Herpes simplex (herpetic infection)

Herpetic infection (herpes simplex) is a widespread anthroponous virus disease with a predominantly contact mechanism for the transmission of the pathogen, characterized by the defeat of the outer covers, the nervous system and the chronic recurrent course.

Herpes simplex virus (type 1 and 2) leads to the development of a recurrent infection characterized by damage to the skin, mouth, lips, eyes, genitals. With severe infection, encephalitis, meningitis, and herpes of newborns develop, and in immunocompromised patients - disseminated form. On the skin or mucous there are single or multiple accumulations of small bubbles filled with a clear liquid on a slightly elevated inflamed base. Diagnosis of herpes simplex (herpetic infection) is clinical; laboratory confirmation of the diagnosis includes culture, PCR, direct immunofluorescence or serological methods. Treatment of herpes simplex (herpetic infection) is symptomatic; with severe infection, the use of acyclovir, valaciclovir and famciclovir is useful, especially if it begins early enough, with a relapse or primary infection.

ICD-10 codes

• B00.0. Herpetic eczema.
• B00.1. Herpetic vesicular dermatitis.
• B00.2. Herpetic viral gingivostomatitis and pharyngostomatitis.
• B00.3. Herpetic viral meningitis (G02.0).
• B00.4. Herpetic viral encephalitis (G05.1).
• B00.5. Herpetic viral eye disease.
• B00.7. Disseminated herpetic viral disease.
• B00.8. Other forms of herpetic viral infection.
• B00.9. Herpetic viral infection, unspecified.

What causes a simple herpes (herpetic infection)?

The disease of simple herpes (herpetic infection) is caused by the herpes simplex virus (HSV). There are two immunological types. HSV-1 usually causes herpes of the lips and keratitis. HSV-2 affects, as a rule, genitals, as well as the skin. Infection occurs mainly by direct contact with affected areas, mainly during close contacts.

Herpes simplex virus persists in a latent state in the nerve ganglia; relapses of herpetic rashes are provoked by excessive exposure to sunlight, diseases with fever, physical or emotional stress, weakening of the immune system. Often the provoking factor remains unknown. Relapses are usually less severe and generally less frequent with time.

What are the symptoms of herpes simplex (herpetic infection)?

Symptoms of herpes simplex (herpetic infection) and the course of the disease depend on the localization of the process, the age of the patient, the immune status and the antigenic variant of the virus.

The most common are skin and mucous membranes. Lesions of the eyes (herpetic keratitis), CNS infections, herpes of newborns are rare, but they have a very serious clinic. HSV in the absence of skin manifestations rarely causes fulminant hepatitis. Especially strong herpes infection occurs in patients with HIV infection. There may be progressive and persistent esophagitis, colitis, perianal ulcers, pneumonia, encephalitis, meningitis. The onset of HSV can occur with erythema multiforme, possibly as a result of an immune response to the virus. Herpetic eczema is a complication of HSV infection in patients with eczema when affected with herpes eczematous areas.

Lesions of the skin and mucous membranes. Rashes may appear anywhere on the skin and mucous membranes, but most often around the mouth, on the lips, conjunctiva and the cornea, on the genitals. After a short prodromal period (typically less than 6 hours with relapse of HSV-1), when tingling and itching are felt, small strained vesicles appear on the erythematous base. Single clusters of bubbles vary from 0.5 to 1.5 cm in diameter, sometimes their groups merge. Dermal lesions, firmly fused with the underlying tissues (for example, on the nose, ears, fingers), are painful. After a few days the vesicles begin to dry out to form a thin yellowish crust. Healing occurs in 8-12 days from the onset of the disease. Individual herpetic lesions usually heal completely, but as a result of recurrence of rashes on the same sites, atrophy and scarring are possible. Sometimes a secondary bacterial infection may join. In patients with decreased cellular immunity due to HIV infection or other causes, skin lesions may persist for weeks or more. Localized infection can disseminate frequently and dramatically in immunocompromised patients.

Acute herpetic gingivostomatitis often develops as a result of primary infection of HSV-1 and is typical for children. Incidentally, with oral-genital contact, the disease can cause HSV-2. Bubbles inside the mouth and on the gums are opened for several hours or days, forming ulcers. Often there is fever and pain. Difficulties in eating and drinking can lead to dehydration. After resolution, the virus remains asleep in the semilunar ganglia.

Herpes labialis is usually a recurrence of the herpes simplex virus. It develops like ulcers on the red border of the lips or less often as ulceration of the mucosa on the hard palate.
Herpetic panaritium - swelling, tenderness, erythematous lesion of the distal phalanx as a result of the penetration of the herpes simplex virus through the skin and is most common in medical workers.

Genital herpes is the most common ulcer disease in developed countries transmitted through sexual contacts. Usually called HSV-2, although 10-30% of HSV-1. Primary lesion develops 4-7 days after contact. Vesicles usually open with the formation of ulcers, which can merge. In men, the bridle, head and body of the penis are affected, in women - the labia, clitoris, vagina, cervix, pyreneum. They can be localized around the anus and in the rectum during anal sex. Genital herpes can cause urinary disorders, dysuria, urinary retention, constipation. Severe sacral neuralgia may occur. After recovery, scars can form, relapse occurs in 80% of HSV-2 and 50% of HSV-1. Primary genital lesions are usually more painful (compared to relapse), prolonged and prevalent. It is usually bilateral, involves regional lymph nodes with the development of common symptoms. Relapses can have pronounced prodromal symptoms and may involve the buttocks, groin and thigh.

Herpetic keratitis. HSV infection of the corneal epithelium causes pain, lacrimation, photophobia, corneal ulcers, which often have a branching pattern (dendritic keratitis).

Herpes newborns. Infection develops in newborns, including those of them whose mothers did not know about the previous herpetic infection. Infection often occurs in childbirth, a type 2 virus. The disease usually develops at the 1-4 th week of life, resulting in the appearance of mucosal vesicles on the skin or involvement of the CNS. Disease is a serious cause of morbidity and mortality.

Herpes infection of the central nervous system. Sporadically there is a herpetic encephalitis and can be severe. Characteristic of multiple convulsive seizures. Asp infection of HSV-2 can occur aseptic meningitis. They usually self-resolve, with the development of lumbosacral radiculitis, which can lead to a delay in urine and severe constipation.

How is simple herpes simplex (herpetic infection) diagnosed?

Herpes simplex (herpetic infection) is confirmed on the basis of typical symptoms. Laboratory confirmation is useful in cases of severe infection, in immunocompromised patients, pregnant or with atypical rashes. To confirm the diagnosis, the Tzanka test is performed - the base of the alleged herpetic lesion is slightly scraped, and the resulting skin or mucous cells are placed on a thin glass. The cells are stained (according to Wright-Giemsa) and examined under a microscope for the presence of cytological changes caused by the virus, including characteristic multinucleated giant cells. The diagnosis becomes determined when it is confirmed by culture methods, the increasing titer of antibodies to the corresponding serotype (with primary infection) and biopsy. The culture material is obtained from the contents of the vesicles or from fresh ulcers. HSV can sometimes be identified by the method of immunofluorescence of the material obtained by scraping from the affected areas. For the diagnosis of herpetic encephalitis, the PCR method in cerebrospinal fluid and MRI is used.

Simple herpes can be confused with herpes zoster, but the latter rarely recurs and is characterized by more pain and more extensive lesions that are located along the sensory nerves. Differential diagnosis of herpes simplex (herpetic infection) also includes ulcers of the genitals of another etiology.

In patients with frequent relapses, poorly treatable antiviral drugs, one should suspect an immune deficiency, possibly an HIV infection.

How is simple herpes (herpetic infection) treated?

Treatment of herpes simplex (herpetic infection) is prescribed taking into account the clinical form of the disease.

Lesions of the skin and mucous membranes. Isolated lesions often remain untreated without any consequences. Acyclovir, valaciclovir or famciclovir is used to treat herpes (especially primary). Acyclovirresisting infection is rare and almost always in immunocompromised individuals; thus the foscarnet is effective. Secondary bacterial infection is treated with topical antibiotics (eg, murine or neomycin-bacitracin) or, in severe cases, with systemic antibiotics (eg, penicillin-resistant beta-lactams). Any forms of herpetic damage to the skin and mucous are treated symptomatically. Systemic anapgetics can be useful.

Gingivostomatitis in typical cases requires the use of local anesthetics in the form of tampons (for example, 0.5% solution of diclonin or 2-20% ointment of benzocaine every 2 hours). When extensive areas are affected, a 5% solution of viscous lidocaine is applied to lubricate around the mouth 5 minutes before meals (Note: lidocaine can not be ingested because it anesthesizes the oropharynx, larynx and epiglottis.) Children are required to be monitored for aspiration hazard. In severe cases, acyclovir, valaciclovir and famciclovir are used.

Herpes-labialis is treated with local and systemic use of acyclovir. The duration of the rashes can be reduced by applying 1% cream of penciclovir every 2 hours after awakening for 4 days, starting with the prodromal period and immediately after the appearance of the first rashes. Toxicity is minimal. There is cross-resistance with acyclovir. Cream with 10% docosanol is effective when applied 5 times a day.

Genital herpes is treated with antiviral drugs. In primary rashes, aciclovir is used at a dose of 200 mg orally 5 times a day for 10 days, valaciclovir 1 g orally 2 times a day for 10 days, famciclovir 250 mg orally 3 times a day for 7-10 days. These drugs are useful for severe infection. Nevertheless, even the early administration of drugs does not prevent relapses.

With recurrent herpes, the duration of the rashes and their severity are critically reduced with the use of antiviral drugs. Apply acyclovir in a dose of 200 mg orally every 4 hours for 5 days, valaciclovir 500 mg orally 2 times a day for 3 days, famciclovir 125 mg orally 2 times a day for 5 days. Initially, when the first symptoms of relapse occur, patients with frequent exacerbations (i.e., more than 6 per year) should receive acyclovir at a dose of 400 mg orally 2 times a day, valaciclovir 500-1000 mg orally once a day, famciclovir 250 mg orally 2 times in a day. The dose should depend on the preservation of kidney function. Adverse effects during ingestion are infrequent, but may include nausea, vomiting, diarrhea, headache, rash.

Herpetic keratitis. In the treatment, local antiviral drugs such as idoxuridine or trifluridine are used under the supervision of an ophthalmologist.
Herpes newborns. Apply acyclovir 20 mg / kg intravenously every 8 hours for 14-21 days. CNS infection and disseminated forms are treated at the same doses for 21 days.

Herpetic infection of the central nervous system. For the treatment of encephalitis, aciclovir is administered 10 mg / kg intravenously every 8 hours for 14-21 days. Aseptic meningitis is treated with intravenous aciclovir. Among the side effects observed phlebitis, rash, neurotoxicity (drowsiness, confusion, convulsions, coma).