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Sunday, March 3, 2013

Herpes Simplex Virus: Sign and Symptoms, Complications, Diagnosis, Treatment and Prevention of Herpes 1 and 2


Get to know about the Clinical features/Sign and Symptoms, Complications, Diagnosis, Treatment and Prevention of Herpes simplex 1 and 2. Also find out the difference between herpes simplex virus 1 and 2

Herpes Simplex virus 1 and 2:

They cause various widespread mucocutaneous infections
HSV 1 usually involves the skin of the head, neck and trunk (above the waist) while HSV 2 involves the skin of the genital organs (below the waist). These viruses infects sensory and autonomic neurons and cause latent infection in the nerve ganglia. Primary infection is followed by episodes of reactivation throughout life.

Clinical features/Signs and Symptoms of patient with Herpes Simplex Virus 1 and 2:

HSV 1 and 2 both have several forms primary and recurrent diseases. 
Primary infection by HSV 1 in children is usually Gingivostomatitis and in adults is pharyngitis. 
Primary attack with HSV 2 is usually painful vesicular lesions of the male and female genital tract and anal area. Primary attack may be associated with fever and regional lymphadenopathy.
Recurrence: Recurrent attack occurs throughout life and is usually triggered by:
1. Concomitant medical illness eg fever
2. Menstruation
3. Mechanical trauma
4. Psychological stress
5. Immunosuppression
6. For oral lesions, exposure to uv rays(eg sunlight)
Usual recurrent disease associated with HSV 1 is usually Herpes labialis or the classical cold sore or fever blisters characterized by vesicular lesion around the mucocutaneous junction of the lips or nose. For HSV 2 it is usually painful genital vesicular lesion.

Other serious complications in patients with Herpes Simplex Virus 1 and 2:

Eczema Herpeticum
1. Disseminated cutaneous lesions- in patients with underlying skin disease such as eczema (eczema herpeticum)
2. Herpes Keratitis – pain and blurring of vision, corneal scarring and blindness.
3. Meningitis or transverse myelitis – associated with primary HSV 2, is usually mild and self-limited disease with few consequences.
4. Sporadic viral encephalitis – usually with HSV 1(both primary and secondary). It is a very serious condition characterized by hemorrhagic necrotizing temporal lobe ceribritis which cause temporal lobe epilepsy and alternate consciousness/coma.
Other features are fever, headache, vomiting, altered mental state.
Without treatment mortality is 80% and is the major cause of death due to sporadic encephalitis in the United States. 
Those who survive have severe neurological problems. 
MRI imaging often reveals the lesion. Examination of spinal fluid shows a moderate increase of lymphocytes, a moderate increase in the amount of protein and a normal amount of glucose. The virus can be rarely isolated from the spinal fluid but its DNA can be detected by PCR (Polymerase chain reaction) technique.
6. Herpes Whitlow – A pustular lesion of the skin of the fingers or hand which occurs as a result of contact with patient’s lesions. It was previously seen with health-care workers and dentists but is prevented by wearing protective gloves. Usually associated with HSV 1.
Wrestling may cause Herpes 
7. Herpes Gladitorum –
Occurs in wrestlers and others who have close body contact.
It is usually characterized by vesicular lesion on the head, neck and trunk. 
Usually associated with HSV 1.




8. Neonatal Herpes – Usually associated with primary infection of the mother at term and occurs mainly due to contact with vesicular lesions within the birth canal. 
Even If there is no lesion in the birth canal, the neonate can be infected due to asymptomatic shedding of HSV 2. 
Serious neonatal infection is likely to occur when the mother is suffering from primary infection than a recurrent infection due to two reasons:
· The amount of virus produced during a primary infection is more than during secondary infection
· Mothers who have been previously infected with can pass immunoglobulin G (an antibody) across the placenta which can protect the neonate from serious disseminated infection.

Neonatal herpes may be prevented by performing cesarean section on women. But even if the baby is not infected while passing through the birth canal, serious neonatal herpes can still occur due to handling of the baby by carriers.
Over two-thirds of cases develop disseminated disease with cutaneous lesions, hepatitis, pneumonia, and frequently encephalitis.
9. Dissemination to viscera: (eg esophagus, liver, lungs, retina, brain) occurs in immunocompromised patient leading to diseases like esophagitis, hepatitis, pneumonitis, encephalitis or retinitis.


Comparison of diseases caused by HSV 1 and HSV 2:

Site
Disease caused by HSV 1
Disease caused by HSV 2
Skin
Vesicular lesion above the waist
Vesicular lesion below the waist (especially genitals)
Mouth
Gingivostomatitis
Rare
Eye
Keratoconjunctivitis
Rare
Central Nervous System
Encephalitis (temporal lobe and orbital gyri of frontal lobe)
Meningitis or Transverse myelitis
Neonate
Rare
Skin lesion and disseminated infection
Dissemination to viscera(esophagus, liver, retina, brain) in immunocompromised patient
Yes
Rare

Diagnosis of patient with Herpes Simplex Virus 1 and 2:

Diagnosis is made by:
1. Demonstration of virus in vesicular fluids by direct immunoflurescence or culture
2. Demonstration of viral DNA by PCR (eg HSV encephalitis in diagnosed by detecting viral DNA in cerebro-spinal fluid)
3. A rapid diagnosis from skin lesions can be made by using the Tzanck smear, in which cells from the base of the vesicle are stained with Giemsa stain. The presence of multinucleated giant cells suggest herpes virus infection.
4. Serelogical (blood tests) are of little value in the diagnosis of herpes 1 and 2.

Treatment / Management of patient with Herpes Simplex Virus 1 and 2:
Acyclic antivirals are the drug of choice. Therapy must be started with 48 hours of clinical disease (both primary and secondary). 
Oral lesions in an immunocompromised patient may be treated with topical aciclovir. Aciclovir resistance may be present in immunocompromised patients in which case foscarnet is the treatment of choice. If HSV encephalitis is suspected then empiric antiviral must be given immediately.


Prevention of Herpes Simplex Virus 1 and 2 infection:

1. Avoid contact with vesicular lesion or ulcer.
2. Cesarean section for women at term with genital lesion or positive viral culture.

Get to know about the other types of herpes viruses:



1 comment:

  1. My daughter is 5 years old & has a primary immunodeficiency (natural killer cell deficiency). When she takes this Ocuvir 200mg medicine for the treatment of her HSV (oral), her chronic HSV is less severe, and although new ones do form, they fade away very quickly and at some points, her face is clear.

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