Herpes – HSV 1

• transmitted from person-to-person via infected oral secretions during close contact.
• incubation period – 1 to 26 days (median 6 to 8 days) and lesions range from 1 to 8 days in duration
• infection is lifelong, it is rarely fatal in the immunocompetent host, producing either asymptomatic or mild clinical disease.
• Populations at risk
  • Athletes involved in contact sports
  • healthcare workers
  • children between the ages of 7m – 5y 

Symptoms

1. Most common clinical manifestations of hsv-1 occur in the oropharynx of children and adults.
2. Oral infections — gingivostomatitis and pharyngitis    
3. Children with consequent difficulties in eating, drinking, and swallowing may require hospitalization for pain control and/or dehydration.
   1. Signs include fever, malaise, myalgias, irritability, and cervical lymphadenopathy, which can last up to two weeks. 
   2. Viral transmission can occur through close contact with oral lesions.
4. Other cutaneous manifestations
   1. Herpetic whitlow — hsv infection of the finger
   2. Herpes gladiatorum — outbreaks of hsv-1 skin infections have also occurred among wrestlers and rugby players,classically occur on the face, neck, and arms.
   3. Erythema multiforme — associated with the onset of erythema multiforme 
5. Genital hsv-1 infections — although the majority of genital herpes simplex virus (hsv) infections have historically been due to hsv-2, hsv-1 is responsible for an increasing proportion of genital infections.
6. Ocular infections
   1. Keratitis — recurrent hsv-1 keratitis continues to be a leading cause of corneal blindness in industrialized nations 
   2. Acute retinal necrosis, conjunctivitis and blepharitis 
7. Neurologic syndromes — sporadic cases of encephalitis with high rates of morbidity and mortality
8. Hepatitis — fulminant hepatitis(risk include neonates, patients taking steroids, hiv-infected patients)
9. Respiratory tract infections and hsv esophagitis — in  immunocompromised hosts are at risk for herpes simplex virus (hsv) esophagitis, which usually presents with odynophagia, dysphagia, or retrosternal chest pain.

Reactivation risk: 

1. Sunlight
2. Trauma
3. Heat
4. Menstruation
5. Stress
6. Trigeminal nerve manipulation
7. Infectious disease and immunocompromised states.

DDx: 

1. Recurrent aphthous ulcers (occur exclusively on nonkeratinized mucosal surfaces such as the inner surfaces of lips, buccal mucosa, ventral tongue, and mucobuccal fold in the anterior part of the oral cavity  )- In contrast, recurrent oral HSV-1 lesions (“cold sores”) occur at the border of the vermillion (ie, the colored portion of the lips))
2. 
3. aphthous stomatitis
4. syphilis, bacterial pharyngitis
5. Epstein-Barr virus
6. Stevens-Johnson syndrome. 
7. Herpangina –  group A coxsackieviruses, painful posterior pharyngeal lesions that do not bleed
8. Hand, foot, and mouth disease – caused by a number of coxsackie A and B viruses
9. Oral candidiasis –  white plaques on the buccal mucosa, palate, tongue, or 
10. Stevens-Johnson syndrome –prodrome of malaise and fever, followed by the rapid onset of 
11. erythematous or purpuric macules and plaques. The skin lesions progress to epidermal necrosis and sloughing. 
12. Behçet syndrome – recurrent oral aphthae and any of several systemic manifestations, including genital aphthae, ocular disease, skin lesions, gastrointestinal involvement, neurologic disease, vascular disease, or arthritis

Complications of herpetic gingivostomatitis 

1. Dehydration (the most common complication
2. Secondary bacteremia with upper respiratory bacteria (eg, Streptococcus pyogenes, Kingella kingae) 
3. Esophagitis, epiglottitis, or pneumonitis
4. Herpes simplex virus (HSV) encephalitis 
5. Eczema herpeticum
6. Lip adhesions

Treatment

1. supportive management
   1. oral fluids
   2. antipyretic drugs
   3. analgesia
2. topical anaesthetic
   1. benzydamine 1% gel (adult and child >6 y), 2- to 3-hourly
   2. lidocaine 2% viscous solution
      1. rinsed in the mouth for 30 seconds then spit out
      2. adults and children > 12 y, can be gargled and swallowed.
3. antiviral therapy
   1. most effective when started promptly 
   2. only reduces the duration of symptoms by about 24 hours 
   3. does not appear to diminish recurrences. 

Aciclovir 400 mg (child: 10 mg/kg up to 400 mg) orally, 5 times daily for 7 days 

         OR

famciclovir 500 mg orally, 12-hourly for 7 days 

         OR

valaciclovir 1 g orally, 12-hourly for 7 days

Adverse effects of acyclovir include nausea, vomiting, diarrhea, headaches, and renal failure caused by crystallization in the renal tubules, which is more likely if the patient is dehydrated

Recurrence 

Aciclovir (adult and child) 5% cream topically, 5 times daily (every 4 hours while awake) for 5 days (Using aciclovir cream for longer than recommended has no benefit) OR  famciclovir 1500 mg orally, as a single dose.