Herpes Simplex Virus Karen Estrella-Ramadan 07/02/12

 Double stranded DNA virus  Serotypes:  HSV-1: “above the waist”  HSV-2: “ below the waist”: sexually transmitted  25%: oral lesions  Transmission: both symptomatic and asymptomatic (1%) and may occur with primary (higher concentration) or recurrent infection  Shedding: primary: 1wk (genital and gingival), recurrent: 3 days

Neonatal  20-40% preterm  75% sec to HSV-2  Primary genital infection: risk: near to 50%  Reactivation: <5%  However: >75% who acquire it have been born of mothers who didn’t have symptoms  Occurs between birth and 4wks of age

Types 1. Disseminated: CNS, liver, lungs EARLY (<1wk) 2. SEM: skin, eyes, mouth (1-2wks) 1. Trauma 3. Localized: CNS (LATE: 2-3wks)

Mucocutaneous  HSV-1  Incubation: 2d-2wk  Consider child abuse if child with HSV2  Manifests as:  Herpes labialis  Gingivostomatitis  Ezcema herpeticum  Herpetic whitlow  Herpes gladiatorum  Genital herpes

Herpes labialis  recurrrent: w/ stress, hormonal changes, immunosupression, UV light  Sec to latency in trigeminal ganglion  Prodrome: localized pain, tingling, itching, burning 6hr-48hrs  1 or group in vermillion

Gingivostomatitis 1 st episode: 6mo-5y Anterior oral mucosa + fever, fussiness, drooling  decrease po, painful submandibular or cervical adenopathy Last for days, shedding up to 23 days Watch for dehydration, manage pain

Ezcema herpeticum Fever + vesicles  umbilicated pustules in areas of ezcema

Herpetic whitlow Complication of primary oral or genital herpes via brake in skin in hand Thumb suckiing

Herpes gladiatorum Thorax, face, ear, hands in wrestlers

Conjuntivitis and keratitis  Complication from autoinoculation from oral shedding

Genital  > primary: asymptomatic, 70-80% seropositive  Lesions develop over 7-8 days, shedding: 2 days  Infections due to HSV-2 are more likely to recur than HSV-1, reactivation: less pianful  If HSV-1: consider autoinoculation in children but sexual abuse on prepubertal  Prevention; condoms

CNS manifestations  Fever, change in mental status, seizures, focal neuro findings  Encephalitis: Risk 0.5-5% of children  HSV-1  cute and fulminent if not tx  Dx: CSF: pleocytosis, > Lymphocytes  50% may have RBC  Meningitiss: nospecific, mild nadn self limited  Rare, no need for antiviral tx, related fo HSV-2  3-12 days fter genital lesions  Other: Bell’s palsy, trigeminal neuralgia, atypical pain syndrome

Diagnosis  In neonates: if suspicion tx until confirm it  Mucocutaneous: if clinically compatible no cx  CNS: EEG and MRI : will show abnormalities in temporal lobe  Edema, hemorrhage, necrosis

 Cx: first signs at 72hrs, final at 2wks  90% skin: will be positive but almost none in CSF  Tzank: multinucleated giant cells and eosinophilic inclusions: not specific for HSV

Tx NEONATAL  If active lesions: c/s only if ROM is less than 6hrs  If born during active infection: controversy if tx vs. observe  However if rash develops or signs of sepsis get:  Cx of lesions: nasopharynx, conjunctivae, stool, umbilicus  Observe for dev: vesicles, jaundice, resp distress, sz  Remember: it can happen even after 4 wks!!!  IV ACYCLOVIR + HYDRATION  2 wks SEM, 3 wks CNS (continue until CSF PCR neg)  For ophthalmic add: topical  Prognosis developmental delay:2% SEM, 70% on CNS and 25% on disseminated (>than 50% die )

TX MUCOCUTANEOUS ::  PO therapy if at onset, decrease course by 2 days  Manage Pain + hydration OCULAR:  1-2% trifluridine, 1% iodoeoxyuridine, 3% vidarabine  No steroids  For recurrency, may give po acyclovir

Tx GENITAL  PO Tx started <5days from onset: decrease shedding by 3-5 days  Topical: no no  Latency: sacral ganglia  If >6 x/yr: give po acyclovir for 1 yr IMMUNOCOMPROMISED:  If resistant to acyclovir, give foscarnet

References  ntent/25/3/86.full.pdf ntent/25/3/86.full.pdf ntent/25/3/86.full.pdf  overview