ulcers complete22

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Ulcers|Definition|

Ulcers:Isthecompletelossofepithelium.

Erosion:isasuperficialdamageleadingtopartiallossofepithelium.

|Classification|

Accordingtoitspreceding,either:Primary

Ulcers

Secondary

Ulcers

Isntprecededbyavesiculobullous

lesion

Isprecededbyavesiculobullouslesion.Thesevesiclesmaybesubepithelialorintraepithelial(Acanth

Non acantholytic)

Traumatic

Infective

Neoplastic

SystemicGITorblooddisorders

Aphthous

Behcetssyndrome

ReitersSyndrome

Subepithelial Intraepithelial

BullousPemphigoid

MucousMembranePemphigoid

ErythemaMultiforme

BullousLichenPlanus

EpidermolysisBullosa

DrugEruption

Acantholytic Acantholytic

=Deathandruptureofgroups

ofepithelialcells.

=Destructionofintercel

attachments.

HerpesSimplex

HerpesZoster

Herpangina

Hand,footandmouthdisease

PemphiguVulgaris

DariersDisease

Accordingtoetiology:1. Physicalandchemical2. Microbial Bacterial NecrotizingulcerativeGingivitis,TB,Syphilis

Fungal HistoplasmosismBlastomycosis

Viral HerpesSimplex,HerpesZoster,Herpangina,Hand,footandmouthdisease

3. Neoplasm SquamousCellcarcinoma4. Immunologicalreactions Aphthousulcers,Behcetssyndrome,PemphigusVulgaris,MucousMembranePemphigoid,Lupu

Erythematosus,LichenPlanus,EpidermolysisBullosa,DrugEruption

5. Blooddisorders Aneamea,Leukemia,Neutropenia6. GastrointestinalDisease CoeliacDisease,UlcerativeColitis,CrohnsDiseases7. Drugs CytotoxisDrugs

erpes Viruses|Facts|

Effectsmostanimalsandhumans. AllHerpesareidenticalmorphologically. TheyareDNAvirus.(VIP) Abilitytoremainlatentinaviableformwithinthehostcellaftertheprimaryinfection,theymaybelatentandpersistforalo

time,andsomemaybecomeactive(reactive)toinfectagainproducingarecurrentformofinfection.

Thereareeighttypes:HerpesSimplexvirus1 (HSV1) Varicella ZosterVirus Epstenin BarVirus (EBV) HumanHerpesVirus6

HerpesSimplexvirus2 (HSV2) Cytomegalovirus HumanHerpesVirus7 HumanHerpesVirus8

|SummeryDiagram|

Herpes HSVVarcellaZosterVirusHSV1

HSV2

AnInfectioninnewborn,showsasage

infectionand/ordermatitisbelowthew

PrimaryHer

Gingivostom

RecurrentLesions

RecurrentintraoralLesionsRecurrentHerpesLabialis

HerpeticWithlow

Primary

Reactivity

ChickenPox

HerpesZoster

RamsyhuntSyndrome

Ifthe

effected

nerve

is

Facial

Nerve

(7th)

(Bells

Palsy)

Onthe

fingers

of

doctors

whose

fingers

are

injured

&

exposed

to

HSV

HerpesSineHerpes

Noclinical

Manifestations

1|P a g e t h e s e p a p e r s a r e m e a n t t o b e a s e c o n d a r y r e f e r e n c e o n l y S l a s h e r X


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Herpes Simplex Infection

|Types|

HerpesSimplexVirus2

HerpesSimplexVirus1 HerpesSimplexVirus2

OralInfections:

Primary: PrimaryHerpeticGingivostomatitis.

Recurrent: RecurrentintraoralHerpes. RecurrentHerpesLabialis.

ExtraoralInfections:

Dermatitisabovewaist. PharyngealInfection. Meningoencephalitis

ExtraoralInfections:

Dermatitisabovewaist. GenitalInfections. Infectioninnewborn.

|Fact|

Incaseofnewborns,theinfectionsareduetothecontactoftheinfantduringdeliverywithavaginallesionofthemother.Minfantsareasymptomaticbutinsomeminoritymayshowmanifestationbythe4

thto7

thday(Jaundice,Hepatosplenomegaly

Thrombocytopeniaandlargevesicularlesionsontheskin)andwithahighmortalityratebythe9th

tothe12th

duetoviremia.

InCaseofAdults,PrimaryinfectionasGenitallesionsisrarebutmaystarttoincreaseaftertheageof14,duetoincreasesexactivity.

HerpesSimplexVirus1

PrimaryHerpetic

Infection

Recurrent

Lesion

HerpeticGingivostomatitis HerpesLabialis,IntraOralHerpes

OccursduetoPrimaryInfection OccursduetoActivationoflatentVirus

NopriorImmunity(ABraisebyconvalescenc) HighAntibodyTitre

LocalandsystemicManifestations LocalmanifestationswithNosystemicManifestations

|Primary(Acute)HerpeticGingivostomatitis|

|Facts|

Commoninchildren(110yearsold)andhighestpeakat23years. Uncommoninadultsandinfantsyoungerthan6months,why?BecausetheinfantacquirestheIgG(maternalAB)thatpassth

placentafromthemotherandlifespanoftheantibodyis6months.

AntibodyTitre:Beginningofthedisease 1weeklater 3weekslater Throughoutlife

NoraiseofABtitre Beginstoraisebyconvalescence (4folds)reachmaximumpeak Remainshigh

Incaseofchildren,9599%ofcasesrunSubclinicalandmaybemisdiagnosedasTeething;while15%ofcasesexhibittheclinicalcourseofthedisease.

Incaseofadults,themanifestationsarenttypical:shorterduration,feweroralulcersandlesspronouncedsystemicmanifestations.

|Pathogenesis|

Intraepithelialvesiclesduetodestructionofthepricklecelllayer. PresenceofMultinucleatedGiantcellsintheepithelialcellsliningthevesicleduetofusionoftheinfectedcellswithnormalc

ordivision

of

the

infected

cells

nucleus

without

the

division

of

the

cytoplasm.

PresenceofnuclearInclusionbodiesintheinfectedepithelialcells(LipschutzBodies). TheNucleusappearshomogenouswithmigrationofchromatin(Ballooningdegeneration)|Duration|

SelfLimitinganddiseasecourseis1014days Diseasecourseislessinadults. DiseaseCourseismoreinimmunosuppressedpatients. Diseasecourseismoreseverein:o Prematureandnewbornsinfants.o Malnourishedandimmunecompromisedpatients(immunesuppressivedrugsormalignancyorsevereburns).



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|Clinicalfeatures|

Prodrome:o Precedesthelesionsby12daysandsubsideswithin3days.o Fever,headache,malaise,nausea,vomitingandrefusaloffeeding.o Lymphadenopathy(Tenderandpalpable):submandibularandupperdeepcervicallymphnodes.

AcuteMarginalGingivitis:o 1 2daysafterprodromeo Acuteinflammation ofthegingivawithbleedingandedemaandpersistduringthewholecourseofthedisease.o Theorallesionappearsasulcerationanderosionofthegingiva(duetotheruptureofthevesicles)BUTthereisnolosingo

marginalgingivaorInterdentalpapillae.DIFFRENTAILDIAGNOSISFROMACUTENECROTIZINGULCERS.

Vesiculareruptions:o Oncethefeversubsides,vesiclesstarttoeruptintheoralcavityandcircumoraltissue(vermillionboardofthelip)and

circumoralskin.

o Thesevesiclesappearonthebothkeratinizedandnonkeratinizedmucosa.o Thesevesiclesmaycoalescetoformabullaewithirregularoutline,thisisdueto: Humidity,mechanicalirritationandhightemperature.

VesicularRuptureandulcerformation:o Thesevesiclemayrupturegiving Ashallowerosionorulcer. Smallandround Surroundedbyaninflammation. Coveredbygrayishmembrane.

o Thisulcermaycoalescetoformalargerulcer.o ThesesUlcersarepainfulExcessiveSalivation(Painreflex)SalivaisfilledwithVirusesthesalivaisinfective

infectingthelipsorhandsandmayevenspreadtotheeye(Conjunctivitis)andgenitals(Vulvovaginitis).

|Diagnosis|

History:o Prodromeprecedingorallesions.o Historyofcontactoflesioneitherprimaryorrecurrentwithotherinfectedpeople.o Nohistoryofrecurrentlesionwithinthesameperson.

ClinicalExamination:o Gingivalinflammation.o Lymphadenopathy.o Ulcerformationaftervesiculareruption.

SpecialInvestigations:Onlypreformedwhenthepatienthasnoobviousclinicalmanifestations.

o CytologicalSmearfromunrupturedvesiclesnucleuswithGeimsaStainGiantcellsandInclusionbodies.o IsolationofHSVintissuecultures(e.g.RabbitsKidney).o Totalleukocyticcount(eithernormalorelevated)o AntibodyTitre:

Onsetofdisease Oneweeklater 3weekslater

NoAntibodies Beginstoraise Maximumpeak



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|Treatment|mainlySupportiveandsymptomatictreatment,why?Becauseitsaselflimitingdisease.

BedRest. Supportivetherapy(liquiddietwithpropercaloriesandhighnutritionalvaluetoraisethebodyresistence. Painreliefbyanalgesicsandtopicalanesthetics. Antipyretic.(Paracetamol) Orabasetoprotecttheulcerduringhealing(Sodiumcarboxymethylcellulose) Antibiotics,why?UseBroadspectrumtoprevent2ndbacterialinfections. Antiviraldrugs,onlyusedwhen:o Inseverecases.o Inimmunecompromisedpatients.o Ifthediseaseisdisseminated.

Drug Rifampicin Acyclovir

Action Antibacterial(Systemic)+Antiviral(Topical) Antiviral(InhibitionofDNAreplicationininfectedcells)

Dose 10mg/kgthreetimesaday(t.d.s.) Lessthan12yearsMorathan12years

ImmunecompromisedPatients

100mg/5timesdaily/forfivedays

200mg/5timesdaily/forfivedays

400mg/5timesdaily/tillhealing

How InAdultsUsedasamouthwash

InInfantsandchildrenAdropperisused(the

childsheadshouldbelowerthanthebodytoallow

thedrugtobeswallowed)

Mouthwashanddropper=topicalantiviral. Swallowing=Systemicantibacterial.

Shouldbeusedinearlystagesofthediseasetoinhibitthevirareplicationduringprodrome.

Ifusedlate,itwillhavelessvalueandeffect;itmayevenelicitresistanceinHSVwithoutanyclinicalvalue.

Itisinactiveinuninfectedcellsnontoxictonormalcells.

HerpeticWhitlow

|Info|

Aninfectiononthefingersofdoctors,dentistsandnurseswithHSV. AfingerinjuryisneededforthediseasetooccurandwithanexposuretooralorpharyngealHerpesinfection. RubberdamandGlovesareessentialasprotectivemeasures.|ClinicalFeatures|

LocalFeatures:Itchingandpainofinfectedfinger. Systemicfeatures:maymanifestifthepatientisseronegative(meansthataspecificABisntpresentandinourca

themissingABisagainstHerpes).

Deepvesiclesmycoaleseinthedistalsegmentofthefinger. SelfLimiting. Incisionofthevesiclemaycomplicateittoamoreseriousproblemincluding2ndbacterialinfectionorencephaliti Healswithin1820days.

|RecurrentHerpeticLesions|

|Info|

AfterPrimaryinfection,theVirustravelsfromtheoralsiteofinfectionviathePeriaxonsheathofthesensorynerto

the

trigeminal

ganglion

and

other

cranial

and

cervical

ganglia.

Thevirusremainslatentintheganglioninapotentiallyviablestatetillreactivatesbylocalorsystemicpredisposinfactors(Trauma,sunexposure,commoncold,fever,allergy,stress,menstruation,GITdisturbanceandimmunosuppression).

Theviruscanbeisolatedinthetrigeminalgangliaofbothpeoplewhosufferreactivationandthosewhodoesnt. Incaseofgenitalherpes,type2becomeslatentinthesacralganglia. Reactivationsofinfectiondosenotstimulateariseintitreofherpesantibody. LesionsareeitherRecurrentHerpesLabialis(ColdSore)orRecurrentintraOralHerpes.



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|RecurrentHerpesLabialis|

|Info|

Vesiclesatthemucocutaneousjunctionofthevermillionboarderofthelip. Thevirustravelsfromthetrigeminalgangliondownthemaxillaryormandibularbranchestoreachtheareasofsk

suppliedbythesenerves.

|ClinicalFeatures|

Prodrome:burningortinglingsensationandsorenessatthesiteofthedevelopingofthevesicle. Localedema,erythemaandvesicleformation:o vesiclesaresmallinsize(1mm)o Surroundedbyerythema.o Occursasclusterandmycoalescesformingalargerlesions(12cm).

Vesiclesmayrupture:o Ulcerateandcoveredbyacrustofpurulentexudatesdueto2ndinection.

Recurrence:o Mayoccurmonthly,every2months,everyyear,onceinalifetimeortwiceinthelifetime.

|Pathogenesis|

Identicaltoprimaryform.

|Duration|

o Selflimitingin714dayso Healswithoutscarformation.

|Treatment|

Sunexposureprevention:o Sunblocker(Zincoxide).o Sunscreenlotionorcream(ParaminobenzoicAcid).

Ifsunlightexposureisapredisposingfa

o AvoidSunExposure. Antiviral:o Acyclovirointment5timesdaily/forfivedays.o Treatmentbeginswithin24hoursafterlesionsonset.o Ifapplicationofointmentislate,thelesionwillrespondpoorly.

InimmunecompromisedPatients:o CuringDose: Acyclovir 400mg/5timesdaily/tillhealing.o ProphylacticDose: Acyclovir200mg/34timesdailyortopicalointment.

|RecurrentIntraoralHerpes|

|Info|

ThevesiclesappearonthekeratinizedMucosa(tongue,Palateandgingiva). Thevesiclesare1mminsizeandsurroundedbyerythema.TheyMayoccurinclusters. Vesiclesmaruptureformingmultipleulcers.TheseulcersarepinheadsizedandsurroundedbyErythema. Theseulcerstendtocouleesforminglargerulcerswhichare:o irregular,superficial,surrounded erythemaandareverypainful.

Healswithoutscarformation Healswithin714days.|Pathogenesis|

Identicaltoprimaryform.

|Treatment|

2%tetracyclinemouthwash RifamipicinElixirmouthbath.



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Varicella Zoster Virus Infection

|Info|

Varicella=Primaryinfection=Chickenpox Zoster=Reactivationof=Shingles.

Itneveroccursasaprimaryinfection

Thesameviruscausestwodifferentdiseases. InthePrimaryInfection(chickenPox)thevirusmigratesfromtheepidermisviathePeriaxonsheathofthesensor

nervesandremainslatentwithineither:

o Dorsalrootganglionofspinalcord.o ExtramedullaryGanglionofcranialnerves.

Oncetheyarereactivatedbypredisposingfactors(e.g.radiation,malignancyetc) ThelatentvirusistriggeredandspreadsfromtheGangliontothenervetrunktoinfectaspecificdermatom

resultinginherpeszoster.

|ChickenPox(Varicella)|

ACommonchildhoodfever(mildandfebrileillness)duetoprimaryinfectionwithVaricellaZostervirus.|Transmission|

Itinvadestheupperrespiratorytrackby:o ViaContaminatedDropletsintheair.o Viadirectcontactwithfreshskinlesionsofinfectedpersoneitherchickenpoxorshingles.

|IncubationPeriod|

About2weeks(1021days)duringwhichthevirusproliferateswithinthemacrophages. ThentheVirusspreadsanddisseminatesthroughblood(Viremia). ThenSpreadstotheskin,mucusmembraneandotherorgans.|Age|

Atanyagebutthepeakincidenceisat510years. Thediseaseismoresevereinolderchildrenanddebilitate(Weak)adults,whilemildinyoungerchildren. Mostcommoninspringandwinter.|ClinicalFeatures|

Prodrome:Mildfever,Headacheandmalaise. InGeneral:o Vesicularrashinsuccessivewavesfor36days,why?Duetorepeatedwavesofviremia.o Becauseofthesuccessivewavesthepatientwillhavemixedskinlesionsatthesametime(Papules,vesicles,

Pustulesorcrust).

o Feversubsidesandnewlesionswillstopdeveloping. ExtraoralLesions:o Appearsasaskinrash(Cropsofredpapulesonthetrunkspreadstotheface,Scalpandextremities).o ThesepapulesdevelopwithinhoursintovesicleswhichappearclearlikeTeardrops.o TheseVesiclescontentsbecomeCloudydevelopintopustules.o ThesePustulesrupturebecomescabbedandcrusted.

Healing:o Healswithnoscarformationunless2ndinfection.

Intraorallesions:o Appearsasmultiplevesicles,shallow,notpainfululcers.o Nosymptomatic,diagnosticortreatmentproblems.



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|Treatment|

Healthychildren:noneedfortreatment,why?Becauseitsselflimitingdisease. Immunocompromised:o Acyclovir: Lessthan12yearsold: 5 mg/kg every8hours for7days Morethan12yearsold: 10mg/kg every8hours for7days

=Varicellaorzosterrespondswelltoacyclovirbutcomparedtoherpessimplexlesseffective.

=But

because

the

Drug

has

low

toxicity

the

dosage

can

be

increased

to

get

the

needed

effect.

o Prophylaxis: PassiveimmunizationbyZIG(VaricellaZosterImmunoglobulin)preparedfrompooledplasmawithhightitre

VaricellaZosterAntibody.

UsefulforprophylaxisandreducingtheseverityofthediseaseinvulnerablecontactsofchickenpoxorlessoftHerpesZoster.

o Vaccine: UsedincaseofchildrenwithLeukemiaorsolidtumorsasitprovidesgoodprotection. ItsdonebytheuseofanAliveAttenuatedVirusVaccine.

|HeroesZoster(Shingles)|

|Etiology|

Reactivationoflatentvaricellazostervirusisbymanypredisposingfactors,whichincludes: Trauma,Radiation,Surgery,Malignancy(Lymphoma,leukemiaortumorinthedorsalrootganglion),Immune

suppression.

Reactivationofthelatentvirus(whichwasprimarychickenpox)resultsininfectionoftheposteriorrootganglionspinalcordorextramedullaryganglionofthecranialnervethenspreadsdownthenervefibersoftheskinofthe

dermatomeleadingtovesiculareruption,unilateral,segmental,alongtheCutaneousdistributionofthenerve

|EffectedNerves|

C3,T5,L1,L2andOphtahlmtic(1stdivisionofthetrigeminalnerves)

Lesscommonthefacialnerve(withersensoryornerve)

|ClinicalFeatures|

Age:adultsandoldage.o Rareinchildrenexcept: Childhadchickenpoxinthefirstfewmonthsoflife. MotherhadchickenpoxduringearlypregnancytheinfantwillsufferfromCongenitalVaricellaSyndrome.

Limbdeformity,ocularlesion,Extensivescarring,Muscularatrophy,cerebralandpsychomotorretardation Course:3 4weeks. Prodrome:o 25days.o Fever,malaise,tendernessintheinvolvednerve.o Unilateralitchingandneuralgicpain(burningorstabbing/Constant,intermittentorradiating).


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SkinLesion:o Unilateralandlinerpapulesorvesiclesalongthedermatomicdistribution(skinandmucosamembrane)supplie

bytheaffectednerve.

o Thepapulesorvesiclesaresurroundedbyerythema.o TheycontainClearfluid.o Afterafewdaystheclearfluidbecomespurulent.o Oneweeklaterthevesiclesruptureformingacrust.o TheSkinlesionsaremixed(similartochickenpox)papules,veiclles,pustulesandcrustarepresenttogether,wh

becauseit

occurs

in

successive

waves.

Healing:o 34weeks.o Scarformation,why?Dueto2ndinfection. Scarsarepainlessandsometimesverypainfultotouch(Hyperalgesia). Scarsarediagnositicforpostherpeticneuralgia.

Oralmanifestations: Mayinvolveoneofmorebranchesoftrigeminalnerve. Vesiclesulcersscarring(Painfulandsurroundedbyerythema). MaybebilaterallesionsinViremia. Confluentandnecroticorallesionsinimmunesuppressedpatients.

1. Involvementofmandibulardivision. Unilaterallesions. Involvingcheek,tongue,vestibuleoflowerjawandCutaneouslesionsextendingfromthechintothevert

2. InvolvementofMaxillarydivision. Unilaterallesion. Involvinghardpalate,softpalate,vestibuleofupperjaw,skinofcheekandsidesofthenose.

3. InvolvementofOpthalmicdivision. Unilaterallesion. Involvingcornea,foreheadandeyelid Mostcommon(1520timesmorethanthemandibulardivision).

|Pathogenesis|

Identicaltoherpessimplexviralinfection.|Diagnosis|

Casehistory(Fever,Prodromeetc). Clinicalexamination(vesiclesandulcers=Unilateral,alongnervecourse,painful). Specialinvestigation(sameasherpesSimplex)

|Treatment|

Disseminatedherpeszosterandimmunesuppressedpatients Elderypatients

IVacyclovir10mg/kgevery8hoursfor10days Acyclovir

Prednisone4060mg/day

Decreaseover3weekstopreventpostherpeticneuralgia

HealthyPatients

Mildclinicalmanifestations Severeclinicalmanifestations

Sedation

Avoid2nd

infection

by

proper

hygiene

0.2%chlorhexidinemouthwash

Rifampicinelixirmouthbath4timesdaily.

5%Acyclovirointmentforskinandeyelesions. 800mgacyclovirtablets5timesdailyfor710days.

Topicalcapsaicin(hotpeppers),why?

Topicalanaethesiaarenteffectivesincepainarisefromthesensorynerve.


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|HeroessineHerpes(ZosterSineEruption)|

|Info|

PaincausedbyHerpeszostervirusalongthecourseofthenervewithoutanyclinicallesions. AdiagnosticProblemasitcanbemistaken,why?Becauseitmaybemistakenforappendicitis,cholecystitsorden

pulpitisleadingtounnecessarysurgery.

Diagnosisisbasedontheincreaseintheantibodytitre(besidestheclinicalsymptoms).|Complications|

Commoninimmunecompromisedpatientsandoldpatients.

Complication1:postherpeticneuralgia:

o Painpersistsafterhealingandresolutionofherpeszosterlesion.o Painmaylastweeks,monthsoryears.o Reason:duetoinflammationandfibrosisoftheaffectednerveo Scars: arediagnostic.

|Treatment|

Antidepressants,carbamzepineandchlorpramzine. Spontaneousimprovementsafter24months.Complication2:GeneralizedHerpeszoster:

Involvingtheinternalorgansleadingtopneumonia,meningoencephalitisandhepatitis.Complication3:Herpeszosteraffectingthemotornerveleadingtopralysis:

E.g.Herpeszosteraffectingthesacralregioncausingparalysisofthebladderanddiaphragm.Complication4:Secondaryinfection.

Complication5:BlindnessmayoccuriftheOphthalmicdivisionisinvolved.

|RamsyhuntSyndrome|

|Fact|

Anexampleofherpeszosteraffectingthemotornerveofthefacialnerve7thviainfectionofgeniculateganglion. Thefacialnerveisamixednerve.|Clinicalpicture|

Courseofthediseaseisrapid(resolutionwithin710days),butparalysismaybepermanent. Prodrome:o Sometimespainlocalizedtotheearorradiatestothejawsandneck.o Thisisshortlyfollowedbyherpeticoticus.

Herpeticoticus:o Smallcropsofvesiclesonthetragusoftheearortheexternalauditorycanalandmayreachthetympanic

membrane.

o Maysufferfromtinnitus,vertigoanddeafnessintheaffectedside.o Maysufferfromlossofhighpitchsound,why?Duetoinvolvementofthestapidiusnerve.

Oralmanifestations:o Vesiculareruptionulcersunilateralpainonsoftpalate,faucesandanterior2/3oftongue.o Lossoftastesensation.o Xerostomia,why? Duetodisturbanceintheparotidglandsecretion.o Facialplasy(Bellspalsy).

|Treatment|

Prednisone60mg/dayOR Tailandreducetillzerowithin10days

ACTH100unitsinthefirstday



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Recap on some points of herpes

Round1:Local Vs Systemic

RecurrentHerpesLabialis

RecurrentIntraoralHerpes

Primary(Acute)HerpeticGingivostomatitis

HerpeticWhitlowifseropostive HerpeticWhitlowifseroneagtive

Shingles(alongthenerve)

RamsyhuntSydromeandherpessineherpes(Alongthenervecourse)

ChickenPox

Round2:NoScarformation Vs Scarformation

Ifthereisno2nd

infectionChickenPox

Primary(Acute)HerpeticGingivostomatitis

RecurrentHerpesLabialis

RecurrentIntraoralHerpes

HerpeticWhitlow

By2nd

infectioninChickenPox

Shingles

Round3: AllHerpeshavethesamePathogenesis. Allulcersareprecededbyvesicobullouslesion.

Round4: Diseaseisselflimiting(exceptinherpeszoster,herpessineherpesandRamsyhuntsyndrome)andnoneedfor

interventionexceptinelderlyandimmunocompromisedpatients.

Coxsackieviruses

Name Herpangina Hand,Footandmouthdisease

Types A1,A6,A8,A10,A15,A22.(MostcommonA10)Contagious

A16

Contagious

Time Seasonalcommoninsummerandmayoccurseveraltimesbydifferentstrains.

Transmission EpidemicContaminatedsaliva

Epidemic

Airbornspread

Oral

fecal

contamination

Age Children.Notuncommoninadult

Children(5months 6years)

Occasionallyinyoungadults

ClinicalFeatures

Prodrome Lowgradefever,anorexiaHeadache

Sorethroatanddysphasia

Lowgradefever,anorexia

Coryza(symptomsofaheadcold),diarrhea,vomi

Lymphadenopahathy.

ExtraoralNONE!

Macule,popularandvesicularlesiononthe:

Extensorsurfaceofskinonhands,fingers,feet,to

andsometimesbuttocks.

Intraoral PharyngitisSoftpalate,uvula,anteriorfaucialpillarsand

Pharynx

Pharyngitis

Hardpalate,tongue,cheekmucosa,tonsilsand

Pharynx

Vesicles Bilateraltinyvesicles(12mm)thatrupturetoformulcers

Bilateralvesicles(110mm)thatrupturetoform

ulcers

Ulcers NotverypainfulSmall(12mm)

Shallow

Coveredbygrayishpseudomembrane

Onerythematousbase

Multiple

Largerthanherpangina

Shallow

CoveredbyYellowpseudomembrane

Onerythematousbase

Chiefcomplain Dysphasia Soremouthandrefusaltoeat

Fate Selflimitingandfewdays(notmorethanaweek)

Treatment Notreatmentneeded.Topicalanaestheisaandantisepticinseverecases



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11|

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12/20

| g p p y y

Treatment

|Mildcase|BysymptomaticTreatment:

Topicalanesthesia. Softorliquiddiet.|Moderatetoseverecase|

Systemiccorticosteroids,thedosagevariesdependingontheseverity. Prednisone3050mg/dayforseveraldaysandthentaper.(higherdosageincaseofseverecases).

|DifferentialDiagnosis|

ErythemaMultiforme AcuteHerpeticgingivostomatitis

Acutemultipleulcers

Larger

Oftenbleeds

Irregulardeeper

Acutemultipleulcers

Smaller

Coveredwithapseudomembrane

RoundShallow

Gingivaisntofteninvolvedoreffected Gingivaismainlyinvolvedoreffected

TreatmentbyCorticosteroids TreatmentbycorticosteroidsareCONTRAINDCAITED

Erythema Multiforme Major (StevenJohnsonSyndrome)

|ClinicalPicture|

Age:Anyage.

SystemicFeatures:suddensetoffeverandmalaiseorthepatientmaybeasymptomaticandwithin24hourshave

extensiveoralandskinlesions.

SkinLesions:generalizedVesiculobullouslesionsandatypicaltargetlesion.

EyeLesions:ConjunctivitisorCornealulcerationwhichmayleadtoblindness.

GenitalLesions:

InMales: Balanitis. InFemales:Ulcerinvaginaorvulva.Oral

Lesions:

more

sever

and

extensive

than

Erythema

Mutliforme

minor.

Treatment

SystemicSteroids. Ophthalmicconsultationiscritical,why?o Incaseofocularinvolvementwhichmaytoleadblindness.(themostcommoncomplication)

Toxic Epidermal Necrolysis (LyellsDisease)

|ClinicalPicture|

SkinLesion:largebullaeresultsindetachmentofepidermisinlargesheetsleavingascaled(burn)skin

appearance.

OralLesion:1/3ofcasehasorallesionsandconsideredaminorproblem.

Complications:Ithashighincidenceofdeathdueto2ndbacterialinfectionand/orfluid+electrolyteimbalance.

Treatment

Mangedinaburncenterto:

Removethenecroticskin. Graftplacement.



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Diagnosis of Erythema MultiformeA. Casehistory

a. Historyofdrugintake(Sulfonamide)b. Historyofviralinfection(HerpesSimplex)

B. ClinicalExaminationa. ThehallmarkofErythemaMultiforme:(VIP)

1.TargetLesions(Bulleyeoriris).2.BloodyCrustedLip.3.Oral,skin,eyeandgenitalinvolvement(inStevenJohnsonsyndrome)

C. Libratoryinvestigations: histologicalexaminationshows:a. EpithelialEdema.b. Necrosisofkeratocytes.c. Subepithelialvesicles.d. Perivascularlymphocyticinfiltration.

Ulcers 2ndto Chemotherapy (Anticancercytotoxic)

|Etiology|TheulcersbybeduetodirectorindirecteffectofChemotherapy.

Direct:o Itinterfereswithreplicationandgrowthoftheoralepithelium.

Indirect:o DepressedbonemarrowformationLeukopenialiabilityforbacterial,viralandfungalinfectionOralulce

|ClinicalPicture|

Ulcersarelarge,deep,andirregular. Necroticandfoalodor. Notsurroundedbyinflammatoryhalo.|Treatment|

HealswithintwoweeksafterstoppingChemotherapy.Revise on Ulcers

Ulcers

Multiforme erythematouslesion EMMinor

EMMajor(StevenJohnsonSyndrome)

Reiters

Syndrome

Bechets

Syndrome

(LyellsDisease)

ToxicEpidermalNecrolysusHerpesAssociated

ErythemaMultiforme

Mucocutaneousoccluarsyndroms

(oral,skinandeyelesions)ViralInfections

RecurrentLesions

HerpesCoxsackieviruses

SingleOralUlcers

Chemotherapy

TraumaticUlcer

2nd

tochemotherapy

RecurrentUlcers

ChronicMultiple

MinorUlcers MajorUlcer HerpetiformUlcer

AphthousUlcerPemphigusVulgaris



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Traumatic Ulcer (single Oral Ulcer)|Fact|

Mostcommonsingleulcer.|Etiology|

ByPatient:o Checkbiting,denturessoreness,irritation(fromroughtoothrestoration),lipbiting(afterL.A.orduringan

epilepticattack)

Bydentist(Iatrogenic):o Mechanical:improperuseofdentalinstruments,forcefulremovalof

cottonetc.

o Chemical:silvernitrate,eugenol.o Thermal:hotdentalinstruments,impressioncompound.

|ClinicalFeatures|

Single. Coveredbywhitefibrinclot. Locatednearoratthesitesubjectedtoinjury. Painful(assoonastheinjuryoccurs). Iftheulcerissubjectedtorepeadtedtrumamaybefirmonpalpation+elevatedborder. Ulcerresolveswithin12weekafterremovalofthecause.|Diagnosis|

Byhistoryandclinicalexamination. Siteandshapeoftheulcerisrelatedtothesourceoftrauma. MostdefinitivediagnosticfeatureResolutionofthelesionafterremovalofthecause.

Differential

diagnosis

must

differentiate

from

other

single

ulcers

of

bacterial

origin

or

syphilitic

chancre.

|Treatment|

Removethecause. Drug:o Prevent2ndinfectionby Tetracyclinemouthbath.o Symptomatictreatment Benzdaminehydrochloridemouthswash.

Reevaluateafterremovalofthecause,ifpersistenceoftheulcer12weeksaftereliminationofthecausetheulceisindicatedforbiopsy(toruleoutmalignancy).



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Mucocutaneous-ocular syndrome

BechetsSyndrome ReitersSyndromeEtiology Immunologicfactor

(immunecomplexformationleadingtovasculitis)

Similarto

Aphthous

ulcer

Unknownfactor

MayberelatedtoChlamydiainfection

ClinicalTriadAphthousulcer

Genitallesion

Occularlesion

Pathergytest*

Triad= Aphthousulcer+2oftheothersigns

Genitallesion

Occularlesion

Jointlesion

Pathergytest(Itisasimpletestinwhichtheforearmisprickedwithasmall,sterileneedle.Occurrenceofasmallredbumpustuleatthesiteofneedleinsertion,1to2daysafterthetest,constitutesapositivetest.)

ClinicalPictureOral

Aphthous

ulcers

Minorormajoratleast3timesyearly Shallow

ulcers

Psorisifomlesions(circinateLesion)

=redlesionwithslightlyraisedwhiteborde

Eye Retinalvasculitisblindness Conjunctivitis

Skin Pustuleformationontrauma.

Acneiformnodules

Keratodermablennorrhagica

(WhichisKeratoiclesionon

thesolesoffeetandpalmsof

hands)

Genital Males:ulcersonscrotumandpenis

Females:ulcersonlabia

CircinateBalanitis=Circinatelesionsontheglans

Urtheritis

Joint

Arthritis

TreatmentSteroids

Others

Corticosteroids

CorticosteroidsCombinedwithImmunosuppressers

(azathioprine,cyclosporine)

Corticosteroids

NSAID

Mucocutaneousoccluarsyndroms

(oral,skinandeyelesions)

EMMajor(StevenJohnsonSyndrome)

Reiters

Syndrome

Bechets

Syndrome


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Chronic Multiple UlcersAnautoantibodyisanantibody(a

typeofprotein)manufacturedby

theimmunesystemthatisdirecte

againstoneormoreofthe

individual'sownproteins.

Source:wiki edia

Pemphigus Vulgaris|Facts|

Itsautoimmunediseaseinvolvingskin,mucousmembraneshowingvesiclesandbullae. Uncommonandfatal.

|Etiologyand

Pathogenesis|

CharacterizedbycirculatingIgGautoantibodiesagainstintercellularcementingsubstancesintheepithelium.(Desmoglein) OncetheautoantibodiesattachestotheAntigen(cementingsubstance)releaseofproteolyticenzmesfromepithelialcel

destructionoftheintercellularcementseparationoftheepithelialcellfromeachother(acantholysis).

Presenceoftheweakestjunctionsuprabasalsplitbetweenthebasalandpricklelayer(suprabasalcleft)accumulationfluidinthesuprabasalcleftsformationofepithelialvesicleandbullae.

Suprabasalcleft|ClinicalPicture|

Age:4060yearsold.

Sex:female.

Site:skinandmucousmembrane.

Acanthosis

Oralfeatures:

Site:Buccalmucosa,palate,gingival,lip.o Morecommononthebuccalside,why?Becauseitssecondarytotrumaoppositetotheocclusalplane.o Theorallesionisbeforetheskinlesionin60%ofcases,why?Becausetheorallesioncontainslessintercellularcementing

substance.

PositiveNikolskySign:o Onintactoralmucosa: Lateralpressure mayleadtopeelingofepitheliumleavingalargedenudedarea(DesquamatedGingivitis). Lateralpressure mayleadtoformationofvesicleorbullae.

oOn

vesicle:

Verticalpressureextensionoflesiontoadjacenttissueincreaseinsizeofvesicle. TheBullae/vesicle:o Thinwalledonanon erythematousbase.o Thebullarapidlyrupturesandbreaksgivingashallowulcer.o Theulcerisirregularwithdetachedmarginsontheperipheral,why? Theedgesoftheulcercontinuetoextendperipherallyincreasinginsize(extendtolipcrustforming)+(extendtoth

throatleadstodifficultyinswallowing) detachedepitheliumatthemarginsirregularmargins.

o Theulcersare: Big,irregular,shallowandbleeding,why?Becausetheulcershasepitheliumdetachmentsontheperipheral.

SkinFeatures:

Site:Groin,Axilla,faceandneck. TheBullae/Vesicle:o ThinwalledonanonerythematousBase.o Shallowulcers.o ContainsclearorHemorrhagicorseropuruelntfluid.o Thebullaerupturesulcers+bleeding+easydetachmentofepitheliumontheperipheryulcersirregularmargino Whyirregularmarginsoftheulcers?Becauseofeasydetachmentofepitheliumontheperipheryoftheulcer.



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PositiveNikolskySign:

Bypressure theupper(outer)layerofepitheliumcanbeeasilyremovedandslipped. Bypressureonskin formationofbullaeorvesicle. Bypressureonintactbullae forcethefluidintosurroundingunaffected

tissue.

|Diagnosis|

Casehistory. ClinicalexaminationPositiveNikolskysSign. LaboratoryInvestigations:I. Biopsy: Intraepithelialbullae.

II. immunofluorescence: DirectandindirectimmunofluorescenceIgGintheintercellularattachmentzone.

Directshows: detectstissuewithAutoantibodyattachedtothem Indriectshows: detectstheCirculatingAutoantibody.

III. Cytologicsmear: DefinitionofTZankCells:

Acantholyticcells+whichshowsignsofdegeneration.ral.

.

.

Thenucleiarelarge,surroundingbyalightstaininghaloofcytoplasmthenadarkstainingattheperiphe

TZankcellsarepresentin Theliningofthebullae Inthefluidofthebullae

|Treatment|

Earlydiagnosisimprovesoutcomeoftreatment,why?o Atlatestagesseverskininvolvement2ndinfection+severeimbalanceoffluidelectrolytemaybefatal.o Atlatestages: Highdosageofcorticosteroidtocontrolthedieses.

Theamountofcorticosteroidsusedshouldbemonitored,why? becauseriskofdeathduetohighdosageocorticosteroidsishigherthandeathduetothedisease.

Topical

Drugs

for

the

oral

lesions:

o TopicalAnesthesia.o Antiseptics.o Corticosteroids.

Systemiccorticosteroids:o Usedaloneorcombinedwithimmunesuppressivedrugs,whycombined? Toreducethedosage,e.g.Azathioprine,Cyclosphosphamide.

Directimmunofluorescence

TZank

PositiveNikolskySign


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Recurrent Oral Ulcer|Fact|

Severaldiseaseshouldalsobeincludedinthedifferentialdiagnosiswithhistoryofrecurringulcers:

RecurrentUlcers CyclicNeutropeniaBehcetsSyndrome

RecurrentErythema

MultiformRecurrent

Herpes

Simplex

Virus

RecurrentAphthousUlcer

MajorUlcer HerpetiformUlcerMinorUlcers

Recurrent Aphthous Ulcer

|Definition|

Recurringulcersconfinedtooralmucosawithnootheroralsignsorlesions.|Etiology|

1) Hereditaryfactors.2) Hematologicfactors. Irondeficiency. Vit.B12deficiency. FolicAciddeficiency. CyclicNeutropenia.

3) ImmunologicFactors. Crossreactiontooralorganism. DisturbanceinlymphocyteCellproliferation. AntibodydependentCellmediatedcytotoxicty.

4) Hormonalfactor. Thuscommonwithfemalesduringmenstruationorpregnancy.

5) Hypersensitivitytocertainfoods.6) PsychologicalStress.7) Cessationofsmoking.8) Trauma.9) RelatedtoothersyndromesMucocutaneousocularsyndrome(behcetsSyndrome).10)GastrointestinalDisease: CaeliacDisease.

|GeneralClinicalPicture|

Age:beginsinthe2nddecadeoflife(Mayhappeninchildhood)

Sex:Morecommoninfemales.

|Types|

MinorAphthousUlcer MajorAphthousulcer Herpetiformulcer.



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Minor Aphthous Ulcer

|ClinicalPicture|

Prodrome burningsensation24/48hoursbeforeulceration. Shape localizedareaofErythema+centralsmallwhitepapule. Healing healsbyepithelizationfromtheboardertothecenter. Healing 714days. Healing withoutscarformation. Reccurenceemayoccurseveraltimesayear. Ulcer: Graduallyenlargeoverthenext48hours. Number: 1to6. Site: MostcommonlythenonkeratinizedMucosa. Shape: Symmetrical(Roundoroval). Depth: Shallow. Size: lessthan1centimeterindiameter. Floor: byFibrinExudates. Base: Notindurated. Margins: byErythema. Sensation: Painful. Regional: Onlylocalwithnoregionalaffections.

Major Aphthous Ulcer

|ClinicalPicture|

Passesthesamestagesasminortype. Healing withinafewmonths.Itcanbeconfusedwithsquamouscellcarcinoma,why?

Becausethelesionisinduratedandcanlastformonths.

Healing

withscar

Formation.

Site: mostcommonlyontheoropharyngealregionsmainlyontheglandbearingmucosa. Size: largerthen1centimeterindiameter. Depth: Deep. Floor: necrotic. Base: indurated Margins: byErythemaandraisedborders(duetoedema). Sensation: ExtremelyPainful. Regional: Associatedsometimeswithfeverandregionallymphadenopathy.

MinorAphthousUlcer MajorAphthousUlcer

Non

keratinized

Mucosa.

Less

than

1

cm

in

diameter More

than

1

cm

in

diameter

Oro

pharyngeal

regioMarginserythematous Margins erythematous+edematous

Shallow Notindurated Indurated Deep

Coveredbyfibrinexudate CoveredNecrotic

Healswithin714days Healswithoutscarformation Healswithscarformation Healswithinafewmon

RecurrentIntraoralherpes RecurrentAphthousU

Keratinizedmucosa NonkeratinizedMuc

SurrounedbyTissuetags Notissuetags,why

Thereisnovesicularl

DifferentialDiagnosis

Herpitform Ulcer

|ClinicalPicture|

Smallcropsofmultipleshallowulcers. Theulcersarescatteredoveralargeareaoftheoralmucousmembrane.



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| g p p y y

20 | P a g e t h e s e p a p e r s a r e m e a n t t o b e a s e c o n d a r y r e f e r e n c e o n l y S l a s h e r X

|Diagnosis|

Itsmainlybasedonexclusion,why?Becausethereisnospecifictestforit.1) CaseHistory: Historyofrecurrence.(rememberthatitsnottheonlydiesesthatshowrecurrence).

2) ClinicalExamination.3) Laboratoryinvestigations: Toidentifyanypossiblesystemicdiserase:

Gastrointestinaldieses..

.

.

.

asone.

lone.

.

.

.

.

Cyclicneutropenia Nutritionaldeficiency:Iron,Vit.b12,folicacid BehcetsSyndrom Allergy

|Treatment|

Evaluationandelevationofanypossiblesystemicdiseasethatcauseit. Medications:

A. Mildcases: Topicalanesthesia. Topicalorabase(adhesivepastetocoverit). TopicalJojobagel.B. Severecases: Topicalcorticosteroidspreparations(4timesdaily),dependingonthelocationofthesite.

Lozengespreparations Hydrocortisone,Betameth Ointmentpreparations Triamcino

C. Resistantcases: Intralesionalinjectionofcorticosteroids(Tramcinolone).D. ResistantcasesinAIDSpatients: Thalidomide.

|Recommendations|

Do

not

apply

caustic

agent

or

cauterization

to

the

lesion,

why?

Destroyssensitivenerveendingsoffersshorttermreliefofpain Tissuedamage Delayofhealing Increaseinscarformation

ulcers complete22

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