Genital herpes
Case 4
Which of the following is a true statement about genital herpes?
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A. Most primary HSV, except in neonates, is asymptomatic.
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B. The Tzanck prep is very sensitive and specific and is more diagnostic than just clinical diagnosis.
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C. Up to 2/3 of patients with a history of asymptomatic infection actually have symptoms.
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D. As with HIV, saliva transmits infection poorly.
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E. A and C.
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F. A and D.
Which of the following is a true statement about genital herpes?
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A. Most primary HSV, except in neonates, is asymptomatic.
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B. The Tzanck prep is very sensitive and specific and is more diagnostic than just clinical diagnosis.
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C. Up to 2/3 of patients with a history of asymptomatic infection actually have symptoms.
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D. As with HIV, saliva transmits infection poorly.
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E. A and C.
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F. A and D.
The best answer is E
Most primary infection with HSV is asymptomatic, except in newborns. But, most infections with HSV, with further questioning or examination, do have mild symptoms that go unnoticed by the patient. So, both A and C are correct.
From the reference Chayavichitsiop P, Buckwalter J, Krakwoski AC, Friedlander SF. Herpes simplex. Pediatrics in Review. 2009. 30(4): 119-129, it is noted that viral shedding frequency from the genital area is substantially greater for HSV2 than HSV1. In addition, HSV1 appears to be increasing in prevalence in the anogenital area. Recurrences are far less frequent for genital HSV1 compared to HSV2; 95% of recurrent genital herpes is HSV2. HSV2 is becoming as common as HSV1 in the extragenital regions (not orofacial).
Transmission of HIV, not HSV, is poor through saliva. There was, however, a recent report that mothers with HIV who chewed their food and then fed it to their infants were noted to have caused their children to convert to HIV+. HSV is transmitted well through saliva. Transmission is generally by exposure to active lesions or mucosal secretions of a person with active infection. Note that HSV2 shedding is significantly higher in immunocompromised (HIV) patients. The incubation is 2-12 days, usually 4 days. Active viral shedding lasts one week. HSV remains stable outside the host for a short period of time.
The Tzank Prep is not very sensitive or specific. Viral culture is the gold standard. Serology has not been well studied in children. However, most immunogenic epitopes are shared between HSV1 and 2. One envelope protein, glycoprotein G (gG), elicits a predominantly type-specific immune response. Type Specific Serologic tests use antigens for HSV-1 (gG1) and HSV-2 (gG2). The sensitivities vary from 80-98%, and false negatives may occur. Specificities are >96%, and false positives can occur.
Further Reading
- Handout for CHAMP webcast of October 22, 2009: STIs: A Bug's Life in Perspective - Herpes 2009-oct-22-handout-What-to-Do-Herpes.pdf.
- US Department of Health and Human Services/Centers for Disease Control and Prevention. Sexually Transmitted Infections Treatment Guidelines, 2021. Morbidity and Mortality Weekly Report; July 23, 2021: Vol. 70 (4). It is available online at https://www.cdc.gov/std/treatment-guidelines/default.htm. The section on Sexual Assault and Abuse and STIs can be accessed directly at https://www.cdc.gov/std/treatment-guidelines/sexual-assault.htm.