HSV

Question 1

What are the three groups that neonatal herpes can be divided into?

Answer 1

disease localised to the skin, eyes or mouth
CNS local disease - encephalitis only
disseminated HSV - with multi organ involvement

Question 2

What proportion of neonatal HSV present as skin lesions?

a) 30%
b) 50%
c) 60%
d) 75%

Answer 2

a - 30%

Question 3

What proportion of neonatal HSV present as CNS local disease?

a) 30%
b) 50%
c) 70%
d) 90%

Answer 3

c) 70% (n.b 60% of these present without eye or mouth skin lesions)

Question 4

What is the timeframe in which CNS neonatal HSV presents in the postpartum period?

Answer 4

10 days up to 4 weeks

Question 5

Which of presentations of neonatal HSV carries the highest risk of mortality

Answer 5

Disseminated HSV carries a mortality of 30% (17% have long term neurological complications)

Question 6

What is the incidence of neonatal HSV in the UK?

Answer 6

1.65 per 100,000 deliveries

much higher incidence in the USA 33 per 100,000 deliveries

Question 7

What is the most worrying time for a primary HSV outbreak in a pregnant mother?

a) first trimester
b) second trimester
c) third trimester
d) post-partum

Answer 7

c) third trimester

Question 8

What is the risk of transmission to a neonate in recurrent HSV at the time of delivery

Answer 8

Risk is very low -> 0-3%

Question 9

What is the risk of transmission to the neonate if primary HSV and lesions present at the time of delivery?

Answer 9

41%

Question 10

What adults are more at risk of developing disseminated HSV?

Answer 10

immunocompromised, patients who are HIV positive

disseminated HSV is rare in the adult population

Question 11

Describe the relationship between HIV and HSV

Answer 11

• HIV and HSV synergistically increase each others viral replication;
• therefore those with HIV and at increased risk of acquiring HSV
• those with HSV and HIV leads to increased HIV risk of transmission.

Question 12

Emily is 16 weeks pregnant with her first baby. She has attended her GP surgery with pain in her vulva and it hurts when she passes urine. On examination the GP can visualise multiple superficial ulcers and suspects primary HSV.

The GP rings you for advice, how would you manage Emily and what would your advice be to the GP.

Answer 12

1. Advise the GP to do a viral swab of the lesions for HSV typing and to confirm the diagnosis
2. blood tests for HIV and STS, CT/GC should also be offered
3. Treat the presumed HSV with acyclovir 400mg TDS for 5 days (advise GP to inform Emily, it is not licenced in pregnancy but it is very safe and we use it a lot)
4. topical lidocaine/ paracetamol and saline bathing
5. refer to GUM for counselling –> reassure no increased risk of miscarriage; reassure that as long as delivery does not ensue in the next 6 weeks plan for vaginal delivery and provide acyclovir 400mg TDS from 36/40 gestation to reduce the risk of viral shedding/recurrence.

Question 13

In women with known HSV prior to pregnancy what would you advise them to do if and when they fall pregnant?

Answer 13

1. Reassure them that the risk to the baby is very low - risk of transmission of HSV to the neonate is between 0-3% even if there are vaginal lesions at the time of delivery
2. Advise them to tell their midwife about the HSV diagnosis
3. reassure them that majority of women will have a NVD no indication for a c-section due to the HSV
4. from 36/40 start on acyclovir suppression 400mg TDS

Question 14

Natalie is 30 weeks pregnant and presents to GUM with painful genital ulcers. You suspect HSV. Her swab subsequently comes back positive for HSV type 2 how would you mange her?
She denies ever having oral or genital HSV previously

Answer 14

Start treatment with aciclovir 400mg TDS and continue it now until delivery
pain relief and supportive measures

As she has presented with presumed primary HSV outbreak she needs serology; if her serology is negative for abs this confirms the diagnosis of primary HSV, in which case we need to plan/lease with obstetrics team for a c-section.

council regarding HSV

Question 15

What is the risk of neonatal HSV from mothers with recurrent HSV at the time of the delivery

Answer 15

0-3%

Question 16

What is the risk of neonatal HSV in mothers who have primary HSV outbreak during the third trimester?

Answer 16

up to 41%

Question 17

How would you manage a mother in labour with primary HSV outbreak?

Answer 17

offer C-section,

prescribe IV acyclovir 5mg/kg TDS only if VD

Question 18

if a woman with primary HSV outbreak during labour opts for a vaginal delivery how would you manage the risk of neonatal HSV transmission?

Answer 18

Ideally offer all women a C-section
start the mother on IV acyclovir 5mg/kg TDS
try and avoid invasive procedures e.g. foetal scalp electrode, artificial rupture of membranes, , blood gas monitoring

Question 19

How would you manage a HIV positive mother with primary HSV at the time of labour?

Answer 19

same as you would with a patient not known to have HIV
IV aciclovir 5mg/kg TDS
c-section
baby - IV aciclovir 20mg/kg TDS

Question 20

at what point in the pregnancy should HIV positive women with known HSV be offered acyclovir suppression?

Answer 20

32 weeks gestation

Question 21

Jodie has just delivered her baby boy by C-section. She had a primary HSV outbreak at 32 weeks. How should her baby be managed?

Answer 21

1. Inform paediatric/neonatology team
2. If baby is well no need for HSV swabs , routine baby care; no active treatment required
3. NIPE at 24 hours and discharge if well
4. advise parents on good hand hygiene
5. safetynetting advise to parents - any skin/mouth or eye lesions, irritability or reduced feeding to seek medical advice

Question 22

Emily had primary HSV at 32 weeks and delivered her baby boy by NVD at 38 weeks. She had no lesions at the time of delivery.
Baby is well on delivery - how should the baby be managed?

Answer 22

1. ensure neonatal team are informed
2. swab baby for HSV - skin, eyes, oropharynx and rectum
3. no need for LP if baby is well
4. Prophylactic IV aciclovir 20mg/kg TDS for 10 days whilst awaiting results
5. strict infection control procedures
6. mum can breastfeed as long as no lesions around nipples

Question 23

A patient presents with an episode of severe vulva ulceration. She has never had any symptoms like this before. Her HSV swab comes back positive for HSV type 2. Her serology at the time of diagnosis was negative for HSV antibodies.

What is the best way to define this HSV episode?

a) primary episode
b) recurrent episode
c) non-primary infection
d) initial episode

Answer 23

a) primary episode - it is her first episode with no antibodies to either HSV 1 or 2
this is a sub category of initial episode

Question 24

A patient presents with an episode of severe penile ulceration. He has never had any genital symptoms previously, but does suffer from oral cold sores occasionally . His HSV swab comes back positive for HSV type 2. His serology at the time of diagnosis was positive for HSV 1 IgG antibodies

What is the best way to define this HSV episode?

a) primary episode
b) recurrent episode
c) non-primary infection
d) initial episode

Answer 24

c) non-primary infection (initial episode of HSV type 2 infection, but pre-existing antibodies to HSV 1)

Question 25

John presents with genital ulcers which are very painful. He has experienced these symptoms before but never had time to get "checked out". His HSV swab is positive for HSV type 1 and bloods done at the time show HSV type 1 IgG antibodies. What is the best way to define this HSV episode? a) primary episode b) recurrent episode c) non-primary infection

Answer 25

b - recurrent episode

Question 26

what proportion of patients present with symptoms at the time of HSV acquisition? a) 10% b) 30% c) 50& d) 75%

Answer 26

b - 30%

Question 27

Of the patients whom present with symptoms of HSV at the time of acquisition what is the incubation period

Answer 27

2 days - up to 2 weeks

Question 28

which type of HSV is more likely to recur - HSV 1 or HSV 2

Answer 28

HSV 2

Question 29

what is the median recurrence rate of HSV 2

Answer 29

0.34 recurrences/ month approximately 4 recurrences per year

Question 30

what type of HSV accounts for the majority of adult infections and oral-labial infections

Answer 30

HSV type 1

Question 31

What is the effect of HIV on HSV symptomatic and asymptomatic shedding?

Answer 31

The presence of HIV increases the viral shedding symptomatically and asymptomatically (especially in lower CD4 counts)

Question 32

what are the symptoms of genital HSV

Answer 32

can be asymptomatic painful genital ulceration associated pain when the urine hits the lesions increased vaginal discharge systemic symptoms - fever and malaise/aches and pains

Question 33

what are the signs associated with genital HSV?

Answer 33

blistering/ulceration of external genitals and or perianal bilateral tender inguinal lymphadenopathy note in recurrences - blisters and lymphadenitis are usually unilateral

Question 34

what are some of the complications that can result from genital HSV?

Answer 34

1. Secondary infection with staphylococcus aureus or candida (usually in the second week) 2. ascetic meningitis 3. auto-innoculation to fingers/ adjacent skin 4. autonomic neuropathy 5. HSV proctitis in MSM population (esp if co-existing HIV infection)

Question 35

What are the methods we can use to diagnose HSV

Answer 35

1. Viral PCR | 2. Serology of HSV type 1 or 2 IgG

Question 36

What is the increased sensitivity of viral PCR for HSV typing compared to viral culture

Answer 36

HSV PCR increases detection by 11-71% compared to viral culture

Question 37

In what clinical situations would you consider doing HSV serology

Answer 37

1. Pregnancy when a female presents with symptoms in the third trimester to try and establish if this is a primary or recurrent outbreak 2. Sero-discordance relationships with huge anxiety about transmission (can relieve anxiety if can prove they both have HSV), or when say the male partner is HSV positive and planning pregnancy and we want to have more information for the female partner 3. identify recurrent genital disease of unknown cause

Question 38

Is oral or topical anti-virals better in the management of HSV

Answer 38

oral anti-virals > topical

Question 39

When would you consider IV anti-virals over oral RX

Answer 39

1. disseminated HSV infection | 2. when vomiting or swallowing issues

Question 40

what are the first line anti-viral treatment options for genital HSV

Answer 40

1. Aciclovir 400mg TDS for 5 days | 2. valaciclovir 500mg BD for 5 days

Question 41

What are the second line anti-viral treatment options?

Answer 41

1. Aciclovir 200mg 5 times daily for 5 days | 2. Famciclovir 250mg TDS for 5 days

Question 42

If a patient with genital HSV is unable to pass urine how would you manage this situation, what type of catheter should you consider?

Answer 42

good analgesia, admit to hospital --> bladder scan --> if in retention needs a catheter, note a supra-pubic catheter could be better than urethral in this situation

Question 43

How would you advise patients to manage HSV recurrences? What is the first line treatment option in terms of anti-virals

Answer 43

often can be managed using supportive care only can use anti-virals patient initiated in the prodromal phase to try and prevent genital sores developing - antiviral options - aciclovir, valaciclovir, famciclovir usually aciclovir 800mg TDS for 2 days

Question 44

when would you consider starting suppressive therapy and what is the usual anti-viral dose prescribed

Answer 44

usually if >= 6 episodes of genital HSV in 1 year or extensive anxiety in serodiscordance relationships and worry about transmission/ anxiety issues - aciclovir 400mg BD for 6-12 months; stop after 12 months; quite normal for patients to get a rebound episode on stopping

Question 45

Chloe has been on suppressive treatment for the past 3 months with aciclovir 400mg BD. Despite this she is still getting once monthly HSV outbreaks. What would you advise her to do in terms of her suppression dose

Answer 45

Increase to TDS during outbreaks

Question 46

how can patients prevent transmission of HSV to partners

Answer 46

male condoms reduce the risk of transmission by 50% suppression reduces viral shedding by 80-90% disclosure

Question 47

By what proportion do antivirals reduce asymptomatic shedding

Answer 47

by 80-90%

Question 48

In HIV positive patients with known HSV what is the best method to reduce symptomatic and asymptomatic viral shedding and severity of HSV outbreaks. Either A) anti-viral suppression B) ART C) Using condoms D) Disclosure

Answer 48

b) ART - establishing patients on ART (anti-retroviral treatment) is the most effective way to reduce viral shedding

Question 49

how should patients with genital HSV be treated who are known to be HIV positive and on ART

Answer 49

Treat as you would in standard treatments i.e. aciclovir 400mg TDS for 5 days for an outbreak; however HIV +ve patients have increased risk of drug resistance and treatment failure

Question 50

David is HIV positive and not on ART, he presents with severe genital ulceration and you suspect HSV. What treatment would you provide for the HSV? He is adamant he does not want ART.

Answer 50

Options: 1. Aciclovir 400mg five times daily for 7-10 days 2. valaciclovir 500mg-1g BD for 10 days 3. Famciclovir 250-500mg TDS for 10 days continue therapy until all lesions have re-epitheliased consider IV aciclovir is severe

Question 51

What are the risks associated with primary HSV in HIV +ve patients not on ART?

Answer 51

fulminant hepatitis, pneumonia, neurological disease or disseminated infection

Question 52

where is the mutation most commonly found in aciclovir resistance?

Answer 52

mutation often found in thymidine kinase. Thymidine kinase is responsible for converting aciclovir into it's active form.

Question 53

what percentage of HSV isolates can show aciclovir remittances in HIV + individuals

Answer 53

5-7%

Question 54

what are the systemic treatment options that can be used for drug resistant HSV in PLWHIV?

Answer 54

Foscarnet or cidofovir | n.b give with good hydration and probenceid to reduce nephrotoxicity