HERPES SIMPLEX VIRUS INFECTION IN THE NONPREGNANT WOMAN
Biology and epidemiology.
HSV is an exclusively sexually transmitted disease.
It is a double-stranded DNA virus.
Its two types are as follows:
HSV-1: Gingivostomatitis is the major clinical presentation but HSV-1 also causes 15% of primary genital herpes cases.
HSV-2: HSV-2 primarily affects the genital area.
HSV is endemic in the United States with 500,000 new cases per year.
Incidence is approximately 1% to 2% of the population.
Genital HSV is prevalent: 50 million cases currently in the United States.
About 50% to 80% of adults have antibodies to HSV-1 or HSV-2.
The highest frequency of HSV occurs in the 15-year-old to 29- year-old age group.
HSV is often associated with other STDs.
- HSV may present as a primary, latent, or recurrent disease.
Signs and symptoms: There are three distinct syndromes associated with HSV.
First episode primary genital herpes refers to the initial genital HSV infection and includes the following:
No evidence of HSV-1 or HSV-2 antibodies
Severe local symptoms
Multiple painful lesions, vesicles, ulcers, inguinal adenopathy
Systemic symptoms such as fever, malaise, nausea, myalgia
First episode primary herpes is defined as three or more of the following:
At least two extragenital symptoms
Multiple bilateral genital lesions
Persistence of genital lesions more than 16 days
Distal HSV lesions on the fingers, buttocks, or oropharynx
First episode nonprimary genital herpes is defined by the following:
Initial clinical episode
Antibodies to HSV-1 and HSV-2 present
Less severe clinical course
Symptoms similar to recurrent genital herpes
Recurrent herpes simplex infection involves the following:
Milder and shorter duration
Caused by reactivation of latent virus, not reinfection
Usual unilateral distribution of recurrent lesions
Typical lesion outbreak (preceded by prodromal symptoms such as paresthesias, itching, or pain)
Recurrent infection finished in 5 to 10 days
Systemic manifestations absent with few lesions
Classical appearance of genital lesions is painful vesicles and ulcers in various stages of progression.
History of prodrome and recurrences supports diagnosis.
Viral culture is the gold standard for diagnosis; most positive cultures are identifiable in 48 to 72 hours.
More likely positive in first episode than recurrence
Positive culture more likely in early vesicle lesions than later ulcerative crusted lesions.
Tzanck smear is a cytologic test.
Presence of intranuclear inclusions and giant cells
A negative Tzanck smear or negative culture does not exclude HSV.
Indirect and direct immunoperoxidase stains are more sensitive than a Tzanck smear.
The monoclonal antibody test with type-specific assays for HSV- specific glycoprotein G1 or G2 can also be used.
Positive predictive value: 93%
Negative predictive value: 92%
Enzyme-linked immunosorbent assay (ELISA) is also a testing option.
Acyclovir (Zovirax) was the first effective chemotherapeutic agent for genital herpes. The drug interferes selectively with viral thymidine kinase and ultimately inhibits viral DNA synthesis.
2015 CDC treatment guidelines:
First clinical episode of genital herpes
Acyclovir, 400 mg PO, tid x 7 to 10 days
Acyclovir, 200 mg PO, five times a day x 7 to 10 days
Famciclovir, 250 mg PO, tid x 7 to 10 days
Valacyclovir, 1 g PO, bid x 7 to 10 days
May extend therapy if incomplete healing
Treatment instituted during prodrome or first 2 day9 of onset of lesions may provide limited benefit from therapy.
Recommended regimen is as follows:
Acyclovir, 200 mg PO, five times a day x 5 days
Acyclovir, 400 mg PO, tid x 5 days
Acyclovir, 800 mg PO, bid x 5 days
Famciclovir, 125 mg PO, bid x 5 days
Valacyclovir, 500 mg PO, bid x 3 to 5 days
Valacyclovir, 1 g PO, qd x 5 days (3) Daily suppressive therapy
(a) This therapy indicated in patients with frequent (>6) recurrences per year.
Therapy may reduce frequency of HSV recurrence 70% to 80%.
Should consider discontinuation of therapy to reevaluate frequency of recurrences after 1 year of suppressive therapy.
Acyclovir, 400 mg PO, bid
Famciclovir, 250 mg PO, bid
Valacylovir, 500 mg PO, qd
Valacyclovte, 1 g PO, qd
Patients can be treated with intravenous therapy if indicated for complications of HSV such as encephalitis, pneumonitis, disseminated infection, or hepatitis.
Recommended regimen is acyclovir, 5 to 10 mg/kg body weight IV, q8h x 5 to 7 days or until clinical resolution followed by an oral regimen for at least 1<Q days.
Infected patients should abstain from sex during periods of active genital lesions.
Use of condoms during all sexual exposures should be encouraged.
Patients should be informed about the risks of neonatal infection.