bacterial infection. • Life threatening complications Viral pneumonia, Encephalititis, Haemorrhagic chickenpox.

NEONATAL VARICELLA • VZV can cross the placenta in the late stages of pregnancy to infect the fetus congenitally. • Mild disease to fatal disseminated infection. • If rash in mother occurs more than 1 week before delivery sufficient immunity is transferred to the fetus.

LABORATORY DIAGNOSIS • C/Fs of varicella or Herpes zoster are characteristic laboratory confirmation is rarely required. • Laboratory diagnosis for atypical presentations (as seen in immunocompromised patients)

LABORATORY DIAGNOSIS…. cntd • Direct detection - electron microscopy (no d/d between HSV and VZV). • IF on skin scrapings can distinguish the 2 • VZV Ig. G is indicative of past infection and immunity. Ig. M is indicative of recent primary infection. • Virus Isolation - rarely carried requires 2 -3 weeks for a results.

HERPES ZOSTER (Shingles) • Manifestation of recurrent infection following a primary attack of chicken pox. • Caused by varicella zoster • Unlike herpes labialis repeated recurrences of zoster are uncommon. • Infection typically affect adult of middle aged group

• Pain precedes the rash (vesicles). • Severe pain, and commonly occurs on the trunk on one side. • The trigeminal nerve is affected 15% of cases

• Lesions localized to one side, along distribution of nerve (e. g. any divisions of the trigeminal nerve up to the midline) • Malaise can be severe. • Regional lymph node are enlarged and can be lifethreatening in HIV disease.

TREATMENT Only in severe cases : • Oral acyclovir 800 mg five times daily for 7 -10 + analgesic.

RAMSAY HUNT SYNDROME Involvement of facial nerve with VZV • Facial nerve palsy • Vesicles in external auditory meatus • Vesicles on palate • Symptoms : dizziness, loss of taste. • Usually self limiting condition rarely permanent facial weakness may remain.

Clinical case scenario A 21 years old female presented with a complaint of malaise and loss of appetite X 1 month and sore throat and fever (especially in afternoon) since 5 days. O/E: Cervical hepatosplenomegaly+. Mononuclear lymphadenopathy+, CBC lymphocytosis showed (mostly Mild Absolute atypical lymphocytes). Her serum was tested by Monospot where Ig. M was positive. 2/25/2021 Diagnosis? 53

Diagnosis • Human Herpes Virus 4 (HHV-4) / Epstein Barr virus infection • Infectious mononucleosis / Glandular fever/ Kissing’s disease 2/25/2021 54

HHV 4 Ebstein Barr virus - EBV 2/25/2021 55

EBV or HHV-4 • 1964 – Epstein, Barr and Achong – identified a new type of herpes virus EB virus affecting B lymphocyte lineage. • CD 21 receptors necessary for acquiring EBV infection 2/25/2021 56

EBV EPIDEMIOLOGY • Source of infection: Saliva of infected persons – • Not highly contagious, droplets and aerosols not effective in disease transmission • Intimate oral contact (as in kissing) – predominant mode of transmission – hence the name ‘Kissing disease’ 2/25/2021 57

EBV – Clinical spectrum • Infectious mononucleosis • EBV associated malignancies: • Burkitt’s lymphoma • Lymphomas in immunodeficient persons e. g. AIDS & transplant recipients • Nasopharyngeal carcinoma in East Asia/China 2/25/2021 58

Infectious mononucleosis • Glandular fever • Acute self-limited illness • Usually seen in non-immune young adults following primary infection with EBV • Incubation period: 4 -8 weeks. 2/25/2021 59

Infectious mononucleosis (EBV) 2/25/2021 60

2/25/2021 61

Infectious mononucleosis • Ampicillin Rx may lead to develop maculopapular rash • May associate sub-clinical Hepatitis • Complications: Hematological, Neurological, Cardiac & Pulmonary conditions and Splenic rupture • Spontaneous resolution occurs in 2 -4 weeks 2/25/2021 62

Lab diagnosis of EBV • Leukopenia followed by leukocytosis in later stages with atypical lymphocytosis (Abnormal mononuclear cells) • Paul – Bunnell test: Standard diagnostic test for Heterophile antigen detection • Monospot test 2/25/2021 63

Lab diagnosis of EBV cont. . • Differential agglutination test: Differential absorption of Agglutinins with Ox red cells and Guinea pig kidney cells • Immunofluorescence • ELISA 2/25/2021 64

Lab diagnosis of EBV cont… • Ig. M antibody to VCA (Viral Capsid Antigen) indication of primary infection • EB Nuclear Antigen (EBNA) is also a useful marker of primary infection • Ab to Early antigens (EA) high in EB-associated lymphomas 2/25/2021 65

Case scenario A 27 years old male a K/C/O HIV/AIDS presented to Ophthalmology OPD with Progressive diminution of vision X 3 months. CD 4 counts<100 cells/mm 3. Fundus examination: Fluffy retinal infiltrates+ Multiple hemorrhages+ Serological tests positive for Ig. G antibodies and PCR were positive for DNA (Herpes group). Diagnosis? Rx 2/25/2021 66

DIAGNOSIS • CMV retinitis made • Patient was started on Ganciclovir. • Note: Patient did not take Anti-HIV medications regularly. …to be initiated urgently 2/25/2021 67

Thanks …. . to be continued to next class 2/25/2021 68