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Signs herpes outbreak is coming

The conclusions, findings, and opinions expressed by authors contributing to this journal do not necessarily reflect the official position of the U.S. To date, the pathogenesis of VZV infection is not fully understood because VZW is an exclusively human pathogen and is difficult to replicate in animal models (Breuer & Whitley, 2007).
Among immunocompromised populations, herpes zoster rashes typically are more severe and prolonged and may become disseminated, indicating VZV viremia.
VZV rashes typically are presented by a well-defined dermatomal distribution in immunocompetent individuals, so the diagnosis can be established by characteristic clinical presentation. Acyclovir, famciclovir, and valacyclovir are nucleoside analogs that inhibit replication of human herpesviruses and are approved by the U.S. Since VZV prophylaxis has been shown to effectively decrease the incidence of VZV reactivation and reduce disseminated VZV infection in BMT recipients, VZV prophylaxis should be considered for hematologic patients without BMT with severe myelosuppression.
Among high-risk patients without transplantation, reactivation and disseminated VZV infection also can occur.
Natalie is a 21 year-old female who presents to clinic with a one week history of non-painful, non-itchy blisters and ulcers around her vagina.
Worldwide, the prevalence of HSV-1 ranges from 45% to >90%, with a strong predominance amongst lower socioeconomic status (SES) groups, underdeveloped countries, and HIV positive individuals (Smith et al.
Neonatal herpes is primarily acquired by vertical transmission during passage through the genital tract with delivery, mainly in the presence of active genital herpes lesions. Postnatal infections (~5%) can occur from contact with infected parents or healthcare professionals. Often, there is a prodrome of a fever, followed by the eruption of mouth lesions commonly associated with submandibular and cervical lymphadenopathy.
Recurrent herpes labialis: The recurrent oral herpes presents much differently with a common prodrome of tingling, pain, paresthesias, itching, and burning.
In men, the vesicles can appear on the glans penis, prepuce, shaft, and may be found on the scrotum, thighs, and buttocks. In women, the vesicles can appear on the external genitalia, labia majora or minora, vaginal vestibule, and introitus. HSV-2 genital herpes can cause frequent recurrence with a prodrome of tenderness, burning, or pain at the site of eruption. In most cases, necrosis of the temporal lobe is the cause of the common clinical manifestations. Apart from the typical vesicular lesions, in neonatal encephalitis or disseminated herpes, the infant can present with non-specific signs such as lethargy, failure to feed, irritability, or fever. Congenital herpes contracted in utero (4%), can result in microcephaly, hydrocephalus, chorioretinitis and vesicular skin lesions, and these babies are often born prematurely and with subsequent low birth weight (Rudnick et al. In the absence of sophisticated diagnostic equipment, the Tzanck (Giemsa) test can be used. Viral cultures have a low sensitivity of only 50%, therefore a negative result does not rule out infection. For genital lesions, consider syphilis and chancroid as other possible infectious causes, or consider drug eruptions and Behcet’s disease as non-infectious causes. Diagnosis of HSV keratitis is usually clinical with recognition of the typical dendritic ulcer (with fluorescein staining and ultraviolet light) that has branching with terminal bulbs, along with swollen epithelial borders that contain the virus.
Cerebral spinal fluid (CSF) collection should be completed after ruling out a space-occupying lesion. There is a long list of differentials in infants who present with non-specific symptoms, including bacterial, other viral or traumatic causes. Oral episodic treatment for primary or recurrent outbreak can be used to decrease the severity and length of the outbreak.
In immunocompromised patients or in patients with frequent outbreaks, chronic suppressive therapy with daily acyclovir or valacyclovir can be used to prevent recurrences (Dynamed – Herpes labialis). For an outline of the preferred treatment regimens for first clinical episode, episodic treatment, and chronic suppressive therapy, please see the Centers for Disease Control and Prevention Sexually Transmitted Infections Treatment Guideline 2010. To decrease intracranial pressure in severe cerebral edema, dexamethasone, mannitol, and lasix can be used. Treatment for 14 days is usually sufficient in infants with disease limited to their skin, eyes, and mouth. Dynamed – Herpes Genitalis (updated Oct 2011), Herpes Labialis (updated May 2011), Herpes Keratoconjunctivitis (updated Sept 2011), Herpes Encephalitis (updated Dec 2011), Neonatal Herpes (updated Nov 2011). Feel free to use and share this material as widely as possible, according to our Creative Commons license.
Herpes simplex is caused by the herpes simplex virus (HSV), also known as herpesvirus hominis. Reactivation and replication of latent HSV occurs in the area supplied by the ganglia in which latency was established. HSV has many different presentations, as described below, the severity of which depends on the age, the immune status of the individual, and whether it is a primary or recurrent infection - primary HSV infections are accompanied by systemic signs, longer duration of symptoms, and higher rate of complications. The clinical presentation of a cold sore is that of grouped vesicles, especially of the lips and perioral skin. In women, ulcers can affect the external genitalia, as well as the vagina and cervix, which is involved in 70%-90% of cases. Recurrent genital herpes simplex is very common, with up to 95% of patients with HSV-2 suffering one or more further episodes.

Those at risk are immunocompromised patients, and neonates not protected by maternally acquired antibodies. Systemic infection, such as hepatitis and encephalitis may develop with or without widespread cutaneous lesions. EM is a hypersensitivity reaction usually triggered by infections, most commonly herpes simplex. BACKGROUND: Primary herpes simplex virus (HSV) infection usually involves one mucosal region.
Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. However, the clinical presentation may be atypical or may have disseminated disease without rashes in immunocompromised patients; as a result, laboratory tests, including polymerase chain reaction, direct fluorescent antibody, and viral culture are needed to confirm the diagnosis. Monitoring CD4 counts may be useful for clinicians in determining the need for VZV prophylaxis among high-risk populations, such as (a) hematologic patients with cancer following cytotoxic chemotherapy who fail to recover from myelosuppression over a prolonged period of time, (b) patients with myelodysplastic syndrome who have severe leukopenia refractory to granulocyte-colony-stimulating factor or granulocyte- macrophage-colony-stimulating factor, and (c) patients anticipating a prolonged course of immunosuppressive therapy who also are VZV seropositive (indicting a latent VZV state). Two patients with solid cancers in the first author's practice developed disseminated VZV infections -- one patient with breast cancer receiving standard adjuvant chemotherapy and one patient with metastatic colorectal cancer who received chemotherapy over four years. On further questioning, she reports she has been feeling well and denies fever, aches and pains, or headache in the last couple of weeks. She works at the local grocery store where she met her new boyfriend, a truck driver for the grocery store chain. There is a 2-3cm line of ulcers with an erythematous background on the vaginal vestibule bilaterally, with 1-2 non-erupted vesicles at the top of the line on the right side. The virus stays latent in the nerve root and therefore those infected are carriers for life, with or without recurrent episodes of symptoms (Dynamed Herpes Genitalis, 2011). Prevention of maternal primary HSV infection during pregnancy and prevention of vertical transmission during vaginal delivery is imperative (Dynamed Neonatal Herpes, 2011).
In a primary infection, the mouth lesions are known as herpetic gingivostomatitis and they classically present as painful vesicles found over a red, swollen base. This is followed by local pain, pruritus, dysuria, vaginal and urethral discharge, and tender lymphadenopathy.
Episodic anti-viral therapy should be taken before the vesicular eruption occurs if possible.
Transmission occurs through direct contact or by contact with saliva, but herpes keratoconjunctivitis is mainly found in immunocompromised individuals (Dynamed, 2011).
It is usually caused by HSV-2 in neonates, but HSV-1 is the cause in all other populations (infants over three months of age through to adulthood). Complications of neonatal herpes can include seizures, learning difficulties, blindness, psychomotor retardation, spasticity, and death.
Polymerase chain reaction (PCR) is more sensitive and specific than viral culture alone, and can be used to determine the type of HSV infection. The CSF should be sent for PCR assay as it is the only definitive diagnostic method and is highly sensitive and specific for detecting HSV infection. Consider this in any infant up to one month old with fever, lethargy, poor feeding, or seizure, or in infants up to 8 weeks old with a vesicular rash.
With disseminated disease or central nervous system involvement, treatment should be for 21 days.
An estimate of the global prevalence and incidence of herpes simplex virus type 2 infection. Use of trade names is for identification only and does not imply endorsement by any of the groups named above. Primary infection with VZV results in varicella or chickenpox, which largely affects children with a mild, self-limiting course (Wharton, 1996). Women have a slightly higher risk than men, and African Americans have a lower incidence of herpes zoster (Opstelten, Van Essen, Schellevis, Verheij, & Moons, 2006).
During initial viraemia, infected CD4 T cells cause down regulation of the histocompatibility complex class I expression and allow VZV to escape from the immune system (Ku, Padilla, Grose, Butcher, & Arvin, 2002).
The most common rash sites are the thoracic and lumbar dermatomal zones (Yawn et al., 2007). Therefore, considering VZV prophylaxis is clinically reasonable to reduce the risk of deadly disseminated VZV infection among high-risk patients with cancer without BMT. With the primary infection, 4-7 days after exposure, additional symptoms and signs may include: fever, myalgias, headache, lymphadenopathy, and cervicitis. She noticed the blisters while showering and has been trying some polysporin on them, which she thinks may have helped a bit, as now most of the blisters have popped and just ulcers remain. They have been together a month and had their first sexual experience a couple weeks ago with oral and vaginal sex. There is no significant vaginal discharge, although her cervix is erythematous and friable.
Transmission rates are reduced with the use of long-term suppressive antiviral treatment, such as daily valacyclovir therapy: this can be especially useful in immunocompromised patients (Corey et al. Women with a primary HSV infection during their third trimester that remains active during delivery have a 33% chance of transmitting the infection to their infant, compared to a risk of only 3% in women with a secondary reactivation of HSV during this time.
The lesions that develop are vesicular clusters on an erythematous base located along the vermillion border and on the lip. HSV keratitis may present with pain, photophobia, blurred vision, tearing, gritty sensation, and redness.

Only 30% of cases are due to primary infection, with the remaining 70% from latent infection (Dynamed Herpes Encephalitis, 2011). Consider Herpes Zoster, corneal abrasions or erosions, and bacterial or fungal keratitis as an alternative cause of this presentation. In the presence of the vesicular rash, a viral culture should be obtained, but empiric treatment with acyclovir should be started while waiting for the results.
After clinical resolution of primary infection, viral latent infection is established when VZV retrogrades into the sensory dorsal roots of ganglia (Breuer & Whitley, 2007). In addition, infected T cells transport VZV via T-cell trafficking from tonsillar tissue to the skin, where VZV replicates and produces cell-free VZV, resulting in highly infectious skin lesions.
The rashes initially are erythematous and maculopapular, then progress to coalescing clusters of clear vesicles that contain high concentrations of VZV, which are contagious for VZV seronegative individuals. However, direct fluorescent antibody offers rapid diagnosis and is highly sensitive (Chan, Brandt, & Horsman, 2001). Therapy should be initiated within 72 hours of rash onset or as soon as possible (Dworkin et al.) (see Table 1). A retrospective analysis of 192 allogeneic peripheral blood stem cell transplantation recipients indicated that a very low dose of acylovir (200 mg daily) protected against VZV reactivation (Kim et al., 2008). In addition, the prophylaxis regimen may decrease patients' physical suffering and associated hospitalizations.
This is then followed by the vesicular outbreak; however up to 80% of HSV infections are asymptomatic (Salvaggio et al. She says that she remembers her boyfriend had a cold sore around his mouth at the time of the oral sex. However, the worldwide HSV-2 seroprevalence has been increasing over the past 20 years (Salvaggio et al. Active disease is an absolute contraindication for vaginal delivery and requires Caesarean delivery. The vesicles ulcerate and can be extremely painful, often causing avoidance of eating or drinking by those affected. HSV-1 genital herpes may recur much less frequently and may cause non-painful vesicular outbreaks.
There are no specific symptoms to distinguish herpes encephalitis from other causes; therefore, the investigational work-up is important.
Vaccination in children to prevent primary VZV has reduced chickenpox cases in the United States (Marin, Guris, Chaves, Schmid, & Seward, 2007).
Uninfected T cells also arrive at the infection sites, become primed with cell-free VZV, and mount a systemic immune response to control the initial infection (Ku et al., 2005). In immunocompetent people, the rashes crust in 7-10 days and are no longer infectious (Harpaz et al., 2008). The specimen is obtained by scraping the bases of uncrusted vesicular skin lesions and placing the scrapings on a plain glass slide. Similarly, 137 BMT recipients who were given long-term acylovir of 200 mg daily until the end of immune suppression and at least one year following BMT had significantly decreased incidence of VZV reactivation, and visceral dissemination and serious complications were completely eliminated (Asano-Mori et al., 2008). Intrauterine infection occurs about 5% of the time, with the highest rate of transmission early in pregnancy leading to abortion, stillbirth, or congenital abnormalities at birth. This is significant as patients with ocular HSV who have had previous stromal involvement are at an increased risk for stromal keratitis.
Herpes zoster, the second clinical condition of VZV infection, results from the reactivation of this latent neurotropic virus and commonly presents with painful, unilateral vesicular skin eruption distributing within the dermatomal zones (Gnann & Whitley, 2002). Following initial infection, the VZV-specific cell-mediated immunity keeps VZV in latency and prevents its reactivation (Breuer & Whitley). Although VZV cutaneous dissemination may start with a dermatomal rash, it presents without any primary dermatomal involvement in some cases. More women are affected by genital herpes than men, due to the mechanism of sexual intercourse making women at higher risk of contracting the virus from men.
Patients with epithelial keratitis only, do not have an increased rate of recurrent HSV disease. When an individual's immune system is compromised, such as in older adults or people with cancer undergoing chemotherapy or transplantation, his or her VZV-specific cell mediated immunity also is likely to be impaired, leading to VZV reactivation.
The most common complication following herpes zoster infection is postherpetic neuralgia, a persistent pain that can last months to years and occasionally becomes permanent.
However, the rate of transmission is highest in the presence of active lesions; therefore sexual contact during this time should be avoided. Patients often lose corneal sensation, which can be detected by checking for corneal reflex with a thin, wisp of tissue paper. Adjunct therapy for pain and postherpetic neuralgia often is required for patients with herpes zoster. The use of fluorescein stain and an ultraviolet light will reveal the classic dendritic ulcer on the cornea.

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