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genital Herpes (Herpes genitalis)

Etiology: 1) sexually transmitted disease 2) Herpes simplex virus (HSV-1, HSV-2)* 3) disorders linked to HSV recurrences a) Mollaret's meningitis b) recurrent erythema multiforme * HSV-1 is usually acquired in childhood via nonsexual contact, & is the primary cause of orolabial herpes but can cause genital herpes * HSV-2 is usually acquired via sexual contact, uncommonly causes orolabial herpes, but does cause genital herpes [7] Epidemiology: 1) transmission of virus occurs most readily when there are active genital lesions 2) periods of asymptomatic shedding are associated with most transmission 3) in women, asymptomatic shedding greatest in year following primary infection (4.3% of days) 4) vertical transmission (to fetus) associated with active lesions or asymptomatic shedding greatest with 1st episode (33-50%), declining subsequently to 3% 5) genital HSV-1 shedding frequent after 1st episode genital HSV-1, especially after primary infection, declining within the 1st year, 65% of patients at 2 months, 33% at 11 months [9] Clinical manifestations: 1) asymptomatic in 60-90% 2) recurrent genital lesions more common with HSV-1 than HSV-2 3) painful genital vesicles & erosions a) group vesicles on an erythematous base b) lesions ulcerate when vesicles rupture 4) inguinal lymphadenopathy, fever, myalgia, malaise with with primary infection [1] Laboratory: 1) Herpes simplex virus DNA most sensitive assay [1] 2) viral culture to confirm diagnosis & distinguish HSV-1 from HSV-2 3) serologic test for syphilis 4) HIV1 serology 5) Herpes simplex virus Ab - HSV-2 Ab in serum & HSV-1 Ab in serum - may be negative during primary infection - serologic screening for genital herpes not recommended [6,8] Management: 1) daily treatment with acyclovir, famciclovir, or valacyclovir may reduce asymptomatic shedding of virus by 90%, reducing risk of transmission to partner 2) treatment indicated for primary infection & severe recurrences 3) pharmaceutical agents a) acyclovir 800 mg PO TID for 2 days [2,3]; 400 mg PO TID for 7-10 days [1] - topical acyclovir not effective [1] b) famciclovir 1000 mg PO BID for 1 day [3]; 250 mg PO TID for 7-10 days [1] c) valacyclovir 1 g PO BID for 7-10 days [1]; 500 mg daily to reduce heterosexual transmission d) topical antivirals not effective [1] 4) HIV patients may have resistant strains of HSV-2 a) increase dose of standard antivirals if not response to usual dose [1] b) foscarnet IV & topical trifluridine c) cidofovir d) resistance testing if no response to high-dose antiviral agent [1] 5) recombinant glycoprotein D HSV-2 vaccine may provide prophylaxis against primary infection & recurrences in previously infected individuals 6) patient initiated therapy for infrequent recurrences [1] 7) suppressive therapy for frequent recurrences (> 5/year) - reduces symptomatic recurrences - reduces asymptomatic viral shedding - reduces risk of transmission of HSV-2 to susceptible partner by ~50% [7] 8) offer screening for other sexually-transmitted diseases (see laboratory) [7] 9) screening of asymptomatic individuals not recommended [8]

Related

Herpes simplex type 2 (HSV-2); human herpesvirus 2

General

sexually-transmitted disease; sexually-transmitted infection; venereal disease (STD, STI) Herpes virus infection

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 17, 18. American College of Physicians, Philadelphia 1998, 2006, 2009, 2015, 2018. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  2. Journal Watch 22(9):69, 2002 Wald A et al Two-day regimen of acyclovir for treatment of recurrent genital herpes simplex virus type 2 infection. Clin Infect Dis 34:944, 2002 PMID: 11880960 - Leone PA et al Valacyclovir for episodic treatment of genital herpes: a shorter 3-day treatment course compared with 5-day treatment. Clin Infect Dis 34:958, 2002 PMID: 11880962
  3. Prescriber's Letter 13(9): 2006 Summary Chart of 2006 CDC treatment guidelines for STDs Detail-Document#: 220912 (subscription needed) http://www.prescribersletter.com
  4. Hollier LM and Eppes C. Genital herpes: oral antiviral treatments. BMJ Clin Evid 2015 PMID: 25853497
  5. Hofstetter AM, Rosenthal SL, Stanberry LR. Current thinking on genital herpes. Curr Opin Infect Dis. 2014 Feb;27(1):75-83. Review. PMID: 24335720
  6. USPSTF. Draft Recommendation Statement. Aug 2016 Genital Herpes Infection: Serologic Screening http://www.uspreventiveservicestaskforce.org/Page/Document/draft-recommendation-statement/genital-herpes-screening1 - USPSTF. Draft Evidence Review. Aug 2016 Draft Evidence Review for Genital Herpes Infection: Serologic Screening. http://www.uspreventiveservicestaskforce.org/Page/Document/draft-evidence-review/genital-herpes-screening1
  7. Gnann JW Jr, Whitley RJ Genital Herpes N Engl J Med 2016; 375:666-674. August 18, 2016 PMID: 27532832 http://www.nejm.org/doi/full/10.1056/NEJMcp1603178
  8. US Preventive Services Task Force Serologic Screening for Genital Herpes Infection. US Preventive Services Task Force Recommendation Statement. JAMA. 2016;316(23):2525-2530. PMID: 27997659 http://jamanetwork.com/journals/jama/fullarticle/2593575 - Feltner C, Grodensky C, Ebel C et al Serologic Screening for Genital Herpes. An Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2016;316(23):2531-2543 PMID: 27997660 http://jamanetwork.com/journals/jama/fullarticle/2593576 - Hook EW 3rd. A Recommendation Against Serologic Screening for Genital Herpes Infection - What Now? JAMA. 2016;316(23):2493-2494 PMID: 27997636 http://jamanetwork.com/journals/jama/fullarticle/2593550 - Yeung H, Sheth, AN Collins LF Reaffirmed USPSTF Recommendation Against Serologic Screening for Genital Herpes. Empowering Clinicians and Reducing Potential Harm. JAMA Dermatol. Published online February 14, 2023. PMID: 36787146 https://jamanetwork.com/journals/jamadermatology/fullarticle/2801596
  9. Johnston C et al. Viral shedding 1 year following first-episode genital HSV-1 infection. JAMA 2022 Nov 1; 328:1730-1739. PMID: 36272098 https://jamanetwork.com/journals/jama/fullarticle/2797619