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Genital Herpes

Genital Herpes. Min Kim, MSN, APRN, ANP-BC. Overview. C ommon STD caused by herpes simplex virus C hronic, life-long viral infection Two serotypes: HSV-1 & HSV-2 Majority cases caused by HSV-2 HSV-1 is usually associated with oral lesions, but can cause genital herpes. Epidemiology.

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Genital Herpes

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  1. GenitalHerpes Min Kim, MSN, APRN, ANP-BC

  2. Overview • Common STD caused by herpes simplex virus • Chronic, life-long viral infection • Two serotypes: HSV-1 & HSV-2 • Majority cases caused by HSV-2 • HSV-1 is usually associated with oral lesions, but can cause genital herpes

  3. Epidemiology • At least 50 million persons in the United States infected • An estimated 81% of infected persons have not been diagnosed • 1.6 million new cases each year • More common in women than men, about 1 in 4 women vs 1 in 8 men

  4. Epidemiology(cont.) • Many persons have mild, asymptomatic, or unrecognized infections • Asymptomatic persons can shed virus intermittently in genital organs • Majority of HSV infections are transmitted by person unaware that they have infection

  5. Transmission • HSV-2 is transmitted sexually and perinatally • HSV-1 is usually transmitted via a non-sexual route; however, sexual transmission appears to be increasing • Risk of spreading the infection is much greater when a person has active signs or symptoms • Transmission can occur even if there are no visible ulcers

  6. Transmission(cont.) • Incubation period after acquisition is 2-12 days • Washing with soap and water readily inactivates HSV • There is no risk of becoming infected after exposure to environmental surfaces

  7. Clinical manifestationstypes of infection • Primary • Non-primary (non-primary first infection) • Recurrent

  8. Primaryinfection • The first infection ever with either HSV-1 or HSV-2 • No serum antibody is present when symptoms appear • More severe symptomsthan in recurrent disease. • Serum antibody may take several weeks to a few months to appear

  9. Non-primary first infection • Newly acquired infectionwith HSV-1 or HSV-2 in an individual previously seropositive to the other viral type • Type-specific antibody to the prior infection is present initially • Manifestations tend to be milder than those of primary infection

  10. Recurrent infection • Reactivation of genital HSV • The HSV type recovered in lesion is the same type as antibodies in the serum • Infection in which antibody is present when symptoms appear • May not be aware of previous episodes • Symptoms are mild and short in duration

  11. Signs and symptoms of primary infection • Numerous bilateral painful lesions • Lesions last average of 11-12 days • Typical lesion progression: papules, vesicles, pustules, ulcers, crusts, then healed • The median duration of viral shedding is about 12 days • Systemic symptoms peak within 3-4 days of onset of lesions and gradually recede over next 3-4 days (fever, headache, malaise, myalgia) • Local symptoms include pain, itching, dysuria, vaginal or urethral discharge, and tender inguinal lymphadenopathy

  12. Genital Herpes

  13. Latent stage • After initial outbreak, virus travels to a bundle of nerves at the base of the spine • Remains dormantfor a period of time • There are no symptoms during this stage • Triggers for recurrence — Illness, stress, sunlight, fatigue, and menstrual periods in women

  14. Signs and symptoms of recurrent infection • llness lasting 5-10 days • Prodromal symptoms (localized tingling, irritation) are common and begin 12-24 hours before lesions develop • Systemic symptoms usually absent • Duration of genital lesions is approximately 4-6 days • Average duration of viral shedding is 4 days • Lesions tend to be unilateral, and much less extensive than with primary infection • HSV-2 primary infection is more likely to recur than HSV-1 primary infection • Recurrences are more frequent if the primary episode is prolonged (i.e., greater than 30 days)

  15. Diagnosis • Clinical diagnosis of genital herpes should be confirmed with laboratory testing • Classical symptoms are often absent in many patients • Need to distinguish genital herpes from other STIs that also produce genital ulcers, such as syphilis and chancroid

  16. lab tests • Virologic tests • Type-specific serologic tests

  17. Virologic Tests Viral culture is gold standard for HSV diagnosis • Preferred if genital ulcers / lesions present • Most cultures will be positive within 24-72 hours Antigen detection • Better than culture for detecting HSV in healing lesions • The direct fluorescent antibody test distinguishes between HSV-1 and HSV-2 Cytology (Tzanck or Pap) identifies typical HSV-infected cells. It should not be relied upon for HSV diagnosis Polymerase Chain Reaction (PCR) assays • PCR is the preferred test for detecting HSV DNA in cerebral spinal fluid • Not FDA-cleared for testing of genital specimens • Not widely available, and may lack standardization across laboratories

  18. Type-Specific Serologic Tests Serologic tests • Detect Antibodies to HSV • HSV-2 antibody indicates anogenital infection as almost all HSV-2 infections are sexually acquired • HSV-1 antibody does not distinguish anogenital from orolabial infection Type-specific serologic assays might be useful when • Recurrent or atypical genital symptoms with negative cultures • A clinical diagnosis of genital herpes w/o laboratory confirmation • A sex partner with genital herpes • As part of a comprehensive evaluation for STDs among persons with multiple sex partners, HIV infection, and among MSM at increased risk for HIV acquisition

  19. Treatment • Antiviral drug therapy • Partially controls symptoms • Does not eradicate the virus • Does not affect the risk, frequency, or severity of recurrences after the drug is discontinued • Three oral meds: acyclovir, valacyclovir, and famciclovir • Topical antiviral treatment is of minimal clinical benefit, and it is not recommended

  20. Treatment for First Clinical Episode • Patients with first clinical episode genital herpes should receive antiviral therapy • Drastic effect on sxs, if sxs are of less than 7 day’s duration • Acyclovir 400 mg orally 3 times a day for 7-10 days, OR • Acyclovir 200 mg orally 5 times a day for 7-10 days, OR • Famciclovir 250 mg orally 3 times a day for 7-10 days, OR • Valacyclovir 1 g orally twice a day for 7-10 days • Treatment may be extended if healing is incomplete after 10 days of therapy

  21. Suppressive therapy • Can be administered continuously • Reduce the frequency of occurrences • Acyclovir 400 mg orally twice a day, OR • Famciclovir 250 mg orally twice a day, OR • Valacyclovir 500 mg orally once a day, OR • Valacyclovir 1 g orally once a day • Rebound outbreaks when suppression tx is discontinued • Suppression therapy does not eliminate latent infection

  22. Episodic therapy for recurrent Genital Herpes • Initiation of therapy within one day of lesion onset • Provide pt w/ appropriate meds or Rx in hand • Instruct pt to self-initiate tx immediately when sxs begin CDC recommendation • Acyclovir 400 mg orally 3 times a day for 5 days, OR • Acyclovir 800 mg orally twice a day for 5 days, OR • Acyclovir 800 mg orally 3 times a day for 2 days; OR • Famciclovir 125 mg orally twice a day for 5 days, OR • Famciclovir 1000 mg orally twice a day for 1 day, OR • Valacyclovir 500 mg orally twice a day for 3 days, OR • Valacyclovir 1 g orally once a day for 5 days

  23. Management of Severe Disease IV acyclovir • Severe HSV disease • Complications requiring hospitalization - disseminated infection, pneumonitis or hepatitis • Complications of the central nervous system - meningitis or encephalitis Herpes in HIV Infected Persons • May have prolonged or severe episodes • Increased doses of antiviral drugs may be beneficial

  24. Pt Counseling and Education • Helping patients cope with infection • Preventing sexual & perinatal transmission • Natural history of disease • Treatment options • Transmission • Prevention

  25. Prevention • Transmitted when lesions not present • Transmitted mostly during asymptomatic periods • Inform current SP about diagnosis with genital herpes • Inform future partners before initiating relationship • Abstain from sexual activity when lesions or prodromal sxs present • Avoid oral sex if ulcers or blisters around the mouth • Correct & consistent use of latex condoms reduce the risk • Suppressive tx reduces transmission when used by persons with multiple partners including MSM

  26. Neonatal herpes prevention • Risk of neonatal HSV infection should be explained to all patients, including men • Advise to inform prenatal & neonatal care providers • Advise pregnant women who are not infected with HSV-2 to avoid intercourse during the third trimester with men who have genital herpes

  27. References • Xu F, Sternberg MR, Kottiri BJ, et al. Trends in herpes simplex virus type 1 and type 2 seroprevalence in the United States. JAMA 2006; 296:964. • Corey L, Adams HG, Brown ZA, Holmes KK. Genital herpes simplex virus infections: clinical manifestations, course, and complications. Ann Intern Med 1983; 98:958. 3. KimberlinDW, Rouse DJ. Clinical practice. Genital herpes. N Engl J Med 2004; 350:1970. • http://www.cdc.gov/std/treatment/2010/default.htm (Accessed on March 7, 2014) • SchillingerJA, McKinney CM, Garg R, et al. Seroprevalence of herpes simplex virus type 2 and characteristics associated with undiagnosed infection: New York City, 2004. Sex Transm Dis 2008; 35:599. 6. Berger JR, Houff S. Neurological complications of herpes simplex virus type 2 infection. Arch Neurol 2008; 65:596. 7. Gupta R, Warren T, Wald A. Genital herpes. Lancet 2007; 370:2127.

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