Herpes Simplex Virus 1 and 2 (HHV1, HHV2) | Figure 4.2
A: Eczema herpeticum
(Courtesy of
Dr. Sophie M. Worobec)
B: Perianal HSV ulcers
(Reprint Bolognia JL, Jorizzo
JL, Rapini RP. Dermatology.
2nd ed. St. Louis, MO:
Mosby Elsevier; 2008)
C: HSV corneal ulcer
(Reprint from Mandell G, ed.
Atlas of Infectious Diseases.
Philadelphia, PA: Current
Medicine LLC; 2002) |
| Figure 4.1
A: Recurrent HSV infection
(Courtesy of Dr. Paul Getz)
B: Primary genital HSV
(Courtesy of Dr. Paul Getz)
C: Primary genital HSV |
(Figure 4.1A–C) - Neurotropic virus which hides in the dorsal root ganglion until reactivation
- HSV-1 associated more with orolabial herpes, HSV-2 with genital herpes
- Primary infections:
- Primary herpetic gingivostomatitis: typically in children; presents with abrupt onset of striking gingivitis (erythematous, friable gingiva), painful vesicles clustered on oral mucosa, tongue, lips, and/or perioral skin → vesicles rupture, leaving small ulcers with characteristic gray base; ± pharyngitis, tonsillitis, difficult to eat and swallow, enlarged lymph nodes, fever, and anorexia
- Primary genital infection: more severe and prolonged than recurrent infection, presents with constitutional symptoms and painful grouped vesicles in genitalia → progress to pustules, crusting and exquisitely tender ulcers, ± painful lymphadenopathy, cervicitis, urethritis, proctitis
- Recurrent infections:
- Herpes labialis: most common HSV-1 manifestation triggered by pyrexia, stress, sunburn, and/or trauma; prodrome (pain, burning, tingling) may precede eruption; grouped vesicles on erythematous base which typically evolve into pustules and then painful ulcers (often involving vermilion border)
- Genital herpes: ± prodrome followed by grouped vesicles → pustules → ulceration
- Other types of infections:
- Herpes gladiatorum: HSV primary infection primarily noted in wrestlers and involving extramucosal sites typically over face, neck, or arms
- Herpetic whitlow: painful primary herpetic infection of hand (typically distal phalanx) resulting in exquisite pain and swelling of finger with characteristic vesicular lesions; more common in health-care workers or caregivers
- Eczema herpeticum (Kaposi varicelliform eruption): rare disseminated form of HSV mainly seen with atopic dermatitis (also Darier disease, Hailey–Hailey, etc.); presents as monomorphic umbilicated vesiculopustules or punched out ulcerations with hemorrhagic crust; may progress to life-threatening infection (Figure 4.2A)
- Herpes-associated erythema multiforme (HAEM): self-limited eruption associated with HSV infection; presents with typical concentric target plaques; begins on extremities and spreads centripetally, ± mucosal involvement
- HSV encephalitis: dormant HSV in trigeminal ganglion → travels retrograde to the brain, targets temporal region of brain, 70% mortality if untreated
- HSV folliculitis: rare manifestation
- Chronic ulcerative HSV: presents mainly in immunocompromised patients as persistent ulcers involving perianal/buttock area and can be pustular, exophytic, or verrucous as well (Figure 4.2B)
- Keratoconjunctivitis: can be primary or recurrence, latter typically presents branching dendritic corneal ulcerations (seen with fluorescein stain), can lead to scarring and blindness (Figure 4.2C)
- Diagnosis:
- Tzanck smear shows multinucleated epithelial giant cells (fusion of infected keratinocytes) – does not differentiate between HSV and VZV
- Viral culture or direct fluorescent antibody (DFA)
- Histology shows keratinocyte edema causing ballooning degeneration and acantholysis, intranuclear inclusion bodies, and dense inflammatory infiltrate ± epidermal/adnexal necrosis
- Treatment: acyclovir, valacyclovir, famciclovir; if acyclovir-resistant use foscarnet or cidofovir
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