HSV
Genital herpes is a sexually transmitted infection which is seen throughout the world and continues through life. It is the most common cause of diseases accompanied by genital ulceration. Genital herpes is a serious health problem because the infection continues through life with remissions and relapses, it causes recurring painful ulcers, the virus transmitted from mother to infant causes serious neonatal infections, and there is no known cure for it.
Herpes simplex viruses (HSV) are the most common human pathogens causing infections in orofacial (mouth, jaws and the face) and genital regions. Genital herpes infection is caused by herpes simplex virus 1 (HSV-1) and herpes simplex virus 2 (HSV-2). HSV-1 mainly causes infection in oral, facial, and ocular regions and in the central nervous system (CNS) and is transmitted during childhood. While in the past genital herpes infections were mostly caused by HSV-2 and orofacial infections were mostly caused by HSV-1, HSV-1 is reported to cause genital herpes at an increasing rate today, particularly in developed countries.
The real prevalence of the genital herpes infection is unknown due to asymptomatic cases. The majority of infected individuals are not aware of the infection due to short duration of symptoms and signs or its asymptomatic nature.
HSV enters the body through the skin on the mouth, genitals and anus or small cuts in the skin elsewhere on the body. The virus lives in the nerves beneath the skin and may remain inactive and unnoticed for many years.
It is not completely understood what causes the virus to activate and cause blisters. Isolated factors such as, menstruation (periods), emotional upset and sexual activity have been known to trigger an episode. Sunburn can also trigger a herpes episode (or cold sore) on the face or lips.
There is a high risk of the virus spreading between sexual partners before, during, and for the week following an episode. Even when a person has no symptoms, herpes can be directly spread to their partner, if the infected person is currently "shedding" the virus at the time of sexual intercourse or oral sex.
Although genital herpes can be diagnosed via patient history and examination, herpes diagnosis may not always be easy. There may be atypical localizations such as hip and thigh or atypical presentations such as vulvar (Pic. 1)/penile (Pic. 2)/perianal fissures, recurrent erythema (skin redness), recurrent pain, cystitis (bladder inflammation), urethritis (urethra inflammation), and genital discharge without lesions. In such cases, the patient may be subjected to unnecessary antiviral treatments and experience negative social and psychosocial effects due to the diagnosis. For a thorough infection management, the clinical diagnosis must be supported with laboratory confirmation. Supporting the diagnosis is also important for detection of possible cases, further consulting services, and prevention of serious complications such as neonatal herpes.
HSV targets the reproductive system, and the infection among males and females leads to infertility problems, but the mechanism seems different in the two populations. The causal relationship between the infection and infertility in males and females would be established through further researches.
Associated diseases
HIV
There is a strong relationship between HSV-2 positivity and human immunodeficiency virus (HIV). The risk of HIV transmission is three times higher in women and men infected with HSV-2. Worldwide, more than half of individuals infected with HIV have HSV-2 infection. Genital herpes lesions are suggested to facilitate HIV acquisition due to disruptions in physical barriers of skin and mucosa. In addition, HSV-2 infection is suggested to accelerate HIV disease and increase viral load.
Complications
Genital herpes is a serious health problem because the infection continues through life with remissions and relapses, it causes recurring painful ulcers, and there is no known cure for it.
Complications such as urinary retention (inability to completely empty the bladder), meningoencephalitis (infection or inflammation of the meninges and brain), disseminated disease (connective tissue disease), pneumonia (infection of lung), and hepatitis, which are usually observed during the first attack and in immunosuppressive individuals.
Neonatal herpes
A serious complication of genital herpes in the mother during pregnancy, neonatal herpes, has a mortality risk of 60% if not treated. Transmission from the mother to the infant mostly (85%) occurs during vaginal birth due to viral shedding. Intrauterine (5%) and postnatal (10%) transmission cases are less common.
Its clinical manifestation involves eye, mouth, and skin infection, central nervous system disease, or disseminated disease which starts within the first 28 days of life. Eye, mouth, and skin infection (Pic. 3) is present in 45% of cases and characterized by vesicular lesions without central nervous system (CNS) involvement or disseminated disease. CNS disease is observed in about 30% of cases and characterized by lethargy, feeding difficulty, and seizures. CNS disease may be accompanied by skin lesions.
The mortality is 6% and permanent moderate and severe neurological damage is 50% with intravenous (IV) acyclovir treatment. Disseminated disease consists of the remaining 25% of cases and presents multiple organ involvement with clinical sepsis. The mortality is 30% in spite of acyclovir treatment.
Risk factors
In women, the sites of infection are mainly the vulva and the vagina, with some cases involving the regions of cervix and perianal. In heterosexual men infection is typically on the glans or the shaft of the penis, whereas anal infection is also reported with homosexual men.
Although herpes virus affects the genital area, it does not seem to cross over into other reproductive reas and has a little if any affect on a sperm production nor a woman’s ability to conceive. However, there is a risk of serous complications during pregnancy (neonatal herpes).
Still, a couple with active herpes should be able to try again to conceive within a month or two once all signs of lesions have dissipated.
If a person is aware of a potential herpes episode they should take extra precautions to protect their sexual partner from infection. There is potential to pass on the virus even if there are no symptoms or visible signs of an outbreak.
To help reduce the risk of transmission:
Unfortunately, it is not possible to predict how or when a herpes episode will occur in an individual. Some people may never experience visible signs or symptoms; others may only experience one episode, whilst a minority of people will have recurrent episodes. These episodes will vary between people, in general, after a person has the initial episode, recurrences are less severe, usually involve more rapid healing of the affected area and longer intervals between episodes.
An episode of herpes usually occurs in several stages over seven to ten days these include:
Often people do not experience any signs or symptoms before or during the primary episode or consequent herpes episodes. . In these instances, it is possible for the infected person to pass the virus to sexual partners and not be aware that they themselves are infected.
There are a small number of people who experience more severe symptoms during the primary and recurrent episodes, these may include some or all of the following: flu like symptoms, generally feeling unwell, fevers, joint pains, groin discomfort, tingling or itching and painful blisters followed by ulceration of the affected area
In more severe cases, to can take up to three weeks for the blisters to heal and associated symptoms to disappear. It is advisable for people to attend a sexual health clinic or visit a doctor once the blisters appear to discuss management of the condition.
An episode of genital herpes can be managed by:
Currently, there is no cure for herpes. There are antiviral drugs to manage the virus, and if taken at the beginning of an episode, they can help reduce the duration and severity of the episode. The antivirals do not kill the virus; they act on the body to decrease the amount of virus present which decreases the likelihood of future herpes episodes and the risk of transmission between partners.
Pharmacotherapy
Antiviral medication
Systemic antiviral use is the essential point of genital herpes treatment. Studies have shown that systemic antiviral treatment limits the severity and duration of the genital herpes attack. The important point to keep in mind is that antiviral treatment does not eliminate latent infection (overt disease is not produced) and does not affect posttreatment recurrence risk and severity.
In treatment of HSV-1- and HSV-2-induced genital herpes, it is recommended to use acyclovir, valacyclovir, and famciclovir as the standard primary care. While acyclovir is available in intravenous and oral forms, valacyclovir and famciclovir are available in oral form only. These three agents have similar activities in terms of reducing disease severity, duration, and recurrence.
HSV treatment with acyclovir has been shown to slow down HIV progression in individuals co-infected with HIV and HSV-2.
Topical medication
A topical medication is a medication that is applied to a particular place on or in the body. The effect of topical agents is weaker than systemic agents and they do not contribute to combined treatment. They are not recommended for use in case of genital herpes since they lead to an increase in resistance. Intravenous treatment should be considered only when oral agents cannot be tolerated and in complicated cases. Washing with serum physiologic and using analgesic and topical anesthetic agents are additional approaches which may be beneficial.
Surgical therapy
Not used.
If patient prefer not take a risk of sharing the virus through unprotected sex, he/she and his/her partner might want to consider alternate ways to have a family. These options include assisted reproductive techniques (ART). ART is the technology used to achieve pregnancy in procedures such as fertility medication, artificial insemination, in vitro fertilization (IVF) and surrogacy.
Artificial insemination should be done with partner’s or donor sperm. IVF and ART generally start with stimulating the ovaries to increase egg production. Most fertility medications are agents that stimulate the development of follicles in the ovary. After stimulation, the physician surgically extracts one or more eggs from the ovary, and unites them with sperm in a laboratory setting, with the intent of producing one or more embryos. Fertilization takes place outside the body, and the fertilized egg is reinserted into the woman's reproductive tract, in a procedure called embryo transfer.
Surrogacy via a gestational carrier is also an option when woman is affraid of transmission of herpes during pregnancy or labor.
Process by which a woman donates eggs for purposes of assisted reproduction or biomedical research.
A micromanipulative fertilization technique in which a single sperm is injected directly into an egg.
The procedure in which a man (sperm donor) provides his sperm for fertility treatment.
A process in which an egg is fertilised by sperm outside the body: in vitro. Own or donated gametes may be used.
