HERPES

From Big Medical Encyclopedia

HERPES (herpes; grech, herpo to creep) — the viral diseases which are morphologically characterized by an enanthesis, mucous membranes of the grouped bubbles on the hyperemic basis.

As independent nozol, forms distinguish a herpes simplex (herpes simplex) — the most widespread and most studied infection and the surrounding herpes (herpes zoster).

The herpes simplex

(a synonym bubble deprive)

the Aetiology

the Disease is caused by the simple G.'s (herpes simplex virus) virus relating to the DNA-containing group of viruses and having a wide spread occurance. For the first time infectious character of simple G. was established by Gryuter (W. Griiter, 1912), having caused this disease in a rabbit introduction patol, material from the sick person; in the fabrics affected with a virus Lipshyutts (V. of Lipschutz, 1921) found acidophilic inclusions, and Kaudri (E. Cowdry, 1934) defined them as little bodies of inclusion of a virus G. (see. Herpes viruses ).

Most of researchers subdivides simple G.'s virus into two types. The part of the activator of not genital defeats is assigned to strains of the first type; strains of the second type, in their opinion, cause preferential genital G.

Epidemiology

. The sick person and virus carriers is a source of an infection. The virus is transmitted to hl. obr. in the contact way. The greatest number of diseases is observed in cold months, but epidemics are not watched an exception of small flashes in preschool institutions, schools, hospitals. Viral diseases of skin are very widespread among children, including herpes.

The pathogeny

Primary infection in most cases occurs in the early childhood, and infection can occur vnutriutrobno, at the time of delivery and in the first days of life of the child; the passive antiviral antibodies transported with blood of mother usually warn a course of a disease, however G.'s development in the newborn is in certain cases possible. By first year of life oroimmunity weakens and under provocative conditions the virus becomes more active. Having got to an organism, simple G.'s virus breeds in fabrics ekto-and an endodermal origin, affecting skin, mucous membranes, a cornea, and at generalization of process — sometimes a liver, a brain and other bodies, remaining in an organism throughout all life (so-called hron, a carriage of a virus G.). A wedge, displays of a disease and its recurrence arise under the influence of the provoking and irritating factors (overcooling, an injury, napr, an odontectomy, uv radiations, etc.), against the background of easing of cellular, humoral immunity. The disease arises as independent or the nek-eye accompanies infectious diseases (to a lung fever, malaria, flu, a meningococcal infection, etc.).

Some authors explain activation of a virus and emergence of a recurrence with reaction of an organism to cooling, overfatigue and other phenomena; at this there is an increased secretion of glucocorticoid hormones under the influence of which zymolysis of intranuclear colonies of a virus is intensified and there is its activation.

Patogistologiya

Patogistologiya: the so-called ballooning colliquation of an epithelium of Unna which is expressed focal change of cells of an aculeiform layer which are rounded, increase in a size is observed and, taking a form of spheres, otjedinyatsya one from another; at the same time as a result of amitotichesky division multinucleate large cells are formed. The serous exudate which is formed in epidermis separates the changed cells, the cavity of a bubble filled with exudate with the epithelial cells weighed in it is formed; in kernels of the degenerated cells note acidophilic inclusions. In a derma hypostasis of a papillary layer, considerable expansion circulatory and limf, vessels and the infiltrate consisting preferential of lymphocytes and neutrophils which small amount gets also into a cavity of a bubble is observed.

In the fabrics affected with a virus G. reveal characteristic huge multinucleate cells with intranuclear inclusions; the last in an early stage — diffusion and basphilic, later they become dense and eosinophilic. The expressed dystrophy of kernels and cytoplasms of cells is noted. In cells of the struck fabrics find virus particles. By means of a method of definition of fluorescent antibodies (see. Immunofluorescence ) in cells herpetic antigen is revealed. Data gistokhy. studying testify to a perversion of exchange of the cells affected with a virus, to loss of ability to utilize, by them in particular a glycogen.

The clinical picture

the Clinical picture is characterized by emergence on skin of group of bubbles to dia. 0,1 — 0,3 cm against the background of limited, slightly edematous pink spot. Contents of bubbles, in the beginning transparent, gradually grow turbid. In 3 — 4 days bubbles dry up with formation of friable honey-yellow crusts or are opened, forming a number of the small closely located surface erosions which begin to live also with formation of crusts. Quite often bubbles merge in a multichamber flat bubble, after opening to-rogo the erosion of the wrong melkofestonchaty outline is formed. Then crusts disappear, erosion are epithelized and on 6 — the 8th day heal, without leaving any permanent changes of skin. Sometimes terms of healing are extended up to 1 month and more.

There is one center more often, but sometimes at the same time or consistently in 1 — 2 day 2 — 3 new, as a rule, located closely to each other. The rash of bubbles is followed by feeling of an itch, burning, and sometimes pains, a febricula.

Fig. 1 — a herpes simplex
Fig. 2 — a herpes simplex

Usual localization — face skin: a circle of a mouth, especially red border of lips (herpes labialis — tsvetn. fig. 1), a nose of herpes nasalis), is more rare skin of cheeks, a century, auricles. Often G. is localized on skin of generative organs (herpes genitalis — tsvetn. fig. 2): at men — on a head and a trunk of a penis, on an inner surface of a prepuce, on skin of a scrotum; at women — on big and small vulvar lips, in a crotch. Of genitalias can be followed by fever, increase limf, nodes, neuralgic pains, extensive erosion, hypostasis of generative organs can be formed; at a frequent recurrence development of elephantiasis of vulvar lips is possible.

Simple G. can affect a mucous membrane of an oral cavity, a pharynx, a throat, almonds, a conjunctiva, a cornea, and also a mucous membrane of an urethra, a vagina, a neck of uterus. On the basis a wedge, observations of a combination of G. of generative organs and cancer of a neck of uterus the assumption of a possible etiol, communication of these diseases appeared. Cases of a herpetic encephalomeningitis with allocation from cerebrospinal virus herpes simplex liquid are described.

In addition to typical the wedge, pictures, at palindromias are possible the atypical damages of skin representing separate forms: disseminated, migrating, hemorrhagic, necrotic, zosteriformny, edematous, erosive and ulcer and abortal.

In case of a complication simple G.'s virus of eczema at children the wedge, a picture of an acute varioliformny pustulez of Kaposha — Yuliusberg can develop (the same as at a complication of eczema a virus of chicken pox or a virus of a smallpox vaccine — see. Vaccinal rashes ).

A peculiar form of simple G. is herpetic stomatitis (see), preferential arising at children of 1 — 3 years. The disease begins with temperature increase and a febricula, at children the concern, small appetite, a sleep disorder is noted. In 1 — 2 day on a hyperemic and edematous mucous membrane of cheeks, lips, language pour out groups of bubbles which are opened, forming very painful erosion, pruinose in a look aft (see). Increase and morbidity regional limf, nodes is noted, ulitis (see). At the same time an enanthesis around a mouth and a nose, and also on fingers of hands can be observed.

G.'s disease a fruit (infection occurs through a placenta) is sometimes possible or during passing of the newborn in patrimonial ways of mother in case of presence of G. of genitalias at it. At the newborn serious condition with a generalized rash and a lethal outcome can develop.

The diagnosis comes easy and usually the wedge, a picture is based on characteristic, however at localization of rashes on generative organs and formation of erosion of simple G. happens it is necessary to differentiate with primary syphilis: in favor of G. scalloped outlines of an erosion, lack of dense infiltrate in its basis testify. The zosteriformny kind of simple G. differs from the surrounding G. in absence of the pains irradiating on the course of a nerve.

Laboratory diagnosis

Laboratory diagnosis of simple G. is based on detection of a virus, morfol, studying of the fabrics affected with a virus and serol, reactions. Material for allocation of a virus — contents of vesicles, scrapings from the struck cornea, saliva, blood, cerebrospinal liquid, etc. Patol, material it is necessary to take in a heat of a disease, to bring quickly to laboratory, to store at a low temperature.

Horion-allantoisnaya a cover of the chicken embryo infected with a virus of a herpes simplex: plaques (white spots) are visible.

Virus allocate with infection 11 — 12-day chicken embryos (for chorion-allantoisnuyu a cover), white mice (in a brain), rabbits (for a cornea), and also infection primary tripsinizirovannykh and the intertwined lines of cellular cultures. On chorion-allantoisnoy to a cover of chicken embryos plaques (fig.) to dia form. 1 — 2 mm, at rabbits on a cornea develops a keratitis, at white mice — encephalitis, in fabric cultures — destruction of cells (so-called cytopathic effect).

By method light, luminescent and a submicroscopy in tissues of the person, animal and cellular cultures reveal multinucleate cells, intranuclear inclusions, a specific antigen, characteristic of simple G., and virus particles (virions), typical on structure.

The serodiagnosis is based on identification of increase of credits of specific antibodies in blood by a research of the serums taken at the beginning and the end of a disease. Are for this purpose used reactions of binding complement (see) and neutralizations of a virus (see. Virologic researches ), which are carried out on white mice, in fabric cultures and chicken embryos. Antigens for reactions are prepared from tissues of the animals infected with simple G.'s virus and virussoderzhashchy cultural liquid. The same reactions apply also to identification of again allocated virus strains with use of standard herpetic immune serums of animals.

Treatment

At a herpes simplex are effective interferon in the form of lotions, rinsings, instillations (6 times a day) and 50% of ointments. At recurrent herpes the antiherpetic vaccine, interferon in injections, pyrogenal (on a course 20 — 25 injections), hystoglobulin or protivokorevy gamma-globulin on 3 ml of 1 times in 3 days is effective (on a course 4 — 6 injections). At a persistent heavy current of G. it is recommended to alternate the specified means at an interval of 3 — 4 months. Locally, including on mucous membranes, use of 0,25% of oxolinic ointment, 5% of tebrafenovy ointment, 1 — 2% of ointment florenalya is effective. During fading of a disease keratoplastichesky means are shown: sea-buckthorn oil, karotolin, the oil of a dogrose, ointments containing vitamin A.

Forecast usually favorable, the disease comes to an end in 7 — 8 days, however in connection with hron, a carriage of this infection a frequent recurrence is possible.

Prevention consists in a hardening of an organism, especially children.

The surrounding herpes

(a synonym shingles)

the Aetiology

the Disease is caused by a virus of chicken pox (Varicella virus). The infectious nature of the surrounding G. was established by Kundratitts (To. Kundratitz, 1925), and a community of the causative agent of chicken pox and the surrounding G. that assumed still to Ya. B Oka in 1909, was proved experimentally later; for the first time Varicella virus was allocated by Weller (T. Weller, 1953) from vesicular liquid of patients with the surrounding G. by means of a method of fabric cultures (see. Chicken pox , etiology, Herpes viruses ).

The epidemiology

Incidence of the surrounding G. is characterized by a sporadichnost (more often in the spring and in the fall), epidemics are not observed. The surrounding G. arises preferential at the adults, apparently, having partial immunity to this virus; at children up to 10 years it is observed extremely seldom. At contact with the sick adult the child can get sick chicken pox (see).

The pathogeny

the Pathogeny is insufficiently studied; since the virus of the surrounding G. neurodermotropic, with a big tendency to defeat of the central and peripheral nervous system, is believed that initially the virus gets into skin, mucous membranes and further, on limf, to ways to intervertebral nodes and back roots of a spinal cord. Process begins with defeat spinal and cerebral gangliyev. In hard cases front and back horns, white matter of a spinal cord, a brain are involved in process. The surrounding G. arises more often as an independent disease, in certain cases as a complication, napr, pneumonia, a lymphoid leukosis, a lymphogranulomatosis, metastasises of cancer, etc. The injury, overcooling can be a reason for its development.

Patogistologiya

Changes in an epithelium and a derma at surrounding the same G., as at simple G. V to a nervous system — inflammatory infiltration (preferential lymphocytes and plasmocytes) and hemorrhages in nerve knots with the subsequent dystrophy of ganglionic cells and nerve fibrils. Similar changes are observed also in back roots; inflammatory and dystrophic changes in back, and sometimes and in front horns of a spinal cord, a boundary trunk of a sympathetic nerve, and also inflammatory infiltration of covers of a brain are less often noted. Dystrophic changes in peripheral nerves have, apparently, secondary character and depend on intensity of defeat of nodes and back roots. In cerebrospinal liquid quite often find a lymphocytosis and the increased protein content. According to E. V. Malkova (1963), intervertebral nodes of chest department most often are surprised.

Clinical picture

Incubation interval on average 2 — 3 weeks. The disease begins with pains on the course of the struck nervous branches, fevers, a headache, feeling of a pricking, burning, an itch. Skin defeats are more often characterized by an acute rash on the course of separate sensory nerves of limited pink spots usually of 3 — 5 cm and more on which surface already by the end of the first or on second day groups of closely located bubbles of 0,1 — 0,3 cm and more largely are formed, filled with transparent contents. The rash of bubbles on spots occurs at the same time, but spots can appear with intervals in several days in view of what the habit view of a rash can be polymorphic. Quantity of the centers of defeat variously (from one to many); in some cases, closely adjoining to each other, they merge and form a continuous tape. In several days contents of bubbles grow turbid, the erythematic background usually considerably turns pale and bubbles are located as if on healthy skin. Since 6 — the 8th day bubbles dry up, forming crusts which by the end of the 3rd week disappear, leaving easy pigmentation.

In some cases, is more often at elderly people, neuralgic pains of various intensity in the affected nerve can proceed within several months after healing of skin defeat.

Fig. 3 — 6 — forms of the surrounding herpes: fig. 3 — usual

Skin rashes, as a rule, are followed by increase and morbidity regional limf, nodes and can be localized in the field of any sensory nerve, is the most frequent on the course of intercostal nerves (color. fig. the 3), second place on the frequency of localization is taken by face skin and the heads, especially in the field of branches of a trifacial, is more rare — extremities; defeat, as a rule, unilateral.

Fig. 4. a hemorrhagic form of the surrounding herpes

Especially hard the disease proceeds if rashes develop in areas of an innervation of frontal, nasociliary and supraorbital nerves. After prodromal intensive neuralgic pains there are a redness and puffiness of skin of a forehead, a century, a nose, temporal area and a conjunctiva, dacryagogue and a photophobia, then against the background of an erythema groups of bubbles which exudate it becomes frequent quickly hemorrhagic (tsvetn are formed. fig. 4); in some cases the gangrenous form can develop. Often on edge of a cornea there are small bubbles which are leaving behind scars; the iritis can develop (see. Iridocyclitis ), ulcer keratitis (see), amotio of a retina (see), a hemorrhagic exudate in an anterior chamber of an eye (see. Hyphema ).

Fig. 5. a gangrenous form of the surrounding herpes

Kinds (form) of the surrounding G. are possible also a wedge: 1) abortal — formations of the developed bubbles does not come, and against the background of a pink edematous spot there are only small grouped papules which quickly disappear; 2) violent — closely grouped bubbles merge, forming bubbles sometimes of considerable size, with uneven scalloped outlines; 3) hemorrhagic — contents of bubbles accepts hemorrhagic character, after healing sometimes there are superficial scars; 4) gangrenous (the most severe form of G. — tsvetn. fig. 5): on site bubbles or directly against the background of a pink spot the small closely grouped strupa or a continuous black scab with melkofestonchaty outlines are formed, after rejection of a scab there is a superficial ulceration which is beginning to live with formation of the small grouped scars or a continuous hem; the rash is followed usually by megalgias, a current long (6 — 8 weeks); 5) generalized G. — a rash separate (so-called aberrating) bubbles on various body parts reminding elements of chicken pox in addition to elements of the surrounding G. on the course of a nerve.

Fig. 6. Hunt's syndrome. The smoothness of the right nasolabial fold caused by neuritis of a facial nerve because of herpes

A peculiar form of the surrounding G. is Hunt's syndrome caused by defeat of a cranked node and which is characterized by severe neuralgic pains in an ear, neuritis of ear and facial nerves, herpetic rash on skin of an auricle (tsvetn. fig. 6), outside acoustical pass, sometimes on a mucous membrane of an oral cavity, etc. (see. Hunt syndrome ). At this localization the encephalomeningitis quite often develops.

In certain cases at the surrounding G. sensitivity can be broken, the hyperesthesia, a giperalgiya, paresthesia develop. Sometimes note trophic, vascular and secretory frustration, disturbance of sweating, a hair loss, etc. Development of herpetic neuritis is possible without damage of skin. The recurrence of the surrounding G. is celebrated as very rare exception.

The diagnosis, as a rule, does not represent difficulties: localization of rashes on the course of a nerve, hemilesion, neuralgic pains, monomorphic character of bubbles distinguish the surrounding G. from other diseases of skin, including of simple.

The main method of laboratory diagnosis is allocation of a virus for what use vesicular and cerebrospinal liquid (at patients with an encephalomeningitis), and also washouts from a nasopharynx of patients. The virus does not breed in chicken embryos and does not infect laboratory animals therefore for its allocation use exclusively embryonal fabric cultures of the person. Slow development of cytopathic effect, a maximum is characteristic of a virus of the surrounding G. to-rogo occurs to 15 — to the 30th day of cultivation. In a monolayer the centers of the rounded cells in which kernels find inclusions are formed. The viral antigen in cells can be found by means of a method immunofluorescence (see). For identification of the allocated virus use neutralization tests in culture of fabric and RSK with blood sera of the had persons (see. Virologic researches , Reaction of binding complement ). Investigate vesicular liquid of patients, in a cut multinucleate cells with intranuclear inclusions are found.

It is necessary to differentiate the surrounding G. with natural and a vaccinia, and also with a zosteriformny kind of simple. Unlike viruses of smallpox the virus of the surrounding G. does not form plaques on chorion-allantoisnoy to a cover of chicken embryos, nepatogenen for rabbits, and also differs on character of a cytopathic effect on cultures of cells markedly; the virus has no the hemagglutinating properties and has no general with a virus of smallpox of antigens.

Treatment

Local — similar to treatment of simple. As the general treatment salicylates, analgetics, vitamins B are shown 1 , B 12 , interferon in injections, diadynamic current, diadinamoelektroforez with novocaine, adrenaline, ultrasound, Ural federal district, UVCh; at sharply expressed neuralgic pains — Promedolum, Omnoponum, and also reperkussionny novocainic blockade. For the purpose of prevention of consecutive infection — antibiotics of a broad spectrum of activity.

Forecast

Forecast, as a rule, favorable; process comes to an end in 2 — 3 weeks, without leaving on skin of marks (at a necrotic form there are scars), however neuralgic pains proceed long.

Prevention: to exclude contacts with patients with chicken pox, to avoid overcoolings.

Herpes of pregnant women (Milton)

the Aetiology of a disease is not established. There are no accurate data for reference of this disease to G. though there are indirect data: observations are described that the herpetiform rashes passing without treatment were found in newborns whose mothers are sick with G. There is a nek-swarm a similarity in a wedge, a picture G. of pregnant women with a disease of Dyuringa (see. Dyuringa disease ), however the issue of their identity is not resolved.

In G.'s pathogeny of pregnant women the possible role of an endointoxication, a sensitization to autoallergens is supposed. The disease is observed usually in the second half of pregnancy. It is clinically shown by a polymorphic enanthesis of a trunk and extremities (a vesicle, a papule, an urtikariya on an erythematic background) which are followed by a severe itch, disturbance of the general state.

An effective therapeutic complex are desensibilizing, including corticosteroid, drugs.

Herpes tonsurans — see. Trichophytosis .

Herpes iridis — see. Keratitis .


Bibliography: Zhdanov B.M. and the Guide * m about in and the p C. Ya. Virusologiya, page 433, M., 1966, bibliogr.; Luriya G. and Darnell D. The general virology, the lane with English, M., 1971; Rozentul M. A. General therapy of skin diseases, page 135, M., 1970; The Screen to ying Yu. K. and Sharapova G. Ya. Skin and venereal diseases, page 210, M., 1972; Modern questions of clinic, a pathogeny and therapy of a dermatosis, under the editorship of V. A. Rakhmanov, page 85, M., 1968, bibliogr.; Shubladze A. K. and M and e in with to and I am T. M. Gerpes, M., 1971, bibliogr.; Scherbakov I. M. Use of interferon and interferonogen in dermatology, Vestn, dermas, and veins., No. 3, page 8, 1973, bibliogr.; Nasemann T. Die Infek^ tionen durch Herpes simplex — Virus, Jena, 1965, Bibliogr.; Partridge J. B. a. M i 1 1 i s R. R. Systemic herpes simplex, infection in newborn treated with intravenous idoxuridine, Arch. Dis. Childh., v. 43, p. 377, 1968.

S. T. Pavlov; T. M. Mayevskaya (vir.)

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