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Viruses have different structures, compositions, pathological and clinical manifestations. Viruses are extremely small in size that are capable of passing the bacterial filtrate.

General considerations

Small viruses lack enzyme system while large ones such as the organisms of trachoma, lymphgranuloma venerum have some and this is why the latter group is susceptible to chemotherapy, while the first is not.

Viruses are obligate intracellular parasites, the principle site of attack in the skin is the epidermis . These may cause localized or systemic manifestations that varies from erythematous lesions, vesiculation, ulceration , scarring or severe constitutional symptoms .



Herpes simplex is the most common of all viral infections. The herpes virus causes infection. Many patients become carriers.

Herpes infection is a contagious disease and spread by droplet infection, contact as in kissing or contact with lesions of infected individuals and infected fomites .

Clinical picture of herpes simplex

The incubation period of herpes infection is from 4-5 days . The lesions may be cutaneous or mucocutaneous. Primary lesions may affect any age but is most common in children , while new born under 4 month of age has transferred maternal antibodies and are rarely infected .

In the majority of cases infection is subclinical or asymptomatic .

Primary and recurrent infections are highly infectious and heal completely but the virus can be detected in the cells for many years.

Tingling and burning sensation appears at the involved site, then few small grouped vesicles on an erythematous base appear which rupture and heal within two days. The course may be longer when secondary bacterial infection complicate the lesions.

Herpes infection is characterized by an acute eruption of grouped vesicles upon an erythematous base most frequently on the mucocutaneous junction. The symptoms may be very mild attacks or very severe even fatal in newborn.

Infection may be primary in individuals who have no specific neutralizing antibodies or recurrent which is exceedingly common in individuals who posses specific antibodies.

Fig. 87. Herpes labialis

Fig. 88. Herpes labialis

Fig. 89. Herpes of lip & Tongue

Fig. 90-. Eczema herpeticum

Fig. 91. Eczema herpeticum



Herpes simplex virus (HSV) infection in the newborn is generally a serious disease with a high mortality rate.

Modes of infection

Transmission of the HSV type II by contact with infected genital tract secretions during delivery.
Intra-uterine HSV infection may occur, due both to transmission across the placenta, or to an ascending from the infected genitalia if the mother has prolonged rupture of the fetal membranes.

Contact with non-genital sites, both maternal and non-maternal.

Clinical features

The skin lesions are isolated or grouped vesicles that appear mainly on the scalp and face. Occasionally generalized bullous lesions or widespread erosions may occur without obvious vesicles . Healed lesions may show atrophy or scarring simulating epidermolysis bullosa .

When the infection is acquired during birth, the initial lesions have a predilection for the scalp in vertex presentations, and the perianal area in breech presentations

Oral lesions are also frequent, and take the form of erosions on the tongue, palate, gingiva and buccal mucosa.

Central nervous system involvement

Fatal cases may occur when infection is disseminated, even when appropriate antiviral therapy is given.

Early recognition and adequate early treatment with Acyclovir does appear to protect infants from dissemination of infection where this is initially confined to the skin .

Types of herpes simplex

Type 1: causes cutaneous and oral lesions. Some rare genital lesions are due to this type.
Type 2: this is the cause of herpes progenitalis.

Different clinical types of Herpes Simplex

1.       Primary herpes simplex infection

Cutaneous lesions appear as painful grouped vesicles on an erythematous base around the mouth that ulcerate leaving a painful ulcer.


                                                                                                                 Fig. 91a. Primary herpes simplex

Different clinical variants of herpetic lesions may appear with different clinical pictures according to the site involved either in the skin or the mucous membrane.

2. Mucous membrane lesions

This is a very common viral infection in young children between the age of 2-5 years , in older children and young adults . The condition begins with fever and the sudden development of painful oral lesions, which ulcerate. These may be misdiagnosed as Vincent‘s angina, aphthous stomatitis or other ulcerating bullous diseases. The mucous membrane becomes red, swollen and painful with ulceration. These are considered very important cardinal signs of herpetic infection of the mucous membranes .


                                                                        Fig.91b. Herpes of the mucous membrane

Extensive involvement of the mucous membrane of the mouth, tongue and pharynx may interfere with feeding and the child becomes debilitated and seriously ill .

The lesions show shallow ulcers on an erythematous base covered with whitish exudate, which bleeds when removed.

Blood tinged saliva in severe cases causes dribbling in young children.

3. Herpetic vulvo-vaginitis

The lesion appears on the vaginal mucous membrane as painful sharply defined plaques accompanied usually by vesicles on the adjacent skin .

Lympadenopathy of the inguinal lymph nodes.

Constitutional symptoms such as fever and malaise may accompany herpetic vulvo-vaginitis.

The inflammation may resolve within 10 days .

Recurrence of the mucous lesions is uncommon while the skin lesion may recur precipitated by fever, fatigue, debilitating diseases or trauma

4. Eczema herpeticum (Kaposi‘s Varicelliform eruption)

This is a primary herpes simplex infection in infants and children with atopic dermatitis due to inoculation of the atopic area with the vaccine virus. The condition may be very severe and even fatal.


                                                                                                                                          Fig.91c. Eczema herpeticum

Clinical features

Sudden appearance of umbulicated varicelliform eruption on the sites previously involved by atopic dermatitis. The vesicles may be hemorrhagic or complicated by secondary bacterial infection causing more severe constitutional symptoms such as fever and lymphadenopathy.

The vesicles may continue to appear during the course of the disease till enough neutralizing antibodies are formed where in such cases the symptoms become less severe , with shorter course and called the abortive form .

N.B. Infants or children having atopic dermatitis should not be vaccinated with small pox vaccine due to the risk of eczema herpeticum.

The risk of vaccination far exceeds the risk of small pox infection .

5.Fatal viraemia (generalized infection of the new born)

This is a systemic viral infection that begins in the first week of life. This manifests with fever, subnormal temperature, cyanosis, hepatosplenomegaly, kidney and adrenal involvement besides the herpetic skin lesions .

This is a severe and even fatal herpetic lesion of the newborn caused by herpes virus type 2 due to infection of the mother by herpes genitals. When the mother has genital herpes during labor, there is a strong indication of delivery by cesarean section.

6. Herpetic whitlow

Herpes virus may be seeded on a wound.



                                                                          Fig.91d & e. Herpetic whitlow

Vesiculation and ulceration appears on the infected area .

Care should be taken not to incise the wound because the content of the vesicles are infectious and the condition is self-limiting causing minimal symptoms.

7. Herpetic kerato-conjunctivitis

Herpes simplex may affect the eyes causing corneal ulcers , keratitis or kerato-conjunctivitis. The adjacent skin of the eyelids may show herpetic vesicles and ulceration.

8. Herpes progenitalis

This is a venereal disease, which is sexually transmitted. The condition begins with burning and tingling on the affected skin followed by the appearance of small vesicles that tend to ulcerate . The course is short but recurrence is common at the same site or near by in the genital area .

The common site is on the penis and scrotum in males, vulva and vagina in females. Infected mothers may transmit the disease to their babies during or after labor.

9.Anogenital herpes in infants and children

Ano-genital herpes in younger age groups have number of possible causes. Sexual abuse should be considered where thorough history and investigations are necessary to detect the mode of infection. Direct infection from the nursery, mother, housemaids or others may be one of the possible causes       

10.  Central nervous system herpetic infection

Rarely herpes virus may invade the nervous system leading to encephalitis, meningeal irritation, and cranial nerve lesions with localized neurological signs and coma. The condition may be fatal .

11.  Recurrent herpes simplex

One of the distinct features of herpes simplex is its tendency for recurrence. It is believed that the herpes virus becomes dormant in the tissues and flare up when there is optimum predisposing factors.

Herpes simplex has certain familial tendencies and infection with the virus will not lead to lasting immunity as most other viruses . Recurrence of the herpetic attack usually involves the same previous location or a near by areas.

Recurrence of the lesion may be precipitated by different factors such as common cold, fever, strong sunlight, psychic trauma, gastrointestinal upset and menses. Almost all humans eventually had an attack of herpes simplex during their life.

Diagnosis of herpes simplex

Diagnosis of herpes simplex can be established by:

·         Clinical picture.

·         Smear from the base and roof of the vesicles demonstrates giant cells and multiple nuclei and inclusion bodies .

·         Electron microscopy demonstrates the intercellular virions characteristic of herpetic lesions .

·         Indirect fluorescent antibody .

·         Neutralizing antibodies shows rising titer in primary herpetic lesions.

·         IgM antibody to herpes simplex virus

·         Tissue cultures . This is usually expensive and rarely needed .


It should be noted that topical corticosteroids are contraindicated in viral disease infection since they may cause flare up of the lesions and depress serum interferon.

Mild uncomplicated eruptions of herpes simplex require no treatment.

Mucocutaneous lesions may be treated simply by 10 percent aluminium acetate or 1:8000 potassium permanganate compresses to dry the lesions .

Topical Acyclovir : every four hours is usually enough for primary and in non-recurrent lesions. Topical Acyclovir is of established value for herpetic keratitis.

Systemic Acyclovir : is the treatment of choice for severe or potentially severe herpes simplex infection. Treatment should be started as soon as possible. The usual dose is 5 mg/kg 8-hourly intravenously .

In neonatal herpes and encephalitis: twice that dose has been used. As the drug is excreted via the kidneys the dose must be scaled down in renal failure. Transient rises in blood urea and creatinine may occur; slow infusion over one hour in an adequately hydrated patient is recommended.

In the immune compromised patient , mucocutaneous herpes simplex respond well to intravenous Acyclovir . The infection can be prevented by intravenous or oral Acyclovir, which should be started several days before the anticipated immuno-suppression and continued throughout the period of greatest risk.

The risk to the infant from primary herpetic vulvo-vaginitis in the mother at the time of delivery is so great that ceasarian section is indicated, and prophylactic Acyclovir should be considered for the neonate .

Acyclovir orally has proven clinical value against herpes simplex and varicella-zoster viruses, though the latter is somewhat less sensitive to it. The usual adult oral dose is 200 mg five times daily meanwhile, 800 mg twice daily has been used with success. The drug is given for 5 days or more. Acyclovir is effective in eczema herpeticum and neonatal herpes which reduces the mortality and morbidity of herpes simplex encephalitis .

Chicken pox and herpes zoster dose: 

* children 6 years and over: 800 mg four times daily for 5 days.

* 2-5 years : 400mg  Zovirax fout times daily for five days.

* under 2 years :200mg Zovirax suspension ( teaspoonful , 5ml ) four times daily for five days.

Herpes simplex :

* Adults and children above 2 years : one tablet 200mg or 5 ml suspension five times daily for  5 days.

* children under 2 years : half the adult dose.

Recurrent attacks of herpes simplex :

Initial eruptions of genital herpes improve significantly by oral Acyclovir but recurrent infections respond less well .

Frequent recurrences can be suppressed by long-term treatment.

Prophylactic doses vary between 200 mg and 1000 mg daily (adult doses). A typical regimen is 400 mg twice daily, gradually reduced to find the minimum effective dose for the individual patient.

The prevention of the predisposing factors should be considered.

Treatment of the more severe recurrences in adults may, however, be worthwhile. In such cases it is important to use Acyclovir tablets for longer period in smaller tapering doses which may last for few months .

The regime that I usually use in such cases is as follows :

Five tablets, 200 mg daily are given for five days, then three tablets daily for another five days, and two tablets daily for five days, one tablet daily for five days and then one tablet twice weekly for one month and one tablet weekly for three month. I tried this regime and gave encouraging results with severe recurrent cases of herpes especially type 2 herpes.

Interferon: may have some effect on recurrent herpes simplex.

Other reported methods include topical surfactants and Cryotherapy.

Systemic Vidaribine or Phosphonoformate for severe cases of herpes simplex infection resistant to Acyclovir.



Herpes zoster is a vesicular viral eruption caused by the varicella -zoster virus . A cross immunity is believed to exist between the two diseases. Children infected by varicella are immune to herpes zoster and vice versa.

Fig. 92. Herpes zoster

Herpes zoster

  Fig. 93. Herpes zoster

Clinical picture

The incubation period is 1-2 weeks. The eruption has a rapid onset, usually unilateral and appears along the course of nerves. The lesion is preceded by prodromal symptoms such as mild fever, pain, burning and tingling at the site of infection.

Grouped clear vesicles on an erythematous base appear which become purulent and rupture later on to form crusted lesions  

                                                        Fig. 93.d,e&F. Herpes zoster 

                     Fig. 93b&c . post-herpetic scar                                                                                                                                                                                                                                                                                                                                                                                                                                                           Fig. 93b. Post herpetic scar                                                                                                                                                                                                                                                                           

Scarring at the site of the primary lesion usually follows healing.

In children the clinical picture may manifest with erythema multiform-like reaction characterized by sudden appearance of round red papules. Erythema multiforme may be recurrent in the spring or precipitated by exposure to sunlight or after corticosteroid treatment .

Post herpetic neuralgia may appear after healing of the lesion accompanied with severe pain that may be agonizing and persist is for a long time.

Herpes zoster lesions are usually localized but generalized eruption may occur with chronic debilitating diseases such as malignant lymphomas .


Gangrene of the zoster lesions especially in debilitated patients.

Cellulitis and pustular lesions due to secondary bacterial infection.

Kerato-conjunctivitis in ophthalmic lesions may cause scarring and blindness due to progressive ophthalmic involvement.

Encephalitis and ataxia due to cerebellar disturbance is a rare complication.

Pneumonitis with cough , dyspnea , cyanosis and scattered calcified nodules of the lung.

Post herpetic neuralgia  is uncommon complication that is sometimes severe and lasts for a long time causing agonizing pain.                                                                               


Potassium permanganate compresses 1: 8000 can dry wet oozing lesions.

Topical Acyclovir (Zovirax )cream applied every four hours.

Disposal gloves should be used when applying the cream by the fingers.

Oral Acyclovir - adult dose is 200mg. five times daily for five days or 800mg twice daily. Faciclovir 250 mg. three times daily is also effective. Another antiviral preparation is Valacyclovir 1000 mg. three times a day for one-week. These doses are the adult dose.

Children's doses depend on the body weight. Younger age groups can be given Acyclovir in a dose of 5mg,/kgm body weight.

Strong sedatives sometimes are necessary to relieve severe pain .

High doses of vitamin B complex may help relief of post herpetic neuralgia .

Steroid injection as ( depot medrol 40mg. ) is believed to minimize post herpetic neuralgia if given early . Children can be given 10-mgm depot medrol as a single injection in the early stage of the disease . Topical steroids are contra indicated in viral skin diseases .



Congenitally acquired herpes zoster in the newborn occurs due to transplacental infection with varicella -zoster virus . This is a serious problem that produces congenital abnormalities . Congenital varicella zoster may be acquired by transplacental varicella-zoster virus infection . The manifestations that appear after birth are cutaneous scars , limb and eye abnormalities . The manifestations are serious if infection occurs in late pregnancy .


Acyclovir is given in a dose of 1000 mg./day orally for five days . Topical Acyclovir is applied to the skin or the ophthalmic lesions repeatedly .



Chicken pox is a highly infectious viral diseasecaused by the varicella - zoster virus. Children are the most common age group infected. A rash that has a central distribution characterizes the disease, which occurs in widespread infection and occurs in epidemics especially in schools and crowded communities. Usually there is lasting immunity for varicella and herpes zoster ,however zoster may occur sometimes after a varicella infection.

Clinical Picture

The incubation period is from 1-2 weeks . Transmission is usually by droplet infection, direct contact with the lesion or from recently contaminated fomites.

Systemic manifestations:

The disease presents with a mild attack of sore throat , fever , headache that lasts for 2-3 days . This is followed by the appearance of the characteristic rash on the trunk and mucous membranes, which may become generalized .

Skin manifestations:

Skin rash manifests with erythematous macules, vesicles and pustules which rupture leaving crusted lesions. The rash is pleomophic where different stages of the rash , macular , vesicular and pustular lesions of different sizes are present at the same time .

The crust may separate after one week leaving in severe cases scars and hyperpigmentation especially in the dark skinned patients .

The lesion has a characteristic central distribution ; on the trunk more than on the extremities .

Itching is usually mild but may be severe in some cases .


The clinical picture is usually mild but may become severe mainly in adults , involving the skin and mucous membranes associated with fever and severe constitutional symptoms .



             Fig. 93 c,d,e,f,g,h. Complicated chicken pox (Caurtesy of Dr. W.Khalaf - R.K.H -K.S.A)                              

Encephalitis, meningeo-encepalitis and pneumonia are uncommon complications of the disease.

   Fig. 94. Chicken pox

   Fig. 96-. Chicken pox

   Fig. 95. Chicken pox

   Fig. 97-. Chicken pox


The diagnosis of chicken pox depends on different data mainly:

·         Characteristic clinical picture.

·         The centripetal distribution of the skin lesions.

·         Pleomophic different stages of the eruption.

·         Laboratory investigations.

Differential Diagnosis

Small pox

Eczema herpeticum

Pustular impetigo

Drug eruption


Children should not go to school until complete healing of the lesions.

Mild cases can be treated with mild soothing agents.

Calamine lotion, which is commonly used to dry the lesions and minimize itching, but excessive use can cause more dryness and irritation.

Weeping wet lesions are better treated by Potassium permanganate compresses 1:9000 applied twice daily .

Non-steroid anti-inflammatory topical cream such as Pufexamac (Droxaryl Cream) may be applied. This medication is safe and we found out that it is very effective in rapidly clearing the skin lesions and relieving itching.

Antihistamine orally may be needed for relieving of itching.

Severe cases especially in adults, may need isolation and hospitalization till the severe eruption, constitutional symptoms or complications are controlled.



The risk of fetal infection with varicella occurs when a pregnant woman develops chicken pox 3 weeks before delivery .

Clinical Manifestations

The manifestations, prognosis and the severity of the disease depend on the onset of infection in the mother and infant.

1.       Pre-natal infection

a.       Mild neonatal infection - the infection is usually mild if the onset of the disease in the mother is in the first week before delivery and within the first 4 days in the neonate.

b.       Severe and disseminated neonatal infection - this may occur if the mother is infected within 4 days before delivery and the neonate is infected in the first 5-10 days after delivery.

The infection is likely to be disseminated and severe, with involvement of the lungs, liver and the brain. In these cases there is usually a high mortality rate.

c.       Congenital varicella syndrome - Intra-uterine varicella infection in the first trimester may result in a characteristic combination of defects in the neonate known as the "congenital varicella syndrome." Limb hypoplasia and zosteriform cutaneous scarring are common manifestations.

2.       Post-natal infection

Post-natal acquired varicella that may be more severe in the following cases:

If exposure occurs in the first few days of life, particularly in infants whose mothers had not previously been infected and therefore did not provide passive immunity.

Premature infants in whom very little passive immunity have been transferre

General Manifestations

Headache, nausea, vomiting, fever, nucheal rigidity, and rarely seizures.

Central nervous system involvement occurs in less than 1% of cases of varicella.

Cerebellar ataxia and Parkinson-like features are the most common presenting neurological signs .

Skin manifestations

The same as the ordinary varicella in different age groups. The lesions may be severe and the rash is more widespread and extensive.


Distinction between neonatal varicella and herpes simplex virus infection can be reliably confirmed only by viral culture.

A history of genital herpes in the mother .

The presence of kerato-conjunctivitis .

Typical herpetic oral lesions.


The condition may be serious. It may endanger the infant‘s life.

Hospitalization and proper nursing is of prime importance .

Zoster-immune globulin or gamma globulin should be given to neonates born to any mother who develops chicken pox during the last 4 days of pregnancy.



Infectious exanthemata include viral diseases that are characterized by exanthematous skin lesions, fever and systemic manifestations. The problem may pass without disturbing the child health or may be severe endangering his life .

Exanthemas include mainly measles, rubella, roseola and infectious mononucleosis .



Measles is an endemic viral disease . The most majority of the population have had the disease. Measles is infectious during the prodromal stage, which is followed by the skin rash.

Clinical Feature

Prodromal symptoms:

The incubation period is from 2-3 weeks . The lesions begin with a prodroma of fever up to 39*C, headache, malaise, sore throat, coryza and conjunctivitis. The early manifestations are not characteristic at the beginning and may be confused with influenza.                                                           

The symptoms subside as the rash develops.

Skin manifestations

Skin rash begins few days after the prodroma where the symptoms may be more severe and the child may become seriously sick .

Rash appears first on the forehead and is characteristically more dense behind the ears which later involves the face, trunk and extremities. The temperature then returns to normal following spread of the rash .

Mucous membrane involvement

One of the main characteristic of measles is the Koplik‘s spots that appear as small bluish white lesions on an erythematous base around the orifices of the parotid duct and occasionally on the lower lip.

Conjunctivitis and photophobia are common manifestation of measles .

Lymphadenopathy may be present but usually it is not a marked feature.

Severe cases may show serious complications such as encephalitis .


The different lines of treatment are general and these include the following: Palliative treatment

Bed rest and protection from exposure to strong sunlight .

Symptomatic treatment mainly for cough .

Antibiotics : If there is secondary bacterial infection .

Corticosteroids may be needed in cases complicated by encephalitis .

Light food and fluids are given especially during the prodromal stage .

Hospitalization in severe and complicated cases of measles where concentrated plasma globulin may be given.


( Rubella )

German measles is a very mild exanthematous disease. If a pregnant women is infected during the first trimester, serious fetal malformation may develop such as deafness, cardiac malformation, cataract, microcephaly and dental malformation .

Usually miscarriage is medically indicated if these abnormalities are confirmed .

Clinical Features

Prodromal Manifestations

Prodromal symptoms may be very mild and usually pass without notice .

Enlargement and tenderness of lymph glands begin 5-7 days before the rash appears. The enlargement is generalized but characteristically involves the suboccipital, postauricular and cervical glands but this is not pathogonomonic for rubella. The tenderness of the glands subsides after a day or two but palpable enlargement may continue for several weeks.

Skin Manifestations

Skin eruption  present with  fine round pink macules that appear on the face, head and trunk which persist for 2-3 days and then disappear .

Mucous Membrane Manifestations

Dull-red macules or petechiae may be detected on the soft palate, but Koplik‘s spots are not detected .


Arthritis is not uncommon, involving small joints of the hands feet or knees, elbows and shoulders.

Purpura, thrombocytopenic or non-thrombocytopenic .

Encephalitis is very rare.


Usually the condition resolves within few days and no treatment is required.

Vaccination with the rubella virus vaccine for females in the child-bearing age is necessary, taking much care that the female is not pregnant.



Mothers who have had rubella during the first trimester of pregnancy may give birth to infants with a syndrome triad consisting of :

·         Congenital cataract

·         Cardiac defects

·         Deafness

Skin Manifestations

Cutaneous lesions are among the most prominent clinical features of congenital rubella.

The typical lesions are present at birth or appear during the first 48 hours. The skin rash is discrete, rounded, red or purple infiltrated macules, 3-8 mm in diameter. The lesions are mainly on the face, scalp, the back of the neck and on the trunk.

Occasionally the lesions are slightly raised. They tend to fade over a period of weeks. These lesions have often been described as purpuric‘ and have generally been attributed to thrombocytopenia, which is another common feature of congenital rubella .

Systemic Manifestations

Disseminated infection of rubella causes intra-uterine growth retardation, microcephaly, micro-ophthalmic and a wide variety of other serious manifestations.


No specific treatment.

Symptomatic treatment for the accompanying manifestations .



This is a serious problem, if infection occurs during the first trimester of gestation. Prenatal damage with risk of fetal abnormalities occur in most cases. Intra-uterine infection leads to malformation of the fetus.

Heart and eye damage is most frequent in embryos infected under 6 weeks.

Deafness and mental deficiency occurs in embryos of all ages up to about 16 weeks.

Mental retardation and microcephaly may not be apparent until a year or more after prenatal infection .



Roseola is an exanthematous viral disease affecting babies and young children.

Clinical features

Prodromal symptoms

The disease usually presents with variant and grave manifestations such as fever, convulsions and lymphadenopathy. The child may be seriously ill. On the fourth or fifth day the fever suddenly drops and the child general condition is improved where he becomes active and has an increased appetite.

Skin manifestations

Rose-colored discrete macules appear after the drop of fever . The common sites for the rash is the trunk, neck , buttocks , extremities and to less extent on the face . The rash may persist for few days where it vanishes gradually.

Mucous membranes are not involved .


(Exanthema subitum)

Roseola infantum is a common exanthematous disease of babies and young children almost restricted to the first 3 years of life. The disease is believed to be due to Coxsackie virus .

The incubation period is about 10 days and is characterized by sudden onset of high fever that usually subsides with the onset of the skin eruption.

Clinical Features

Prodromal manifestations -

High fever, convulsions.

Sudden drop of fever.

Within four days the child who has been severely ill sits and resumes his activities.

Skin manifestations

Skin eruption appears when fever begins to subside .

Periorbital edema and hematuria are usually the early manifestations.

The skin rash is morbilliform erythema consisting of discrete rose-pink maculopapules that appears first on the trunk with mild involvement of the face . The skin lesions may become extensive where it may spread to the neck , arms, and legs. After 1 or 2 days the rash fades, leaving neither scaling nor pigmentation.

Mucous membranes are spared from any lesion .

Cervical and occipital lymph nodes are usually enlarged.

Systemic manifestations as febrile convulsions are not uncommon but encephalitis is rare.  The disease is uniformly benign.

Differential Diagnosis

Roseola may simulate different skin conditions such as measles and drug eruption . The disease can be differentiated from measles by the absence of prodromal respiratory symptoms , distribution of the eruption and the absence of Koplik‘s spots .


(Variola Major)

Small pox is a highly infectious viral disease that has a high mortality rate and occurs in epidemics. Different strains of small poxvirus have different virulence and variable clinical manifestations.

Clinical Picture

The clinical picture of small pox may vary greatly . The incubation period is about 12 days .

Skin manifestations

The cutaneous lesions may show hemorrhagic pustules or erythema multiforme like eruption.

Sudden onset of fever and malaise with an exanthematous papular, vesicular, pustular and crusted lesions involving characteristically the face, extremities, palms and soles.

Secondary bacterial infection may cause, secondary pyogenic infection of the skin .


Corneal ulcer .

Encephalitis .


·         Microscopic examination of skin scrapings of fresh vesicles show elementary bodies.

·         Electron microscopy.

·         Culture of the scrapings or the contents of the vesicles .

·         Complement fixation test.


No specific treatment against small pox has been developed .

Cases are isolated in a designated small pox hospital .

Complicated cases by secondary infection can get benefit from antibiotics. Corticosteroids may have a value in encephalitis.

Symptomatic palliative treatment.

Preventive measures by small pox vaccination .

However, routine vaccination of children is no longer necessary in areas where the disease is eradicated, while in certain areas infected with small pox vaccination is necessary.



The vaccina virus is an attenuated Cow box virus that has been propagated in laboratories for small pox vaccination. Skin lesions due to vaccinia virus result from complications of vaccination against small pox .

The manifestations appear in different clinical pictures :

Immediate response or immune response : A papule appears immediately after vaccination that involutes after the third day of vaccination.

Primary response : In the third day of vaccination a papule appears that becomes a vesicle on the ninth day then a pustule . The condition is accompanied by regional lymphadenopathy.

Accelerated response : A papule appears on the fifth day and then a small vesicle is formed which involutes on the ninth day.

Generalized vaccina : generalized papulo-vesicular eruption may follow 10 days after vaccination. The eruption then changes to pustular type, which may involute within three weeks . Successive crops may follow . Retinitis and ocular paralysis may complicate the condition .

Eczema vaccinatum : This is the same as eczema herpeticum , which occurs with herpes simplex due to inoculation of the vaccine at sites of atopic dermatitis.

Multiple vaccination : Multiple skin sites may be involved due to contact of the skin from vaccinated site of the same individual or contact with other vaccinated .

Roseola vaccinia : Infants and young children are mostly affected. The skin rash is morbilliform eruption. The vaccinated area becomes crusted and surrounded by an erythematous halo, which involutes within few days.

Vaccina necrosum : This occurs in infants under six months of age that are unable to produce antibodies in response to vaccination . Necrotic metastatic lesions occur throughout the body. The condition is usually fatal .

Roseola vaccinia : Symmetrical discrete papular , macular and morbilliform eruption appears two weeks after primary vaccination with small pox vaccine. The site of vaccination becomes crusted and surrounded by an erythematous halo .


This is a viral disease caused by Coxsackie virus 16 affecting mainly children.

Clinical Features

Prodromal symptoms: fever precedes the appearance of the rash.

Skin manifestations: a striking features of this disease is the appearance of oval, linear or crescent maculopapular eruption that shortly becomes vesicular on the hands, feet and in the mouth. The eruption, which appears on the hands and feet, is usually parallel to the skin lines.

Spontaneous recovery is usually within two weeks and treatment may be not needed .



This is a highly contagious viral disease that has an incubation period from 2-10 days. It is transmitted to man directly from infected animals such as cattle, goats or from consuming their infected milk . The disease may have serious complications and sometimes may be fatal especially in children .

Clinical Features

Prodromal symptoms are mild. This includes fever, malaise, burning and dryness of the mouth with excessive salivation .

Skin eruption appears with the decline of fever and disappearance of the prodromal symptoms.

Skin and mucous membrane manifestations : Swelling , itching and burning sensation of the fingers may be the earliest skin manifestations . Vesicles then appear on the mouth , oropharynx , palms ,soles , fingers and toes.


Symptomatic treatment.



HIV disease in childhood in many respects has the same manifestations such as that of the adult type.

Clinical Features

The most common manifestations of HIV in infected infants and children are:

·         Failure to thrive.

·         Encephalopathy with developmental delay.

·         Chronic parotid swelling .

·         Hepatosplenomegaly.

·         Lymphadenopathy .

·         Chronic diarrhea.

·         Bacterial infections: septicemia, pneumonia, otitis media and cutaneous infection mostly due to Staph. aureus causing impetigo, abscesses and cellulitis.

·         Pneumonitis: which may be due to infection with Epstein-Bar virus , is common and characteristic.

·         Malignancy :Kaposi‘s sarcoma occurs in only about 5%.

Laboratory diagnosis

1.       B-cell dysfunction: is an important early finding .

2.       Circulating HIV antigen :is likely to be obscured by maternal antibody.

3.       T-cell defects: characteristic of adult HIV disease are usually a late feature in young children

4.       HIV antibodies - the presence of HIV antibody IgG in infancy may simply represent passively acquired maternal antibody, and cannot be used as an indication of HIV infection.


Some infected children develop AIDS within their first year. In the majority of cases, the infection progresses more slowly .

Treatment of HIV infection in childhood

Treatment of complications .

Treatment of secondary bacterial infections mainly pneumocystis pneumonia.

Antiviral drug therapy at present cannot cure the infection.

The principal agent is zidovudine (Azidothymidine, AZT, Retrovir).In spite there is imptovement of some cases, but these must be weighed against the drug toxicity including anemia, granulocytopenia, myositis, headache, confusion, insomnia, nausea, fever, rash and nail pigmentation.

Zidovudine is usually given orally for prolonged periods. Occasional cases of resistance have been reported. Serum and CSF HIV antigen levels can be greatly reduced and may become undetectable.

Long-term intravenous infusion of Zidovudine may lead to improvement of childhood neuro-developmental abnormalities .

There is no available vaccine or specific treatment now for HIV, meanwhile efforts are tried in the different international centers to find a curative treatment.


Prevention of transmission of HIV is therefore of paramount importance. The guiding principle is to avoid contact between infected secretions and mucosal surfaces or broken skin.



There are reports of occasional cases of apparent transmission in breast milk. In one case a baby probably acquired HIV from an infected wet nurse. The risk is believed to be low compared with that of pre- or intrapartum transmission in such cases .


(Verruca Vulgaris)

General Considerations

Warts are extremely common viral infection of the skin of children and young adults. They have different morphological characters concerning the shape, size and sites involved. They may be single or multiple, sessile with rough hard surface or flat as those on the face. Warts may be dry such as warts of the skin surface or wet as those on the anogenital areas .


The human wart virus causes warts that belong to the Papovavirus, which contains DNA. Warts are contagious viral infection. Auto-infection is common especially in children who have warts of the fingers and used to put the finger in mouth or bite an area infected with warts. This may cause auto-infection to lips.

Direct contact of the infected area to the traumatized skin surface may cause infection.

Morphological types

The common warts are raised, dry lesions with rough gray surface. The most common sites involved are extremities particularly the fingers.

Plantar warts are inverted warts due to continuous pressure during walking. Such type is  not raised as other warts. Warts may be single or multiple and may be painful if they are located on the pressure sites.

Fig. 104. Plantar Warts

Fig. 98-. Verruca Vulgaris

Fig. 99-. Filiform Warts

Fig. 100. Anal & Perianal Warts

Fig. 101. Warts of the eyelids

Fig. 102. Moist crural warts

Fig. 103. Flat Warts of the face


Fig. 105. Fungating warts

Fig. 106. Warts of the knee

Fig. 107. Warts treated by Co2 Laser

Fig. 108. Periungual Warts treated by salicylic & Lactic acid

Fig. 109. Warts (Koebner's Phenomond)

Flat warts : Located mainly on the face and sometimes are not easily differentiated from freckles.

Filiform warts : Located mainly on the neck and face which are differentiated from cutaneous horns and skin tags by being harder than skin tags .

Moist ano-genital warts : Common on the glans penis in males and vulva in females besides the anal area or the skin of the anogenital area.


                                           Fig.100a&b. Ano-genital warts (Condyloma accuminata),(before treatment)

(Recurrence after expensive and unsuccessful surgical excision besides different topical medications for the last three months in other medical centers. The father claims that cost was more than 3500 $ !!


       Fig.100c.  Photo of the same infant treated in our medical center after three applications of 20% topical Podophyllin in Benzoin co , one application every two days and washed after four hours . ( The cost of that treatment was only THREE DOLLARS !!!!! ).


Fig.100.d&e.The same child after 10 days(she was given mupericin cream (Bactroban cream) applied once daily .                                                                                                                                

 N.B: Human papillomavirus (HPV) is the causative of genital warts.


Different treatment regimes have been used for treatment of warts since a long time. Some of these regimes are traditional used by non-medical personnel such as religious persons reading from the holy book to the infected individuals or to occlude warts by caustics for sometimes or by suggestion .

Treatment of warts depend on different factors .

There is a different alternative methods for treatment .

  1. Common warts can be treated by liquid nitrogen, Electrodessication using local infiltrating anesthesia . It is important to dissecate the base of the wart but not to go deeper where the warts are intraepidermal in order not to leave much scarring after electrodessication.

  2. Moist anogenital warts can be treated effectively by 15-25 percent Podophyllin in collodion or in tincture Benzoin to be applied cautiously to the affected areas and washed after 8 hours . Application may repeated after three days or one week, where after the warts slough .

  3. Peri ungual warts are difficult to treat. Electrodessication may be
    used but recurrence is common.

     Different lines of treatment are known.The cheapest and most reliable is Podophyllin resin in different concentrations ,(10-25%) in Tinc. Benzoin co. or collodion ( applied every other day or twice weekly ) and washed after 4-6 hours. 

    Other topical medications are Immiquimod (Aldara cream and  Podofiliox ( Condylox gel 0.5 )

    The recent and effective treatment for warts is by CO2 Laser.
    We use CO2 laser for treatment of most reluctant and extensive warts such as peri ungual , moist warts and plantar warts using topical (Emla cream as an anesthetic preparation ).

  1. Plantar warts - we use a formula containing the following : salicylic acid 20 per cent, lactic acid 20 percent in flexible collodion. This preparation is very effective in treatment of plantar warts and in common warts especially in children who refuse other methods, which may need local infiltrating anesthesia.

    This preparation should be used with great care to the wart area and to be used by the mother for her child because it may cause severe chemical burn if it comes in contact with sensitive parts of the skin.

    When this preparation is applied to plantar warts, it causes gradual exfoliation of the skin, so daily before applying the medication , the area is scrapped or shaved to remove the dead skin . Black or gray spots can be seen these represent the thrombosed vessels. Application is repeated on these areas, where usually after one week to ten days the patient begins to feel deep-seated pain on applying the medication. This indicates that the medications reached the tip of the inverted wart. Another two applications may be enough to reach a curative stage for the plantar warts .

  1. Facial warts can be treated by liquid nitrogen or by salicylic 5 % , lactic acid 3 % in collodion preparation with different strengths according to the age of the patient and type of skin. Young children may need less concentrated preparations as 3% salicylic, 3 % lactic acid in collodion .


Epidermolysis dysplasia is a viral infection caused by the human Papovirus

Clinical Features

  • Skin lesions: Symmetrical lesions characteristically appear on the extremities, dorsum of the hands and feet, neck and face. The lesions are dry, rough, flat well-defined papules simulating verruca vulgaris.

  • Mucous membrane lesions may appear on the anogenital area and on the lips.

  • Nail dystrophy

  • Hyperkeratoses of the palms and soles may accompany some cases.

  • The disease may be complicated by malignancy such as epidermal carcinoma in an early age.


Traditional treatment as for warts is usually not possible to eradicate all lesions since theses are numerous .

CO2 Laser can be used successfully to ablate the lesions using local anesthesia (Emla cream) under occlusion method .


Sand fly fever is a viral disease transmitted by the female sand fly (Phlebotomus papatassii) found in the Mediterranean area. The disease is characterized by fever, headache, shaking chills, back pain, muscle ache and fatigue .

Clinical Features

Skin manifestations

Small pruritic nodule appears after few days at the site of the sand fly bite. Scarlitiniform eruption appears on the face and neck.

Constitutional symptoms

Fever, headache, malaise, nausea and abdominal pain .

Systemic manifestations

Eye involvement: conjunctival injection

Stiffness of the neck .

The disease has a chronic course where recovery may occur , but relapsing attacks of fever may continue for long time .


Non-specific treatment of symptoms .


(Break bone fever)

Dengue is a viral infection caused by dengue virus. The disease is transmitted by Aedes aegypti mosquito that is the vector of the organisms . The disease is endemic in the Mediterranean areas , Africa ,Hawaiian and Caribbean islands .

Clinical Features

The disease is characterized by fever, headache, shaking chills, back pain, muscle ache and fatigue.

In childhood the usual infection is asymptomatic, or there may be mild fever, sometimes accompanied by a rash.

In adults a biphasic fever with headache, severe backache and a rash is more characteristic.

Skin Manifestations

Maculopapular or scarlatiniform rash appears on the third to fourth day of the fever. It starts on the chest and trunk and spreads to the face, arms and legs. The rash fades as the fever subsides but can be followed by petechiae on the arms and legs. In dark-skinned people the rash is frequently not visible.

Systemic Manifestations

Hemorrhagic complications: petechiae, which can be demonstrated by a positive tourniquet test (Hess test ). This typically occurs in children who have had a previous dengue infection of a different serotype.

Body temperature falls within one week and shock ensues, where at this stage the patient may die.

Pleural effusion and ascitis


Different criteria may be of help in the diagnosis of the disease. These include the following:

  1. Typical clinical picture such as fever chills and aching pain .

  2. Skin eruption is of the morbilliform type or exanthematous involving the face, neck and chest.

  3. Confirmation is obtained by culture of blood in the acute phase.

  4. Serological studies on acute and convalescent sera.


The disease has favorable prognosis and treatment is only symptomatic.



Infectious mononucleosis is considered as viral infection perhaps due to EB virus.

Clinical Features

Systemic manifestations

Prodromal symptoms : fever , headache and malaise .

General manifestations: splenomegaly, lymphadenopathy mainly the cervical and to a less extent the axillary and inguinal lymph nodes .

Skin manifestations

Skin rash appears in one third of cases. The skin lesion is an erythematous macular eruption on the upper extremities and trunk . Rarely scarlatiniform, urticarial or morbilliform eruption may be seen with edema of eyelids.

Mucous membrane of the buccal cavity may show distinctive multiple pinhead-sized petechiae .


  • Paul-Bunnel test is positive with a titers of 1:112 or higher .

  • Blood picture - Lymphocytosis with abnormal large lymphocytes and leucocytosis.

  • Liver function tests may show elevated SGOT and SGPT.


Mollascum contagiosum is a common viral disease in school age and in adults. Lesions involve usually the skin and to a lesser extent mucous membrane of the mouth and tongue.

Modes of Infection

Transmission of the viral infection occurs from:

  • Swimming pools

  • Infected fomites.

  • Autoinoculation.

Clinical Feature

The common sites involved are the face, hands, trunk and genitalia. The eruption may be single, multiple, localized or generalized and has a chronic course .The incubation period is 2-4 weeks.

Fig. 110. Mollascum contagiosum

Fig. 111. Mollascum contagiosum

The primary lesion of mollascum contagiosum can be easily diagnosed. The papules appear as flesh colored, solid then become pearly white, soft, rounded, dome shaped papules with central umbulication and contain caseous plug. The papules may suppurate due to secondary bacterial infection.

Different morphological patterns may follow the course of mollascum contagiosa:

Giant form : The papule may reach a huge size; more than 10 cm. which may suppurate and is confused in the early stage with verruca vulgaris, kerato acanthoma and basal cell carcinoma.                                                   



Fig. 111b. Giant Mollascum Contagiosum

Mollascum contagiosum cornuatum : The lesions are horny, small papules.

Generalized form : Extensive wide spread lesion involving face , trunk, extremities and genitalia . The mouth  as well as the tongue may also become involved.


Mollascum contagiosum can be easily diagnosed by the distinctive umbulicated pearly papules.

Histopathology shows acanthoma with downward proliferation of the ret ridges.

Basophilic Mollascum inclusion bodies are detected in the cytoplasm of the ret mucosum.


Curettage - is the easiest and most reliable. The lesions are sprayed with Ethyl chloride until it becomes white freezing and then scrapped with curette.

Electrodesiccation - certain lesions, such as the eyelids especially in children can be removed by electro-desiccation using infiltrating local Xylocaine anesthetic.

When infiltrating anesthesia is not possible due to irritable child , topical (Emla) cream can be used .The cream is rubbed to the area and thick layer of the cream is applied and occluded by cellophane cover for about 40 minuets then the lesions can be easily curetted .

Topical tincture iodine and cantharidin is used by others to treat mollascum contagiosum .

We use a paint containing 10% Salicylic acid and 10% Lactic acid in flexible collodion .This preparation is effective and can be used for treatment of infants and young children who can not afford other lines of treatment.


(Mucocutaneous lymph node syndrome (MLNS)

Kawasaki and co-workers in Japan introduced this syndrome which affects mainly young children is of unknown etiology, in 1967. It is typically sporadic and occurs throughout the world but is most common in Japan. There is no evidence of person-to-person spread.


Many infectious agents have been suspected as the cause, including streptococci, staphylococci, rickettsia and viruses, but in most the etiology remains unknown. Cytokines released from monocytes affect vascular endothelial cells of which make them susceptible to damage by circulating cytotoxic antibodies .

Clinical Features

The manifestations of the syndrome are mainly diffuse vasculitis .

Systemic manifestations

The onset is acute with a remittent fever that lasts more than 5 days. The patients look toxic.

Mucous membrane manifestations

Mucous membranes of the conjunctiva, mouth and tongue may be involved. This may lead to conjunctival injection, dry red lips and mouth. "Strawberry tongue" similar to that seen in streptococcal disease . These features continue while the fever lasts.

Skin manifestations

Children may show perineal eruption on the perineal and crural areas covered by the diapers .

A generalized polymorphic rash develops. This appears as urticarial, scarlatiniform, and morbilliform, macular, papular within 1-5 days of the onset of the fever. It is mainly on the trunk and proximal extremities and lasts for up to a week. Palms and soles become erythematous red, indurated and later show desquamation.

A sub acute phase of the illness follows the end of the fever. This is characterized by desquamation of the skin of the fingers and toes which begins at the skin-nail junctions

Cervical lymphadenitis is present in 50-80% of patients..

Arthralgia and arthritis may present at this time, but in less than half of the patients, typically that of knees, hips and elbows.

Cardiovascular manifestations :

These are the most serious complications and sometimes fatal. The manifestations are myocarditis, aneurysm, stenosis or obstruction of the coronary arteries .

In most cases, recovery takes place slowly and is usually complete within 10 weeks.


  1. Gamma globulin: a daily infusion of 400 mg/kg is recommended .

  2. Symptomatic treatment: Acetylsalicylic acid (Aspirin ) for the fever and arthritis.

  3. Systemic steroids : may be life saving in systemic in cardiac manifestations.


Pityriasis rosea is a papulo-squamous self-limiting disease of unknown etiology. Recently a viral infection is suspected to be the cause. Most of cases are seen in autumn. The commonest affected are adults but children and rarely infants may have the disease .

In our observations we found a large number of patients who give a history of appearance of the eruption after using new clothes and bed coverings few weeks before the onset of skin manifestations .

Clinical Features

General manifestations:

  • Mild symptoms as headache and slight malaise.

  • Slight fever, malaise .

  • Enlargement of lymph glands, generalized or confined to the cervical glands, may be present.

Skin manifestations

Herald patch

Usually a single lesion may precede the skin eruption . Herald patch appears mainly on the chest, trunk or extremities in the form of large, rounded or oval , bright red patch with well defined edge and covered by fine scales.

Fig. 112. Pityriasis rosea (Typical distribution along the rib lines)

Fig. 113. Pityriasis rosea

Fig. 114. Pityriasis rosea (Herald patch)

The scales are characteristically more on the periphery , attached at the edges and loose towards the center. Within one week a skin eruption appears mainly on the trunk, back and the chest characteristically arranged along the lines of the ribs. The lesions are discrete, oval, dull pink color macules and patches covered by dry scales . The center of the lesions may appear hypopigmented . Pruritus is usually absent unless there is irritation of the lesions by excessive bathing , sweating or other local irritants . The skin lesions commonly fade after 3-6 weeks, but some clear in 1 or 2 weeks and a few persist or as long as 2-6 months leaving no trace .

Different Clinical Varieties

Different morphological forms of pityriasis rosea may be seen in children and adults. In children the lesions may be papular or urticarial in the early stages. In adults typical medallions studded with purpuric points, and acutely purpuric lesions are manifestations of rare types of pityriasis rosea.

The herald patch is absent or undetected.

Papulovesicular, vesicular and even pustular forms may occur, and erythema multiforme-like lesions .

Differential Diagnosis:

Tinea corporis: The lesions show central clearing with an active edge. Skin scrapping will show the causative dermatophyte.

Psoriasis. The lesions show silvery scaly patches. The scales covers the whole patch.


Pityriasis rosea is a self-limiting disease . Complete healing without treatment of the lesions usually takes from 2 weeks to 6 months .

No treatment is usually needed .

Rarely the symptoms may need antihistamine and mild topical steroid for few days to relieve itching .

When there is distressing symptoms especially with extensive lesions, a topical steroid, usually of moderate strength or ultraviolet (UVB) may be used.

Usually we do not give treatment for pityriasis rosea and the best is to avoid skin irritation and minimize bathing , chaffing and excessive sweating. In extensive lesions accompanied by pruritus, we give pufexamac cream for one week.



This is a viral disease that may spread in epidemics in winter. The disease is caused by pleomophic small virus affecting mainly children in the pre-school age.

Clinical Features

Respiratory manifestations

The clinical features in babies and young children are mainly respiratory tract manifestations. These include bronchiolitis and pneumonia. In older children and adults the upper respiratory symptoms occur, indistinguishable from a common cold.

Skin manifestations

A transient fine, pink macular rash on the face and trunk has been observed in a few instances in children, but is of no diagnostic significance. The lesions may be extensive that involve the arms, shoulders, chest, back and buttocks .


Examination of the nasopharyngeal exudate to detect viral antigen .

Culture takes longer time .

Serological tests .


(Papular Acrodermatitis of Childhood)

Gianotti-Crosti syndrome is a viral disease that manifests with characteristic skin lesions and usually associated with hepatitis B infection.

The syndrome mainly affects children between the ages of 6 months and 12years .

Clinical Features

General manifestations

Constitutional symptoms are not usually marked although there may be mild fever and lassitude. This may be preceded by upper respiratory tract infection.

Skin manifestations

Profuse usually symmetrical, pruritic, dull red papules develop which become later purpuric. The sites involved are first on the thighs and buttocks, then on the extensor aspects of the arms and finally on the face. There may be jaundice in cases associated with hepatitis. The eruption usually fades within one month or less.

Generalized lymphadenopathy - mostly the axillary and inguinal lymph nodes is common.

Laboratory findings: Leukopenia or a slight leucocytosis with 2-15% of monocytes.

In the hepatitis B cases, liver involvement appears to be invariable but usually there are mild changes.



Cytomegalic virus infection affects mainly infants .The disease is usually fatal under two months of age. In adults the disease may be associated with malignancy such as acute leukemia.

Clinical Picture

Skin manifestations - the skin lesion presents with hemorrhagic petechiae, ecchymoses or purpuric rash..

Constitutional symptoms: are convulsions, diarrhea and vomiting hepatosplenomegaly and jaundice .


Brain damage, cerebral hemorrhage, intracranial calcification and optic atrophy are serious complications.

Hepatosplenomegaly, liver damage, jaundice may complicate certain cases of cytomegalo virus infection.


Cytomegalovirus infection is suspected in patients having the following :

Fever of long duration .

Hepatitis often with prolonged pyrexia .

Glandular fever like illness with negative Paul -Bannel test.

Diagnosis can by confirmed by the isolation of the virus from urine, blood or saliva .

Demonstration of highly antibody titers in the blood.



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