HSV Flashcards
Genital herpes in pregnancy presents risk of transmission to baby and neonatal infection, associated with high morbidity and mortality. Does not cause spontaneous miscarriage
How can it present in neonate?
Localised to skin/ eye/ mouth - best prognosis with minimal morbidity
CNS disease - encephalitis
Disseminated infection - multiple organ involvement
Timing of infection during pregnancy is crucial.
Why is this?
Risk greatest in women who acquire infection within 6 weeks of delivery, as viral shedding may persist, and no time for antibody response to be transmitted to foetus
Early pregnancy means lesions can heal before delivery, reducing risk transmission
Recurrent herpes has lower risk of neonatal HSV infection, but lesions at time of delivery can cause infection
How to manage patient presenting before 28 weeks gestation with primary genital herpes?
Swab for viral PCR to confirm
Aciclovir 400mg TDS for 5 days - reduces severity of symptoms, and viral shedding. IV if disseminated HSV
Aciclovir from week 36 until delivery
As long as no delivery within 6 weeks, can have vaginal delivery.
Refer to iCASH/ obstetric team
How to manage patient presenting after 28 weeks gestation with primary genital herpes? (not in labour)
Swab for viral PCR to confirm
Aciclovir 400mg TDS until delivery.
IV aciclovir 5mg/kg TDS - if disseminated HSV
C-section should be recommended
Check HSV IgG serology on booking bloods - helps confirm whether acute or recurrent infection. 15% of women presenting with first episode, may in fact be reactivation
Refer to iCASH/ obstetric team
What is management of pregnant women with recurrent genital herpes? (not in labour)
Prior to 36 weeks, offer analgesia/ saline baths
From 36 weeks until delivery - aciclovir 400mg TDS
Can have normal vaginal delivery
What is management of women with primary/ recurrent genital herpes, at onset of labour?
Risk of transmission to neonate estimated 41% if primary and 3% for recurrent
Swab for viral PCR to confirm. Even if result back late, will inform management of neonate
Consider HSV serology IgG, as will inform management of neonate
Aciclovir 5mg/kg TDS IV intrapartum
Consider aciclovir 20mg/kg TDS for neonate
C-section should be recommended if primary
Offer vaginal delivery if recurrent, but can opt for C-section
Management of neonate
What is management neonate born by C-section, if mother had primary HSV infection in third trimester?
No lesions at delivery
Low risk
Normal management of neonate including baby check
Inform parents to watch for skin/ eye lesions, or poor feeding
Management of neonate
What is management neonate born by SVD, if mother had primary HSV infection in previous 6 weeks
High risk
Swab - skin, conjunctiva, oropharynx
Lumbar puncture if unwell. Do not perform if well
Empirical treatment - IV aciclovir 20mg/kg TDS
Can breastfeed - unless lesions around nipples. Can transfer immunoglobulin
Management of neonate
What is management neonate if mother has recurrent HSV, but no lesions at delivery.
Low risk - maternal IgG will offer some protection
Normal management of neonate including baby check
Inform parents to watch for skin/ eye lesions, or poor feeding
How to manage HIV positive patient
Primary HSV pregnancy
Recurrent HSV pregnancy
Primary - same as other patients
Recurrent - aciclovir 400mg TDS from 32 weeks (as opposed to 36 weeks). Mode of delivery mostly depends on HIV status
Genital herpes (not pregnant) confirmed on swab, or high clinical suspicion
What is the management primary infection?
treatment should commence within 5 days of the start of the episode, or while new lesions are forming for people with a first clinical episode (not crusted over)
if crusted over - already healing, so do not offer therapy
- oral aciclovir 400 mg three times a day for 5–10 days
- refer to GUM clinic for further STI assessment (also refer partner)
- clean affected area with saline
- topical lidocaine
- avoid sex until lesions fully healed
Patients with genital HSV are likely to have up to 5 episodes of recurrence in first year. Some can be asymptomatic.
Transmission can occur whilst asymptomatic.
What information do we want to know about attacks?
Symptoms -
- lesions still forming
- prodromal - tingling/ burning
- episode severity in last year symptoms usually milder, and less lesions on subsequent episodes
- episode frequency in last year
- episode duration (the initial episode can last for up to 20 days, while recurrent attacks usually last 5–10 days)
- how often had treatment
- examination — lesions are usually unilateral (initial episodes are bilateral) and localized to the same area in each attack.
Recurrent genital/ orofacial HSV occurs as virus genome remains in latent state indefinitely
What is treatment approach recurrent HSV?
- Only try if self-care measures not working
<6 episodes per year -
- Rescue pack - aciclovir 400mg TDS for 5 days. Start once experience prodromal symptoms/ new lesions
> 6 episodes per year -
- long term aciclovir 400mg BD
- avoid sex whilst new lesions
- use condoms with new/ uninfected partner
Prophylaxis is the same for orofacial and genital HSV infection
What are long term effects of genital HSV?
No long term effects
Can affect pregnancy if recurs at time of delivery
Genital HSV
Who should be referred?
Everyone to iCASH - require full STI assessment
Urgent referral -
Pregnant
Immunocompromised - if no response to treatment
Complications -
- herpetic proctitis.
- severe local secondary infection.
- urinary retention due to pain
- meningitis/ encephalitis
Orofacial HSV
What is treatment?
Only treat if new lesions, and not crusted over
Topical aciclovir
Which species of HSV cause which infections?
HSV1
orofacial
conjunctival
HSV2
genital
meningitis
Both can affect each site
HSV2 detected on orofacial/ eye swab.
What other investigations are required?
Suspicious of genital source
Examine genitalia
Screen for other STIs (if HSV1 do not need to investigate)
What is herpetic whitlow?
HSV 1/2 lesions on fingers
Usually children, or medical staff who do not wear gloves
HSV can infect eyes
What clinical picture can it cause?
Can infect different sites -
Blepharitis
Conjunctivitis
Keratitis (cornea)
Uveitis
Retinitis
- May have systemic symptoms - fever, malaise, coryzal symptoms
- local symptoms - red eye, pain, blurred vision, photophobia
If considering HSV, requires ophthalmology assessment. If neonate, needs urgent review.
How to diagnose?
Often clinical diagnosis
Swab for viral PCR - check HSV/ VZV
Scrapings/ biopsy for HSV/ VZV
What is treatment of HSV in these conditions?
Blepharitis/ conjunctivitis
Urgent opthalmology review
Saline washes
Topical aciclovir - 5xday for 10 days (although no evidence of benefit)
Topical antibacterial - no evidence of benefit, but can reduce secondary bacterial infections
What is treatment of HSV in these conditions?
Keratitis
Uveitis/ retinitis
- Urgent opthalmology review
- Saline washes
- Oral aciclovir - 400mg 5xday for 10 days
- Topical antibacterial
- Topical corticosteroid
- Corneal graft - if site threatening scar remains
Uveitis/ retinitis may need managed as inpatient
What are sequalae of HSV keratitis/ uveitis/ retinitis?
Sight impairment long term
Systemic infection - meningitis/ encephalitis
HSV can cause encephalitis/ meningitis
When to suspect encephalitis?
Fever
Seizure
Reduced consciousness
Altered behaviour
What is treatment for HSV encephalitis?
Aciclovir 10mg/kg TDS for 14-21 days
Can stop once repeat LP is HSV negative
Examine genitalia for HSV lesions
When to suspect viral meningitis?
Usually sub-acute presentation
Fever
Neck stiffness
Photophobia
Vomiting
What is treatment for viral meningitis?
Normally self-limiting condition, recovery in 5 days
Symptomatic therapy
If signs of encephalitis - start aciclovir
Genital HSV at time of labour, planning for C-section.
Prolonged PROM
How does this affect management?
High risk transmission to foetus
Even though C-section, treat as exposed
Neonate born with suspected HSV (e.g maternal HSV at time of delivery)
What investigations/ treatment required?
Start aciclovir while await results
Swab - skin/ mouth/ eyes
LP if septic/ CNS features
Neonate born with suspected HSV, commenced on empirical aciclovir.
When to stop aciclovir therapy?
Skin/eyes/ mouth disease
CNS/ disseminated infection
Skin/ eyes/ mouth lesion (opthalmology assessment if eye) -
- PCR neg - stop aciclovir
- PCR pos - aciclovir 14 days
CNS/ disseminated infection -
- PCR neg - stop aciclovir
- PCR pos - 21 days aciclovir. Repeat LP before stopping
Negative PCR results should not be used in isolation. If high clinical suspicion, then continue aciclovir
Neonate born with confirmed CNS HSV, started on aciclovir.
When to stop treatment?
complete 21 days
repeat LP at 21 days - if PCR still positive, then continue treatment, and repeat LP after 7 days (day 28)
What is nuclear material of HSV?
dsDNA
How is HSV transmitted?
sexual
saliva/ kissing/ cold sores
What are risk factors for HSV reactivation?
common cold
stress
direct sunlight
menstruation
immunocompromise
what is eczema herpeticum?
Primary infection with HSV 1/2
starts as cluster of itchy/ painful blisters - can be confused with chickenpox or impetigo (near face/ mouth)
can occur in normal skin, or areas of eczema
systemic symptoms - fever, lymphadenopathy
considered a dermatology emergency
What is treatment of eczema herpeticum?
common in children <2
considered dermatology emergency
IV aciclovir initially, until resolving
then oral aciclovir 5x daily, for 10-14 days
opthalmology review if eyelid/ eye involvement
differential for blistering rash on face includes HSV/ VZV/ enterovirus/ impetigo
How to differentiate these?
Impetigo - systemically well
HSV - eczema herpeticum can look like impetigo, but systemically unwell
VZV - will spread to body easily
What are complications of eczema herpeticum?
scarring
dissemination -
any organ including encephalitis
