Herpetic Ulcer : A Case Report and A Review Literature

Herpes infection causes painful sores in lips, gingiva, tongue, palate & buccal mucosa, which is characterized by sudden onset and severity of symptoms .It also causes symptoms like fever and muscle ache. The causative agent for herpetic infection has been identified as herpes simplex virus which is a DNA virus, in two forms HSV-1 &HSV-2. Most oral, facial and ocular infection results from HSV-1.In this paper we presented acase of Herpes infection in 23year old male patient.


INTRODUCTION
Herpetic infections typically affectchildren, but this infection also occurs in adults, because of the limited symptoms a dentist may be the first health care practitioner consulted.HSV is a double standard DNA virus and is a member of Human Herpes Virus (HHV) Family officially known as Herpetoviridae 1 virus exists in 2 forms,HSV-1 affects mostly in oral, facial and ocular infections and HSV-2 accounts for most genital and cutaneous lower body herpetic lesion.
Oral herpes is an infection which is caused by herpes simplex virus .The virus causes painful sores on lips, gingiva, palate, and the buccal mucosa,this usually occurs in older children and consists of fever, malaise, headache, cervical lymphadenopathy and a vesiculo-ulcerative eruption on the peri-oral skin, vermilion border of lip or any intra-oral mucosal surface.HSV-1 is usually acquired during childhood but the prevalence of infection is seen in both the age groups.
Pain, burning, tingling, or itching occurs at the infection site before the sores appear.Then clusters of blisters erupt.These blisters break down rapidly and, when seen, appear as tiny, shallow, grey ulcers on a red base.The diagnosis is based on information provided on clinical examination.Treatment is use of antiviral medications either topical or systemic.

Case report
A 23 year old male patient came to the department of oral medicine and radiology in Tagore dental college with a chief complaint of pain and burning sensation in the upper part of the mouth for the past 3 days.History reveals that he developed small vesicles in the upper part of the mouth after that it ruptured before 3 days.He had burning sensation while having spicy foods for the past 3 days.
On clinical examination right submandibular lymph node was palpable which is 1x1cm in size, mobile and tender on palpation.Intraoral examination reveals multiple small ulcersin size of 1x1 mm seen in the area adjacent to the right midpalatine raphae (Figure 1).Ulcers have well defined margin and surrounded by eythematous border.A single large ulcer seen in palatal mucosa of 16, 17 (Figure 2).Ulcer is 3x2 cm in size and margins of the ulcer is well defined.It hadeythematous border and yellow pseudomembranous slough in the base.Ulcerwas soft in consistency and severetender on palpation.Other clinical findings such as calculus, stains and multiple dental caries were present.
Based on the history and clinical examination the patient was diagnosed as herpetic ulcer.Patient was advised for medications such as diclofenac mouth rinse, acyclovir ointment and multivitamins supplement.Patient advised to drink plenty of water and soft diet.Then we recalled patient after 1 week and follow up was being made.

DISCUSSION
Two of the known Herpesviridae, HSV-1 and HSV-2 are responsible for primary and recurrent mucocutaneous herpetic infections.Even though herpetic gingivostomatitis is primarily an HSV-1 infection isolated cases of HSV-2 association have been reported in older patients, probably transmitted sexually and causing genital infection.
Herpetic infection, both acute and recurrent, is a self-limiting disease with a healing period of 1 to 2 weeks.The most common mode of transmission of HSV is the saliva 4 of the carriers.Infection on the hands of health care personnel from patients shedding HSV may result in herpetic whitlow.
Primary infection occurs in childhood from infected saliva or herpetic lesions 5 .Reactivation can occur at any time and may be triggered by ultraviolet light, stress, fever, cold, pregnancy or menstruation, gastrointestinal upset or local trauma.Recurrences are generally less severe than the primary infection and severity and frequency tend to diminish with time.
It is important to distinguish primary from recurrent herpetic infection.In general terms, a primary infection is more severe, with associated lymphadenopathy, fever and malaise.Recurrent infections occur at various intervals (ranging from monthly in some individuals to seldom in others)and affect the non-movable intraoral tissues (the hard palate and attached gingiva)in contrast to primary herpes which can occur anywhere in the mouth.
Once HSV penetrates the host's epithelialcells, viral replication occurs.The newly formed HSV come into contact with sensory nerve endings and are transported to the corresponding ganglion 2 .In oral herpes, the most common site is the trigeminal ganglion.Here the viral DNA enters the ganglion, where it becomes inactive or latent.The incubation period is the period during which viral replicationand transport to the sensory ganglion occur.For HSV this period is variable and can range from 2 to 12 days, but in most cases it is approximately 1 week.The severity of the primary infection depends on the degree of viral replication, the host's response to the foreign pathogen and the speedwith which latency is established.
Pain, burning, tingling, or itching occurs at the infection site before the sores appear.Then clusters of blisters erupt.These blisters break down rapidly and, when seen, appear as tiny, shallow, grey ulcers on a red base.A few days later, they become crusted or scabbed and appear drier and more yellow 8 .The most intense pain caused by these sores occurs at the onset and make eating and drinking difficult.
The diagnosis of herpetic ulcer is usually made by clinical presentation and history.In the present case the typical cluster like appearance of ulcers on the palate surrounded by erythema and extreme tenderness which is seen adjacent to midpalatine raphae and a single large ulcer was seen palatal mucosa of 16 and 17.
The diagnosis can be confirmed via laboratory tests: 6 Serological assays (anti-HSV IgM and IgG), the Tzanck test and immunofluorescence, but the culture of viral isolates is still considered to be the gold standard 7 .HSV antibody testing can detect both viral types -HSV-1 and HSV-2.
Treatment of the acute herpetic infection includes symptomatic measures; if the disease is diagnosed early, systemic antiviral therapy is advised in order to accelerate clinical resolution.Recurrent herpetic lesions 9 are frequently managed with topical application of antiviral agents.Palliative and supportive management of oral herpetic infections variably consists of controlling fever and pain, preventing dehydration, and shortening the duration of lesions.Topical anaesthetics, analgesics, and antipyretics, rinsing with lidocaine viscous (2%), before each meal, effectively reduce pain during eating.

CONCLUSION
Oral herpetic infections are not limited to children but can occur at any age.The recognition of the classic presentation of signs and symptoms is important, particularly in middle-aged and elderly people in who can complicate with the pre-existing medical condition.Prevention is better than cure.Lifestyleadaptation and modification and stress management techniques may help to prevent the severity of the infection.and Treatment, 10th ed.: BC Decker Inc.; USA.68-71 (2003).9.

Fig 1 :Fig 2 :
Fig 1: Shows multiple small ulcers inthe area adjacent to the right midpalatine raphae