Herpes Simplex Virus Type Ii Hsv2

Genital herpes simplex virus (HSV) infection is not a reportable disease but is considered to be extremely common in the U.S. with approximately 45 million adults (approx 22% of the population aged 15-74 yr) estimated to be infected in 1990, based on the serologic results of a random sampling of civilian adults examined as part of the National Health and Nutrition Examination Survey (NHANES III) (12). This represents a 32% increase compared to 1978, when the seroprevalence of HSV-2 was 16% among the adult population during NHANES II (13). The prevalence of HSV-2 infection increased with increasing age, and the odds of having HSV-2 were higher in women (odds ratio [OR] = 1.6), blacks (OR = 5.7), previously married individuals (OR = 2.0 - 2.8), and those with lower family income (OR = 1.2) (13). The highest seroprevalences in NHANES III were seen in black men and women aged 60-74 (61% and 81%, respectively) (12). Therefore, HSV-2 infection is prevalent in older adults and should be considered in the differential diagnosis of a genital or perineal ulceration or rash, especially if it is resistant to usual local care measures.

The majority of people testing positive for antibodies to HSV-2 have subclinical, atypical, or asymptomatic disease, with the minority displaying the classic presentation of vesicular outbreaks. Studies estimate that 70-80% of patients testing positive for HSV-2 antibodies are not aware of the infection, but up to 50% of these individuals will give a history of atypical symptoms that may be due to HSV reactivations (14). Recurrences are very common, averaging four to five per year for HSV-2 in the first few years after acquiring the virus but then tend to become less frequent the longer the time period from initial infection (15). Immune suppression associated with aging or other concomitant morbid conditions in the elderly may lead to an increase in the frequency of recurrences or a recrudescence after many years of no clinically recognizable outbreaks.

The gold standard for diagnosis of HSV infection remains the viral culture; however, the overall sensitivity of culture is estimated to be approximately 50% (14), so a negative culture result does not exclude the diagnosis. The yield from culture is better from early lesions, such as vesicles or fresh ulcers, than from resolving ulcerations, and is more likely to be positive in primary infection than in the recurrent form of the disease. The Tzanck test—staining of cells from the lesion base to look for multinucleated giant cells—may be helpful for diagnosis but is positive only 50% of the time. Currently available serologies are not useful for diagnosis because they do not differentiate between infection with HSV-2 and HSV-1, the latter of which infects the majority of the U.S. adult population. Newer serologies that are type-specific, detecting antibodies to the surface glycoproteins gG1 and gG2, will be useful tools in diagnosing atypical presentations of herpes but are not yet commercially available. Furthermore, polymerase chain reaction (PCR) for HSV DNA is being developed, which, in the future, may supplant virus culture as the test of the choice for the evaluation of genital ulcerations (14).

Table 1

Treatment of Genital HSV-2

Table 1

Treatment of Genital HSV-2

Stage of infection

Duration of therapy

Medications

Acyclovir

Famciclovir

Valacyclovir

Primary

7-10 d

400 mg po tid

250 mg po tid

1 g po bid

Recurrent

5 d

400 mg po tid or

125 mg po bid

500 mg po bid

800 mg po bid

Suppression

1 yra

400 mg po bid

250 mg po bid

500 mg po qdfc or

"Therapy longer than 1 yr may be indicated if recurrences continue to occur frequently; however, there is insufficient experience with famciclovir or valacyclovir to recommend therapy with these agents for more than 1 yr

^Valacyclovir 500 mg qd dose less effective than other doses of valacyclovir for very frequent recurrences (>10 per yr) (ref. 10).

Abbreviations: po, orally; qd, once daily; bid, two times a day; tid, three times a day.

"Therapy longer than 1 yr may be indicated if recurrences continue to occur frequently; however, there is insufficient experience with famciclovir or valacyclovir to recommend therapy with these agents for more than 1 yr

^Valacyclovir 500 mg qd dose less effective than other doses of valacyclovir for very frequent recurrences (>10 per yr) (ref. 10).

Abbreviations: po, orally; qd, once daily; bid, two times a day; tid, three times a day.

The treatment of herpes simplex infection has been made easier by the availability of famciclovir and valacyclovir, which allow less frequent dosing than acyclovir. However, all three drugs are equally efficacious. (See Table 1 for doses and duration of treatment.) If an elderly patient experiences frequent recurrences (>6 per yr), then chronic suppression should be considered. The need for suppressive therapy should be reevaluated after 1-2 yr by a trial off medications. If recurrences are sporadic at that time, then sporadic treatment is in order. If recurrences are frequent again, then another year of suppression is indicated. HIV testing should be considered in the elderly patient experiencing frequent herpetic recurrences who has not recently acquired herpes, as frequent recurrences in long-term disease is unusual.

Counseling of older individuals with HSV genital infection should include information about the natural history, probability of recurrences, benefit of treatment, and chances for transmission. Transmission can occur in the absence of clinical symptoms or signs of an outbreak; in fact, most sexual transmission occurs due to asymptomatic shedding. Therefore, patients with genital herpes should be counseled to use condoms at all times to reduce the risk of transmitting the infection to a partner.

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