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HighlightsHerpes VirusesHerpes simplex virus 1 (HSV-1) is the main cause of herpes infections that occur on the mouth and lips.
TransmissionTo infect people, the herpes simplex viruses (both HSV-1 and HSV-2) must get into the body through tiny injuries in the skin or through a mucous membrane, such as inside the mouth or on the genital area.
Unfortunately, only 5% of infected pregnant women have a history of symptoms, so in many cases herpes infection is not suspected, or symptoms are missed, at the time of delivery. Eczema HerpeticumA form of herpes infection called eczema herpeticum, also known as Kaposi's varicellaform eruption, can affect patients with skin disorders and immunocompromised patients. Herpes in Patients with Compromised Immune SystemsHerpes simplex is particularly devastating when it occurs in immunocompromised patients and, unfortunately, co-infection is common.
The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition.
Both viruses can be carried in bodily fluids (such as saliva, semen, or fluid in the female genital tract) or in fluid from herpes sores. If there is evidence of an active outbreak, doctors usually advise a Cesarean section to prevent the baby from contracting the virus in the birth canal during delivery.Approach to the Pregnant Herpes Patient. The infection may recur after treatment has been stopped and, even during therapy, a patient can still transmit the virus to another person.
A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions.
The risk for infection is highest with direct contact of blisters or sores during an outbreak.Once the virus has contact with the mucous membranes or skin wounds, it begins to replicate.
It is most common in infants but can appear in people of all ages, particularly people taking antibiotics or those with impaired immune systems. Drugs can, however, reduce symptoms and improve healing times.Acyclovir and Related DrugsAntiviral drugs called nucleosides or nucleotide analogues are the main drugs used to treat genital herpes. The risk of infection is highest during outbreak periods when there are visible sores and lesions.
The virus is then transported within nerve cells to their roots where it remains inactive (latent) for some period of time. Scarring and corneal thinning develop, which may cause the eye's globe to rupture, resulting in blindness.
Centers for Disease Control and Prevention (CDC) recommends that all patients diagnosed with HSV-2 should be tested for HIV.The majority of patients with HIV are co-infected with HSV-2 and are particularly vulnerable to its complications.
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Samples are cultured to detect the virus at 3 - 5-day intervals prior to delivery to determine whether viral shedding is occurring. However, at some point, it often begins to multiply again without causing symptoms (called asymptomatic shedding). If no lesions are present and cultures indicate no viral shedding, a vaginal delivery can be performed and the newborn is examined and cultured after delivery.Some doctors recommend anti-viral medication for pregnant women who are infected with HSV-2.
Iridocyclitis is another serious complication of ocular herpes, in which the iris and the area around it become inflamed.GingivostomatitisHerpes can cause multiple painful ulcers on the gums and mucous membranes of the mouth, a condition called gingivostomatitis. Any duplication or distribution of the information contained herein is strictly prohibited.
During shedding, the virus can infect other people through exchange of bodily fluids.Sometimes, infected people can transmit the virus and infect other parts of their own bodies (most often the hands, thighs, or buttocks). Recent studies indicate that acyclovir (Zovirax, generic) valacyclovir (Valtrex), or famciclovir (Famvir) can help reduce the recurrence of genital herpes and the need for Cesarean sections.
Untreated, this condition can be extremely serious and possibly fatal.Ocular Herpes and Vision LossHerpetic infections of the eye (ocular herpes) occur in about 50,000 Americans each year. This process, known as autoinoculation, is uncommon, since people generally develop antibodies that protect against this problem.Transmission of Oral Herpes. In most cases, ocular herpes causes inflammation and sores on the lids or outside of the cornea that go away in a few days. HSV is part of a group of other herpes viruses that include human herpes virus 8 (the cause of Kaposi's sarcoma) and varicella- zoster virus (also known as herpes zoster, the virus responsible for shingles and chicken pox). However, other conditions can resemble herpes, and doctors cannot base a herpes diagnosis on visual inspection alone. For a recurrent episode, treatment takes 1 - 5 days depending on the type of medication and dosage.To suppress outbreaks, treatment requires taking pills daily on a long-term basis. HSV-1 is the most prevalent form of herpes simplex virus, and infection is most likely to occur during preschool years. Neonatal herpes can spread to the brain and central nervous system, causing encephalitis and meningitis and can lead to intellectual disability, cerebral palsy, and death.
In addition, many patients who carry the virus do not have visible genital or oral lesions. Acyclovir and famciclovir are taken twice a day, valacyclovir once a day.Suppressive treatment can reduce outbreaks by 70 - 80%. Herpes can also spread to internal organs, such as the liver and lungs.Infants infected with herpes are treated with acyclovir.
It is generally recommended for patients who have frequent recurrences (6 or more outbreaks per year). It is important to treat babies quickly, before the infection spreads to the brain and other organs.Effects on the Brain and Central Nervous SystemHerpes Encephalitis. In children, this is often caused by thumbsucking or finger sucking while they have a cold sore.
Valacyclovir may work especially well for preventing herpes transmission among heterosexual patients when one partner has herpes simplex virus 2 (HSV-2) and the other partner does not.
Until recently, the general rule was to assume that HSV-1 infections occur in the oral cavity (mouth) and are not sexually transmitted, while HSV-2 attacks the genital area and is sexually transmitted. It can also occur in adult health care workers, such as dentists, because of increased exposure to the herpes virus. Centers for Disease Control (CDC) recommends that both virologic and serologic tests be used for diagnosing genital herpes. However, valacyclovir may not be as effective as acyclovir for patients who have very frequent recurrences of herpes (more than 10 outbreaks per year). It is now widely accepted, however, that either type can be found in either area and at other sites.
In addition, because herpes simplex virus 1 can be passed in saliva, people should also avoid sharing toothbrushes or eating utensils with an infected person.Transmission of Genital Herpes. Patients diagnosed with genital herpes should also be tested for other sexually transmitted diseases.According to the CDC, up to 50% of first-episode cases of genital herpes are now caused by herpes simplex virus 1 (HSV-1). Genital herpes is most often transmitted through sexual activity, and people with multiple sexual partners are at high risk. However, recurrences of genital herpes, and viral shedding without overt symptoms, are much less frequent with HSV-1 infection than herpes simplex virus 2 (HSV-2). Centers for Disease Control, famciclovir is somewhat less effective than acyclovir or valacyclovir for suppressing viral shedding.Because the frequency of herpes recurrences often diminishes over time, patients should discuss annually with their doctors whether they should stay with drug therapy or discontinue it. The virus, however, can also enter through the anus, skin, and other areas.People with active symptoms of genital herpes are at very high risk for transmitting the infection. Fortunately, rapid diagnostic tests and treatment with acyclovir have significantly improved survival rates and reduced complication rates.
It is important for doctors to determine whether the genital herpes infection is caused by HSV-1 or HSV-2, as the type of herpes infection influences prognosis and treatment recommendations.Virologic TestsViral culture tests are made by taking a fluid sample, or culture, from the lesions as early as possible, ideally within the first 3 days of the outbreak.
Studies suggest that daily drug therapy is safe and effective for up to 6 years with acyclovir, and up to 1 year with valacyclovir or famciclovir.Side Effects. The virus does not multiply, but both the host cells and the virus survive.At unpredictable times, the virus begins multiplying again.
Unfortunately, evidence suggests about a third of all herpes simplex virus 2 (HSV-2) infections occur when the virus is shedding but producing no symptoms. Nearly all who recover suffer some impairment, ranging from very mild neurological changes to paralysis. Most people either have no symptoms or don't recognize them when they appear.In the past, genital herpes was mostly caused by HSV-2, but HSV-1 genital infection is increasing.
Patients who are treated with acyclovir within 2 days of becoming ill have the best chance for a favorable outcome.Herpes Meningitis. If infection is severe, testing technology can shorten this period to 24 hours, but speeding up the test may make the results less accurate.
Although there is some evidence these drugs may reduce shedding, they probably do not prevent it entirely. This may be due to the increase in oral sex activity among young adults.SymptomsSymptoms vary depending on whether the outbreak is initial or recurrent. Herpes meningitis, an inflammation of the membranes that line the brain and spinal cord, occurs in up to 10% of cases of primary genital HSV-2. Viral cultures are very accurate if lesions are still in the clear blister stage, but they do not work as well for older ulcerated sores, recurrent lesions, or latency. The use of condoms during asymptomatic periods is still essential, even when patients are taking these medications.Risk for Resistant Viruses. Unfortunately, a third to half of the times shedding occurs without any symptoms at all.Eventually, the symptoms return in most cases, causing a new outbreak of blisters and sores. At these stages the virus may not be active enough to reproduce sufficiently to produce a visible culture.Polymerase chain reaction (PCR) tests are much more accurate than viral cultures, and the CDC recommends this test for detecting herpes in spinal fluid when diagnosing herpes encephalitis (see below).
This close-up view of early herpes outbreak shows small, grouped blisters (vesicles) and lots of inflammation (erythema). PCR can make many copies of the virus’ DNA so that even small amounts of DNA in the sample can be detected. In fact, studies indicate that 10 - 25% of people infected with HSV-2 are unaware that they have genital herpes. Fortunately, after lasting for up to a week, herpes meningitis usually resolves without complications, although recurrences have been reported. PCR is much more expensive than viral cultures and is not FDA-approved for testing genital specimens.
However, patients who do not respond to standard regimens should be monitored for emergence of drug resistance.Treatment for Oral HerpesOral TreatmentsAcyclovir (Zovirax, generic), valacyclovir (Valtrex), and famciclovir (Famvir) -- the anti-viral pills used to treat genital herpes -- can also treat the cold sores associated with oral herpes. Even if infected people have mild or no symptoms, they can still transmit the herpes virus.Symptoms of Genital HerpesPrimary Genital Herpes Outbreak. However, because PCR is highly accurate, many labs have used it for herpes testing.An older type of virologic testing, the Tzanck smear test, uses scrapings from herpes lesions.
In addition, acyclovir is available in topical form, as is penciclovir (a related drug).Topical TreatmentsThese ointments or creams can help shorten healing time and duration of symptoms.
For patients with symptoms, the first outbreak usually occurs in or around the genital area 1 - 2 weeks after sexual exposure to the virus.
The scrapings are stained and examined under a microscope for the presence of giant cells with many nuclei or distinctive particles that carry the virus (called inclusion bodies). However, none are truly effective in eliminating outbreaks.Penciclovir (Denavir) heals herpes simplex virus 1 (HSV-1) sores on average about half a day faster than without treatment, stops viral shedding, and reduces the duration of pain. The first signs are a tingling sensation in the affected areas (such as genitalia, buttocks, and thighs) and groups of small red bumps that develop into blisters. Ideally, the patient should apply the cream within the first hour of symptoms, although the medication can still help if applied later. The Tzanck test is not reliable for providing a conclusive diagnosis of herpes infection and is not recommended by the CDC.Serologic TestsSerologic (blood) tests can identify antibodies that are specific for either herpes virus simplex 1 (HSV-1) or herpes virus simplex 2 (HSV-2).
The patient applies the cream five times a day, beginning at the first sign of tingling or pain. When the herpes virus infects someone, their body’s immune system produces specific antibodies to fight off the infection. Studies have been mixed on the cream’s benefits.Over-the-counter topical ointments may provide modest relief.
The lesions may sometimes itch, but itching decreases as they heal.About 40% of men and 70% of women develop other symptoms during initial outbreaks of genital herpes, such as flu-like discomfort, headache, muscle aches, fever, and swollen glands. If a blood test detects antibodies to herpes, it’s evidence that you have been infected with the virus, even if the virus is in a non-active (dormant) state. They include Anbesol gel, Blistex lip ointment, Camphophenique, Herpecin-L, Viractin, and Zilactin. The CDC recommends only type-specific glycoprotein (gG) tests for herpes diagnosis.Serologic tests are most accurate when performed 12 - 16 weeks after exposure to the virus. The virus sheds for a much shorter period of time (about 3 days) compared to in an initial outbreak of 3 weeks.
Women may have only minor itching, and the symptoms may be even milder in men.On average, people have about four recurrences during the first year, although this varies widely. There are some differences in frequency of recurrence depending on whether HSV-2 or HSV-1 causes genital herpes. Samples need to be sent to a lab, so results take longer than the in-office Biokit test.Biokit HSV-2 (also marketed as SureVue HSV-2). HSV-2 genital infection is more likely to cause recurrences than HSV-1.Symptoms of Oral HerpesOral herpes (herpes labialis) is most often caused by herpes simplex virus 1 (HSV-1) but can also be caused by herpes simplex virus 2 (HSV-2). Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful.
It usually affects the lips and, in some primary attacks, the mucous membranes in the mouth. Its major advantages are that it requires only a finger prick and results are provided in less than 10 minutes. There have been several reported cases of serious and even lethal side effects from herbal products.
A herpes infection may occur on the cheeks or in the nose, but facial herpes is very uncommon.Primary Oral Herpes Infection.
Always check with your doctor before using any herbal remedies or dietary supplements.Many herbal and dietary supplement products claim to help fight herpes infection by boosting the immune system. There has been little research on these products, and little evidence to show that they really work. In adolescents, the primary infection is more apt to appear in the upper part of the throat and cause soreness.Recurrent Oral Herpes Infection. Most patients have only a couple of outbreaks a year, although a small percentage of patients have more frequent recurrences. It is costly and time consuming, however, and is not as widely available as the other tests.False-negative (testing negative when herpes infection is actually present) results can occur if tests are done in the early stages of infection.
False-positive results (testing positive when herpes infection is not actually present) can also occur, although less often than false-negative. Recurrences are usually much milder than primary infections and are known commonly as cold sores or fever blisters (because they may arise during a bout of cold or flu). The polymerase chain reaction (PCR) assay of cerebrospinal fluid detects tiny amounts of DNA from the virus, and then replicates them millions of times until the virus is detectable. PCR identifies HSV in cerebrospinal fluid and gives a rapid diagnosis of herpes encephalitis in most cases, eliminating the need for biopsies. The CDC recommends PCR for diagnosing herpes central nervous system infections.Imaging Tests. Seroprevalence of herpes simplex virus type 2 among persons aged 14 - 49 years -- United States, 2005-2008. Magnetic resonance imaging (MRI) scans may be used to differentiate encephalitis from other conditions.Brain Biopsy. The outbreak of infection is often preceded by a prodrome, an early group of symptoms that may include itching skin, pain, or an abnormal tingling sensation at the site of infection. Brain biopsy is the most reliable method of diagnosing herpes encephalitis, but it is also the most invasive and is generally performed only if the diagnosis is uncertain. With the increased use of PCR, biopsies for herpes are now only rarely performed.Similar ConditionsCanker Sores (Aphthous Ulcers).
The prodrome, which may last as short as 2 hours or as long as 2 days, stops when the blisters develop.
Simple canker sores (known medically as aphthous ulcers) are often confused with the cold sores of herpes simplex virus 1 (HSV-1).
Canker sores frequently crop up singly or in groups on the inside of the mouth or on or under the tongue. Recurrent outbreaks feature most of the same symptoms at the same sites as the primary attack, but they tend to be milder and briefer. Occasionally, the symptoms may not resemble those of the primary episode but appear as fissures and scrapes in the skin or as general inflammation around the affected area.Triggers of Recurrence. They include sunlight, wind, fever, physical injury, surgery, menstruation, suppression of the immune system, and emotional stress. Oral herpes can be triggered within about 3 days of intense dental work, particularly root canal or tooth extraction.Timing of Recurrences.
Human herpes simplex virus infections: epidemiology, pathogenesis, symptomatology, diagnosis, and management.
For most people, outbreaks recur with more frequency during the first year after an initial attack. In most healthy people, recurring infections tend to become progressively less frequent, and less severe, over time. However, the immune system cannot kill the virus completely.Risk FactorsRisk for Oral HerpesOral herpes is usually caused by HSV-1. Centers for Disease Control and Prevention, about 1 in 6 American teenagers and adults, are infected with HSV-2. While HSV-2 remains the main cause of genital herpes, in recent years HSV-1 has significantly increased as a cause, most likely because of oral-genital sex. Except for people in monogamous relationships with uninfected partners, everyone who is sexually active is at risk for genital herpes.Risk factors for genital herpes include a history of a prior sexually transmitted disease, early age for first sexual intercourse, a high number of sexual partners, and loq socioeconomic status. Women are more susceptible to HSV-2 infection because herpes is more easily transmitted from men to women than from women to men. Third trimester antiviral prophylaxis for preventing maternal genital herpes simplex virus (HSV) recurrences and neonatal infection. African-American women are at particularly high riskPeople with compromised immune systems, notably patients with HIV, are at very high risk for HSV-2.
A meta-analysis to assess the efficacy of oral antiviral treatment to prevent genital herpes outbreaks. This group is at higher than average risk for herpetic whitlow, herpes that occurs in the fingers.Wrestlers, rugby players, and other athletes who participate in direct contact sports without protective clothing. These individuals are at risk for herpes gladiatorum, an unusual form of HSV-1 that is spread by skin contact with exposed herpes sores and usually affects the head or eyes.Preventing TransmissionInfected people should take steps to avoid transmitting genital herpes to others. Epub 2007 Apr 9.Martin ET, Krantz E, Gottlieb SL, Magaret AS, Langenberg A, Stanberry L, et al. It is almost impossible to defend against the transmission of oral herpes since it can be transmitted by very casual contact.Genital herpes is contagious from the first signs of tingling and burning (prodrome) until the time that sores have completely healed. While condoms may not provide 100% protection, they have been proven to significantly reduce the risk of sexual disease transmission.
Natural condoms made from animal skin do NOT protect against HSV infection because herpes viruses can pass through them.Use a water-based lubricant. Lubricants can help prevent friction during sex, which can irritate the skin and increase the risk for outbreaks.
Genital shedding of herpes simplex virus among symptomatic and asymptomatic persons with HSV-2 infection. Only water-based lubricants (such as K-Y Jelly, Astroglide, AquaLube, and glycerin) should be used. Oil-based lubricants (such as petroleum jelly, body lotions, and cooking oil) can weaken latex. However, it is best not to use condoms pre-lubricated with spermicides.Do not use spermicides for protection against herpes. If you do, be sure to immediately wash your hands with hot water and soap.The herpes virus does not live very long outside the body.
While the chances of transmitting or contracting herpes from a toilet seat or towel are extremely low, it is advisable to wipe off toilet seats and not to share damp towels.Recent studies have suggested that male circumcision may help reduce the risk of HSV-2, as well as human papillomavirus (HPV) and HIV infections.
Except in very rare instances and special circumstances, HSV is not life threatening.Herpes and PregnancyPregnant women who have genital herpes due to either herpes simplex virus 2 (HSV-2) or herpes simplex virus 1 (HSV-1) have an increased risk for miscarriage, premature labor, inhibited fetal growth, or transmission of the herpes infection to the infant either in the uterus or at the time of delivery. Herpes in newborn babies (herpes neonatalis) can be a very serious condition.Fortunately, neonatal herpes is rare.
Although about 25 - 30% of pregnant women have genital herpes, less than 0.1% of babies are born with neonatal herpes.
The baby is at greatest risk during a vaginal delivery, especially if the mother has an asymptomatic infection that was first introduced late in the pregnancy.
Transmission can occur if the amniotic membrane of an infected woman ruptures prematurely, or as the infant passes through an infected birth canal.
This increased risk is present if the woman is having or has recently had an active herpes outbreak in the genital area.Very rarely, the virus is transmitted across the placenta, a form of the infection known as congenital herpes. Also rarely, newborns may contract herpes during the first weeks of life from being kissed by someone with a herpes cold sore.
Infants may get congenital herpes from a mother with an active herpes infection at the time of birth.
Aggressive treatment with antiviral medication is required, but it may not help systemic herpes.
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