Herpes Simplex

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Herpes simplex is a viral infection caused by the herpes simplex virus (HSV). HSV-1 is associated primarily with oral infections, and HSV-2 causes mainly genital infections.

CLINICAL

Primary Infection

  • Symptoms occur from 3 to 7 days after contact (respiratory droplets, direct contact).
  • Constitutional symptoms include low-grade fever, headache and myalgias, regional lymphadenopathy, and localized pain.
  • Pain, burning, itching, and tingling last several hours.
  • Grouped vesicles, usually with surrounding erythema, appear and generally ulcerate or crust within 48 hr.
  • The vesicles are uniform in size (differentiating it from herpes zoster vesicles, which vary in size). Scattered erosions covered with exudate may be noted on genitals.
  • During the acute eruption the patient is uncomfortable; involvement of lips and inside of mouth may make it unpleasant for the patient to eat; urinary retention may complicate involvement of the genital area.
  • Lesions generally last from 2 to 6 wk and heal without scarring.

Recurrent Infection

  • Generally caused by alteration in the immune system; fatigue, stress, menses, local skin trauma, and exposure to sunlight are contributing factors.
  • A cluster of lesions generally evolves within 24 hr from a macule to a papule and then vesicles surrounded by erythema; the vesicles coalesce and subsequently rupture within 4 days, revealing erosions covered by crusts.
  • The crusts are generally shed within 7 to 10 days, revealing a pink surface.
  • Rapid onset of diffuse cutaneous herpes simplex (eczema herpeticum) may occur in certain atopic infants and adults.


DIFFERENTIAL DIAGNOSIS

  • Impetigo
  • Behçet’s syndrome
  • Coxsackie virus infection
  • Syphilis
  • Stevens-Johnson syndrome
  • Herpangina.
  • Aphthous stomatitis.
  • Varicella.
  • Herpes zoster

LABORATORY TESTS

  • Direct immunofluorescent antibody slide tests provide a rapid diagnosis.
  • Viral culture is the most definitive method for diagnosis; results are generally available in 1 or 2 days. The lesions should be sampled during the vesicular or early ulcerative stage; cervical samples should be taken from the endocervix with a swab.
  • Tzanck smear is a readily available test that will demonstrate multinucleated giant cells. However, it is not a highly sensitive test.
  • Pap smear will detect HSV-infected cells in cervical tissue from women without symptoms.
  • Serologic tests for HSV: immunoglobulin (Ig) G and IgM serum antibodies. Antibodies to HSV occur in 50% to 90% of adults. The presence of IgM or a fourfold or greater rise in IgG titers indicates a recent infection (convalescent sample should be drawn 2 to 3 wk after the acute specimen is drawn).

MANAGEMENT

  • Topical acyclovir, penciclovir, and docosanol are optional treatments for recurrent herpes labialis, but they are less effective than oral treatments.