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

Also see Herpes simplex. Epidemiology: 1) less prevalent than HSV-1 - overall serologic prevalence in USA is 25% 2) higher prevalence in HIV patients 3) risk of vertical transmission to fetus a) 30-50% with 1st episode b) risk is < 3% with recurrent Herpes - highest (3%) with active lesions 4) cofactor in transmission of HIV 5) most common sexually transmitted ulcerative disease 6) transmission occurs through direct contact with infected secretions of skin lesions Pathology: - CD111 serves as receptor for HSV2 - latent virus in nerve ganglion Clinical manifestations: 1) primarily associated with genital lesions - gluteal & presacal lesions also occur - sacral lesions may occur with aseptic meningitis 2) only 20% of seropositive individuals recall symptoms - thus partner of affected individual may be asymptomatic 3) itching & burning characteristic of prodrome [1] 4) recurrent rash is common - most commonly occur on labia or the penis - recurrent gluteal & presacal lesions also occur 5) vesicle is primary lesion of herpes simplex 6) fissure is atypical presenting feature [1] 7) painful genital ulcers, fever, inguinal lymphadenopathy, headache may be noted [1] 8) sacral radiculopathy, transverse myelitis, meningitis * images [10] Laboratory: - confirm diagnosis with - Herpes simplex virus 2 culture - Herpes simplex virus 2 DNA - Herpes simplex virus 2 glycoprotein G IgG Ab - Herpes simplex virus 2 Ag in tissue - see Herpes simplex - see ARUP consult [8] Differential diagnosis: (genital Herpes) 1) papillomavirus 2) molluscum contagiosum 3) HIV infection 4) fungal infection, Candida - vaginal discharge - small erythematous papules (satellite lesions) 5) bacterial infection a) syphilis b) chancroid c) granuloma inguinale 6) follicular abscess 7) hidradenitis suppurativa 8) vulvular dystrophy 9) cancer of the vulva Management: 1) see Herpes simplex 2) chronic daily valacyclovir 500 mg PO QD may reduce risk of sexual transmission [2]; VAMC dose is 500 mg BID 3) 1% tenofovir gel used intravaginally before & after sex reduces incidence of HSV2 by ~ 50% [9] 4) condoms useful for prophylaxis [4] 5) viral shedding with potential of transmission to others occurs even in asymptomatic individuals [1] 6) genital shedding of HSV2 twice as high when symptomatic [6]; corollary: genital shedding of HSV2 occurs in asymptomatic patients 7) even high-dose antivirals do not eliminate viral shedding [7]

General

Herpes simplex (HSV) or Herpes hominis

Properties

KINGDOM: virus GENOME-TYPE: deoxyribonucleic acid (DNA) DOUBLE-STRANDED GENOME-SIZE: 120-200 kB ENVELOPE: PRESENT CAPSID-SYMMETRY: ICOSAHEDRAL

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 17, 18. American College of Physicians, Philadelphia 1998, 2009, 2012, 2015, 2018.
  2. Journal Watch 24(4):31, 2004 Corey L et al Once-daily valacyclovir to reduce the risk of transmission of genital herpes. N Engl J Med 350:11, 2004 PMID: 14702423
  3. Ferri's Clinical Advisor, Instant Diagnosis and Treatment, Ferri FF (ed), Mosby, Philadelphia, 2003
  4. Wald A et al. The relationship between condom use and herpes simplex virus acquisition. Ann Intern Med 2005 Nov 15; 143:707-13 PMID: 16287791
  5. Corey L. Synergistic copathogens--HIV-1 and HSV-2. N Engl J Med. 2007 Feb 22;356(8):854-6 PMID: 17314346
  6. Tronstein E et al Genital Shedding of Herpes Simplex Virus Among Symptomatic and Asymptomatic Persons With HSV-2 Infection. JAMA. 2011;305(14):1441-1449 PMID: 21486977 http://jama.ama-assn.org/content/305/14/1441.short
  7. Johnston C et al Standard-dose and high-dose daily antiviral therapy for short episodes of genital HSV-2 reactivation: three randomised, open-label, cross-over trials The Lancet, Early Online Publication, 5 January 2012 PMID: 22225814 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61750-9/fulltext - Van de Perre P and Nagot N Herpes simplex virus: a new era? The Lancet, Early Online Publication, 5 January 2012 PMID: 22226046 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61614-0/fulltext
  8. ARUP Consult: Herpes Simplex Virus - HSV The Physician's Guide to Laboratory Test Selection & Interpretation https://www.arupconsult.com/content/herpes-simplex-virus
  9. Abdool Karim SS et al Tenofovir Gel for the Prevention of Herpes Simplex Virus Type 2 Infection. N Engl J Med 2015; 373:530-539. August 6, 2015 PMID: 26244306 http://www.nejm.org/doi/full/10.1056/NEJMoa1410649
  10. Brady MP (images) Cutaneous and Mucosal Manifestations of Viral Diseases. Medscape. March 2017 http://reference.medscape.com/features/slideshow/viral-skin