​Kembara Xtra - Medicine - Genital Herpes

​Kembara Xtra - Medicine - Genital Herpes 
Chronic, recurrent sacral ganglia-innervated herpes simplex virus (HSV) type 1 or 2 infection.
Anogenital and orolabial lesions are brought on by HSV-1.
HSV-2 is the source of anogenital lesions.
First episode, nonprimary: initial genital eruption; prior antibodies are present. Primary episode: occurs in the absence of preexisting antibodies to HSV-1 or HSV-2 (may be asymptomatic).
Reactivation: repeated incidents

The opposite of herpes genitalis

Epidemiology 
Between the ages of 15 and 30 are the most prevalent contaminated years; incidence rises with age as cumulative exposure risk rises.
Female is more prevalent than male.
Non-Hispanic blacks are the most common race.
Incidence
Since genital herpes is not an illness that needs to be reported, the true incidence is unclear. According to studies, the incidence in the United States ranges from 572,000 to 1.6 million new cases annually, with 18 to 24 year olds experiencing the highest rates.
Prevalence
HSV-2 is generally present in 10–40% of the general population and up to 60–95% of HIV-positive people. In the United States, the prevalence of HSV-1 is 48% and that of HSV-2 is 12% between the ages of 14 and 49. HSV-1 prevalence was highest in Mexican Americans (72%) while HSV-2 prevalence was highest in non-Hispanic Blacks (35%). Up to 90% of seropositive individuals lack an official diagnosis. 140 million persons are thought to have HSV-2 infection and 3.7 billion are thought to have HSV-1 infection worldwide.

Pathophysiology and Etiology 

HSV is a herpetoviridae family double-stranded DNA virus that spreads by genital-to-genital contact, oral-to-genital contact, and maternal-fetal transmission.
After exposure, there are 4 to 7 days of incubation.
Viral shedding is possible even in the absence of lesions, increasing the risk of transmission (precautions such as abstinence and condom use may not be observed). Risk of transmission is highest when lesions are present. With HSV-2, viral shedding happens more frequently, erratically, and intermittently.
HIV risk is increased by HSV infection.

Risk Elements 
Age, the number of partners you've had throughout your life, STI and HIV history, having had intercourse before the age of 17, and being with someone who has HSV-1 or HSV-2 all raise your risk.
HSV-1 infection increases the chance of HSV-2 infection by three times.
Trauma, stress, fever, and immunosuppression all raise the chance of reactivation.

Use barrier contraception and refrain from sexual activity when signs or lesions are present as a preventative measure; abstinence is the only effective form of defense.

Syphilis, HIV, chlamydia, gonorrhea, and other STIs are associated conditions.

Presenting History A lot of patients are asymptomatic (74% of HSV-1 and 63% of HSV-2) or are unaware of the disease's clinical symptoms.

When symptoms first appear, they are frequently more intense, last longer, and are linked to constitutional symptoms.
Multiple vaginal ulcers, dysuria, pruritus, fever, tender inguinal lymphadenopathy, headache, malaise, myalgias, cervicitis/dyspareunia, and urethritis (watery discharge) are common presenting symptoms (primary episode).
First non-primary episode: Symptoms are typically less severe than the initial bout.
Prodrome of tingling, burning, or shooting pain (2–24 hours before lesion emerges); a single ulcer; lesion may have an unusual form; dysuria; and pruritus (4–6 days on average in duration).
Recurrent bouts are more common with HSV-2 than HSV-1, particularly in the first year following infection. Over time, recurrences become less frequent.
Less frequent manifestations include proctitis, stomatitis, pharyngitis, sacral paresthesias, and constipation (from anal involvement leading to tenesmus).

clinical assessment 
Lesions around the groin/perineum, in the anus, the vagina, and on the cervix may have different stages and display papular, vesicular, pustular, ulcerated, or crusty appearances.
Meningitis, recurrent meningitis (Mollaret syndrome), sacral radiculitis/paresthesias, encephalitis, transverse myelitis, and hepatitis are among the extragenital symptoms of inguinal lymphadenopathy.

Child Safety Considerations

80% of neonatal infections are caused by asymptomatic maternal viral shedding during an undetected primary infection in the third trimester, which affects 20 to 50/100,000 live births.
Transmission varies between 30% and 50% if the main episode airs close to the delivery time. HSV-1 carries a greater danger than HSV-2 in this regard. High morbidity and mortality rates are linked to neonatal illness.

 When children have genital lesions, suspect sexual abuse.

Differential diagnosis: Granuloma inguinale, lymphogranuloma venereum, Cytomegalovirus, Epstein-Barr virus, HIV, syphilis, chancroid, Herpes zoster, drug eruption, trauma

Neoplasia and Behçet syndrome

Laboratory Results 

Initial examinations (lab, imaging)
Use laboratory testing to validate the clinical diagnosis.
Use Dacron or polyester-tipped swabs with plastic shafts for viral isolation (swab or scrape) for culture or PCR; cotton tips and wood shafts impede viral growth and/or reproduction.
- Culture by taking a fluid sample from the vesicle's roof.
Specificity >99%; sensitivity varies by sample; for vesicles, 52–93%; for ulcers, 41–72%; and for crusted lesions, 19–30%.
- Live virus must be sent promptly to the lab in the proper medium at 4°C for culture.
- PCR has the highest specificity (>99%) and sensitivity (98%) but is also costly and hard to come by.
It is typically utilized for CSF and can raise detection rates by up to 70% (4). 
Serologic tests that are type-specific
- Between 10 days and 4 months following infection, sera convert. If a culture or PCR result is positive, antibody testing is not required.
- HSV IgM is frequently present with recurrent disease and does not differentiate between new and old infection, therefore IgM antibody testing is not helpful.
- To distinguish between HSV-1 and HSV-2, the Western blot (gold standard) and type-specific IgG antibody (glycoprotein G) enzyme-linked immunosorbent test (ELISA) are used.
- Western blot is >97-99% sensitive and specific, but it requires a lot of work and is not always available.
- ELISA is 81–100% sensitive and 93–100% specific for detecting HSV-2 but less so for detecting HSV-1. There's a chance of false positives.
- The following situations do not typically call for type-specific antibody screening: HIV-positive patients who are asymptomatic
Couples that don't get along (one partner has known HSV, the other doesn't)
No active lesions but recurrent symptoms


Treatment Options: Topical anesthetics, sitz baths, ice packs to the perineum, analgesics, and NSAIDs

Medication 
Within 72 hours after the onset of symptoms (including prodrome), begin antiviral treatment. Antivirals may be helpful after 3 days if new lesions develop or if there is substantial discomfort. HIV-positive individuals will need higher doses for a longer period of time.
Initial Line
(4) AcyclovirReduces discomfort, the amount of time the virus is discharged into the body, and the time it takes for the condition to fully resolve [A].
- Initial episode
400 mg PO TID for 7 to 10 days, with the possibility of a longer course if necessary for incomplete healing.
For those with HIV, 400 mg TID for 5 to 10 days - Daily suppression. 800 mg BID for 5 days. 800 mg TID for 2 days.
400 mg BID; 400 to 800 mg twice or three times daily for HIV patients; 5 to 10 mg/kg/dose every eight hours until symptoms improve; then switch to oral medication to finish the 10-day course (14 days for CNS involvement).
HIV infection: 400 mg PO 3–5 times per day, or as needed, until clinical remission is achieved.
In cases of renal impairment, adjust the dose.
Valtrex (Valacyclovir) (4)[A]: Acyclovir prodrug with enhanced absorption and less frequent dosing
First episode: 1 g PO BID for 7 to 10 days; second episode: 500 mg PO BID for 3 days; third episode: 1 g PO daily for 5 days; fourth episode: 1 g PO daily for 5 to 10 days for HIV-positive individuals; fifth episode: daily suppression.
For people with HIV, 500 mg PO BID; 1 g PO daily; and 500 mg PO daily
Primary episode: 250 mg PO TID for 7 to 10 days; Famciclovir (Famvir) (4)[A] - Episodic therapy
 500 mg PO once, followed by 250 mg PO BID for 2 days; 125 mg PO BID for 5 days; 1 g PO BID for 1 day
 For HIV-positive individuals, 500 mg PO BID for 5–10 days–daily suppression For people with HIV, 500 mg PO BID ISSUES FOR REFERRAL. 250 mg PO BID.
In consulting with an expert in infectious diseases, for acyclovir-resistant HSV:

Foscarnet: 40 to 80 mg/kg/dose IV every eight hours until clinical improvement - First-line therapy - Linked to serious nephrotoxicity
Cidofovir: once per week, 5 mg/kg IV
Pregnancy Considerations
Clinical management guidelines from ACOG:
 Screening: Pregnant women who do not have antibodies to HSV-1 or HSV-2 should abstain from sexual activity in the third trimester if their partner has antibodies.

 Suppressive therapy: To lower the reactivation rate and lower the risk of neonatal infection, pregnant women with a history of genital herpes should be administered suppression treatment beginning at 36 gestational weeks and continuing until delivery:
- 400 mg TID of acyclovir; 500 mg BID of valacyclovir
During pregnancy, keep an eye out for outbreaks, and check for lesions as soon as labor starts. If prodromal signs or lesions are present at the beginning of labor, a C-section is advised.

Child Safety Considerations
Infants at high risk include those with present maternal lesions at delivery, those born during a primary maternal episode, and those with active symptoms or lesions. Keep a tight eye on things and collect samples for diagnostic testing (HSV PCR and ocular, nasal, anal, and oral cultures). If symptomatic, continued therapy is necessary:
- Acyclovir 20 mg/kg IV every eight hours for 14 days in cases of cutaneous or mucosal lesions and 21 days in cases of disseminated or CNS disease
Low-risk infants who are asymptomatic can be watched as ocular, nasal, anal, and oral cultures as well as serum HSV PCR are taken. Infants who may have HSV infection should be kept apart from other newborns; breastfeeding is not prohibited and maternal separation is not required.

HIV and other STI Follow-Up Patient Monitoring Test.

In order to treat following outbreaks and lower the risk of transmission, patient education is helpful: - Two options are episodic therapy and daily suppressive therapy.
- Inform partners of past relationships before initiating sex.
- Steer clear of sexual activity while lesions or symptoms are present.
- Even in the absence of signs or lesions, viral shedding and transmission can take place.
Shedding increased with the presence of HSV-2 and HIV; 100% condom use lowers the risk of HSV-2 transmission by 30%.
– When two partners have the same type of herpes (HSV-1 or HSV-2), sexual activity between concordant couples does not raise the incidence of outbreaks.
Make sure the maternal care team is aware of the HSV status.


Prognosis: Signs and symptoms disappear in 3 to 21 days, and there are typically 1 to 4 episodes each year.

Antivirals can lessen transmission, shedding, and outbreaks but do not completely remove viruses from the body.
Child Safety Considerations
Neonatal infection survival rates: localized >95%, CNS 85%, systemic 30%.

Complications 
Low self-esteem, guilt, rage, sadness, fear of rejection, and fear of transfer to partner are examples of behavioral disorders.
HSV-2 increases the chance of HIV infection by two to three times.
Disseminated HSV hepatitis, especially during pregnancy

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