ID - HSV

Question 1

Herpes simplex virus causes ____ _____ and _______ ______

Answer 1

cold sores; genital herpes

Question 2

HSV-1 is the primary cause of what?
How is it transmitted?

Answer 2

1. Primary cause of herpes labialis (oral cold sores)
2. Transmitted via saliva through oral-to-oral contact, may also be transmitted through oral-to-genital contact

Question 3

HSV-2 is the primary cause of what?
How is it transmitted?

Answer 3

1. Primary cause of genital herpes
2. Transmitted via sexual contact through contact with genital surfaces, skin, sores, or fluids of an infected individual

Question 4

What to know about HSV in terms of it hanging out in the body? (3)

Answer 4

1. Asymptomatic viral shedding
   - Patients can be asymptomatic and shedding the virus, thus spreading the virus unknowingly
2. Herpes virus travels via axons to nerve cell bodies in the dorsal root ganglia
3. HSV stays in the ganglia
   - Lifelong latency and recurrence (cyclic)
   - May be reactivated at any time

Question 5

What is a primary HSV infection?
How does it present?
How long does it last?

Answer 5

1. First episode of HSV infection with no antibodies for HSV present
2. May be asymptomatic or present as more severe disease (in orolabial infection: primary HSV gingivostomatitis)
3. Longer duration (7-18 days) and more severe signs and symptoms

Question 6

What is a non-primary HSV infection?
How long does it last?

Answer 6

1. First episode in a patient who has antibodies for one type of HSV and acquires the other type of HSV
2. Shorter duration and less severe signs and symptoms than primary infections
   - Possibly due to partial protection of antibodies of one HSV against alternate serotype

Question 7

What is a recurrent HSV episode? (3)

Answer 7

1. Latent HSV reactivated: Likelihood of recurrence greater with HSV-2
2. Typically, less severe than primary or non-primary infections
3. Prodrome symptoms: tingling, itching, pain prior to symptoms

Question 8

The severity of HSV symptoms depends on: (4)

Answer 8

1. Previous exposure: primary, nonprimary, recurrent
2. Type of virus: HSV-1, HSV-2
3. Site of infection: oral, genital, ocular, nervous system
4. Individuals’ immune status: immunocompromised

Question 9

What are some potential complications associated with HSV? (4)

Answer 9

1. Herpes Gladiatorum: skin infection
2. Herpetic Whitlow: finger infection
3. Keratoconjunctivitis: conjunctival infection
4. Herpes Encephalitis: can cause neurological effects

Question 10

What are some risk factors for HSV? (4)

Answer 10

1. Physical contact with infected person through:
   - Kissing
   - Sexual contact
   - Sharing utensils (cold sore)
2. Having multiple sexual partners
3. Female > Male
4. Immunocompromised

Question 11

What are some potential factors that increase the risk of HSV manifesting? (8)

Answer 11

1. Stress/fatigue
2. Infection/fever
3. Immunosuppression
4. Hormonal changes
5. Menstruation
6. Physical trauma/dental extractions/surgery
7. Sun exposure
8. Temperature extremes

Question 12

Herpes labialis is also known as?

Answer 12

Cold sores or fever blisters

Question 13

True or False? Herpes virus can be cured/treated

Answer 13

False

Question 14

It takes about - weeks for cold sores to fully resolve

Answer 14

1-2

Question 15

The first infection of herpes labialis is referred to as?
How long does it last?

Answer 15

Primary herpes gingivostomatitis
Lasts from 1-3 weeks

Question 16

Primary infection of herpes labialis is commonly asymptomatic. However, if symptomatic, patients may present with? (5)

Answer 16

1. Painful blisters around the mouth area
   - Blisters may crack, release clear, sticky liquid, then crust over
2. Lymphadenopathy
3. Red, swollen gums
4. Sore throat
5. Systemic: fever, malaise, myalgia

Question 17

Recurrent herepes labialis happens as the ______ ___ is ___________
How long does it typically last?

Answer 17

latent HSV is reactivated
Around 8-10 days

Question 18

What are the potential signs and symptoms of recurrent cold sore? (2)

Answer 18

1. Painful blisters around the mouth area
2. Red and erythematous base

Question 19

What is the prodrome phase of a cold sore?

Answer 19

Prodrome symptoms: tingling, itching, burning before blisters and sores

Question 20

What are the goals of therapy for HSV?

Answer 20

1. Minimize pain or discomfort
2. Minimize the duration of lesions and viral shedding
3. Prevent autoinoculation
4. Prevent recurrences
5. Prevent transfer of virus

Question 21

If prodromal symptoms are present, what are the oral antiviral options that can be used for cold sore? (3) (1st-line)

Answer 21

1. Acyclovir
2. Famciclovir
3. Valacyclovir

Question 22

If prodromal symptoms are present, what are the topical antiviral options that can be used for cold sore? (3) (2nd-line, less effective)

Answer 22

1. Topical acyclovir 5%
2. Topical acyclovir 5%/hydrocortisone 1%
3. Topical Docosanol 10%

Question 23

If there is an active lesion (cold sore) can antivirals be used?

Answer 23

No

Question 24

What treatment options can be used for an active cold sore lesion? (2)

Answer 24

1. Oral analgesics and/or
2. Topical anesthetics or protectants

Question 25

What are some non-pharm methods to help prevent cold sores? (4)

Answer 25

1. If stress is a known trigger, reducing stress may reduce occurrences 2. Prevent sun-induced recurrences by using sunscreen with SPF 30+ on affected areas 3. Frequently wash hands to prevent transmission of the virus to other parts of the body or other individuals 4. Avoid skin-to-skin contact until blister has dried up and crusted over

Question 26

What are some non-pharm methods to help with cold sore symptoms? (4)

Answer 26

1. Gently clean area with mild soap and water 2. Cool or warm compresses 3. Topical protectants prevent blisters from drying out and breaking - Petrolatum - Cocoa butter - Calamine 4. Prevent autoinoculation - Avoid oral sex, kissing, and touching lesions until lesions completely healed - Frequently wash hands

Question 27

What is a potential OTC topical antiviral that patients can try? How to use it? (2) Is it useful?

Answer 27

Docosanol cream (Abreva®) - Prevents HSV from spreading to healthy cells - Apply at the first sign of pain, itching, burning, redness, or tingling - May decrease duration of painful symptoms and time to healing by 17 to 79 hours

Question 28

When would we refer someone if they present with a cold sore? (5)

Answer 28

1. Immunocompromised patients 2. Patients with recurrent, persistent cold sores (≥ 6x/year) 3. Moderate to severe primary infection (systemic symptoms) 4. Lasts longer than 2 weeks 5. Signs of secondary bacterial infection - Select patients may benefit from antiviral therapy (most beneficial if started early, within 48 hours of symptom onset)

Question 29

Rate of recurrence of genital herpes __________ with increasing age

Answer 29

decreases

Question 30

With genital herpes how should diagnosis be confirmed? (3)

Answer 30

With lab tests to exclude other STIs (e.g., chancroids) 1. PCR 2. Viral culture 3. Serology lab tests

Question 31

How does primary infection of genital herpes present? How long does viral shedding typically last? How long for lesions to heal?

Answer 31

1. May be asymptomatic or unrecognized by the patient 2. Viral shedding lasts on average about 12 days 3. Lesions heal in 2-4 weeks

Question 32

If genital herpes primary infection is symptomatic, what are some potential signs and symptoms? (5)

Answer 32

1. Painful, pustular lesions 2. Local itching, tingling, pain 3. Dysuria 4. Lymphadenopathy: swollen glands 5. Systemic symptoms: fever, myalgia, malaise

Question 33

How does recurrent genital herpes present? How long does viral shedding last? How long for lesions to heal?

Answer 33

1. Recurrent infections are generally milder and have a shorter duration than primary infection 2. Viral shedding lasts on average about 4 days 3. Lesions heal in 7-10 days

Question 34

When to begin treatment of recurrent genital herpes?

Answer 34

During prodrome symptoms

Question 35

With recurrent genital herpes, suppressive therapy may be indicated if the patient: (4)

Answer 35

1. Is experiencing frequent recurrences (≥6 recurrences per year) 2. Is experiencing complications from infection 3. Is serodifferent or has serodiscordant partners 4. Has multiple sexual partners - Use of suppressive therapy should be reevaluated on a yearly basis

Question 36

True or False? All patients with genital herpes should be treated with an antiviral?

Answer 36

True

Question 37

How does treatmet of genital herpes in HIV infected/immunosuppressed patients change?

Answer 37

Should be treated fir a longer course than normal. Consider IV acyclovir

Question 38

What are the 3 choices of oral antivirals for genital herpes? Should maybe know how long since symptom onset they can be started for both primary and recurrent episode

Answer 38

1. Acyclovir - Primary = start within 7 days of symptom onset - Recurrent = start within 12 hours of symptom onset 2. Famciclovir - Primary = start within 5 days of symptom onset - Recurrent = start within 6 hours of symptom onset 3. Valacyclovir - Primary = start within 3 days of symptom onset - Recurrnet = start within 12 hours of symptom onset

Question 39

True or False? HSV cannot be transferred to the neonate in pregnancy

Answer 39

False - it can be Mainly during labor: direct contact during virus shedding Greatest risk is during a primary infection near term

Question 40

When is a C-section required during pregnancy for an HSV patient?

Answer 40

If there’s an active infection or prodrome symptoms are present during delivery

Question 41

If a patient is pregnant and they have HSV, when would it be recommended to start suppressive antiviral therapy?

Answer 41

At 36 weeks - Reduce risk of recurrence * Caesarean is not required * Limited data on famciclovir

Question 41

What are our 2 antivirals of choice for a pregnant patient with HSV?

Answer 41

1. Acyclovir 2. Valacyclovir (In neonates, can use IV acyclovir)

Question 42

What is the only antiviral used in HSV encephalitis/meningitis?

Answer 42

Acyclovir IV

Question 43

What are some general things to know about HSV encephalitis/meningitis? (5)

Answer 43

1. HSV encephalitis/meningitis is a medical emergency - Typically in elderly, immunocompromised patients, but can occur in anyone - Leads to seizure, personality changes, fever, photophobia - HSV-2 meningitis less severe than HSV encephalitis 2. Rapid diagnosis and treatment is essential for reducing morbidity and mortality 3. Intravenous acyclovir is the drug of choice for majority of patients 4. HSV encephalitis should be treated with IV therapy for 14-21 days 5. HSV meningitis may be treated with oral therapy for 10-14 days