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4 Herpes Simplex Diagnosis –Tzanck Smear: 60-90% accurate, 3-13 % false + Nonspecific (HSV and VZV) Used on acute vesicular lesions Multinucleated giant cells jig saw nucleus. 10 Herpetic Infections Herpetic Sycosis –blade shaving after facial herpes induces a slowly spreading folliculitis of the beard with few isolated vesicles. 13 Herpetic Infections Herpetic Keratoconjunctivitis –Punctate keratitis or as dendritic ulcers. 25 Intrauterine and Neonatal Herpes Prevention and management: –70% of mothers of HSV infected infants are asymptomatic at delivery and have no HX of infection.
30 Herpes Simplex in the Immunocompromised Any erosive mucocutaneous lesion should raise suspicion of herpes simples. 34 Varicella Presentation: Faint erythematous macules develop into teardrop vesicles in 24 hours. 38 Varicella Treatment: –Acyclovir for severe cases, high risk individuals and adults (>13 years). 39 Varicella Prevention: Varicella Vaccine –Live attenuated virus –95% effective Those who do contract varicella have mild case. 40 Varicella in Pregnancy Increased risk of spontaneous abortion (3% by 20 wks), congenital varicella syndrome and fetal death.
Herpes Simplex Keratitis (HVS) is one of the most challenging entities confronting the clinician from a diagnostic as well as a therapeutic point of view. Although stromal disease accounts for approximately less than 10% of initial episodes of ocular HSV disease, it has been found to count 20% to 50% of recurrent ocular HSV disease. The most common mistake in managing a patient with recurrent immune stromal keratitis is under treatment with topical steroids.
Vanishingly low-dose topical cortical steroids once a day or even every other day may be necessary to prevent current recurrent inflammation in some patients. But many ophthalmologists fear that the development of cataract and higher IOP with prolong steroid usage.

However, oral agents such as acyclovir (Zovirax, GlaxoSmithKline, UK) and now acyclovir are quite effective for prevention of recurrent of recurrent epithelial keratitis. Spread by Skin to Skin contact –Active lesions are infective –Asymptomatic shedding accounts for the majority of transmission.
HSV-2 facts: –20% truly asymptomatic, 20% recognize their lesions, 60% have lesion but don’t recognize them as HSV or don’t notice them at all. Herpes infection in pt with atopic dermatitis results in infection throughout the eczematous areas with hundreds of vesicles.
Herpes Simplex has a variety of clinical presentations and manifestations within the cornea, including infectious, neurotrophic, and immunologic etiologies.
Rather, it arises from impaired corneal innervation in combination with decreased tear secretion.
The goal for the clinician and the patient should be prevention of recurrent flare episodes. The complication of stromal scarring is more severe than cataract formation or elevated intraocular pressure. All topical antivirals have toxicity not only to the cornea but to the conjunctiva and nasal lacrimal system.
The patients who benefit from long-term oral antiviral medications are those patients with a history of frequent recurrent infectious epithelial keratitis, patients with HSV keratitis on long-term topical steroids, and, finally, any patient who has undergone a penetrating keratoplasty for HSV. Prior HSV-1 infection does not protect from HSV-2 infection but may lessen severity of first outbreak. Intrauterine infection (rare) –Primary lesions of mother –May cause fetal anomalies: skin lesions, scars, microcephally, microphthalamos, encephalitis, calcifications. The keratopathy may be exacerbated by chronic use of topical medications, especially topical antiviral agents. This antigen triggers an antigen antibiotic compliment cascading the results in the intra-stromal inflammation.

In addition, the topical agents are not affective at preventing recurrences of infectious epithelial keratitis. The early findings of neurotrophic keratopathy included irregularity of the corneal surface and lack of the normal corneal luster. This level is called the flare dose, and the clinician should not attempt to taper the topical medications below this level until the patients? inflammation has been quiet for several months.
Herpetic Gingivostomatitis –1 % of infections –Erosions, ulcers in mouth with white base associated with fever, lymphadenopathy and malaise. Stromal infiltration is the most common finding in recurrent ISK and can present as punctate stromal opacities or a confluent dense infiltrate of the stroma. Stroma inflammation can be accompanied by anterior chamber inflammation, ciliary flush, and significant discomfort.
The most common mismanagement is the over treatment of the dendritic epitheliopathy stage of neurotrophic keratopathy. The stromal inflammatory reaction can also result in an immune ring that can be an incomplete or a complete ring and can be singular or multiple.
Immediately after the infectious dendritic ulcer the patients may have an abnormal elevated epithelial lesion that is in a dendritic pattern. Long-standing stromal inflammation can result in secondary neovascularization and dead scarring of the cornea. Topical steroids may be needed to reduce secondary anterior stromal scarring from the abnormal epithelium.

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    Spanking new vesicle formation, the number of days.
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