2 PresentationA 21 year old female presents herself to the Gynecologist with recurrent dysuria and genital itching. She has been there twice in the past eight months for suspected yeast infections. She also had to separate visits for what she thought was a UTI. Her bacterial urine cultures were negative both times despite in office urine dips that were mildly positive for leukocytes though negative for blood.
3 MisdiagnosisShe has been treated with Bactim DS for suspected UTI twice and she has been treated with metronidazole and antifungals for possible BV and yeast twice. Though symptomatic with repeated dysuria and genital itching, this patient has never met the diagnostic criteria for yeast, bacteria vaginosis or urinary tract infection. She’s been treated, however, yet continues to return with the same kinds of problems repeatedly. Tests for BV, trich, chlamydia, gonorrhea and yeast were negative.
4 Laboratory Evaluation At this visit, serologic testing for HSV 2 should be done. The recurrent dysuria and pyuria combined with negative urine cultures suggests she could have herpetic urethritis, herpes lesions in her urethra. The urine dip may be mildly positive for white cells because the urethral lesions are adding white cells to the urine as it passes over the lesions, and she may have dysuria because the lesions are ulcerated and urine passing over them is acidic. Her itching may be due to subtle genital lesions associated with HSV 2, and because herpes was not suspected, a close and careful exam of the genital area has not been completed.
5 DiagnosisHer HSV 2 serology is positive, with an index value of >5. Her HSV 1 serology is also positive, consistent with her history of cold sores. So we know, with a high degree of certainty and consistent with CDC guidelines, that our patient has genital herpes. Though we cannot know for certain that her recurrent symptoms are due to her herpes, a 6-12 month course of suppressive antiviral therapy may help to give us an answer. If her symptoms don’t return while on suppression, we may assume that herpes was causing her symptoms. The patient should be educated about transmission of her infection, and be made aware that suppressive therapy may not only help her symptoms, but also reduce the likelihood of infecting others.
6 HSV 1Herpes simplex virus (HSV) infections are very common worldwide. HSV-1 is the main cause of herpes infections that occur on the mouth and lips, including cold sores and fever blisters. It is transmitted through kissing or sharing drinking utensils.
7 HSV-1 can also cause genital herpes, however, HSV-2 is the main cause of genital herpes. HSV-2 is contracted through sexual contact. You may be infected with HSV-1 or HSV-2 but not show any symptoms. Often symptoms are triggered by exposure to the sun, fever, menstruation, emotional stress, a weakened immune system, or an illness.HSV 2
8 Neonatal herpes simplex occurs when infants are contaminated by the mother’s reproductive tract immediately before or during birth, but they have also been traced to hand transmission from the mother’s lesions to the baby. In infants whose disease is confined to the mouth, skin, or eyes, the mortality rate is 30%, but disease affecting the central nervous system has a 50% to 80% mortality rate.
9 Herpetic whitlows occur most frequently in dental and medical personnel or people who carelessly touch lesions on themselves or others. These painful, deep-set vesicles can become inflamed and necrotic and are difficult to treat.
10 Cold sores; usually caused by simplex 1 are normally preceded by a tingling sensation and redness in the area where the cold sore will appear. The cold sore will start to form as very small blisters or groups of blisters. The cold sore then becomes a noticeable red sore followed by painful blisters which are very contagious. As the cold sore starts to heal, a brown scab may form. If this scab cracks open it may bleed. In the final stages, the cold sore goes from brown to yellow. The whole cycle takes about 10 days.
11 Genital sores (usually caused by simplex 2) often appear first as a rash followed by painful and itchy blisters on the affected areas such as the anus, buttocks, penis, scrotum, vulva, vagina or buttocks. These blisters can then turn into painful ulcers. The herpes virus, which is sexually transmitted, can lie dormant in your system for many years without any outbreaks, or occasional outbreaks or you can have frequent outbreaks. Sometimes before an outbreak, you may have some warning signs such as a tingling, burning or itching feeling in the areas where the sores will later appear. Herpes will always have the same symptoms for each outbreak but the first outbreak will be the worst so although the symptoms seem to stay the same, the actual pain and number of sores should lesson each time an outbreak occurs.
12 Some things that can trigger the virus are: Stress Illness Fever Sun exposure Menstrual periods Surgery
13 HSV spreads direct contact. Some people have no symptoms HSV spreads direct contact. Some people have no symptoms. Others get sores near the area where the virus has entered the body. They turn into blisters, become itchy and painful, and then heal. Most people have outbreaks several times a year. Over time, you get them less often. Medicines to help your body fight the virus can help lessen symptoms and decrease outbreaks.
14 Herpes simplex viruses spread from person to person through close contact. You can get a herpes simplex virus from touching a herpes sore. Most people, however, get herpes simplex from an infected person who does not have sores. Doctors call this “asymptomatic viral shedding.”
15 Although there is no cure for herpes, treatments can relieve the symptoms. Medication can decrease the pain related to an outbreak and can shorten healing time. They can also decrease the total number of outbreaks. Drugs including Famvir, Zovirax, and Valtrex are among the medications used to treat the symptoms of herpes. Warm baths may relieve the pain associated with genital sores.