Herpes Simplex

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Herpes simplex virus types 1 and 2 (HSV-1 and HSV-2) are very common pathogens that cause orolabial and genital blisters or erosions. Seroprevalence of HSV-1 is estimated at 80% to 90% worldwide and is the most common cause of oral herpes infection (80%). HSV-2 is the primary pathogen in genital herpes (70%-90%) and is one of the most common sexually transmitted diseases (STDs). Approximately 50 million Americans have genital herpes, and an estimated 1 million new cases occur each year.

Herpes simplex infection can be characterized by an initial infection, episodes of latency, asymptomatic viral shedding, and recurrent activation. Spread of HSV-1 is primarily through direct contact with contaminated saliva or other secretions. Symptoms of primary orolabial herpes usually occur 3 to 7 days after exposure and include a prodrome of fever, sore throat, and lymphadenopathy. Localized pain, tingling, tenderness, or burning can occur before the eruption of the vesicles, which are usually grouped on a background of erythema and edema (Fig. 33-53). The lesions coalesce, ulcerate, and heal within 2 to 3 weeks.

Herpes simplex type 2 usually is transmitted through genital contact and must involve mucous membranes or open or damaged skin. Primary HSV-2 occurs up to 3 weeks after exposure to the virus and has more severe clinical manifestations. Systemic symptoms include fever, malaise, edema, inguinal lymphadenopathy, dysuria, and vaginal or penile discharge. These are more common in women. In men, painful vesicles and erosions usually occur on the penis but can also appear on the buttocks or perineum (Fig. 33-54). In women, lesions occur primarily on the labia but may also appear on the cervix, buttocks, or perineum. Symptoms of the primary episode typically last 2 to 3 weeks. Risk factors for genital herpes include age 15 to 30 (age of greatest sexually activity), increased number of sexual partners, black or Hispanic race, lower income levels and education, female gender, homosexuality, and HIV.

In both serotypes, HSV may be latent for months to years following the primary infection. During latency, the virus resides in the sensory nerve root ganglia. Recurrent outbreaks are often preceded by a prodrome of pain, itching, tingling, burning, or paresthesias and are usually less severe than the primary outbreak.

The diagnosis of herpes simplex is conveniently done with a direct fluorescent antibody test (DFA), and results may be obtained within hours. A viral culture can be performed, but results take 2 to 5 days. Serologic testing is also available and approved by the U.S. Food and Drug Administration (FDA) to establish serostatus, but this is not helpful for acute disease.

The treatment of HSV depends on whether the infection is a first episode or a recurrence. Many different dosing schedules are available with oral antivirals, including acyclovir

Hsv Recurrence
Figure 33-54 Herpes simplex type 2 (HSV-2) recurrence on penis with cluster of vesicles. (Courtesy Jack Rezneck, Sr., and The Color Atlas of Family Medicine.)

(Zovirax), valacyclovir (Valtrex), and famciclovir (Famvir). Suppressive therapy may be considered in patients with recurrent genital herpes. Women who are pregnant or contemplating pregnancy should receive information regarding neonatal transmission and possible cesarean delivery if active lesions are present at the onset of labor. The risk of transmission is highest for women with a primary infection during the third trimester of pregnancy. Neonatal herpes infection can cause long-term CNS morbidity, such as mental retardation, chorioretinitis, seizures, and even death.

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