​Kembara Xtra - Medicine - Herpes Simplex

​Kembara Xtra - Medicine - Herpes Simplex
Typical vesicular rash with primary oral and vaginal distribution brought on by infection with:
- HSV-1: blisters primarily in the mouth, eyes, and face
- Blisters caused by HSV-2, mostly on the genitalia
HSV-1 and HSV-2 historically caused infection in various locations. HSV-1, which can cause genital sores through oral-genital contact, is now as common in primary genital infections as HSV 2 in recent years.
Depending on the host's age, immune state, whether the infection is primary or recurring, and the extent of dissemination, it can cause a wide range of consequences.
Viral shedding normally peaks during the initial (primary) infection and declines with subsequent infections.
Serious systemic symptoms of HSV infection include meningitis, encephalitis, and pneumonia.

Epidemiology 
Affects people of all ages; the majority of HSV-1 and HSV-2 infections occur in young to middle adulthood.
Males outnumber women in terms of prevalence, and there are more than 1 million new cases of HSV each year. HSV can also reactivate, leading to recurring illness.


Prevalence

1-25% of adults may shed HSV-1 or HSV-2 at any given moment, making it widespread. Many people don't know whether they are infected.
90% of the general population has antibodies to HSV-1 by adulthood, while 33% of children under the age of 5 have the virus.
About 417 million people worldwide, between the ages of 15 and 49, are infected by HSV-1; 400 million people have genital herpes caused by HSV-2; and 1 in 5 pregnant women are seropositive for HSV-2. Adults make up 30% of the population.

Pathophysiology and Etiology 
Double-stranded DNA viruses from the Herpesviridae family include HSV-1 and HSV-2. When the virus is shedding, contact with infected skin can spread HSV-1 and HSV-2.
Vertical transmission is a possibility during birthing.

Risk factors include: atopic eczema, particularly in children; prior HSV infection; sexual contact with an infected person (condoms help minimize HSV transmission, but lesions outside condom-protected areas can spread virus). Immunocompromised states include advanced age, chemotherapy, malignancy, or chronic diseases like diabetes or AIDS.
Dental workers are more likely to contract HSV-1 and develop herpetic whitlow as a result of occupational exposure.
Herpes gladiatorum: contact with abrasion sites, frequently acquired through sports with high levels of physical contact (such as rugby and wrestling); Herpes simplex neonatal: typically acquired by vaginal birth to an infected mother; risk is greatest in mothers with primary genital herpes infection; incubation is usually from 5 to 7 days (rarely 4 weeks); cutaneous, mucous membrane, or ocular signs seen in only 70% of cases; HSV-2 patients are at

Prevention 

Avoid direct contact with the elderly, young children, and immunocompromised individuals if active lesions are present.
Maintain good hand hygiene by avoiding sharing drinks, utensils, kisses, and toothbrushes.
Genital herpes: Avoid sexual contact if active lesions are present (although transmission can still happen even when the disease seems dormant); describe the advantages and restrictions of using condoms; promote safe sex; and take into account antiviral medication to lessen viral shedding.


Accompanying Conditions 
Screen all severe, treatment-resistant, or uncommon HSV for concurrent HIV infection. Herpetic Whitlow, Bell Palsy, and Erythema Multiforme: 50% of cases associated with HSV- 1 or HSV-2.

Providing the Past A lot of patients are not aware of a recognized exposure.
A few days before the initial eruption of the typical vesicular rash, there is a prodrome of lethargy, low-grade fever, itching, tingling, or burning skin.
In subsequent outbreaks, a prodrome of pain, burning, tingling, and itching frequently develops 6 to 48 hours before vesicles manifest.
Sunlight, fever, shock, menstruation, and stress all contributed to the outbreak.

clinical assessment 
Vesicles frequently group together and develop into excruciating ulcerated sores with erythematous bases.
Primary herpetic gingivostomatitis and pharyngitis typically affect young children; symptoms include fever, painful throat, pharyngeal edema, and erythema after 2 to 12 days of incubation.
– Fever, poor oral intake, and excessive salivation cause dehydration; small vesicles appear on the pharyngeal and oral mucosa, quickly ulcerate, and multiply to affect the soft palate, buccal mucosa, tongue, floor of mouth, lips, and cheeks; tender, bleeding gums; and cervical adenopathy. takes 10 to 14 days to resolve - During the initial outbreak, children typically show with blisters and fever, whereas adults typically come with sore throat and cervical lymphadenopathy.
Primary herpes keratoconjunctivitis lasts for 2 to 3 weeks; systemic involvement prolongs the process. Symptoms include unilateral conjunctivitis with regional adenopathy, blepharitis with vesicles on the lids, marginal keratitis with dendritic lesions or with punctate opacities, and blepharitis.

Eczema herpeticum: painful diffuse pox-like eruption complicating atopic dermatitis; abrupt onset of lesions in classic atopic sites (upper trunk, neck, and head); high fever; localized edema; adenopathy
Herpetic whitlow is a localized infection of the finger that causes excruciating itching and pain. Vesicles may form and cause edema, erythema, and swelling. mimics pyogenic paronychia; potential side effects include neuralgia and axillary adenopathy; cures in two to three weeks
Transplacental transmission of congenital infection can cause jaundice, hepatosplenomegaly, disseminated intravascular coagulation (DIC), encephalitis, convulsions, temperature instability, chorioretinitis, and conjunctivitis with or without vesicles as symptoms.

 recurring illnesses from endogenous reactivation - Herpes labialis: recurring lesions with HSV-1; typically 1 recurrence every 6 months, but 5-25% may have >1 attack every month; vesicles frequently near vermilion border, ulcerate and crust within 48 hours; heal within 8 to 10 days; may have local adenopathy
- Keratitis, blepharitis, or keratoconjunctivitis may return as a result of ocular herpes; other symptoms include dendritic ulcers, decreased corneal feeling, and decreased visual acuity; uveitis may result in irreversible vision loss.


Multiple Diagnoses 

 Aphthous stomatitis: grayish, shallow erosions with a ring of anterior hyperemia in the mouth and lips Impetigo: honey-crusted vesicles
Unilateral dermatome distribution of herpes zoster

Herpangina: Vesicles predominate on anterior tonsillar pillars, soft palate, uvula, and oropharynx but not more anteriorly on lips/gums (often caused by group A coxsackievirus). Syphilitic chancre: Painless genital ulcer. Folliculitis: "shave bumps" in genital area.
Lymphogranuloma venereum, Stevens-Johnson syndrome, secondary bacterial infection, and fungal infection

Laboratory Results 

Patients with primary genital herpes should be screened for other STIs.
Viral: The human papillomavirus (HPV), hepatitis B and C, and HIV all cross-pollinate.
Bacterial: In fresh primary genital outbreaks, look for concomitant gonorrhea and chlamydia.
Initial examinations (lab, imaging)

 Typically a medical diagnosis. Testing ought to be saved for patients with immunocompromising conditions and unusual presentations.

If you scrape tissue from the lesion onto a slide, fix it with ethanol/methanol, and then use Giemsa or Wright stain to see it, you will see multinucleated large cells that are frequently accompanied by eosinophilic intranuclear inclusions. The findings of varicella (herpes zoster) are the same.
The gold standard for diagnosis is HSV culture. Remove the vesicle's roof, then use a brush dipped in liquid to scrape the base of the vesicle. The proper viral swab and medium are required.
highest yield if swab is taken 48 hours after outbreak. Highly specific (reliable if positive), but 20% false-negative rate; sample may need to be refrigerated; can take up to 6 days to be positive.
Antibody tests that are specific to HSV types can differentiate between HSV-1 and HSV-2.
- Western blot, ELISA, polymerase chain reaction (PCR), and direct fluorescent antibody (DFA)
- At 3 weeks, 50% of infected people test positive; at 6 weeks, 70%; and at 16 weeks, nearly all infected people test positive.
Testing for HSV IgM, which might be positive during the initial or recurring infection, is not clinically beneficial.


Treatment consists of using cool dressings wet with aluminum acetate solution to manage symptoms while lesions heal.
Regarding genital lesions: If lesions are causing urinary problems, pour a cup of warm water over the genitalia while urinating or sit in a warm bath while peeing (sitz baths).
Children with gingivostomatitis who are uncomfortable eating or drinking or who have severe eczema herpeticum may need intravenous hydration.

The First Line of Medicine
Start right away, ideally in the prodromal phase.
Treat outbreak as soon as symptoms appear, if at all feasible.
Start the treatment within a day of the first symptom appearing for episodic treatment of recurrent HSV infection.

Offer suppressive therapy to people experiencing severe physical pain brought on by outbreaks, significant psychological distress brought on by outbreaks, or pregnant women beyond 36 weeks of pregnancy.
Topical treatment
1% cream for penciclovir (Denavir). Apply to oral lesions every two hours while you're awake for four days.
The generic drug acyclovir treats mucocutaneous (or genital) HSV.
Initial infection: 400 mg five times daily for five days.
If severe, begin IV dosage every eight hours for the first few days, then finish the 10-day treatment through PO.
Days: Recurrence
400 mg orally three times daily for five days; 800 mg orally twice daily for five days; and 800 mg orally three times daily for two days.
Keratitis HSV: 400 mg PO five times daily; topical therapy is preferred as the initial line of defense. Suppression: 400 mg BID daily.
Neonatal herpes simplex or encephalitis: 60 mg/kg/day IV divided every eight hours for 14 to 21 days.
 Weight-based dosing is used for older (>3 months of age) immunocompetent patients (40 to 80 mg/kg/day [max 1,000 mg/day] divided q8h for 5–7 days).
- Category B: Safe during pregnancy and lactation 

Valacyclovir (Valtrex): Primary genital herpes: 1 g PO BID for 10 days, beginning within 48 hours of symptoms; Herpes labialis: 2,000 mg PO q12h for 1 day
- For recurrent genital herpes, take 500 mg PO BID for three days, beginning as soon as symptoms appear, and 500 to 1,000 mg PO daily (depending on the frequency of outbreaks).
500 to 1,000 mg daily dosage for suppression
Famciclovir (Famvir) - Primary genital herpes: 250 mg PO TID for 7 to 10 days - Recurrence: 125 mg PO BID for 5 days - Suppression: 250 mg PO BID
Safety measures
Probenecid with IV acyclovir and perhaps probenecid with valacyclovir may impair renal clearance and elevate antiviral medication levels. - Renal dosage for all oral antivirals. - Significant potential interactions.

Next Line

Foscarnet is the drug of choice for treating acyclovir resistance in immunocompromised individuals with systemic HSV. Its recommended dosage is 40 mg/kg IV every eight hours.
Additional topicals
Acyclovir, vidarabine (Vira-A), ganciclovir, and trifluridine are ophthalmic treatments for herpes keratoconjunctivitis. Topical acyclovir and penciclovir reduce the healing period for recurrent herpes labialis by around 10%.
- Topical analgesics: Lidocaine 2% or 5% helps lessen the discomfort brought on by penile and vulvar breakouts.
Docosanol, an over-the-counter topical antiviral

Referral 
Contact an ophthalmologist about recurring herpes keratoconjunctivitis occurrences.

Pregnancy considerations for admission
If there are any active genital lesions (or prodrome) present at the time of delivery, a cesarean section and/or acyclovir are recommended; consider a cesarean delivery if primary genital herpes is detected during the previous four weeks.

After 36 weeks of pregnancy, women with a history of genital herpes can prevent outbreaks around birth by taking daily oral antivirals.
If the mother has a history of genital HSV, avoid using forceps, vacuum extractors, or artificial membrane rupture.
There is a low (1.6% chance) of viral shedding from asymptomatic recurrent genital HSV during birth.
The risk of newborn infection from primary maternal HSV-1 or HSV-2 infection is 60% at the time of delivery.
Child Safety Considerations
Infants who display symptoms of HSV infection or who have a high index of suspicion for exposure at birth should have bodily fluids cultured and begin IV acyclovir treatment as once.

Follow-Up In the vast majority of routine instances, follow-up is not required. Within 10 days, lesions and symptoms swiftly disappear. A week later, extensive cases should be evaluated again, and subsequent bacterial infections should be watched for.
Take long-term suppression into account.


Diet

Avoid meals that are salty, acidic, or sharp if you have oral lesions (such as snack chips, orange juice).

Counsel patients on the virus's natural course, the difficulty of predicting when an individual was exposed, and the fact that the virus will stay forever in the body. Stigmatization can be lessened by acknowledging and talking about the psychological effects of the diagnosis.

To prevent spreading to other body parts or exposing others, place a strong emphasis on personal hygiene. Wash your hands frequently, don't scratch, and cover any active, moist lesions.
Promote responsible sexual behavior.
Before beginning a sexual relationship, let your partner know you have an infection.


The primary disease typically lasts 5 days to 2 weeks; however, antiviral treatment might shorten this time, lessen complications, and even lessen recurrences (if used for suppression).
Viral shedding during recurrence is less prolonged than during primary disease; the frequency of recurrence varies and is influenced by the characteristics of each host.
HSV is never completely eradicated from the body; instead, it remains latent in the dorsal root ganglia and can reactivate, leading to repeated symptoms and lesions. Newborns and immunocompromised people are at most risk for significant morbidity/mortality.

Herpes encephalitis complications: A brain biopsy may be required for the diagnosis.
Recurrent reactivation of latent HSV-1 infection has been linked to neurodegeneration and Alzheimer disease, according to new research.
Inflammatory illness of the pelvis
Acute urinary retention, disseminated herpes, hepatitis, and neonatal infection

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