HERPESVIRUS INFECTIONS IN CHILDREN

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INTRODUCTION
Herpes viruses are DNA viruses that are transmitted in saliva Primary infection usually occur in early life, characterized by latency and reactivated during immunosuppression

Herpes virus DNA

TYPES
8 types Herpes simplex 1 Herpes simplex 2 Herpes varicella zoster ( VZV ) Epstein-Barr virus ( EBV ) Cytomegalovirus ( CMV ). Others are: HHV-6,HHV-7,HHV-8

HERPES SIMPLEX VIRUS

Aetiology & Pathogenesis -Herpes simplex 1 is extremely common and usually causes cold sores on or near the mouth. -Herpes simplex 2 is also common and typically causes genital herpes. -Cross infection of type 1 and 2 viruses may occur from oral-genital contact. -Herpes viruses can be transmitted to a newborn during vaginal delivery -HSV-1 usually occur to children under 6 yrs old -HSV-2 usually occur during adolescent

May cause - meningoencephalitis (infection of the lining of the brain) - eye infections, in particular, of the conjunctiva and cornea. - fatal especially to newborn - common cause of teething

HERPES SIMPLEX STOMATITIS

Clinical featues -The mouth or pharynx is sore usually -A single episode of oral vesicles,which may be widespread,and breakdown to leave oral ulcers. -Initially pin-point but fuse to produce irregular painful ulcers -Gingival edema,erythema and ulceration -The cervical lymph nodes maybe enlarged & tender usually in the anterior triangle -Sometimes fever and/or malaise

1. Initial clinical presentation can be severe, with vesicles throughout the oropharynx and perioral skin, in contrast to the much more limited presentation typical of recurrent herpes.

2. Primary herpes can affect the lips, and the ruptured vesicles may appear as bleeding of the lips

RECURRENT HERPES LABIALIS

Clinical features - Lip lesions at mucocutaneous junction - Lesions begin as macules that rapidly become papular , then vesicular for about 48 hours ,then become pustular , and finally scab within 72-96hrs without scarring - Widespread recalcitrant lesions may appear in immunocompromised patients

Features of recurrent intraoral herpes include : -lesions tend to affect hard palate or gingiva in healthy patient -lesions are frequently on the tongue dorsum in immunocompromised patients

1. Recurrent herpes is most often noted clinically as herpes labialis, with clustered vesicles (often coalescing) on the lip vermilion and often on the perioral skin.

2. Inside the oral cavity, recurrent herpes typically affects only keratinized tissues, such as the gingiva or the hard palate. Vesicles often break quickly, so the clinician may observe small clustered ulcers.

MANAGEMENT
Primary herpetic gingivostomatitis 1. Topical anaesthetic mouth rinse such as diphenydramine,viscous lidocaine, Maalox oral suspension 2. Systemic antiviral therapy : Zovirax (Acyclovir)useful mainly in immunocompromised patients and non-life threatening 3. Adequate fluid intake 4. Antimicrobial oral rinse (chlorrhexidine gluconate 0.12% )

Recurrent herpes labialis Lip lesions maybe minimized with penciclovir 1% cream or aciclovir 5 %

HERPES VARICELLA-ZOSTER
Aetiology and pathogenesis Primary varicella, or chickenpox, usually occurs in children aged 3-6 years who are not immunized at the time of their first exposure to the virus. After primary infection,the virus remains latent in dorsal root ganglia. Recurrent varicella, also known as herpes zoster or shingles, usually occurs in adults, and its incidence increases with age.

Clinical features 1. Rash- often very prominent and seen mainly on the face & trunk 2. Fever 3. Mouth ulcers indistinguishable from HSV,but no associated gingivitis 4. Anorexia 5. Malaise 6. Cervical lymphadenitis

Vesicular lesions may be noted on the oral mucosa in addition to the characteristic and better-known skin lesions.

MANAGEMENT
1. Uncomplicated varicella is a self limited disease and requires no specific treatment. 2. Systemic antiviral treatment acyclovir are used in immunocompromised patients

HISTORY (17 OCT 2011)

Asyraf Bazli Bin Azmi 5 years old/ Malay / Male

 C/O
pain and swollen upper and lower lips. Difficulty on eating.

HPC
Pain and swelling of the lips since 4 days ago. Father claimed that his son had already develop fever since 1 week ago. They went to Hospital Melaka and was admitted due to fever 5 days ago.

 PMH 1) Asthma under follow-up in Hosp. Muar. 2) Diagnosed by pead. Herpetic Gingivostomatitis 3) no known allergic to medications and food

G/C
cooperative, febrile, in pain during mouth opening

ON EXAMINATION
E/O
SMLN not palpable Vesicle noted around upper and lower lip. Ulcers noted at upper and lower lip, right and left corner of the mouth

 I/O
OH poor Teeth conditions as charted Ulcers noted at
Tip of the tongue ~2 mm Right and left buccal cheek with multilocular shape ~2 mm Upper labial sulcus and mucosa Palate multiple numbers ~2 mm

 Management
1) Oral toilette done with cotton pellet soak in Difflam mouthwash 2) Difflam gel applied to ulcers 3) Difflam mouthwash and gel given to father and instruct to apply intraorally 3 times a day 4) Adviced soft diet

REFERENCES
1. Oral and Maxillofacial Medicine 2nd Edition 2. Asia Pacific Journal of Allergy and Immunology(2003)21 :217-221 3. Flaitz C.M., Baker K.A.: Treatment approaches to common symptomatic oral lesions in children. Dental Clinics of North America,2000, 44(3): 671-696. 4.http://www.encyclopedia.com/topic/Herpesvirus_infect ions.aspx 5. http://oralmaxillofacialsurgery.blogspot.com/2010/05/viral-infections-ofmouth.html