HSV Flashcards
Describe non primary HSV infection
First infection with HSV 1 or 2 in an individual with pre existing antibodies to the other type
HSV - 1 aetiology
Historically usual cause of oral but now commonest cause of genital in Uk
HSV 2 aetiology
More likely to cause recurrent anogential Sx
Average number of HSV recurrences per year
4 for HSV 2
4 x less frequent for HSV 1
HSV symptoms
Lesions
Vaginal or urethral discharge
Systemic symptoms common with Primary
HSV signs
Ulcers on external genitalia or rectum/ cervix
Bilateral lymphadenitis
First episode - usually bilat
Recurrent disease - lesions affect favoured sites. Can alternate but usually unilateral for each episode
Lymphadenitis 30%
Recurrent outbreaks limited to infected dermatome
Many can present atypically - fissures, non specific erythema
HSV complications
Superinfection of lesions with Candida or streptococcal species (usually 2nd week)
Autonomic neuropathy (urinary retention)
Autoinnoculation to fingers and adjacent skin
Aseptic meningitis
Herpes proctitis
- Significant cause of proctitis in MSM
- Only 30% of MSM with HSV proctitis had visible external anal ulceration
- more common with HIV
Tests for HSV?
-Do viral PCR NAAT
Swab base of lesion or rectal mucosa
All MSM with proctitis - HSV swab
- serology
IgG type 1 or 2
HSV 2 genital but HSV1 can’t tell if oral or genital
Western blot is diagnostic gold standard
For patients with low likelihood HSV but positive HSV2 serology - repeat test
When is serology helpful for HSV?
Recurrent genital disease of unknown cause
Counselling patients with initial episode (pregnant women)
IX asymp partners of patients with HSV inc pregnancy
HSV first episode general advice
Saline baths
Analgesia
Topical lidocaine (potential for sensitisation but Low risk)
HSV when to start antivirals
Within 5/7 of start of episode
While new lesions are still forming
Systemic Sx persist
HSV usual regimes primary episode
Aciclovir 400mg TDS 5/7
Valaciclovir 500mg BD 5/7
Reduction is median 1-2 days of Sx
HSV alternative regimes for primary episodes
Aciclovir 200mg five times daily
Famciclovir 250mg TDS
Recurrent HSV episode - short course options
Aciclovir 800mg TDS for 2/7
Famciclovir 1g BD for 1 day
Valaciclovir 500mg BD for 3/7
Recurrent episodic HSV regimes 5 day
Aciclovir 200mg fives times daily
Aciclovir 400mg rfs for 3-5 days
Valaciclovir 500mg bd
Famciclovir 125mg bd
Suppressive antiviral therapy
6 recurrences per year Aciclovir 400mg BD Aciclovir 200mg four times daily Famciclovir 250mg BD Valaciclovir 500mg OD
Stop after one year max to reassess for recurrences
Minimum of two recurrences as often rebound flare on stopping
When to use empirical HSV RX?
MSM with proctitis as such a common cause
Asymp shedding - when most likely and how does it change
Most common in those with HSV 2 in first year after infection and in those with frequent recurrences
Cause of transmission
Reduced by antivirals
For many patients it declines with time
How to prevent transmission HSV
Condoms - approx 50% reduction at least 60% of the time.
Drugs reduce asymp shedding by 90%
Study only on valaciclovir showed decreased acquisition in serodiscordant couples
What to tell patient about HSV transmission?
No sex when lesions or prodromes
Asymp shedding
Male condoms may reduce risk of transmission
Suppressive antivirals reducing risk of transmission if sero discordant
Disclose in all relationships
Can contact HSV association for support
Document the discussion
HSV positive partners and strategies if their partner is pregnant
Condom use particularly last trimester
No sex when lesions or in last 6 weeks of pregnancy
Tell Midwife
HSV and hiv
Key points
What to do with dose?
HSV increases hiv acquisition Anti viral resistance more common Double dose if advanced HIV 10/7 More frequent reactivation Optimise ART
Three subgroups of neonatal HSV
1) localised to skin, eyes and or mouth 30%
2) local CNS disease (encephalitis) 70%. Often present late (10/7-4/52).
3 disseminated with multi organ - 30% mortality
Transmission risk factors for neonatal HSV
Primary Duration of ROM prior to del Use of FSE Mode of del New infection in third trimester but particularly in 6 weeks prior to del (no time for maternal antibodies)
Primary episode prior to 28/40 Mx
GUM Usual regime Cons led care for obs No change to plan unless del within next 6/52 Give aciclovir 400mg tds from 26/40
Recurrent HSV in pregnancy mx
Low risk
Vag del
Consider suppression from 36/40 - 400mg tds women’s choice
No increased risk pprom or preterm del
New HSV in third trimester
Aciclovir 400mg tds until del
Section
IgG to check incase recurrent
Primary HSV lesions at labour Mx
Section
Can use iv acickovir for mother ans baby (defo if vag del happens)
Avoid FSE, instruments etc
Pprom before 37/40 and primary lesions Mx
Section if del straight away
If conservative Mx - consider iv aciclovir
Pprom before 37/40 and recurrent lesions Mx
Before 34/40 - expectant ok with oral aciclovir 400 tds
After 34/40 - obs decision/ ? Steroids also
Hiv and HSV in pregnancy transmission and drugs
More likely to transmit hiv if concurrent HSV in pregnancy
Aciclovir from 32/40 as hiv more at risk of preterm del
Neonate born by section following primary infection in 3rd trimester Mx
Low risk
No additional
Report lesions/ poor feeding
Good hand hygiene
Vaginal del following primary episode in later 6 weeks. Mx of neonate
If well - swab skin, eyes, rectum, throat. No LP. Aciclovir 20mg/kg until excluded active infection
Vag delivery post maternal primary HSV within 6 weeks del and baby unwell
Swab everywhere and aciclovir until cultures back
LP also
Neonatal IV dose of aciclovir
20mg/kg tds
Neonatal Mx following delivery and maternal recurrent episode in pregnancy (with or without lesions at del)
Nil different
Says inform neonataologisy
