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Systemic Lupus Erythematosus :Definition, Cause, Symptoms, Diagnosis, Treatment, Prognosis

DEFINITION

Systemic Lupus Erythematosus (Lupus Erythematosus Disseminata, Lupus) is a chronic autoimmune disease that causes inflammation and can affect various organs, including skin, joints and internal organs.

On each patient, the inflammation of the tissues and organs will be different. Severity of the disease varies from mild disease to diseases that cause disability, independent of the number and type of antibody that pops up and the affected organ.

Classification of Lupus

There are several kinds of clinical manifestations of Systemic Lupus Erythematosus:
1. Cutaneous Lupus (discoid lupus): 15%
2. Drug Induced Lupus (dilemma): 5%
3. Crossover or overlap syndrome or MCTD: 10%
4. Systemic Lupus Erythematosus: 70%
– Non-organ threatening disease: 35%
– Organ threatening disease: 35%

CAUSE

Under normal circumstances, immune system functioning to control the body’s defense against infection.

In lupus and other autoimmune diseases, the body’s defense system turns against the body, which produced antibodies to attack its own body cells. These antibodies attack the blood cells, organs and tissue, resulting in chronic disease.

Mechanisms and causes of autoimmune diseases is not fully understood.

The cause of lupus is unknown, but is thought to involve environmental factors and heredity.

Several environmental factors can trigger the onset of lupus:

- Infections

- Antibiotics (especially penicillin and sulfa)

- Ultraviolet light

- Excessive stress

- Certain drugs

- Hormones.

Although lupus is a disease of unknown ancestry, but the cause is unknown genes. Recent discovery of a gene mention of chromosome 1.

Only 10% of patients who have a relative (parent or sibling) who has or will suffer from lupus.

Statistics show that only about 5% of children of lupus patients will suffer from this disease.

Lupus is often referred to as a female disease, although men can also suffer.

Lupus can strike any age, both men and women, although 10-15 times more common in women.

Hormonal factors may explain why lupus is more common in women. Increased symptoms of this disease in the pre-menstrual and / or during pregnancy support the belief that hormones (especially estrogen) may play a role in the onset of this disease.

However, the exact cause of the higher incidence in women and in pre-menstrual, remains unknown.

Sometimes certain heart medications (hidralazin, procainamide, and beta-blockers) can cause lupus-like syndrome, which will disappear when the drug is stopped.

Etiology is not known for sure. There is a strong family factors, especially the immediate family. Increased risk of 25-50% in identical twins and 5% in dizygotic twins, suggesting genetic factors related to. The fact that the majority of cases are sporadic with no known predisposing genetic factors, environmental factors also showed an effect. The infection can induce specific immune responses in the form of molecular mimicry that disrupt the regulation of the immune system.

SYMPTOMS

The number and type of antibodies in lupus, larger than in other diseases, and these antibodies (together with other unknown factors) to determine which symptoms will develop. Therefore, the symptoms and severity of the disease, varies in each patient.

Course of the disease varies, ranging from mild illness to severe disease.

Symptoms in each patient is different, and is characterized by symptom-free period (remission) and the relapse (exacerbation).

In early disease, lupus attacked only one organ, but in the future will involve other organs.

- Muscles and skeleton

Almost all people with lupus have joint pain and most develop arthritis. Joints are often affected are the joints of the fingers, hands, wrists and knees.

Death of bone tissue in the pelvis and shoulders are often a cause of pain in the area.

Arthritis can occur in more than 90% of children with Systemic Lupus Erythematosus (SLE). Generally symmetrical, occurs in several large and small joints. Usually very responsive to treatment compared with other organ abnormalities in Systemic Lupus Erythematosus (SLE)​​. In contrast to the JRA, Systemic Lupus Erythematosus (SLE) is generally very painful arthritis, and pain is disproportionate to the results of physical examination of the joint. Radiological examination showed no change osteopeni joints. Children with polyarticular JRA who several years later to become Systemic Lupus Erythematosus (SLE).

- Leather

In 50% of patients found the butterfly rash on the cheeks and bridge of the nose bone. This rash will usually get worse if exposed to sunlight.

More widespread rash can occur in other body parts are exposed to the sun.

2 to 3% of discoid lupus occurs at the age below 15 years. Approximately 7% of discoid lupus will be within 5 years, so it needs to be monitored on a routine laboratory examination results indicate the presence of antinuclear antibodies (ANA) is accompanied by elevated levels of IgG and high light lekopeni.

- Kidney

Most of the patients showed accumulation of protein in the cells of the kidney, but only 50% who suffer from lupus nephritis (kidney inflammation settled).

At the end of kidney failure can occur, so patients need to undergo dialysis or kidney transplantation.

At about 2/3 of children and adolescents Systemic Lupus Erythematosus will be symptoms of lupus nephritis. Lupus nephritis affects approximately 90% will be children in the first year after Systemic Lupus Erythematosus diagnosted. Based on WHO classification, the order type of lupus nephritis that occurs in children based on its prevalence are:
a. Class IV, diffuse proliferative glomerulonephritis (DPGN) by 40% -50%
b. Class II, mesangial nephritis (MN) by 15% – 20%
c. Class III, focal proliferative (FP) of 10% -15%
d. Class V, membranous at> 20%.

- The nervous system

Neurological abnormality was found in 25% of patients with lupus. The most common is the mild nature of mental dysfunction, but the disorder can occur in any part of the brain, spinal cord and nervous system.

Seizures, psychosis, organic brain syndrome and headaches are some disorders of the nervous system can occur.

Central nervous system (CNS)
CNS symptoms ranging from global cerebral dysfunction with paralysis and seizures to focal symptoms such as headache and memory loss. CNS lupus diagnosis requires evaluation for reactive that exclution psychosocial disorders, infections, and metabolic. Serebralis venous thrombosis usually associated with antiphospholipid antibodies. When the diagnosis of lupus serebralis expected, confirmed by CT scan should be done.

- Blood

Blood disorders can be found in 85% of patients with lupus.

Can form blood clots in the veins and arteries, which can lead to stroke and pulmonary embolism.

Platelet count is reduced and the body to form antibodies against blood clotting factors, which could cause significant bleeding.

Hematologic abnormalities that frequently occur are lymphopenia, anemia, thrombocytopenia, and leukopenia. Anemia often occur due to chronic illness. Interstitial pneumonitis is a result of lymphocyte infiltration. The disorder is difficult to identify and often can not be identified. Usually diagnosed only after reaching an advanced stage.

- Heart

Inflammation of various parts of the heart may occur, such as pericarditis, endocarditis or myocarditis.

Chest pain and arrhythmias may occur as a result of these circumstances.

- Lungs

Can occur in lupus pleuritis (inflammation of the lining of the lungs) and pleural effusion (accumulation of fluid between the lung and packaging).

As a result of these circumstances often arise chest pain and shortness of breath.

Symptoms of lupus:

- Fever

- Tired

- Feel unwell

- Weight loss

- Skin rash

- Butterfly rash

- Skin rash aggravated by sunlight

- Sensitive to the sun

- Swelling and joint pain

- Swollen glands

- Muscle pain

- Nausea and vomiting

- Pleuritic chest pain

- Seizures

- Psychosis.

Other symptoms that may be found:

- Hematuria (blood-containing urine)

- Coughing up blood

- Nosebleeds

- Swallowing disorders

- Patches of skin

- Red spots on skin

- Change the color of the fingers when pressed

- Numbness and tingling

- Sores in the mouth

- Hair loss

- Abdominal pain

- Impaired vision.

Raynaud’s phenomenon is characterized by a pale state, followed by cyanosis, erythema, and re-warm. Occurs because the disposition of immune complexes in the endothelium of blood vessels and local complement activation.

DIAGNOSIS

Lupus diagnosis is confirmed by the discovery of four of the 11 typical symptoms of lupus are:

- Butterfly rash on the face (cheeks and bridge of the nose)

- Rash on the skin

- Injuries to the mouth (usually painless)

- Fluid in the lungs, heart and other organs

- Arthritis (non-erosive arthritis involving two or more peripheral joints, where the bone around the joints are not damaged)

- Abnormalities in kidney function

a. levels of protein in the urine 0.5 mg / day or more

b. presence of abnormal elements in urine derived from red blood cells / white nor Mr renal tubule cells

- Photosensitivity (sensitive to sunlight, causing the formation or worsening of skin rash)

- Nerve or brain dysfunction (seizures or psychosis)

- The results of blood tests positive for antinuclear antibodies

- Immunological abnormalities (positive results on tests of anti-DNA double chain, anti-Sm test, antiphospholipid antibody tests: false positive results for syphilis test)

- Blood disorders

a. Hemolytic anemia or

b. Leukopenia (leukocyte count 4000 cells / mm) or

c. Lymphopenia (lymphocyte count 1500 cells / mm) or

d. Thrombocytopenia (platelet count 100,000 / mm).

When 4 or more criteria is established, the diagnosis of Systemic Lupus Erythematosus (SLE) can be enforced with 98% specificity and sensitivity of 97%.

Complete blood count, ESR, urinalysis, LE cells, ANA *, anti-doublestranded DNA *, antiphospholipid antibodies, other antibodies (anti-Ro, anti-La, anti-RNP), rheumatoid factor, the titer of complement C3, C4, and CH50 *, titers of IgM, IgG, and IgA, Coombs test, creatinine, blood urea *, urine protein> 0.5 gram/24 hours (nephritis) *, and imaging (chest X-ray images *, renal ultrasound, MRI of the head)

The diagnosis is not all laboratory tests should be there, but the initial examination (marked *) should be performed.

Tests to determine the presence of the disease varied, including:

- Blood tests

Blood tests can indicate the presence of antinuclear antibodies, are present in almost all patients with lupus. But these antibodies also can be found in other diseases. Therefore if you find a antinuclear antibodies, should be also checks for antibodies to DNA double chain.

High levels of both antibodies are almost specific for lupus, but not all people with lupus have these antibodies.

Blood tests to measure levels of complement (proteins that play a role in the immune system) and to find other antibodies, it may be necessary to estimate the activity and duration of disease.

- Skin rash or lesions typical

- Chest radiograph showing pleuritis or pericarditis

- Examination of the chest with a stethoscope help indicate the presence of pleural or cardiac friction

- Analysis of the urine showed the presence of blood or protein

- Calculate blood types showed a decrease in some types of blood cells

- A renal biopsy

- Examination of the nerve.

Diagnosing Systemic Lupus Erythematosus (SLE) in children can wear ARA criteria, as follows:
- Malar rash
- Discoid rash
- photosensitivity
- Oral and nasopharyngeal ulcers
- Non-erosive arthritis in two or more of the characteristics of swelling or effusion
serositis (pleuritis or pericarditis or pericardial effusion)
- Renal disease (proteinuria (> 0.5 g / d or> 3 +) or the presence of cellular casts
- Neurological abnormalities, seizures without any other cause, or psychosis without other cause
- Hematologic disorders:
- Hemolytic anemia
- Leukopenia (<40 per mL), lymphopenia (<1500 per mL), thrombocytopenia (<1000 per mL) is not due to drugs
- Immunological abnormalities
- Lupus Erythematosus (LE) cells positive; anti-ds DNA antibodies / anti-Sm positive; antinuclear antibodies (ANA). Abnormal ANA titer is not due to a drug that induces an increase in ANA.

Anti ds-DNA

Limit of normal: 70-200 IU / mL

Negative: <70 IU / mL

Positive:> 200 IU / mL

This antibody was found in 65% – 80% of patients with active Systemic Lupus Erythematosus (SLE) and rarely in patients with other diseases. High amount is specific for Systemic Lupus Erythematosus (SLE), while low to moderate levels can be found in patients with other rheumatic diseases, chronic hepatitis, infectious mononucleosis, and biliary cirrhosis. The number of these antibodies can be down with the right treatment and may increase the spread of diseases, especially lupus glomerulonephritis. The amount is a negative approach in a quiet Systemic Lupus Erythematosus (SLE) disease (dormant).

Anti-DNA antibody is a subtype of antinukleus antibodies (ANA). There are two types of anti-DNA antibodies that attack the double-stranded DNA (anti ds-DNA) and the attack single-stranded DNA (anti ss-DNA). Anti-ss-DNA is less sensitive and specific for Systemic Lupus Erythematosus (SLE) but positive for other autoimmune diseases. Antibody-antigen complex on autoimmune disease are not only for diagnosis but it is a great constributor in the course of the disease. The complex will induce the complement system can cause local and systemic inflammation.

Antinuclear antibodies (ANA)

Normal: zero

ANA is used for the diagnosis of Systemic Lupus Erythematosus (SLE) and other autoimmune diseases. ANA is a group of proteins that react to antibodies attack the nucleus of a cell. ANA is sensitive enough to detect the presence of Systemic Lupus Erythematosus (SLE), positive results occurred in 95% of patients with Systemic Lupus Erythematosus (SLE). But the ANA is not specific for Systemic Lupus Erythematosus (SLE) because ANA is also associated with other rheumatic diseases. High number of ANA related to the emergence of disease and disease activity. After therapy, the illness is no longer active, so the number of ANA is expected to decline. If a negative test result, the patient is not necessarily negative for Systemic Lupus Erythematosus (SLE) should be considered as well as clinical data and other laboratory tests, but if the test result is positive, serologic tests should be done the other to support the diagnosis that the patient is suffering from Systemic Lupus Erythematosus (SLE). ANA may include anti-Smith (anti-Sm), anti-RNP (anti-ribonukleoprotein), and anti-SSA (Ro) or anti-SSB (La).

Systemic Lupus Erythematosus (SLE) complications in children include:
- Hypertension (41%)
- Impaired growth (38%)
- Chronic lung disorders (31%)
- Abnormalities of the eyes (31%)
- Permanent kidney damage (25%)
- Neuropsychiatric symptoms (22%)
- Damage muskuloskeleta (9%)
- Impaired function of the gonads (3%).

TREATMENT

Discoid lupus
Standard therapy is photoprotection, anti-malaria and topical steroids. To address the use of skin rash corticosteroid creams. If the patient is very sensitive to the sun, preferably on the go using sunscreen, sunglasses or long underwear. Cream 5% is more effective luocinonid compare with hidrokrortison cream 1%. Therapy with hydroxychloroquine effective in 48% of patients and effective against acitrenin 50% of patients.

Lupus serositis (pleuritis, pericarditis)
Standard therapy is NSAIDs (with the tight control of renal impairment), antimalarials and sometimes required a low dose steroid. Mild disease (rash, headache, fever, arthritis, pleuritis, pericarditis) requires very little treatment.

Lupus arthritis
For musculoskeletal complaints, the standard therapy is the scrutiny of NSAIDs with renal impairment and antimalarials. As for the complaints of myalgia and depressive symptoms are given serotonin reuptake inhibitor antidepressants (amitriptyline).

Lupus myositis
Standard therapy is high dose corticosteroids (prednisone starting with a dose of 1-2 mg / kg / day in divided doses, when it rose to normal levels of complement, on tapering off the dose carefully in 2-3 years to achieve the lowest effective dose. Methods Another is used to prevent side effects daily administration is by giving prednisone alternate higher doses (5 mg / kg / day, no more than 150-250 mg), methotrexate or azathioprine.

Raynaud’s phenomenon
Standard treatment is calcium channel blockers, such as nifedipine; alpha 1-adrenergic receptor antagonist and nitrates, for example isosorbid mononitrat.

Lupus nephritis
There is no special treatment in Class I of the WHO classification. Lupus nephritis class II (mesangial) has a good prognosis and require minimal treatment. Increased proteinuria should watch out because it describes the change in status of the disease becomes more severe. Lupus nephritis class III (focal proliferative nephritis / FPGN) require the same aggressive therapy with DPGN, especially when there is focal necrotizing lesions. On Lupus nephritis class IV (DPGN) a combination of corticosteroids with intravenous cyclophosphamide was better than if only with prednisone. Intravenous cyclophosphamide has been used extensively both for DPGN and other forms of lupus nephritis. Azathioprine has been shown to improve long-term outcome for type DPGN. Starting with high doses of prednisone daily for 1 month, when the complement levels rose to normal, the dose tapering off gently for 4-6 months. Intravenous cyclophosphamide given every month, 10-14 days after delivery, leucocyte levels checked. Cyclophosphamide dose will then be raised or down depending on the number of leucocyte (normally 3.000-4.000/ml). Lupus nephritis class V on the therapeutic regimen commonly used are (1). monotherapy with corticosteroids. (2). corticosteroid combination therapy with cyclosporine A, (3). sikofosfamid, azathioprine, or chlorambucil. Proteinuria can often be reduced by ACE inhibitors. Lupus nephritis class V at an advanced stage. choice of therapy is dialysis and renal transplantation.

Haematological disorders
For thrombocytopenia, which considered the therapy of this disorder is corticosteroids, intravenous immunoglobulin, intravenous anti-D, vinblastine, danazol, and splenectomy. As for the hemolytic anemia, is considered corticosteroid therapy, intravenous siklfosfamid, danazol, and splenectomy.

Lupus interstitial pneumonitis
Drugs used in this case is a corticosteroid and intravenous siklfosfamid.

Lupus vasculitis with involvement of vital organs
Drugs used in this case is a corticosteroid and intravenous siklfosfamid.

Decrease in mineral density associated with dose and duration of steroid treatment. The use of daily low-dose corticosteroids with high-dose intermittent intravenous supplementation with vitamin D and calcium to maintain bone mineral density. Pathological fractures rarely occur in young Systemic Lupus Erythematosus (SLE). The risk of fractures can be prevented with calcium intake and exercise program better. Through the alternate program, the side effects of steroids on growth can be reduced. Before setting the effect of the drug, such as thyroiditis and endocrine causes of growth hormone deficiency should be excluded. Avaskuler necrosis can occur in 10-15% of patients who receive child Systemic Lupus Erythematosus (SLE) high-dose steroids and long-term.

If the symptoms of lupus caused by medication, then stop using the medicine could cure him, although it can take many months.

To cope with arthritis and given anti-inflammatory pleurisi non-steroid.

Severe disease or life-threatening sufferers (hemolytic anemia, heart or lung disease are widespread, kidney disease, central nervous system disease) often needs to be handled by experts.

To control the various manifestations of severe disease may be given corticosteroids or immune system-suppressing drugs.

Some experts give cytotoxic drugs (drugs that inhibit cell growth) in patients who do not respond well to corticosteroids or who depend on high-dose corticosteroids.

For the manifestation of disease in the acute phase include fever, redness, and muscle pain can be given Hydroxychloroquine, NSAIDs (Ibuprofen, Naproxen, Fenoprofen, Ketoprofen, Dexketoprofen, indomethacin, ketorolac, Diclofenac, piroxicam, meloxicam, mefenamic acid, Etoricoxib, Celecoxib) and steroids (Methylprednisolone, Prednisone). while to deal with chronic conditions may be given medications such as Methotrexate, Cyclophosphamide, Belimumab, Rituximab, Azathioprine and Mycophenolate.

The drugs are often used in patients with Systemic Lupus Erythematosus (SLE) :

antimalarial
Hidroksiklorokin 3-7 mg / kg / day PO as a sulfate salt (maximum 400 mg / day).

Corticosteroids
prednisone
Daily dose (1 mg / kg / day); prednisone alternate higher doses (5 mg / kg / day, no more than 150-250 mg) daily low-dose prednisone (0.5 mg / kg) / day dose of methylprednisolone used in conjunction intermittent high (30 mg / kg / dose, maximum mg) per week.

Immuno-suppressive drugs
cyclophosphamide
500-750 mg/m2 IV 3 times daily for 3 weeks. maximum of 1 g/m2. Should be given by IV infusion installed, and monitored. Monitor leucocytes in 8-14 days following each dose (leucocytes dimaintenance> 2000-3000/mm3)
azathioprine
1-3 mg / kg / day PO 4 times daily.

Non-steroidal anti-inflam-matory drugs (NSAIDs)
naproxen
7-20 mg / kg / day PO divided 2-3 maximum dose of 500-1000 mg / day
Tolmetin
15-30 mg / kg / day PO divided 2-3 maximum dose of 1200-1800 mg / day
diclofenac
<12 years: not recommended
> 12 years: 2-3 mg / kg / day PO : 2 maximum dose of 100-200 mg / day.

Calcium and vitamin D supplements
calcium carbonate
<6 months: 360 mg / day
6-12 months: 540 mg / day
1-10 months: 800 mg / day
11-18 months: 1200 mg / day
Calcifediol
<30 kg: 20 mcg PO 3 times / week
> 30 kg: 50 mcg PO 3 times / week.

Anti-hypertensive
nifedipine
0.25-0.5 mg / kg / dose PO initial dose, not more than 10 mg, repeated every 4-8 hours.
enalapril
0.1 mg / kg / day PO 4 times daily or 2 times a day could be increased if necessary, a maximum of 0.5 mg / kg / day
propranolol
0.5-1 mg / kg / day PO divided into 2-3 doses, may be increased gradually in 3-7 days with regular doses of 1-5 mg / kg / day

Diet

Dietary restrictions prescribed by the therapy given. Most of the patients require corticosteroids, and the time allowed is a diet that contains enough calcium, low fat, low in salt. Patients are advised to be careful with dietary supplements and traditional medicines.

Activity

Lupus patients should continue normal activities. Exercise is necessary to maintain bone density and normal weight. But it should not be exaggerated because of fatigue and stress often associated with recurrence.

PROGNOSIS

Recent years has improved the prognosis of patients with lupus, many patients who show mild disease.

Women with lupus who become pregnant can safely hold up to normal babies, there was no heart or kidney disease is severe and the disease can be controlled.

Systemic Lupus Erythematosus has the numbers for the 10-year survival of 90%. The cause of death can be directly caused by the disease lupus, which is due to renal failure, malignant hypertension, CNS damage, pericarditis, autoimmune cytopenia. The worst prognosis was found in patients who have abnormalities of the brain, lungs, heart and kidney weight. Data from several studies in 1950-1960, showed 5-year survival rates of 17.5% -69%. While the years 1980-1990, 5-year survival rates of 83% -93%. Some researchers reported that 76% -85% of patients with Systemic Lupus Erythematosus (SLE) can live for 10 years by 88% of patients experienced at least flawed in several organs in the long term and persistent.

Herpes Simplex : Definition, Cause, Symptoms, Type, Diagnosis, Treatment, Correlation

Herpes

Currently there are two kinds of herpes : herpes simplex and herpes zoster, both derived from different viruses. Zoster, is caused by Varicella zoster virus. The nature of the disease milder than the type caused by herpes simplex virus (HSV). Zoster rash grows in the form of lengthwise on the body right or left alone.

Herpes Simplex Virus (HSV)

Herpes simplex infection is characterized by recurrent episodes of small blisters on the skin or mucous membrane, which contains fluid and feels pain. Herpes simplex causes eruptions on the skin or mucous membranes. This eruption would disappear even if the virus persists in a dormant state within the ganglia (nerve cell bodies), which supply the flavor on the infected area.

CAUSE

Basically Herpes virus also known as Herpes Simplex Virus (HSV). There are two types of herpes simplex virus that infects the skin, the virus is an advanced differentiated HSV1 and HSV2. The reason 84% of cases of venereal disease. The difference between HSV1 and HSV2 are: the preferred HSV1 namely the skin and mucous membranes in the eyes or mucous in the mouth, nose, and ears. HSV1 is a cause of sores on the lips (herpes labialis) and cuts in the cornea of ​​the eye (herpes simplex keratitis); usually transmitted through contact with secretions from or around the mouth. While the preferred HSV2 namely the skin and mucous membranes in the genital and perianal. HSV2 usually causes genital herpes and mainly transmitted through direct contact with sores during sexual intercourse. Shape to form patches on the skin HSV1 small verikels, whereas HSV2 form big verikels, bold, and centered. There are serology anti -HSV1 antibodies and anti-HSV2 antibodies were found.

SYMPTOMS

Recurrent herpes simplex characterized by tingling, discomfort or itching, which felt a few hours to 2-3 days before the onset of blisters. Blisters surrounded by red areas may appear anywhere on the skin or mucous membrane, but is most often found in and around the mouth, lips and genitals. Blisters (which may be painful) tend to form groups, which makes recommendations to one another to form a larger collection.

Periodically, the virus will come back and began to proliferate, often causes skin eruption of blisters on the same location as the previous infection. Viruses can also be found in the skin without causing real blisters, in this state is from the source of virus infection to others.

The onset of the eruption can be triggered by:
- Exposure to sunlight
- Fever
- Physical or emotional stress
- Suppression of the immune system
- Drugs or certain foods.

Herpes Simplex

A few days later the blisters begin to dry and form a thin yellowish scab as well as a shallow ulcer. Healing usually begins within 1-2 weeks later and is usually completely healed within 21 days. But healing in a moist body parts run slower. If the eruption continues to develop at the same place or if there is secondary bacterial infection, then it could be some scar tissue.

Erythema multiforme

The first herpes infection in infants or small children can cause painful sores and trade at the mouth and gums (ginggivostomatitis) or inflammation of the vulva and vagina which are painful (vulvovaginitis).
This situation causes the child becomes fussy, poor appetite and fever. In infants and older children, the infection can spread through the blood to internal organs (including brain).

A pregnant woman suffering from HSV2 infection can transmit the infection to her fetus, especially if the infection occurs at age 6-9 months of pregnancy. Herpes simplex virus on the fetus can cause a mild inflammation of the lining of the brain (meningitis) or sometimes causing severe inflammation of the brain (encephalitis). Especially for pregnant women infected with HSV2 should be taken seriously, because the virus can penetrate the placenta and cause neonatal damage, impact of congenital and fetal death.

High risk of HSV transmission is especially common among women with primary infection, the mothers who do not yet have antibodies to HSV-seropositive partner, or doing invasive procedures during intrapartum (during birth) of infants, mothers with a history of genital herpes or HSV seropositive.
Transmission to infants predominantly (90%) occurred during the birth process, 5% of the fetus through the placenta or directly on the fetus. The rest, 5%, HSV infection acquired after the birth.
Prolonged contact with infected fluids can increase the risk of infants contracting. Thus, in pregnant women who suffer from primary genital herpes, in the last six weeks of pregnancy is recommended to undergo a cesarean before or within four hours after rupture of membranes. Besides, action will be performed cesareans among women with the virus growth at or near birth. Even so, a cesarean was not always performed on women with recurrent genital herpes. To ensure certainty, it is necessary virus checks and blood began to gestational age 32-36 weeks. Furthermore, at least every week, and cervical cultures taken external genital secretions. If the viral culture were incubated at least four days gave negative results twice in a row, and not appearing genital lesions at delivery, normal delivery can be done.

If infants or adults who suffer from atopic eczema are infected by herpes simplex virus, then it could happen herpetikum eczema, which can be fatal. Therefore patients with atopic eczema sufferers should not be associated with an active herpes infection. In people with AIDS, herpes infections in the skin can be persistent and severe. Inflammation of the esophagus and intestines, ulcers around the anus, pneumonia or neurological disorders are also more common in AIDS patients.

Disorders due to herpes in infants is very diverse, ranging from lesions to include encephalitis (inflammation of the lining of the brain), microcephaly (small head), or hidrocephaly (edema of the head). Infection of a newborn can be fatal. Proved by carrying a mortality rate of 60%, while half of the living will suffer neurological defects or abnormalities in the eye.

Herpetic abscess (herpetic whitlow) is a swelling at the tip of a finger that feels pain and redness, which is caused by herpes simplex viruses that enter through wounds in the skin. Herpetic abscesses most commonly occur on the hospital staff who have never suffered from herpes simplex and in contact with body fluids containing the virus herpes simplex.

In addition, the risks faced by sufferers is death, but this rarely happens. Over the past have not done an effective treatment, it is difficult to predict Herpes disease progression. If infected and treated promptly then chances are the risks can be avoided as soon as possible, while recurrence infection can be limited only recurrence frequency.

Herpes on cornea

In the early stages, this infection resembles a mild bacterial infection because the symptoms are mild (sore eyes, watery, red and sensitive to light). Swelling of the cornea causing blurred vision. The infection often causes only mild changes in the cornea and will disappear by itself. Sometimes the virus penetrates deeper and destroy the surface of the cornea.

Re-infection can cause further damage to the corneal surface. If the sufferer to experience repeated infections, can occur ulceration (formation of an open wound), the formation of scar tissue that is persistently and lost a sense of when the eye is touched. Herpes simplex virus can also cause increased blood vessel growth, impaired vision or blindness.

Clinical symptoms of HSV infection which inflict can be seen in the table as follows:

Clinical Symptoms Virus Inffection Percentage
Sluggish 85 %
Respiratory disorders 60 %
Watery ulcers 60 %
The temperature of hot or cold 50 %
Bleeding 50 %
Hepato megali 50 %
Abnormalities of central nervous tissue 40 %
yellow skin 30 %
blue leather 20 %
Inflammation of the mucous membranes of the eye 10 %
Korioretinis 10 %
Death 70 %

Then, there are other diseases that are included in the group Others Virus (others viruses). This disease group are classified into TORCH disease because it causes disease with symptoms similar to symptoms caused by the four main causes, namely toxo, rubella, CMV and Herpes. Most of the others group virus is a virus that attacks the human nervous tissue (neurophatic).

Viruses belonging to the group include:
- Virus Coxsactie A1 – 17
- Virus Coxsactie B
- Echovirus type 2-72
- Influenza virus type C
- Adenovirus type 1-32
- Viruses like Rhinovirus triggers virus, RSV (Respiratory Syncitial virus), measles, varicella, and others.

DIAGNOSIS

Diagnosis based on symptoms that arise in certain body parts and typical for herpes simplex. To confirm the diagnosis can be done by culturing the virus, blood tests to detect elevated levels of antibodies and biopsy. At a very early stage, the diagnosis is established by using the latest techniques of polymerase chain reaction(PCR), which can be used to identify the DNA of herpes simplex virus in tissue or body fluids.

TREATMENT

For most patients, the only treatment of herpes labialis is to keep the infected area clean by washing with soap and water. Then when the area is dried; if left damp, it will aggravate the inflammation, slow healing and facilitate the occurrence of bacterial infections. To prevent or treat a bacterial infection, can be given an antibiotic ointment (like neomycin-basitrasin). If the more severe bacterial infection or cause additional symptoms, may be given antibiotics by mouth or injection.

Husband or wife infected with genital herpes (herpes simplex) never have to do in the form of individual protection devices must use two different kinds of obstacles, that is spermicidal foam (foam exterminator sperm) and condoms. Spermicidal foam in vitro (in laboratory) capable of deadly virus, while condoms to inhibit or reduce viral penetration. Prevention is a combination of both, which was followed by washing the genitals with soap and water after coitus, can prevent transmission of genital herpes is almost 100%. Meanwhile, the sufferer should try to get rid of the factors originators. In addition to psychiatric treatment that helps overcome the psychological factors. Especially in people with recurrent, factors that play a role in generating the attack, though not as severe primary episode, but involve additional psychiatric disorders.

Anti-viral creams (like idoksuridin, trifluridin and acyclovir) is sometimes applied directly on the blisters. Acyclovir or vidarabin by mouth can be used for severe herpes infections and widespread. Sometimes acyclovir should be consumed every day to suppress the recurrence of skin eruption, especially if the genital area.The standard treatment for HSV are acyclovir in pill form two to five times a day. There is another version of acyclovir with the name of valacyclovir. It can be taken two or three times a day, but it is much more expensive than acyclovir. Famciclovir is another drug used to treat HSV.

Mechanism of action of acyclovir based on the inhibition of viral DNA polymerase enzyme. Immediately converted to acyclovir-guanosine monophosphate asiklo by the enzyme thymidine kinase virus, then changed again to asiklo-guanosine triphosphate (GTP-asiklo). Asiklo-GTP join the viral DNA that would lead to cessation of activity of the enzyme DNA polymerase.

Acyclovir poorly soluble in water, and has a low bioavailability (10-20%) when used orally. Therefore, if the desired high concentration of acyclovir, intravenous injections can be administered to the patient. Moreover, it can also be given valaciclovir who have better bioavailability, which is 55%. Valaciclovir this will be converted to acyclovir in the liver.

This medicine is available on the market in the form of tablets, intravenous injection, topical creams, and eye ointment. Dosage form of a cream used to treat herpes on labia, while herpes that attacks the eyes can be treated with acyclovir dosage forms of eye ointment.

Side effects of acyclovir taken orally and injection include dizziness, nausea, diarrhea, headache, and reaction at the injection site. Had also reported the existence of acyclovir kidney damage when used in intravenous injection in large doses, due to the formation of acyclovir crystals in the kidney. When used topically (topical), side effects that usually happens is that the skin feels dry and burning. Meanwhile, when used on the eyes, some patients will experience discomfort in the eye.

Because acyclovir works by affecting the cell’s DNA, then its use should be avoided during pregnancy. Acute toxicity (LD50) of acyclovir for more than 1 g / kg, this is caused by the low oral bioavailability of this drug.

Therapy on state Acyclovir resistance :
- Intravenous Foscarnet 40 mg/kg BodyMass 8 hours until clinical improvement occurs.
- Cidofovir 1% gel once daily for 5 days which is applied to the lesion.

Topical Medications Over-the-counter (OTC): Most of produ-topical OTC products provide only the liberation of symptoms, they do not reduce the healing time. Using a topical anesthetics containing benzocaine (5% to 20%), lidocaine (0.5% to 4%), tetracaine (2%), or dibucaine (0.25% to 1%) will help relieve burning, itching, and pain . The products most commonly recommended is Lipactin gel and Zilactin. It is important to remember that fatherly-topical anesthetic has a shorter duration of action, usually only lasts 20 to 30 minutes. Leather protectors, such as allantoin, petrolatum, and products containing dimethicone helps retain moisture and prevent wound breakdown (rupture) injuries. Balm, lip balm that contains sun protection may also help prevent additional outbreaks if sunlight is a factor that accelerates. For additional pain relief, use of aspirin, ibuprofen, or acetaminophen may be beneficial. Be sure to use these products as directed, and contact your doctor or pharmacist if you have any questions. Do not use topical steroids have, like hydrocortisone, on the wounds. Docosanol 10% cream (Abreva) is the only topical OTC products that known reduce healing time when applied at the first sign of recurrence (tingling sensations). Docosanol applied five times a day until the wound healed. Side effects are common, including rash and itching at the site of application.

For herpes simplex keratitis or herpes genitalis required special treatment. Local treatment for herpes zoster should include cleaning the wound with salt water and keep it dry. Gentian violet can be applied to the wound.

Treatment of infants and mothers with genital herpes vary, there are hospitals that encourage isolation. Furthermore, in infants viral culture examination, liver function, and cerebrospinal fluid (brain), in addition to strict control during the first month of life. Specimens for viral culture taken from the eyes, mouth, and skin lesions.

To help speed healing in cornea, sometimes ophthalmologists use cotton to remove dead cells and damaged the surface of the cornea. Given anti-viral drugs such as trifluridin, vidarabin or idoxuridine, usually in the form of ointments or eye wash solution.

These drugs do not cure HSV infections. However, these drugs can reduce the length and severity of outbreaks that occur. Your doctor may prescribe “maintenance” therapy with daily anti-herpes therapy for people with HIV who experience frequent outbreaks of HSV. This therapy can prevent most outbreaks. This therapy also significantly reduced the number of days in the month when HSV can be detected on the skin or mucous membranes, even with no symptoms.

Lysine supplements, citrus bioflavonoids, Lactobacillus acidophilus and bulgaricus, and vitamins C, E, and B12 also identified potential in the treatment of herpes simplex virus. However, no clinical evidence to support these treatments, and they are not recommended.

CORRELATION

HSV does not include infections that define AIDS. However, people infected with HIV and HSV simultaneously more likely to experience more frequent outbreaks of herpes. These outbreaks can be more severe and last longer than people not infected with HIV.

Herpes sores provide a way for HIV to pass through the body’s immune defenses, so it becomes more easily infected with HIV. A recent study found the risk of people with HSV infected with HIV is three times higher than people without HSV. Another study found that treating HSV can lead to a significant decrease in HIV viral load. Yet another study found that treating genital herpes does not prevent new HIV infections.

People with HIV and HSV simultaneously also should be very careful when there are outbreaks of HSV. At that time, his HIV viral load usually increases, which increases the risk of transmitting HIV to others.

From the other hand, treatment of HSV in people with HIV and HSV infection can simultaneously reduce HIV viral load. This treatment can also reduce the risk of spreading HIV to others.