Overview
A syndrome of diseases caused by herpes simplex virus infections that may include clustered blisters on the face, lips, and external genitalia This disease is caused by herpes simplex virus infections and is most often treated with medications such as acyclovir.
Definition
Herpes simplex virus infection is an infectious disease that can be transmitted by droplet, vertical, or sexual transmission, which can cause herpes and herpetic keratitis in different epidermal areas.
Herpes simplex commonly occurs on the face, lips, and external genitalia. It may appear suddenly in clusters of blisters and resolve spontaneously in 1 to 2 weeks, but may recur later, especially in the presence of febrile illness.
Typing
Typing according to HSV serotypes
HSV-1: mainly transmitted through direct contact with lesions or secretions containing HSV-1, often manifested as herpes orofacialis, herpetic keratitis, and central nervous system infections.
HSV-2: Transmitted to newborns mainly through sexual contact or through the birth canal. Commonly manifested symptoms include genital herpes, neonatal herpes simplex virus infection, etc.
Morbidity
The prevalence of HSV-1 antibody positivity in developing countries can be as high as 90% at the age of 15-30 years, whereas the prevalence of antibody positivity in developed countries for the same age group is about 50% to 60%.
In Western countries, 20% to 35% of sexually active people are seropositive for HSV-2, and 5% to 12% of female patients in STD clinics have HSV-2 discharged from the cervix, and most are asymptomatic carriers.
The disease is not seasonal, and the incidence is not related to gender. The incidence of the disease is not related to gender. 80% to 90% of primary infections are occult infections, and a few are dominant infections.
Causes
Causes
The basic conditions leading to the epidemiology of herpes simplex virus infection are characterized by the following three components.
Source of infection
Patients in the acute phase and chronic carriers of the virus are the source of infection.
Route of transmission
HSV-1 infections are mainly transmitted by direct contact with lesions or HSV-1-containing secretions, and can also be transmitted by droplet transmission.
HSV-2 infection is mainly transmitted through sexual contact or through the birth canal to newborns.
Susceptible Population
Humans are the only natural host and the population is generally susceptible.
Predisposing Factors
The following factors can cause reactivation of herpes simplex virus infection.
Immunologic factors
Immunodeficiency diseases, such as AIDS, and the use of immunosuppressive drugs, such as azathioprine, can lead to high HSV activity.
Non-immune factors
Ultraviolet radiation, localized skin injury (including sun exposure, surgery, hair plucking, etc.), menstruation, stress and febrile illnesses can be triggers for latent HSV reactivation.
Pathogenesis
Primary infection
In HSV primary infection, the virus multiplies locally and causes infection of sensory nerve endings, which is often latent and may occasionally present clinical symptoms.
Latent infection
HSV runs against the axon to the neuronal cell body, and after a short period of replication, it can enter the latent infection state.
HSV has sensory ganglionophilic and easily forms latent infection, and latent infection is the root cause of recurrence.
The formation of latent infection depends on both host and viral factors, and does not necessarily follow a symptomatic primary infection or an initial attack.
Recurrent infection
After infection with the virus, the body produces antibodies and the virus is latent in the ganglia, which often leads to relapse under some triggering conditions.
Symptoms
The clinical manifestations and course of herpes simplex virus infection are related to the site of invasion of the virus, the age of the host, the immune status of the host, and the typing of the virus.
Main Symptoms
Oral-labial herpes
Gingivostomatitis and pharyngitis caused by primary HSV infection are common in children and adolescents, and are mostly caused by HSV-1, which may manifest as fever, sore throat, red, swollen and bleeding gums, and blisters on the mucous membranes of the oral cavity and pharynx.
Recurrent infection mainly manifests as herpes simplex labiitis, i.e. herpes labialis, which is common around the lip margins, corners of the mouth and nostrils. There is no fever and systemic symptoms, and there may be burning sensation locally 1 to 2 days before the onset of rash.
Genital herpes
Mainly caused by HSV-2.
In men, blisters, pustules and superficial ulcers can be seen on the glans, prepuce and penis; in women, blisters, pustules and superficial ulcers can be seen on the vulva, vagina and cervix.
Herpes keratitis
Often caused by HSV-1. Most often accompanied by conjunctivitis, which can be acutely painful and blurred vision.
Ocular HSV infection is one of the most common causes of blindness.
Cutaneous herpes simplex
Primary infections are common, recurrent infections are rare and mild.
Common clinical types are traumatic herpes, herpetic eczema and herpetic whitlow.
Traumatic herpes: blisters appear on skin abrasions or fissures and may be accompanied by fever and lymph node pressure.
Herpetic eczema: mostly occurring on the basis of atopic eczema or neurodermatitis, manifested as blisters appearing in batches around the lesions and adjacent skin, the skin at the lesions may have edema, vesicles, ulcers, etc., may also be accompanied by high fever, local lymph node enlargement and tenderness.
Herpetic whitlow: It is the primary infection of HSV at the end of fingers, which is more common in thumb and index finger. There may be itching, pain, and erythema of the fingers, with multiple blisters appearing within 1 day, often accompanied by fever and localized lymph node enlargement.
Central nervous system HSV infection
Neonatal central nervous system infection is the main type of HSV infection.
The main manifestation of infection is encephalitis, which mostly starts acutely with fever, headache, vomiting and seizures. Some patients may develop disorientation, convulsions, neck stiffness or even coma in a short period of time.
Meningitis can also occur after infection, usually associated with primary genital herpes, the etiologic agent of which is HSV type 2, and may include fever, headache, nausea, vomiting, and photophobia.
Neonatal herpes simplex virus infection
Mostly caused by HSV-2, the vast majority of neonatal infections are due to upstream spread of viral infection from the mother’s genital tract or via the birth canal.
It may manifest as skin, eye and oral infections, central nervous system infections, and disseminated infections.
HSV infection in immunodeficient individuals
Mostly due to resurrection of latent HSV, with more severe clinical manifestations and prolonged recovery time.
It is prone to cause disseminated visceral infections, which may manifest as pneumonia, esophagitis, hepatitis, colitis and disseminated skin infections.
Consultation
Department of Medicine
Dermatology
When there are blisters around the mouth and throat, blisters, vesicles and ulcers on the skin or genitals, it is recommended to consult a doctor promptly.
Department of Infectious Diseases
When fever, sore throat, skin or genital blisters, vesicles, ulcers, etc. appear, it is recommended to consult a doctor promptly.
Pediatric Internal Medicine
When a child develops fever, headache, vomiting, photophobia, abnormal behavior, respiratory distress, etc., it is recommended to consult a doctor promptly.
Preparation for medical treatment
Preparing for your visit: registering, preparing your documents, common problems
Tips
Take photos of the lesions for the doctor’s reference.
It is recommended to wear loose clothing, try not to wear dresses or jumpsuits, to facilitate the examination.
Preparation List
Symptom list
Its need to focus on the time of occurrence of symptoms, special manifestations, etc.
Are there blisters around the lip edges, corners of the mouth and nostrils?
Is there any eye pain, blurred vision, etc.?
Are there blisters, vesicles, ulcers, pus-filled hemorrhagic exudates, etc. on the skin?
Are there blisters, pustules and superficial ulcers on the genitals?
When did the above symptoms start?
Are there any aggravating or relieving factors for the above symptoms?
Medical History Checklist
Has there been any contact with patients in the acute phase of herpes simplex virus or chronic carriers?
Any history of immunodeficiency such as AIDS?
Checklist
Test results in the last 6 months, which can be carried to the doctor’s office
Pathogenetic tests: herpes simplex virus pathogenetic test results.
Laboratory tests: blood test, cerebrospinal fluid test, etc.
Imaging tests: MRI, CT scan, etc.
List of medications used
Medications used in the last 3 months, if available, bring the box or package to the doctor’s office
Antiviral drugs: adenosine, acyclovir, famciclovir, penciclovir, etc.
Diagnosis
Diagnosis based on
Medical history
The patient has had contact with patients in the acute phase of herpes simplex virus and chronic carriers of the virus prior to the onset of the disease.
Past history of immunodeficiency such as AIDS.
Clinical manifestations
Symptoms
There may be eye pain and blurred vision.
There may be blisters, pustules and superficial ulcers on the genitals.
There may be behavioral abnormalities, phantom smells, speech disorders, disorientation, and convulsions.
Skin may have blisters, vesicles, ulcers, and purulent hemorrhagic exudates.
Physical signs
Some may not have any physical signs.
Meningitis and encephalitis manifestations may have neck stiffness.
Some may have enlarged lymph nodes and tenderness.
Laboratory Tests
Blood tests
Normal or low white blood cells, normal or low neutrophils, and elevated lymphocytes suggest possible viral infection.
A significant increase in white blood cells and neutrophils suggests a possible bacterial infection.
Blood Sedimentation, C-Reactive Protein
are indicators of inflammation to help determine the presence and severity of infection.
Virus examination
细胞学检查
If the skin lesions are scraped for cytologic examination, if multinucleated giant cells and eosinophilic inclusion bodies are seen, it can indicate herpes simplex virus infection, with an accuracy of 60%～90%.
Immunofluorescence test
Herpes simplex virus antigen can be detected in the blister fluid, which can help to clarify the diagnosis.
Specific nucleic acid test
PCR is used to detect the presence or absence of HSV-DNA in the blister fluid, which helps to clarify the diagnosis.
Serum HSV-IgM antibody test
Suggests the presence of recent infection and is often used in epidemiologic investigations.
Imaging
Cranial CT or MRI.
For patients with CNS infection.
It may show hypodense foci in both temporal or frontal lobes, and the lesions are often poorly demarcated, with some having a space-occupying effect.
Cranial MRI is more helpful for early diagnosis and visualization of the lesions.
Differential diagnosis
Herpes simplex virus infection needs to be differentiated from diseases such as impetigo, herpes zoster, and fixed drug rash.
Impetigo
Similarities: blisters and pustules may be present around the lips.
Differences:
Impetigo is a bacterial infection, such as that caused by Staphylococcus aureus. The pustules break easily, forming honey-yellow scabs, and the broken areas may be accompanied by itching.
Herpes simplex virus infection is caused by HSV infection, usually without itching, virus culture can detect herpes simplex virus.
Herpes zoster
Similarities: Both are contagious, and both can present with blisters and pustules.
Differences:
Herpes zoster is caused by varicella-zoster virus infection, the rash is mostly distributed in bands, and can be accompanied by low fever, headache, malaise and other systemic symptoms. Varicella-zoster virus DNA can be detected in the blister fluid.
Herpes simplex virus infection is caused by HSV infection, which mostly occurs at the junction of skin and mucous membranes and does not distribute along the nerves, and herpes simplex virus can be detected by viral culture.
Fixed drug rash
Similarities: blisters can appear on the lips, mouth, and genitals.
Differences:
Fixed drug rash is often caused by sulfonamides, antipyretic and anti-inflammatory drugs, barbiturates and tetracyclines, manifested as limited round or oval erythema, bright red or purplish-red, blisters can be formed in the center of the inflammation is intense. After healing, hyperpigmentation is usually no systemic symptoms.
Herpes simplex virus infection is caused by herpes virus infection, there may be fever, malaise and other systemic symptoms. Herpes simplex virus can be detected by viral culture.
Treatment
Aims of treatment: to shorten the course of the disease, prevent secondary bacterial infection and systemic dissemination, and reduce the chances of recurrence and transmission.
Treatment principle: latent herpes simplex virus infection is difficult to treat with medication, but for replicating viral infection, treatment can be directed at different stages of viral replication.
General treatment
The presence of extensive cutaneous and mucosal herpes should be isolated.
Try to avoid direct contact with the patient’s infected area.
Rest in bed.
Medication
Adenosine
For patients with localized herpes simplex virus infection. The drug can be used in infants with severe HSV infection and in patients with HSV encephalitis, which can significantly reduce the morbidity and mortality.
For recurrent genital herpes it should be administered at the early stage of recurrence and applied to the affected area more than 4 times daily for 7 days.
Adenosine has some toxicity and should be used with caution, and it is recommended to use the drug under the supervision of a doctor after diagnosis.
Adverse reactions include nausea, vomiting, diarrhea, lack of appetite, anemia, leukopenia, and thrombophlebitis.
Acyclovir
The drug of choice for general clinical use. It can be used in patients with keratitis, skin and mucous membrane infections, genital herpes, HSV encephalitis, and herpes zoster.
Its mechanism of action is to inhibit the herpes virus DNA polymerase, thereby blocking viral replication.
For the treatment of acyclovir-resistant patients, phosphinothricin is available.
Adverse reactions include nausea, vomiting, fever, headache, and muscle pain.
Famciclovir
Famciclovir is taken orally as a tablet or capsule, and in the treatment of primary genital herpes, it should be taken immediately after the appearance of the disease.
Its adverse reactions include dizziness, insomnia, drowsiness, diarrhea, anorexia, vomiting, and elevated transaminases. Use with caution in patients with hepatic or renal insufficiency.
Penciclovir
Penciclovir can be administered intravenously or applied topically as a cream.
Its adverse reactions include phlebitis, renal impairment, and pain in the renal region.
It is contraindicated in persons with a history of allergic reaction to the product, and should be used with caution in persons with renal dysfunction, children and pregnant women.
Prognosis
Cure
Most herpes simplex virus infections have a favorable prognosis.
HSV encephalitis, disseminated infections, neonatal infections, and infections in immunodeficient persons have a poorer prognosis.
Daily
Daily management
Dietary management
Ensure food variety, cereal-based, recommended daily intake of cereal and potato foods 250~400g, more vegetables.
Ensure high quality protein intake and reduce fat intake.
Stop smoking and limit alcohol intake.
Life management
People with extensive skin and mucous membrane herpes should be isolated.
Avoid staying up late and pay attention to rest.
Those with genital herpes need to prohibit sexual intercourse and pay attention to good vulvar cleansing at the same time.
When in the active stage of oral HSV infection, avoid kissing, sharing cutlery, cups, bottles and towels.
Follow-up and review
This disease has the possibility of recurrence, such as the reappearance of perioral burning, blisters, genital blisters, ulcers, etc., suggesting that the disease may recur, and need to seek medical treatment in time.
Prevention
Controlling the source of infection
Treat patients with herpes simplex virus infection and try to avoid direct contact with infected patients and their infected areas.
People with extensive skin and mucous membrane herpes should be isolated.
Cutting off the means of transmission
Enhance disease awareness and education on herpes simplex virus infection.
Use of condoms may reduce the transmission of genital herpes. If the patient has genital herpes, even condom use cannot prevent transmission, and sexual intercourse should be avoided.
Cesarean section is recommended if the mother has cervical HSV infection.
Avoid kissing, sharing utensils, cups, bottles, towels, etc. when oral HSV infection is active.
Protection of susceptible groups
Vaccinate against HSV, but the vaccine is currently controversial.
Infants delivered by seropositive mothers should be closely monitored for timely detection of HSV infection and given early antiviral therapy, which may reduce the morbidity and mortality of neonatal HSV infection.