Title
Instructions: Listen to the podcast episode available below, and then submit your answers to the multiple choice questions. You will review the answers and the material covered during your next Continuity Clinic Session.
Herpes Simplex
A 28-year-old woman has a history of genital HSV-2 infection since age 21 years and is in a new relationship. Over the past 3 years, she had only two recurrent outbreaks of lesions that resolved within 1 week without any treatment. She tells you that her new partner has no history of genital herpes. She wants to know if there is a way to decrease her new partner's risk of acquiring HSV-2 if the couple becomes sexually active. In addition to using condoms, the most appropriate risk-reduction strategy is to use oral medication
Show Explanation
• A clinical diagnosis of genital HSV should be confirmed with virologic testing of genital lesions. PCR for HSV DNA is sensitive and provides a rapid, type-specific diagnosis. Serologic testing is not useful for diagnosis of active genital ulcers unless confirmed with virologic testing, as a positive result is consistent with past oral or genital infection.
• Acyclovir, valacyclovir, and famciclovir are antiviral drugs effective for treatment of HSV. Treatment is 7-10 days for an initial infection and 3-5 days for recurrent oubreaks. Treatment reduces time to healing and duration of viral shedding. Among patients who have frequent recurrences, daily suppressive therapy reduces the frequency of genital HSV recurrent by up to 80%. Suppressive versus episodic treatment (which is initiation of treatment within 1 day of lesion onset or during the prodrome), has been shown to improve quality of life.
• Indications for chronic, daily suppressive therapy include reducing the risk of occurrence of the following: the frequency of recurrent outbreaks, viral shedding and recurrent lesions after 36 weeks GA, clinical disease in immunocompromised individuals, or transmission to an uninfected partner. Suppressive therapy for HSV-positve patients reduced transmission to a discordant, uninfected partner by approximately 50%, likely due to a decrease in number of days of asymptomatic viral shedding. Transmission of HSV is most likely to occur during a period of asymptomatic viral shedding.
A 21-year-old primagravida at 35 weeks of gestation presents to the labor and delivery unit 1 hour after experiencing a gush of clear fluid. She reports that for the past 24 hours she has had a low-grade fever and malaise. She also reports tingling and pain in her left labia. On examination, she appears flushed, her temperature is 38.5C, fundus is nontender, and fetal heart rate tracing is category I. Examination of the vulva shows a solitary vesicular lesion on the left labia minora. There is pooling in the vagina, and the fluid is ferning positive. The most appropriate next step in her management is
Show Explanation
• HSV is transmitted through direct contact between mucous membranes or abraded skin during active lesions or viral shedding. Symptoms occur in approximately 5-15% pf primary HSV infections. Symptoms may include a sensation of burning or discomfort, followed by a cluster of painful vesicles and ulcers, which may be accompanied by flu-like symptoms of malaise, fever, and fatigue.
• Diagnosis of primary infection is based on negative initial serology and positive viral detection by PCR or culture of a lesion. Secondary outbreaks occur because the virus lies dormant in the sensory ganglia after initial infection.
• Neonatal HSV can occur with transmission in the intrapartum period. The incidence is 1 in 3200 to 10,000 live births, and it can cause severe neurologic deficits and death. The highest risk of vertical transmission is during a primary outbreak at the time of delivery. With ruptured membranes, the risk is approximately 30-60%. For this reason, if delivery is indicated during a primary outbreak, cesarean should be performed and significantly decreases the risk of vertical transmission. In a patient who is less than 34 weeks gestation, there is no clear consensus on management.
• Among women with recurrent lesions at the time of delivery, the rate of transmission with a vaginal delivery is only 3%. These women should also undergo cesarean delivery. Women with no symptoms or active lesions at the time of delivery have a risk of transmission of 2 in 10,000, and may undergo vaginal delivery.
• Women with a history of active recurrent genital HSV should be offered suppressive treatment at 36 weeks GA to prevent an outbreak at the time of labor. With suppressive therapy, the risk of recurrence at delivery is decreased by 75% and the rate of cesarean is decreased by 40%. Most cases of neonatal HSV occur in infants born to women without a recognizable outbreak.
A 30-year-old woman presents for follow-up after treatment for an initial outbreak of genital herpes. Her partner has never had an outbreak, but his serologic testing is positive for past exposure to HSV 1 and HSV 2. The best next step in management is to recommend antiviral agents for
Show Explanation
• New genital HSV infections can cause severe genital ulcerations and prolonged systemic illness. Recurrent outbreaks are generally less severe but can still present with multiple painful ulcerations and vesicles. Type-specific IGG antibodies to HSV-1 or HSV-2 develop several weeks after infection and persist throughout the person’s lifetime.
• Sexual partners of people with genital HSV should be tested for past exposure, even if they have never had an outbreak. If the partner has no evidence of past infection, they should be counseled to abstain from sexual activity with the person with HSV when lesions or prodromal symptoms are present, and that transmission can occur during asymptomatic periods due to viral shedding. Daily suppressive therapy by the HSV-positive partner can reduce the risk of transmission. If the partner has evidence of past HSV infection, then the recommendation is for use of episodic therapy for the individual with an outbreak.
• Antiviral therapy is used for treatment of both initial and recurrent episodes of genital HSV, with use of acyclovir, valacyclovir, or famciclovir. Daily suppressive therapy can also be recommended to reduce the frequency of symptomatic recurrent outbreaks, and is not necessary but can be used by people who have rare outbreaks.