Herpes simplex virus (HSV)

PEBC

HSV

• causes cold sores and genital herpes

• 2 types:

  • HSV-1:

    • Causes Herpes labialis (oral cold sores)

    • transmitted via saliva through oral to oral contact OR through oral to genital contact

  • HSV-2:

    • causes genital herpes

    • transmitted via sexual contact through contact with genital surfaces, skin, sores or fluids of infected individual

• Asymptomatic viral shedding = pt can be asymptomatic and shed the virus unknowingly

• HSV stays in the ganglia —> lifelong latency and recurrence

  • can be reactivated any time

assessment

Primary infection

• 1st episode with no antibodies for HSV present

• may be asymptomatic or present as more severe disease

• longer duration (7-18 days) and more severe signs and symptoms (fever, swollen lymph nodes, flu like)

Non-Primary infection

• 1st episode in patient who HAS ANTIBODIES for 1 type of HSV and acquires the other type of HSV

• shorter duration and less severe signs and symptoms than primary infection → due to partial protection of antibodies

Recurrent Episode:

• latent HSV reactivated (recurrence greater with HSV2)

• less severe than primary and non-primary

• prodromes = tingling, itching, pain prior to symptoms

clinical presentation

severity of sx depend on:

• previous exposure = primary, nonprimary, recurrent

• type of virus: HSV-1, HSV-2

• site of infection: oral, genital, ocular, nervous system

• immune status: immunocompromised

complications

• herpes gladiatorum = skin infection

• herpetic whitlow = finger infection

• keratoconjunctivitis = conjunctival infection

• herpes encepahilitis = neurological effects

risk factors

RF:

• physical contact with infected person

  • kissing

  • sexual contant

  • sharing utensils (cold sore)

• multiple sexual partners

• Female

• immunocompromised

recurrence triggered by:

• stress/ fatigue

• infection/ fever

• immunosuppression

• hormonal changes

• menstruation

• physical trauma/ dental extractions/ surgery

• sun exposure

• temperature extremes

HSV1 (herpes labialis)

• cold sore or fever blister

• diagnosis = clinical presentation of lesion

• no cure or treatment to eradicate

• lays dormant in ganglia until recurrence

• begin treatment when prodrome sx occur

• takes 1-2 weeks for cold sores to fully resolve w/o therapy

• referral:

  • immunocompromised

  • patients with recurrent, persistent cold sores (≥6x/yr)

  • moderate to severe primary infection (systemic symptoms)

  • lasts >2 weeks

  • signs of secondary bacterial infection

• treatment is most beneficial if started early: within 48 hrs of symptom onset

clinical presentation (cold sore: primary infection)

• 1st infection = primary herpes gingiovostomatitis

• lasts 1-3 weeks

• asymptomatic (commonly)

• symptoms:

  • painful blisters around mouth (can crack, release clear, sticky liquid and then crust over)

  • Lymphadenopathy

  • red, swollen gums

  • sore throat

  • systemic fever, malaise, myalgia

clinical presentation (recurrent infection cold sores)

• recurrent infection → reactivated

• lasts 8-10 days

• asymptomatic shedding

• prodrome sx = tingling, itching, burning before blisters and sores

• signs and symptoms:

  • painful blisters around the mouth area

  • red and erythematous base

goals of therapy

1. Minimize pain or discomfort

2. minimize the duration of lesions and viral shedding

3. prevent autoinoculation —> you can transmit to yourself so dont touch it

4. prevent recurrences

5. prevent transfer of virus

algorithm (cold sores)

• Primary infections are treated longer

• Recurrent infections are higher doses but shorter durations

• Acyclovir is the active drug!! Valacyclovir and Famiciclovir are prodrugs so they are metabolized into acyclovir

  • Due to increase in bioavailability! And need less frequent dosing

non pharm (cold sores)

• Prevention:

  • reduce stress (if trigger)

  • prevent sun induced recurrences → use sunscreen with SPF 30+ on affected areas

  • freq wash hands to prevent transmission of virus

  • avoid skin to skin contact until blister dried up and crusted over

• clean area with soap and water

• cool or warm compresses

  • cool = reduce inflammation

  • warm = relieve pain

• topical protectants prevent blisters from drying out and breaking

  • petrolatum

  • cocoa butter

  • calamine

• prevent autoinolculation

  • avoid oral sex, kissing and touching lesions until lesions competely healed

  • freq wash hands

OTC treatment (cold sores)

Antiviral = Abreva (Docosanol cream)

• prevents HSV from spreading to healthy cells

• apply at first sign of pain, itching, burning, redness or tingling

• may decrease duration of painful symptoms and time to healing by 17-79 hrs

Pain relief/ protectants

• mod - severe pain = acetaminophen or NSAIDs

• Mild pain:

  • benzocaine (anbesol)

  • lidocaine/ prilocaine (EMLA)

  • camphor, menthol (blistex, anbesol cold sore)

  • lidocaine

  • pramoxine ← VERY GOOD

  • Zinc sulfate/ Heparin sodium (Lipactin)

primary infection treatment (cold sore)

• acyclovir = 200 mg 5x/day x 7 days

• famicyclovir = 500mg BID x 7-10 days

• Valacyclovir 1g BID x 7-10 days

• s/e = Headache, nausea.

recurrent infection treatment (cold sores)

higher doses and shorter duration

• Acyclovir = 400mg 5x/day 5 days

• Famicyclovir = 750 mg BID x 1 day or 1500 mg x 1 dose

• Valacyclovir = 2g BID x 1 day

• s/e = Headache, nausea.

genital herpes

• STI

• increases the risk of contracting HIV

• recurrence more likely to occur with HSV-2 infections

• rate of recurrence decreased with increasing age

• diagnosis = confirm with lab tests to exclude other STIs (chancroid)

  • PCR

  • Viral culture

  • Serology

clinical presentation (genital herpes)

primary infection

• may be asymptomatic or unrecognized by patient

• viral shedding lasts 12 days

• lesions heal in 2-4 weeks

• signs and sx:

  • painful, pustular lesions

  • local itching, tingling, pain

  • dysuria

  • lymphadenopathy: swollen glands

  • systemic symptoms = fever, myalgia, malaise

recurrent = milder and shorter duration

• viral shedding = 4 days

• lesions heal in 7-10 days

• begin treatment during prodrome symptoms

• suppressive therapy may be indicated if: (re-evaluate yearly)

  • is experiencing frequent recurrences (≥6 recurrences/yr)

  • experiencing complications from infection

  • is serodifferent or has serodiscordant parterns

  • multiple sexual partners

treatment (genital herpes)

• all patients should be treated with antiviral!

• primary = longer duration

• recurrent = moderate doses and few days

• suppressive = low doses

• acyclovir = more complicated regimen but les expensive

pregnancy

• HSV can be transferred to neonate

• greatest risk during primary infection = near term

• caesarean required if active infection or prodrome symptoms present during delivery

  • if mother contracts HSV in 2nd and more in 3rd trimester = NEED CAESAREAN section

• neonatal HSV = skin, eye, mouth (SEM) disease and can advance to CNS or disseminated disease (risk of morbidity and mortality)

• suppressive antiviral management is recommended at 36 weeks

  • reduce risk of recurrence

  • c-section not needed

  • limited data on famiciclovir

CNS HSV

• HSV encephalitis/meningitis = medical emergency

  • typically in elderly, immunocompromised

  • seizures, personality changes, fever, photophobia

  • HSV2 meningitis less severe than HSV encephalitis

• rapid diagnosis and treatment = essential for reducing morbidity and mortality

• s/e IV Acyclovir:

  • injection site pain

  • nephrotoxicity

  • nausea

  • headache

• IV acyclovir = drug of choice

• HSV encephalitis = IV x 14-21 days

• HSV meningitis = po x 10-14 days