Herpes Simplex Virus

Question 1

Definition

Answer 1

Virus that commonly causes infections and results in multiple clinical manifestation such as:
- oral herpes simplex
- genital herpes simplex
It often presents with cold sores and ulcers

Question 2

Types of HSV

Answer 2

HSV1
HSV2

Question 3

Oral herpes simplex

Answer 3

AKA = herpes simplex labialis
- Infection of the mouth area and lips = often presenting with cold sores
- Most often caused by HSV-1

Question 4

Genital herpes simplex

Answer 4

Classified STI = genital ulcers
It can be caused HSV-1 or HSV-2
The majority of genital herpes simplex infections are transmitted by people who are unaware they are infected.

Question 5

Risk factors for HSV infection

Answer 5

Oral
- Close contact/shared saliva with an infected person

Genital
- Unprotected sexual intercourse
- 15-24 years
- Multiple sexual partners
- Immunocompromised: from medication or HIV infection increases the risk of HSV infection
- Smoking, local trauma, alcohol, stress and UV light: can trigger reactivation of latent HSV infection [2]

Question 6

Signs

Answer 6

Oral:
- Presence of vesicles on mucocutaneous surfaces which have ruptured which crust over and heal.
- Submandibular lymphadenopathy

Gingivostomatitis HSV:
- Cervical and submandibular lymphadenopathy
- Crops of painful vesicles on a red swollen base that often rupture and form ulcers on the pharyngeal and oral mucosa

Genital HSV:
- Presence of multiple pain blisters which burst and leave erosions/ulcers
- Tender inguinal lymphadenopathy

Question 7

Symptoms

Answer 7

Oral:
- Lip ulceration ‘cold sores’
- Malaise/fever
- Sore throat
- Paraesthesia/pain: these precede the lesion by 6-48 hours

Gingivostomatitis:
- Sore throat
- Malaise/fever
- Excessive salivation or drooling (especially in children)
- Painful ulcers in the mouth

Genital:
- Painful ulceration
- Vaginal/urethra discharge
- Malaise/fever
- Groin pain
- Neuropathic pain in then genital area

Question 8

Diagnosis

Answer 8

Oral = Clinical Diagnosis
Genital =
- GOLD STANDARD: HSV swabs = Swabs are taken from the base of the lesion (blister can be popped if necessary) for viral culture or polymerase chain reaction.
- NAAT now considered superior to viral culture
- Virus typing = should be obtained in all patients with newly diagnosed genital herpes

Consider: STI screen

Question 9

Treatment (Oral)

Answer 9

FIRST LINE
- Simple analgesia: paracetamol
- Self-care advice: avoid kissing and oral sex until lesions have fully healed and to avoid touching lesions
- Topical preparations and mouthwash:
- Antiviral treatment: immunocompromised Px or severe oral herpes
* DO NOT PRESCRIBE: Topical anaesthetic or analgesic preparations mouthwash, or lip barrier preparations.

Question 10

Genital herpes: in pregnancy

Answer 10

Antiviral treatment: oral aciclovir
- if within the first 5 days of the start of the genital HSV
- consider further antiviral treatment in recurrent infection
Self care advice: avoid sexual intercourse until lesions have cleared

Question 11

Genital herpes in pregnancy Tx

Answer 11

• If a woman develops her first episode in her 3rd trimester = Cesarean recommended esp in those developing Sx within 6 weeks of delivery
• If a woman has recurrent herpes, they should be treated with suppressive therapy (eg. daily suppressive aciclovir 400mg three times daily 36 weeks of gestation)

Question 12

Complications

Answer 12

• Eczema herpeticum = an outbreak of HSV in people with atopic eczema
• Erythema multiforme: due to hypersensitivity reaction and appears on distal surfaces
• Additional infection with candida or streptococci
• Autoinoculation: leading to keratoconjunctivitis, corneal ulceration (HSV-1) or fingers and adjacent skin sites (genital HSV)