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Genital Herpes

Herpes genitalis (genital herpes) is a sexually transmitted disease caused by the herpes simplex virus (HSV-1 or HSV-2).


Presentation

The clinical presentation depends on the type of infection; the primary genital herpes is characterized by severe, prolonged symptoms. The incubation period ranges from 1 day to 3 weeks. The general symptoms are seen most commonly on first 3-4 days, which includes fever, malaise, headache, muscle pain. Also, locally there is pain, dysuria, itching, vaginal and urethral discharge and tender lymph nodes [6].

In women, the herpetic eruption is seen on external genitalia. Cervix is involved about 70-80% of the times. It is red, edematous and painful. There is dysuria which can cause urine retention and urethritis. HSV is isolated in the urine when tested. The moistness of the genital area makes the vesicles rupture leaving an ulcer which is painful.

In men, the herpetic vesicles are found on glans penis, shaft of penis; the prepuce and scrotum may be involved. The buttocks and the thighs are also not spared. It causes herpetic urethritis and herpetic prostatitis when involving rectum and perianal area. Women are affected more severely than men.

Recurrence is common especially in patients with severe primary infection. There is prodrome in which the patient experiences pain, burning and tenderness at the site of eruption. The lesion may heal in 7-10 days. The symptoms are again more severe in women than men [7].

Malaise
  • The general symptoms are seen most commonly on first 3-4 days, which includes fever, malaise, headache, muscle pain. Also, locally there is pain, dysuria, itching, vaginal and urethral discharge and tender lymph nodes.[symptoma.com]
  • Symptoms of primary infection may include malaise, fever, or localized adenopathy. Subsequent outbreaks, caused by reactivation of latent virus, are usually milder. Asymptomatic shedding of transmissible virus is common.[ncbi.nlm.nih.gov]
  • Less frequent, yet still common, symptoms include discharge from the penis or vagina, fever, headache, muscle pain (myalgia), swollen and enlarged lymph nodes and malaise.[en.wikipedia.org]
  • Primary (first time) genital HSV1 and HSV2 are characterised by ‘systemic’ symptoms, fever, headache and malaise. These symptoms are usually worse within the first few days of the appearance of the rash, and gradually recede in 3-4 days.[stdclinic.ie]
  • General symptoms may include: Decreased appetite Fever General sick feeling ( malaise ) Muscle aches in the lower back, buttocks, thighs, or knees Swollen and tender lymph nodes in the groin Genital symptoms include small, painful blisters filled with[nlm.nih.gov]
Inguinal Lymphadenopathy
  • Patients also may have constitutional symptoms such as headache, fever, inguinal lymphadenopathy, anorexia, and malaise. 7 As the disease progresses, papules, vesicles on an erythematous base, and erosions appear over hours to days.[aafp.org]
Perianal Ulcer
  • Sexually Transmitted Disease Treatment Guidelines: Diseases Characterized by Genital, Anal, or Perianal Ulcers. Available online at . Page last reviewed January 28, 2011. Accessed January 2013. American Sexual Health Association. Fast Facts.[labtestsonline.it]
  • Severe acquired immunodeficiency in male homosexuals, manifested by chronic perianal ulcerative herpes simplex lesions. N. Engl. J. Med. 1981; 305 :1439–1444. [ PubMed : 6272110 ] Smith J. S., Herrero R., Munoz N., et al.[ncbi.nlm.nih.gov]
Colic
  • For those taking acyclovir, there were no serious adverse events; the most common adverse events reported for oral acyclovir were coryza, dizziness, tiredness, diarrhoea and renal colic.[ncbi.nlm.nih.gov]
Low Self-Esteem
  • Loneliness, depression and low self-esteem. Anxiety concerning potential effect on childbearing. Patients need to inform their sex partner(s) that they have genital herpes.[phac-aspc.gc.ca]
Delusion
  • The patient presented with irritable mood and grandiose delusions 72 hours after starting valacyclovir for genital herpes. Valacyclovir treatment was stopped, and risperidone was initiated.[ncbi.nlm.nih.gov]
Paresthesia
  • Genital herpes (GH) causes genital ulcer disease, severe transient pain, and often paresthesias. Whether or not GH can cause urinary retention or chronic neuropathic pain is not well known.[ncbi.nlm.nih.gov]
  • In rare cases, involvement of the sacral region of the spinal cord can cause acute urinary retention and one-sided symptoms and signs of myeloradiculitis (a combination of myelitis and radiculitis): pain, sensory loss, abnormal sensations (paresthesia[en.wikipedia.org]
  • 400 mg three times daily for 5 days 47 (32 to 34) 200 mg five times daily for 5 days 40 (25 to 28) 800 mg twice daily for 5 days 60 (40 to 42) Suppressive therapy 400 mg twice daily 187 (129) Famciclovir (Famvir) Headache, nausea, vomiting, fatigue, paresthesias[aafp.org]
Genital Lesions
  • The revised guidelines highlight infants at greatest risk for HSV disease but do not apply to asymptomatic infants born to mothers with a history of HSV but no genital lesions at delivery.[ncbi.nlm.nih.gov]
  • Antiviral suppressive therapy is used from 36 weeks of gestation until delivery in pregnant women with recurrences to prevent genital lesions at the time of labor so reducing the need of caesarean sections.[ncbi.nlm.nih.gov]
  • Most initial infections do not cause symptoms, but primary genital lesions are usually more painful, prolonged, and widespread than recurrent genital lesions.[merckmanuals.com]
  • This was manifested by severe hepatitis, pancreatitis, and genital lesions. Temporary improvement followed the delivery of a healthy infant by cesarean section.[ncbi.nlm.nih.gov]
  • The case highlights that herpes zoster needs to be considered in the differential diagnosis of genital lesions, particularly in HIV-positive individuals, and the importance of virological diagnosis by PCR to direct appropriate management.[ncbi.nlm.nih.gov]
Chancroid
  • The Act named syphilis, gonorrhoea and soft chancre (or chancroid) as dangerous diseases for which free treatment was to become compulsory. Genital herpes did not get a look in.[spiked-online.com]
  • Differential Diagnosis of Genital Ulcers Infectious Chancroid Fungal infection Genital herpes simplex Granuloma inguinale Lymphogranuloma venereum Secondary bacterial infection Syphilis Noninfectious Aphthous ulcers Behçet syndrome Fixed drug eruption[aafp.org]
  • Genital ulcers can also be caused by syphilis, chancroid or lymphogranuloma venereum, and testing for these should be considered. Testing for other STIs, including chlamydia and gonorrhea, should be considered.[phac-aspc.gc.ca]
  • Other diseases which may cause genital sores are syphilis, chancroid, lymphogranuloma venereum, granuloma inguinale, herpes zoster, erythema multiform, Behçet's syndrome, inflammatory bowel disease, contact dermatitis, candidiasis, and impetigo.[medical-dictionary.thefreedictionary.com]
  • ., syphilis, chancroid) should be considered, especially in high-risk populations. It is important to ask laboratories for glycoprotein G–specific HSV serology, because some still use older assays that do not accurately distinguish HSV-1 from HSV-2.[aafp.org]

Workup

The diagnosis is based on the examination of the patient and the signs and symptoms given by him/her. Tissue culture is the confirmatory test to establish the diagnosis of infection with herpes. The isolation of virus is best done within 48 hours of inoculation. The herpes lesion can be seen under the microscope within an hour for the histological appearance of herpes. The eosinophillic intra nuclear inclusion bodies in multi nucleated giant cells and epithelial cells are characteristic of herpes. Polymerase chain reaction technique is used to detect HSV DNA [8].

Treatment

Specific antivirals are given to treat the lesion. Nucleoside triphosphate is administered to inactivate HSV polymerase. Acyclovir is given empirically to all the patients with HSV infection.

However, in immune compromised individuals and patients with HSV Encephalitis, high doses of Acyclovir are given intra venously [9].

The general symptoms like fever, malaise are treated symptomatically. Proper care of the wound is to be done and secondary bacterial or fungal infection should be treated. The dermatologist should be taken into consultation.

Prognosis

Prognosis is bad as once infected with HSV, the chances of recurrence are very high. If antiviral therapy is administered in time the disease may resolve quickly. Also, one must maintain a strong immunity to reduce the chances of recurrence.

Etiology

Genital Herpes is caused by Herpes Simplex Virus 1 and 2. Out of these, HSV-1 is usually associated with orofacial disease and HSV-2 is associated with genital disease. There are three types of clinical HSV infection: primary, non primary and recurrent [1].

Primary infection: in which there is no serological evidence of previous infection with neither HSV 1 nor 2 and it is a newly acquired infection.

Non-primary, first episode: occurs when there has been a history of previous infection with some other form of herpes and there is a newly acquired genital herpes. Primary and non-primary infection usually occurs due to unprotected sex with the infected partner, frequent change of sexual partners, previous infection with sexually transmitted disease, impaired immunity due to immune compromised disease like HIV/AIDS.

Recurrent: in this there is recurrence of same type of HSV infection again. HSV2 is more common. It usually occurs when the patient is stressed, tired and menstruating. Recurrence is also seen when the immunity is low due to HIV infection and in immune compromised individual due to organ transplant or stem cell transplantation [2].

Epidemiology

Genital Herpes is seen worldwide. It is more common between ages 18 to 45 which correlate directly with sexual activity. Also, it is seen more frequently in lower socioeconomic groups. It is more prevalent in women than men [3].

Sex distribution
Age distribution

Pathophysiology

Herpes Simplex Virus 1 and 2 are the cause of genital herpes. However, infection with HSV 2 is the common cause of genital herpes. HSV is a double stranded DNA virus which has the capacity to replicate in the nervous system. The genital herpes virus infects the sacral nerve root ganglia [S2-S5].

Human beings are the natural reservoir of this virus and the person in close contact with such an infected individual gets affected due to unprotected sex. The virus gets inoculated on the mucosal surface of cervix or through the cracked skin into the host. It can be transmitted via mother’s genital tract to the new born baby during the process of delivery [4] [5].

Prevention

Herpes virus is so common in the metropolitan city that it is extremely difficult to avoid it. One can prevent it by avoiding contact with infected individuals who shed the virus in salivary or genital secretion. One can use condom to prevent it. However, you can acquire it if it is found outside the area covered by condom. Also, oral contact and oro genital contact should be avoided. Caesarean section is advised to the women who have genital herpes at the time of delivery. One must increase the immunity to decrease the chances of recurrence. Antiviral therapy should be taken. However therapies to suppress the infection and HSV vaccine are still under trials [10].

Summary

Genital Herpes is a fairly common ulcerative disease which is seen around the world. It is caused by Herpes Simplex Virus (HSV). Most often patients remain asymptomatic. However, lymphadenopathy and systemic symptoms do occur. There are three types of clinical infections.

Diagnosis is done by clinical history followed by serological test, polymerase chain reaction and viral culture. Recurrence is common but its intensity can be reduced by administrating oral anti virals. One must avoid sexual intercourse when symptomatic.

Patient Information

Genital herpes is caused by herpes simplex virus (HSV) 1 and 2. Infection with HSV 2 is more common. The patient may acquire infection through an infected person by coming in contact with the saliva or genital secretion of such person. The neonate is infected through the infected mother who passes the virus through the genital tract to the baby during delivery. The patient may be asymptomatic or may have symptoms of pain, malaise, fever, headache, painful urination with retention.

The lesion may be seen anywhere around and in the genital region of the male or female who are infected. Females tend to have more severe symptoms than men. Treatment includes symptomatic care and antiviral therapy.

It can be prevented by avoiding contact with the infected individual and wearing condom can minimize the risk of exposure. A healthy immunity decreases the chances of infection. HSV vaccine is still under research.

References

Article

  1. Corey L. Herpes Simplex Virus. In: Mandell Gl, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases. Vol 2. 6th ed. Pennsylvania: Elsevier; 2005:1762-80.
  2. Corey L, Wald A, Celum CL, Quinn TC. The effects of herpes simplex virus-2 on HIV-1 acquisition and transmission: a review of two overlapping epidemics. J Acquir Immune Defic Syndr. 2004 Apr 15;35(5):435-45.
  3. Fleming DT, McQuillan GM, Johnson RE, et al. Herpes simplex virus type 2 in the United States, 1976 to 1994. N Engl J Med. 1997 Oct 16;337(16):1105-11
  4. Benedetti JK, Zeh J, Corey L. Clinical reactivation of genital herpes simplex virus infection decreases in frequency over time. Ann Intern Med. 1999 Jul 6;131(1):14-20.
  5. Gardella C, Brown ZA, Wald A, Morrow RA, et al. Poor correlation between genital lesions and detection of herpes simplex virus in women in labor. Obstet Gynecol. 2005 Aug;106(2):268-74.
  6. Kimberlin DW, Rouse DJ. Clinical practice. Genital herpes. N Engl J Med. 2004 May 6;350(19):1970-7.
  7. Corey L, Adams HG, Brown ZA, Holmes KK. Genital herpes simplex virus infections: clinical manifestations, course, and complications. Ann Intern Med. 1983 Jun;98(6):958-72.
  8. Wald A, Zeh J, Selke S, Ashley RL, Corey L. Virologic characteristics of subclinical and symptomatic genital herpes infections. N Engl J Med. 1995 Sep 21;333(12):770-5.
  9. Johnston C, Saracino M, Kuntz S, Magaret A et al. Standard-dose and high-dose daily antiviral therapy for short episodes of genital HSV-2 reactivation: three randomized, open-label, cross-over trials. Lancet. 2012 Feb 18;379(9816):641-7.
  10. Belshe RB, Leone PA, Bernstein DiIet al. Efficacy Results of a trial of a herpes simplex vaccine. N Engl J Med. 2012;366:34-43.

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Last updated: 2019-07-11 22:01