References:
- Global Infectious Diseases and Epidemiology Online Network: Infectious Diseases of the Philippines, 2013 eBook Edition, ISBN 978-1-61755-582-4, by Stephen Berger. Accessed here.
| Agent | VIRUS - DNA. Herpesviridae, Alphaherpesvirinae, Simplexvirus: Human herpesvirus I and II |
| Reservoir | Human |
| Vector | None |
| Vehicle | Infected secretions, including sexual contact |
| Incubation Period | 1 to 14 days |
| Diagnostic Tests | Viral culture or microscopy of lesions Serology Nucleic acid amplification |
| Typical Adult Therapy | Acyclovir 400 mg PO TID X 7d. OR Famciclovir 250 mg PO TID X 7d. OR Valacyclovir 1 g PO BID X 7d |
| Typical Pediatric Therapy | Acyclovir 10 mg/kg PO QUID X 7 d |
| Clinical Hints | Recurring localized crops of painful vesicles on a red base; regional adenopathy often present; may follow a prodrome of neuropathy or hyperesthesia. |
| Synonyms | Herpes gladiatorum, Herpes rugbiorum, Herpes simplex, Scrum pox. |
The initial attack of herpes simplex is generally more overt than recurrent episodes; however, primary infections are often asymptomatic.
- Symptoms will also vary depending on the site of infection (eye, esophagus, anal region, etc.)
Signs and Symptoms
Following a prodrome of local discomfort, tender papular, vesicular or ulcerative lesions on an erythematous base appear.
- Anorexia, malaise and fever may accompany individual episodes.
- The lesions coalesce, and tender bilateral lymphadenopathy develops.
- Skin lesions usually heal over the next several days to weeks.
- Patients may give a history of occupational exposure (i.e., herpetic whitlow, found in medical or dental personnel; herpes gladiatorum among wrestlers).
- Vesicular skin lesions of tularemia may mimic those of herpes simplex; and herpetic infection may present as folliculitis.
Complications
Immunosuppressed patients and neonates are at particular risk for disseminated and severe infections.
- Lesions of the tongue may present as herpetic geometric glossitis.
- Mucosal herpetic lesions may serve as a portal for bacterial invasion.
- Ocular complications include conjunctivitis, scleritis, severe keratitis and retinal necrosis.
- Corneal infection may present as epithelial keratitis (dendritica/geographica), stromal keratitis (necrotizing vs. non-necrotizing or “interstitial keratitis”), endotheliitis (disciform keratitis), neurotrophic keratopathy (metaherpetic keratitis) or vascularized corneal scars.
- Over 10% of keratouveitis cases are complicated by secondary glaucoma. Herpetic keratitis may complicated ocular steroid injection.
- Herpes simplex infection has been etiologically linked to facial (Bell’s) palsy.
- Pancreatitis, esophagitis, cardiomyopathy and rhabdomyolysis with renal failure have been reported to complicate herpes simplex infection.
- Herpes simplex hepatitis is most common in the setting of pregnancy or immune suppression; however, rare instances of hepatitis and fulminant hepatic failure due to HSV infection have been reported in immunocompetent persons.
- HSV-related erythema multiforme has been reported in stem-cell transplant recipients.
- Disseminated infection among patients with eczema (Eczema herpeticum) may resemble smallpox or present as atopic dermo-respiratory syndrome.
- Chronic (>1 month) mucocutaneous infections may occur in HIV-positive patients, in the absence of disseminated disease.
- Herpetic lesions in HIV-positive patients may be vegetative, hypertrophic, condyloma-like, nodular, ulcerative, or tumor-like nodules or plaques.
- Herpes simplex may contribute to the pathology of periodontitis.
- Herpes simplex has been reported to cause Gerhardt syndrome (inspiratory dyspnea without dysphonia) from vocal cord paralysis.
Acquisition of Herpes simplex by the newborn at the time of delivery is associated with severe illness and results in death in approximately 50% of cases.
- Neonatal herpes simplex infection is characterized by vesicular rash, hypothermia, lethargy, seizures, respiratory distress, hepatosplenomegaly, thrombocytopenia, hepatic dysfunction and cerebrospinal fluid pleocytosis.
Herpes simplex virus is an important cause of encephalitis and keratitis.
Anterior Uveitis Differential Diagnosis
Anterior uveitis due to Rubella virus is characterized by younger age at onset and a chronic course, typically associated with cataract at presentation.
- Rubella virus has been implicated in the etiology of Fuchs heterochromic iridocyclitis.
- Anterior uveitis due to Herpes simplex and Varicella-Zoster viruses is more common in adults, and often follows an acute course.
- Herpes simplex anterior uveitis presents with conjunctival redness, corneal edema, a history of keratitis, and the presence of posterior synechiae. Anterior chamber inflammation is common with Herpes simplex virus, while vitritis is more common with Rubella and Varicella-Zoster virus.
- Rubella, Herpes simplex and Varicella-zoster viruses are associated with intraocular pressure of more than 30 mmHg and development of glaucoma (18%-30%; P = 0.686).
- Focal chorioretinal scars were present in 22% of Rubella cases, 0% of HSV and in 11% of VZV uveitis cases.