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Herpes Simplex Virus

Herpes Simplex Virus

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Herpes Simplex Virus

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  1. Herpes Simplex Virus Karen Estrella-Ramadan 07/02/12

  2. Double stranded DNA virus • Serotypes: • HSV-1: “above the waist” • HSV-2: “ below the waist”: sexually transmitted • 25%: oral lesions • Transmission: both symptomatic and asymptomatic (1%) and may occur with primary (higher concentration) or recurrent infection • Shedding: primary: 1wk (genital and gingival), recurrent: 3 days

  3. Neonatal • 20-40% preterm • 75% sec to HSV-2 • Primary genital infection: risk: near to 50% • Reactivation: <5% • However: >75% who acquire it have been born of mothers who didn’t have symptoms • Occurs between birth and 4wks of age

  4. Types • Disseminated: CNS, liver, lungs EARLY (<1wk) • SEM: skin, eyes, mouth (1-2wks) • Trauma • Localized: CNS (LATE: 2-3wks)

  5. Mucocutaneous • HSV-1 • Incubation: 2d-2wk • Consider child abuse if child with HSV2 • Manifests as: • Herpes labialis • Gingivostomatitis • Ezcemaherpeticum • Herpetic whitlow • Herpes gladiatorum • Genital herpes

  6. Herpes labialis • recurrrent: w/ stress, hormonal changes, immunosupression, UV light • Sec to latency in trigeminal ganglion • Prodrome: localized pain, tingling, itching, burning 6hr-48hrs • 1 or group in vermillion

  7. Gingivostomatitis • 1st episode: 6mo-5y • Anterior oral mucosa + fever, fussiness, droolingdecrease po, painful submandibular or cervical adenopathy • Last for 10-14 days, shedding up to 23 days • Watch for dehydration, manage pain

  8. Ezcemaherpeticum Fever + vesicles umbilicated pustules in areas of ezcema

  9. Herpetic whitlow • Complication of primary oral or genital herpes via brake in skin in hand • Thumb suckiing

  10. Herpes gladiatorum Thorax, face, ear, hands in wrestlers

  11. Conjuntivitis and keratitis • Complication from autoinoculation from oral shedding

  12. Genital • > primary: asymptomatic, 70-80% seropositive • Lesions develop over 7-8 days, shedding: 2 days • Infections due to HSV-2 are more likely to recur than HSV-1, reactivation: less pianful • If HSV-1: consider autoinoculation in children but sexual abuse on prepubertal • Prevention; condoms

  13. CNS manifestations • Fever, change in mental status, seizures, focal neuro findings • Encephalitis: Risk 0.5-5% of children • HSV-1 • cute and fulminent if not tx • Dx: CSF: pleocytosis, > Lymphocytes • 50% may have RBC • Meningitiss: nospecific, mild nadn self limited • Rare, no need for antiviral tx, related fo HSV-2 • 3-12 days fter genital lesions • Other: Bell’s palsy, trigeminal neuralgia, atypical pain syndrome

  14. Diagnosis • In neonates: if suspicion tx until confirm it • Mucocutaneous: if clinically compatible no cx • CNS: EEG and MRI : will show abnormalities in temporal lobe • Edema, hemorrhage, necrosis

  15. Cx: first signs at 72hrs, final at 2wks • 90% skin: will be positive but almost none in CSF • Tzank: multinucleated giant cells and eosinophilic inclusions: not specific for HSV

  16. Tx NEONATAL • If active lesions: c/s only if ROM is less than 6hrs • If born during active infection: controversy if txvs. observe • However if rash develops or signs of sepsis get: • Cx of lesions: nasopharynx, conjunctivae, stool, umbilicus • Observe for dev: vesicles, jaundice, resp distress, sz • Remember: it can happen even after 4 wks!!! • IV ACYCLOVIR + HYDRATION • 2 wks SEM, 3 wks CNS (continue until CSF PCR neg) • For ophthalmic add: topical • Prognosis developmental delay:2% SEM, 70% on CNS and 25% on disseminated (>than 50% die )

  17. TX MUCOCUTANEOUS:: • PO therapy if at onset, decrease course by 2 days • Manage Pain + hydration OCULAR: • 1-2% trifluridine, 1% iodoeoxyuridine, 3% vidarabine • No steroids • For recurrency, may give po acyclovir

  18. Tx GENITAL • PO Txstarted <5days from onset: decrease shedding by 3-5 days • Topical: no no • Latency: sacral ganglia • If >6 x/yr: give po acyclovir for 1 yr IMMUNOCOMPROMISED: • If resistant to acyclovir, give foscarnet

  19. References • http://pedsinreview.aappublications.org/content/25/3/86.full.pdf • http://emedicine.medscape.com/article/964866-overview