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Snapshot
  • A 20-year-old college student presents to the student health clinic complaining of a painful, blistering rash on her upper lip. She says the rash has relapsed and remitted multiple times and she usually feels a mild tingling sensation in the area before a break-out of the lesions. On exam, her upper lip demonstrates clustered vesicles with an erythematous base and crusting.  
Introduction
  • Overview
    • herpes simplex is highly-transmissible viral infection of the skin
      • characterized by painful, recurrent vesicular eruptions of the mucocutaneous surfaces
        • may occur orally or genitally
      • prodromal symptoms such as tingling may occur prior to outbreaks
      • treatment with acyclovir or valacyclovir 
        • for bothersome symptoms
        • to prevent transmission to a serodiscordant sex partner
  • Epidemiology
    • prevalence
      • high rates of infection in the general population
        • prevalence of HSV-1 is almost 50% amongst U.S. adults
        • prevalence of HSV-2 is around 12% amongst U.S. adults
      • almost 80% of infected persons are asymptomatic
    • demographics
      • occurs in sexually active teenagers and adults
      • oral infection also commonly occurs in early childhood
        • transmission from relatives through kissing or sharing utensils
        • if child has genital disease, must rule out sexual abuse
      • almost two times more common in women than men
    • location
      • lesions of either viral type may occur on the mouth or genitals
        • HSV-1 is more commonly found in oral infections
        • HSV-2 is more commonly found with genital infections
    • risk factors
      • sex with an infected person
      • many sex partners
      • condomless sex
        • transmission can still occur when using barrier protection
      • HIV infection or immunosuppression
      • first sexual intercourse at a young age
      • history of STIs
  • Pathogenesis
    • caused by two major strains of the Herpes simplex virus (HSV)
      • HSV-1 
        • oral-labial form
      • HSV-2 
        • genital form
    • transmission occurs from direct contact with active lesions
    • virus resides in the dorsal root ganglia of local nerves until reactivation
      • mechanism for recurrence is not well-understood
        • immunosuppression plays a role
    • intrahost viral spread occurs via epidermal cells
      • subsequent abnormal cell division creates multinucleated "giant cells
  • Associated conditions
    • HIV
    • gonorrhea
    • chlamydia
    • herpes encephalitis
    • Bell palsy
  • Prognosis
    • no cure
    • relapsing and remitting course
      • symptoms become less severe over time 
    • treatment can improve symptoms
Presentation
  • Symptoms
    • common symptoms
      • painful genital or oral burning 
      • vesicular eruptions with crusting
      • tingling prodrome
      • primary genital infection
        • painful inguinal lymphadenopathy
        • fever
        • malaise
      • primary oral infection
        • gingivitis
        • oral ulcers
        • cervical lymphadenopathy
    • location
      • upper or lower lip of the mouth
      • labia, vagina, vulva, cervix
      • penis
      • anus
      • cutaneous lesion on the hand (herpetic whitlow)
      • eye (herpetic keratitis)
    • duration
      • incubation period 2-12 days
      • first outbreak may last 2-3 weeks
        • subsequent outbreaks may clear after 2-7 days
    • severity
      • often asymptomatic
      • primary eruption is most severe
        • severity decreases over time
    • aggravating factors
      • psychological stress
      • fatigue
      • menstruation
      • sunglight exposure
      • illness
    • alleviating factors
      • medication
  • Physical exam
    • inspection
      • many infections present with grouped vesicles on an erythematous base
      • genital infection 
        • often presents with pedunculate papule
        • bilateral, erosive vesicles on the genitals 
        • recurrence typically unilateral
      • oral infection
        • primary infection
          • severe, widespread gingivostomatitis and oral erosions 
        • recurrence
          •  common "cold sore
      • herpetic whitlow  
        • cutaneous lesion on the hand that can be caused by HSV-1 or HSV-2
        • most commonly seen in health care workers who come in contact with oral secretions (respiratory therapists, dentists)
Studies
  • Tzanck smear 
    • useful for presumptive diagnosis
    • multinucleated giant cells 
    • acantholytic cells 
  • Culture or direct fluorecent anti-body staining
    • can be used to distinguish betwen Varicella zoster and Herpes due to similar findings on Tzanck smear
Differential
  • Herpes zoster virus
    • key disgintuishing factor (HZV)
      • dermatomal distribution of vesicles
  • Varicella zoster virus (VZV)
    • key distinguishing factors
      • vesiculopustular lesions
      • primarily on face, trunk, and scalp
Treatment
  • Lifestyle
    • avoid sunlight
    • reduce stress
  • Medical
    • acyclovir (oral or IV)
      • indicated as mainstay of treatment
      • both decreases frequency and severity of recurrences
      • side effects
        • may be nephrotoxic
    • acyclovir ointment
      • may be indicated as adjunct to first line therapy
      • effective in reducing duration of viral shedding
      • does not prevent recurrence
    • acyclovir or valacyclovir suppresive therapy
      • indicated only in patients with >6 breakouts per year or with erythema multiforme
      • acyclovir taken daily
Complications
  • Complications
    • HSV encephalitis
      • incidence 
        • 2-4/1,000,000
      • risk factors
        • immunosuppression
        • older age
        • young children
      • treatment
        • IV acyclovir
 

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(M2.DM.16.73) A 5-year-old male is brought to the pediatrician with complaints of a painful mouth/gums, and vesicular lesions on the lips and buccal mucosa for the past 4 days. The patient has not been able to eat or drink due to the pain and has been irritable. The patient also reports muscle aches. His vital signs are as follows: T 39.1, HR 110, BP 90/62, RR 18, SpO2 99%. Physical examination is significant for vesicular lesions noted on the tongue, gingiva, and lips, with some vesicles having ruptured and ulcerated, as well as palpable cervical and submandibular lymphadenopathy. Which of the following is the most likely causative organism in this patient's presentation? Tested Concept

QID: 106563
1

CMV

0%

(0/2)

2

EBV

0%

(0/2)

3

HIV

0%

(0/2)

4

HSV-1

100%

(2/2)

5

HSV-2

0%

(0/2)

M 6 C

Select Answer to see Preferred Response

(M2.DM.15.62) A 20-year-old college student presents to the campus health clinic complaining of painful lesions that have recently erupted on the right side of his mouth (Figure A). He has always had a problem with severe acne but reports never having experienced pain like this before. Which of the following pathogens is most likely responsible for this outbreak? Tested Concept

QID: 106443
FIGURES:
1

Methicillin-resistant Staphylococcus aureus

0%

(0/34)

2

Methicillin-sensitive Staphylococcus aureus

0%

(0/34)

3

Herpes simplex virus-1

94%

(32/34)

4

Herpes simplex virus-2

0%

(0/34)

5

Propionibacterium acnes

0%

(0/34)

M 6 E

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