Herpes Simplex Virus
Herpes Simplex Virus: Excerpt from The 5-Minute Pediatric Consult
Jason Newland, MDLouis M. Bell, Jr., MD
Herpes Simplex Virus - BASICS
Herpes Simplex Virus - description
Herpes simplex virus (HSV) is a moderately large, double-stranded DNA virus. There are 2 serologically distinguishable subtypes: HSV-1 and HSV-2. HSV produces a wide spectrum of illness ranging from fever blisters to fatal viral encephalitis.
Herpes Simplex Virus - general prevention
- Neonatal infection:
- The risk of HSV infection in an infant born vaginally to a mother with a 1st-episode primary genital infection is high (33–50%). The risk to an infant born to a mother with recurrent HSV infection at delivery is much lower (3–5%).
- Cesarean delivery in a mother with active genital herpes at the time of delivery is the main way to prevent neonatal infection. However, this does not prevent all cases because 60–80% of mothers of infected infants are asymptomatic or have unrecognized infection.
- Postnatal infection:
- Universal body substance precaution policies
- Adults with oral herpes must be particularly careful to use appropriate hygiene.
- Wrestlers with skin lesions suggestive of herpes
- Patients with genital lesions from HSV should not have intercourse until the lesions heal.
- Condoms can prevent the spread of virus.
Herpes Simplex Virus - epidemiology
- Neonatal infection is usually acquired from the maternal genitourinary tract and causes serious disease with high mortality and morbidity.
- HSV-1 usually causes infections of the upper torso, head, and neck.
- HSV-2 usually causes genital infection. However, both forms can infect oral or genital cells, thus the virus type is not a reliable indicator of the anatomic site of infection.
- Route of spread is usually by close bodily contact or trauma such as teething or a break in the skin.
- Incubation period is 2–12 days (~6 days).
- Neonatal HSV infections are acquired from maternal strains, and 75–85% are caused by HSV-2.
- After the neonatal period, HSV-1 infections predominate, and 40–60% of children are seropositive for HSV-1 by the age of 5 years.
Herpes Simplex Virus - prevalence
During puberty and early adolescence, the prevalence of HSV-2 increases, and 20–35% of adults are seropositive for HSV-2.
Herpes Simplex Virus - pathophysiology
- Initial viral replication occurs at the portal of entry.
- Vesicular fluid contains infected epithelial cells.
- After primary HSV infection, the virus remains latent in sensory neural ganglia innervating portions of the skin or mucous membranes originally involved. The virus can be reactivated by an appropriate stimulus such as sunlight or immune suppression.
- HSV can be replicated easily in the laboratory in tissue cultures.
Herpes Simplex Virus - associated conditions
- Gingivostomatitis is the most common form of HSV primary infection in children.
- Encephalitis owing to HSV accounts for 2–5% of all encephalitis in the US.
Herpes Simplex Virus - DIAGNOSIS
Herpes Simplex Virus - signs & symptoms
- Neonatal infection:
- HSV-2, the most common cause of neonatal infection, is usually acquired from maternal labial lesions, but a history of previous or current genital HSV infection is present in only 20–30% of mothers who deliver infected infants. HSV-2 can be transmitted to the infant without rupture of the amniotic membranes or after delivery by cesarean section:
- HSV-1 can be transmitted to a neonate by any adult with active herpes labialis.
- A vesicular rash or bullae are present at birth or within a few days in almost all infants.
- Disseminated infection (32% of cases) involves the liver, lungs, adrenals, and sometimes the CNS.
- Localized CNS infection (33% of cases) presents with irritability, bulging fontanelle, or seizures.
- Localized skin, eye, or mouth infection (35% of cases) presents with rash alone, keratitis, or chorioretinitis.
- Gingivostomatitis:
- Fever and irritability precede the development of vesicular lesions on the lips, gingiva, and tongue. The vesicles then break down and become gray ulcers that are friable and bleed easily.
- Children refuse to drink because of the mouth pain and are at risk of dehydration.
- The child usually starts to improve in 3–5 days and recovers in 14 days.
- Latent virus causes recurrent stomatitis or labiitis.
- Encephalitis:
- The illness begins with fever, malaise, and irritability that last 1–7 days and progress to mental status changes, seizures, and coma. Meningeal signs are not common.
- Patients can develop hemiparesis, cranial nerve palsy, and visual field defects.
- No presence of oral or genital lesions
- It is the result of a primary infection in 30% of cases and recurrent in 70%.
- Vulvovaginitis:
- 35–50% of patients with the 1st episode of genital herpes will be able to give a history of genital HSV infection in their contact.
- The primary illness is characterized by fever, headache, malaise, and myalgias. Local genital symptoms include severe pain, itching, dysuria, vaginal or urethral discharge, and tender inguinal adenopathy. The genital lesions begin as vesicles and progress to ulcers before they crust over. Lesions last for 2–3 weeks.
- An aseptic meningitis syndrome occurs in 1–35% of cases. Patients will have fever, headache, meningismus, and photophobia.
- Latent virus causes recurrent episodes, which are painful but less severe than in primary infections.
Herpes Simplex Virus - history
- Neonatal period exposures:
- History of herpes in mother
- Active vulvar lesions at time of delivery
- Skin lesions
- Oral lesion
- General questions re: Contagious disease:
- Contact with people with herpes
- Unprotected sex
- Drinking from common straws, glasses
- Use of lipstick samples at cosmetic counters
Herpes Simplex Virus - physical exam
See “Signs and Symptoms.”
Herpes Simplex Virus - tests
- Neonatal infection:
- Samples for viral culture should be obtained from the eyes, oropharynx, and rectum.
- Polymerase chain reaction (PCR) testing of the CSF is the test of choice for diagnosing CNS disease.
- Cells from the base of freshly unroofed vesicles can be smeared on a slide for monoclonal antibody immunofluorescence.
- Serologic tests are not useful for diagnosis of maternal or neonatal herpes during the acute phase of the disease.
- Encephalitis:
- CSF reveals a pleocytosis with up to 2,000 WBCs/mm3, and usually >60% of the cells are lymphocytes.
- In an atraumatic lumbar puncture, RBCs, indicating hemorrhagic necrosis, occur in 75–85% of cases.
- CSF protein is elevated (median, 80 mg/dL).
- HSV PCR is the diagnostic test of choice.
- EEG can reveal a typical pattern of unilateral or bilateral focal spikes.
- CT or MRI may show enhancement in the temporal areas.
- Gingivostomatitis:
- Physicians usually make this diagnosis clinically because it is so common in young children.
- Vulvovaginitis:
- A viral culture of the vesicle is the gold standard. Sensitivity is 94% for early lesions and decreases to 27% for crusted lesions.
- Immunofluorescence of infected cells is a more rapid diagnostic test and has a sensitivity of 78–88%.
Herpes Simplex Virus - differencial diagnosis
- Neonatal HSV infection must be distinguished from severe neonatal enterovirus disease or bacterial sepsis, especially in the 1st 4 weeks of life.
- HSV infection should be considered in all neonates with vesicular rash, chorioretinitis, microcephaly, or hepatosplenomegaly. It must be distinguished from other congenital viral infections such as rubella or cytomegalovirus (CMV).
- Herpes gingivostomatitis must be distinguished from herpangina, an enteroviral infection usually presenting as posterior pharyngeal ulcers and sometimes as hand, foot, and mouth disease.
- HSV encephalitis must be distinguished from other viral encephalitis and from the HSV-induced aseptic meningitis syndrome, which is a complication of primary genital infection.
- HSV vulvovaginitis must be distinguished from chancroid and syphilis. Syphilis lesions are usually nonpainful, hard ulcers. Chancroid lesions are multiple purulent ulcers from which Haemophilus ducreyi can be cultured.
Herpes Simplex Virus - TREATMENT
Herpes Simplex Virus - medication
- Neonatal infection:
- IV acyclovir (60 mg/kg/d in 3 divided doses) is the drug of choice. The recommended minimal duration of therapy is 14 days (if the disease is limited to the skin, eye, and mouth) and 21 days if disease is disseminated or involves the CNS. Infants with ocular involvement owing to HSV infection should receive a topical ophthalmic drug (1–2% trifluridine, 1% iododeoxyuridine, or 3% vidarabine) in addition to parenteral antiviral therapy.
- Encephalitis:
- IV acyclovir (30 mg/kg/d) t.i.d. for 21 days is appropriate therapy for HSV encephalitis beyond the neonatal period. In addition to parenteral antiviral therapy, appropriate management of fluids, intracranial pressure, and seizures is essential.
- Gingivostomatitis:
- Most patients are managed with symptomatic therapy including antipyretics and oral fluids like popsicles. Oral anesthetics can be harmful and result in self-injury when children chew on anesthetized lips. Oral acyclovir (15 mg/kg 5 times a day) has been beneficial in reducing duration of lesions and symptoms. Patients with frequent or severe recurrences may benefit from oral acyclovir at onset of symptoms.
- Vulvovaginitis:
- Acyclovir (Zovirax) is the appropriate therapy for genital herpes infection. Oral acyclovir is used for patients with primary genital HSV infection. IV acyclovir is used for patients with severe local or systemic symptoms or complications like aseptic meningitis syndrome. Valacyclovir and famciclovir are as effective as acyclovir with less frequent dosing, and may be considered.
Herpes Simplex Virus - FOLLOW UP
Herpes Simplex Virus - prognosis
Neonatal infection:
- Overall mortality from untreated neonatal HSV infection is 50%, and only 26% of survivors are normal.
- Infants with disseminated disease or localized CNS disease have the worst prognosis.
Herpes Simplex Virus - complications
The major sequelae in survivors are brain damage, seizures, and blindness.
Herpes Simplex Virus - bibliography
American Academy of Pediatrics. Herpes simplex. In: Pickering LK, ed. 2003 Red Book: Report of the Committee on Infectious Diseases. 27th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2006:361–371.Arvin A. Herpes simplex viruses 1 and 2. In: Feigin RD, Cherry JD, Demmler GJ, et al., eds. Textbook of Pediatric Infectious Diseases. 4th ed. Philadelphia: WB Saunders; 2004:1884–1912.- Kimberlin DW, Lin CY, Jacobs RF, et al. Safety and efficacy of high-dose intravenous acyclovir in the management of neonatal herpes simplex virus infections. Pediatrics. 2001;108:230–238.
Sanchez PJ. Viral infections of the fetus and neonate. In: Feigin RD, Cherry JD, Demmler GJ, et al., eds. Textbook of Pediatric Infectious Diseases. 4th ed. Philadelphia: WB Saunders; 2004:866–909.- Waggoner-Fountain LA, Grossman LB. Herpes simplex virus. Pediatr Rev. 2004;25:86–93.
- Whitley R. Neonatal herpes simplex virus infection. Curr Opin Infect Dis. 2004;17(3):243–246.
Herpes Simplex Virus - CODES
Herpes Simplex Virus - icd9
054.9 Herpes simplex virus
Herpes Simplex Virus - FAQ
- Q: What about recurrent cutaneous eruptions in a neonate? Should they be treated?
- A: The need for retreatment of infants with recurrent skin lesions is undetermined and under study. Because of concerns about silent CNS recurrent infection, some experts recommend acyclovir, 300 mg/m2/dose in 3 doses for 6–12 months. One needs to look for neutropenia, which will occur in 25% of patients.
- Q: Is prophylactic therapy for recurrent herpes genitalia helpful? When is it indicated?
- A: Antiviral therapy has minimal effect on recurrent genital herpes. Oral acyclovir initiated within 2 days of onset of symptoms shortens the course. Topical acyclovir is not helpful.
- Q: What steps should be taken in the nursery for an infant born to an HSV-positive mother?
- A: Neonates with documented perinatal exposure to HSV may be in the incubation phase of infection and should be observed carefully. Infants of mothers with active HSV should be isolated if they have been delivered vaginally or by cesarean delivery after membranes were ruptured for more than 4–6 hours. The risk of HSV infection in possibly exposed infants (e.g., those born to a mother with a history of recurrent genital herpes) is low, and isolation is not necessary.
- Q: Is a repeated lumbar puncture necessary at the end of therapy for neonates or for children with HSV encephalitis?
- A: Some experts recommend repeating the lumbar puncture at the end of the planned course of therapy to determine whether the virus is still present by PCR assay. If there is a positive test, prolonging therapy may be considered.
Book Source Details
- Book Title: The 5-Minute Pediatric Consult
- Author(s): M. William Schwartz MD; et al.
- Year of Publication: 2008
- Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: The 5-Minute Pediatric Consult
Authors: M. William Schwartz MD; et al.
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7577-9
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