Let’s switch gears now to genital herpes. Herpes is asymptomatic in about half of cases.
Recurrent viral disease leads to vesicular and ulcerative skin eruptions that can recur
multiple times throughout one’s life. These are caused by HSV in sexually active adolescents.
HSV-1 is typically more associated with oral ulcers but can also cause genital lesions.
HSV-2 is typically more associated with genital infections but can also cause oral lesions.
Generally, these patients will have viral shedding and then transmission through direct contact.
The virus replicates in the epidermal and dermal cells of the skin. It spreads then to sensory nerves
where it can remain latent for the rest of the patient’s life. During periods of stress, those patients
will reactivate and either have asymptomatic viral shedding or a recurrence of a lesion.
This patient has oral herpes and you can see that lesion on his lip. In children especially,
they can then shed that virus in their mouth and get it on to their fingers. This is called herpetic whitlow.
Herpetic whitlow is even common in doctors and dentists who acquire the disease from their patients.
But usually in children, it’s autoinoculation. It’s common in children with their first onset of oral herpes
stomatitis because that’s when they’re shedding the virus the most out of their lesions
around the mouth. Physicians who fail to use gloves are at risk for this problem.
Primary infection can also happen in the genitalia. Generally, these are vesicles on an erythematous
base that can then rupture to form painful ulcers. Multiple lesions involve the vulva, the perineum,
the vagina, the cervix, or the penis. That’s usually during the first outbreak of the disease.
They then resolve with crusting of the vesicles and healing of the ulcers. However again, they can recur
periodically for years afterwards. You may see dysuria or a vaginal or urethral discharge.
Duration of symptoms is typically about three weeks. Constitutional symptoms such as low grade fever
will happen in more than half of cases. It’s important to remember that patients may have
recurrent infections with reactivation of the virus that’s lying dormant inside the nerve root.
So, these patients with recurrences will have smaller lesions. They may have a prodrome of pain
preceding the eruption. The duration of symptoms is usually a little bit shorter, perhaps a week
compared to the primary infection which is usually more like three weeks. In these cases,
constitutional symptoms are uncommon. So, how do we test for HSV? Well, the PCR is the preferred
diagnostic method. You can do viral culturing from active lesions and that usually grows within 24 hours.
A direct fluorescent antibody stain will show cell membranes expressing viral genomic material
on the cell surface on an MHC protein. That then lights up with a direct antibody that is then
made to glow through a fluorescent antibody. The Tzanck smear may show up on an old test
but nobody uses the Tzanck smear anymore. That would show multinucleated, giant cells.
Type-specific antibody serology tests are available but they’re not particularly useful.
This is because a huge number of people will test positive for the virus and yet never have had a symptom.
Roughly, one in four Americans is positive for HSV-2 and a huge majority is positive for HSV-1.
So, how do we treat herpes? Well, there are oral antiviral medications that can be helpful.
There is acyclovir, famciclovir, and the one that has the highest oral bioavailability is valacyclovir.
Valacyclovir is indicated to decrease duration of symptoms and prevent recurrence of new lesions.
It can shorten the duration of viral shedding and reduce transmission risk. In disconjugate couples
where one has herpes and the other one doesn’t, it can reduce transmission rates over the course
of a year but it does not eliminate them. It will not eradicate any latent virus from the body.
It does not affect the risk of future recurrences. So remember, for patients who have very frequent
outbreaks, more than six outbreaks a year, these patients may qualify for daily suppressive therapy
with valacyclovir. It’s not cheap but it makes their lives a lot easier to live.
So, that’s my review of both HPV and HSV. Thanks for paying attention.