Infection with herpes simplex virus type 1 (HSV-1) or type 2 (HSV-2) produces a wide spectrum of clinical problems . Transmission is usually sexual (vaginal, anal, orogenital or oroanal), but perinatal infection of the neonate may also occur. Primary infection at the site of HSV entry, which may be symptomatic or asymptomatic, establishes latency in local sensory ganglia. Recurrences, either symptomatic or asymptomatic viral shedding, are a consequence of HSV reactivation. The first symptomatic episode is usually the most severe. Although HSV-1 is classically associated with orolabial herpes and HSV-2 with anogenital herpes, HSV-1 now accounts for more than 50% of anogenital infections in the UK
Clinical features
SALIENT FEATURES OF LYMPHOGRANULOMA VENEREUM, CHANCROID AND GRANULOMA INGUINALE (DONOVANOSIS)
Lymphogranuloma venereum (LGV)
Infection and distribution
East/West Africa, India, South-east Asia, South America, Caribbean
Organism
Chlamydia trachomatis types L1, 2, 3
Incubation period
3-30 days
Genital lesion
Small, transient, painless ulcer, vesicle, papule; often unnoticed
Lymph nodes
Tender, usually unilateral, matted, adherent, multilocular, suppurative bubo; inguinal/femoral nodes involved; there may be late sequelae1
Diagnosis
Serological tests for L1-3 serotypes; swab from ulcer or bubo pus for Chlamydia
Management
Doxycycline2 12-hourly orallyfor 21 days or Erythromycin 500 mg 6-hourly orally
Single or multiple painful ulcers with ragged undermined edges
Lymph nodes
As above but unilocular, suppurative bubo; inguinal nodes involved in ∼50%
Diagnosis
Microscopy and culture of scrapings from ulcer or pus from bubo
Management
Azithromycin3 1 g orally once or Ceftriaxone 250 mgi.m. once or Ciprofloxacin2 500 mg 12-hourly orally for 3 days or Erythromycin 500 mg 6-hourly orally for 7 days
Granuloma inguinale
Infection and distribution
Australia, Caribbean, India, South Africa, South America, Papua New Guinea
Organism
Klebsiella granulomatis (Donovan bodies
Incubation period
3-40 days
Genital lesion
Ulcers or hypertrophic granulomatous lesions; usually painless4
Lymph nodes
Initial swelling of inguinal nodes, then spread of infection to form abscess or ulceration through adjacent skin
Diagnosis
Microscopy of cellular material for intracellular bipolar-staining Donovan bodies
Management
Azithromycin3 1 g weekly orally or 500 mg daily orally or Doxycycline2 100 mg 12-hourly orally or Ceftriaxone 1 g i.m. daily or Erythromycin 500 mg 6-hourly orally Treatment for at least 3 weeks and until lesions have healed
The first symptomatic episode presents with irritable vesicles that soon rupture to form small, tender ulcers on the external genitalia . Lesions at other sites (e.g. urethra, vagina, cervix, perianal area, anus or rectum) may cause dysuria, urethral or vaginal discharge, or anal, perianal or rectal pain. Constitutional symptoms such as fever, headache and malaise are common. Inguinal lymph nodes become enlarged and tender, and there may be nerve root pain in the 2nd and 3rd sacral dermatomes.
Extragenital lesions may develop at other sites such as the buttock, finger or eye due to auto-inoculation. Oropharyngeal infection may result from orogenital sex. Complications such as urinary retention due to autonomic neuropathy, and aseptic meningitis are occasionally seen.
First episodes usually heal within 2-4 weeks without treatment; recurrences are usually milder and of shorter duration than the initial attack. They occur more often in HSV-2 infection and their frequency tends to decrease with time. Prodromal symptoms such as irritation or burning at the subsequent site of recurrence, or neuralgic pains affecting buttocks, legs or hips are seen commonly. The first symptomatic episode may be a recurrence of a previously undiagnosed primary infection. Recurrent episodes of asymptomatic viral shedding are important in the transmission of HSV.
Diagnosis
Swabs are taken from vesicular fluid or ulcers for detection of DNA by PCR or tissue culture and typing. Electron microscopy of such material will only give a presumptive diagnosis, as herpes group viruses appear similar. Type-specific antibody tests are available but are not sufficiently accurate for general use.
Management
First episode
The following 5-day oral regimens are all recommended and should be started within 5 days of the beginning of the episode, or whilst lesions are still forming:
aciclovir 200 mg five times daily
famciclovir 250 mg 8-hourly
valaciclovir 500 mg 12-hourly.
Analgesia may be required and saline bathing can be soothing. Treatment may be continued for longer than 5 days if new lesions develop. Occasionally intravenous therapy may be indicated if oral therapy is poorly tolerated or aseptic meningitis occurs.
Catheterisation via the suprapubic route is advisable for urinary retention due to autonomic neuropathy because the transurethral route may introduce HSV into the bladder.
Recurrent genital herpes
Symptomatic recurrences are usually mild and may require no specific treatment other than saline bathing. For more severe episodes patient-initiated treatment at onset, with one of the following 5-day oral regimens, should reduce the duration of the recurrence:
aciclovir 200 mg five times daily
famciclovir 125-150 mg 12-hourly
valaciclovir 500 mg 12-hourly
Management in pregnancy
If her partner is known to be infected with HSV, a pregnant woman with no previous anogenital herpes should be advised to protect herself during sexual intercourse because the risk of disseminated infection is increased in pregnancy. Consistent condom use during pregnancy may reduce transmission of HSV. Genital herpes acquired during the first or second trimester of pregnancy is treated with aciclovir as clinically indicated. Although aciclovir is not licensed for use in pregnancy in the UK, there is considerable clinical evidence to support its safety. Third-trimester acquisition has been associated with life-threatening haematogenous dissemination and should be treated with aciclovir.
Vaginal delivery should be routine in women who are symptomless in late pregnancy. Caesarean section (CS) is sometimes considered if there is a recurrence at the beginning of labour, although the risk of neonatal herpes through vaginal transmission is very low. CS is often recommended if primary infection occurs after 34 weeks because the risk of viral shedding is very high in labour
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