Herpes simplex virus type 2 detection by culture and polymerase chain reaction and relationship to genital symptoms and cervical antibody status during the third trimester of pregnancy

Premature Rupture of Membranes with Concurrent Viral Infection

Treatment of viral infections is geared toward ameliorating maternal symptoms and minimizing perinatal transmission. Multidisciplinary teams often are required to manage sequelae due to viral diseases in patients with preterm premature rupture of membranes (PPROM). although data are scarce regarding the antepartum management of common viruses in PPROM, essential principles may be extrapolated from national guidelines and studies in gravid patients. The well-established risks of prematurity are weighed against the often unclear risks of vertical transmission.

The global and regional burden of genital ulcer disease due to herpes simplex virus: a natural history modelling study

Introduction

Herpes simplex virus (HSV) infection can cause painful, recurrent genital ulcer disease (GUD), which can have a substantial impact on sexual and reproductive health. HSV-related GUD is most often due to HSV type 2 (HSV-2), but may also be due to genital HSV type 1 (HSV-1), which has less frequent recurrent episodes than HSV-2. The global burden of GUD has never been quantified. Here we present the first global and regional estimates of GUD due to HSV-1 and HSV-2 among women and men aged 15-49 years old.

Methods

We developed a natural history model reflecting the clinical course of GUD following HSV-2 and genital HSV-1 infection, informed by a literature search for data on model parameters. We considered both diagnosed and undiagnosed symptomatic infection. This model was then applied to existing infection estimates and population sizes for 2016. A sensitivity analysis was carried out varying the assumptions made.

Results

We estimated that 187 million people aged 15-49 years had at least one episode of HSV-related GUD globally in 2016: 5.0% of the world's population. Of these, 178 million (95% of those with HSV-related GUD) had HSV-2 compared with 9 million (5%) with HSV-1. GUD burden was highest in Africa, and approximately double in women compared with men. Altogether there were an estimated 8 billion person-days spent with HSV-related GUD globally in 2016, with 99% of days due to HSV-2. Taking into account parameter uncertainty, the percentage with at least one episode of HSV-related GUD ranged from 3.2% to 7.9% (120-296 million). However, the estimates were sensitive to the model assumptions.

Conclusion

Our study represents a first attempt to quantify the global burden of HSV-related GUD, which is large. New interventions such as HSV vaccines, antivirals or microbicides have the potential to improve the quality of life of millions of people worldwide.

Asymptomatic Herpes Simplex Virus Infection in Iranian Mothers and Their Newborns

This study aims to determine the prevalence of herpes simplex virus (HSV) infection among pregnant women as well as congenital infection of their newborns in Tehran. One hundred samples of blood sera from pregnant women were analyzed for the presence of HSV specific antibodies. Umbilical cord blood samples from the newborns were analyzed for the presence of HSV DNA using real-time PCR. HSV IgG and IgM antibodies were found in 97% and 2% of pregnant women, respectively. Of all the 100 cord blood samples, 6 were positive for HSV DNA in which 2 cases were from mothers who had detectable IgM. It was notable that all corresponding mothers of six HSV positive infants had detectable IgG antibodies in their sera. It was demonstrated that the presence of HSV DNA in cord blood of newborns could be a risk marker for maternal-fetal transmission of the virus in asymptomatic pregnant women.

Retrograde tracing of spinal cord connections to the cervix with pregnancy in mice

In contrast to the uterus, the cervix is well innervated during pregnancy and the density of nerve fibers increases before birth. To assess neural connections between the cervix and the spinal cord, the cervix of pregnant mice was injected with the trans-synaptic retrograde neural tract tracer pseudorabies virus (PRV). After 5 days, the virus was present in nerve cells and fibers in specific areas of the sensory, autonomic, and motor subdivisions of the thoracolumbar spinal cord. In nonpregnant controls, the virus was predominantly distributed in laminae I-III in the dorsal gray sensory areas with the heaviest label in the substantia gelatinosa compared with the autonomic or motor areas. Labeled cells and processes were sparse in other regions, except for a prominent cluster in the intermediolateral column (lamina VII). Photomicrographs of spinal cord sections were digitized, and the total area with the virus was estimated. Compared with nonpregnant controls, the area with PRV was significantly decreased in all the spinal cord subdivisions in pregnant mice except in the intermediolateral column. However, areas with the virus were equivalent in mice injected with PRV at 4 days or 1 day before birth. These findings suggest that the predominant innervation of the murine cervix is from the sensory regions of the thoracolumbar spinal cord, and that these connections diminish with pregnancy. The results raise the possibility that the remaining connections from sensory and autonomic subdivisions, particularly the intermediolateral column, of the thoracolumbar spinal cord may be important for increased density of nerve fibers in the cervix as pregnancy nears term.

Maternal Herpes simplex virus type 2 infection, syphilis and risk of intra-partum transmission of HIV-1: results of a case control study

BACKGROUND

Genital ulcer disease including that caused by Herpes simplex virus type 2 (HSV-2) and syphilis facilitates sexual transmission of HIV-1. The effect of these infections on intra-partum mother-to-child-transmission (MTCT) of HIV-1 is unknown.

METHODS

A case-control study was conducted using archived sera from HIV-1 positive women enrolled in ZVITAMBO, an MTCT trial. Cases were 509 women who transmitted HIV-1 to their infants intra-partum; controls were 1018 women whose infants remained uninfected at 12 months. Maternal serum collected at delivery, were tested for HSV-2 antibody. The 6-week post-partum sample was also tested for syphilis by RPR and TPHA to identify women with incubating or active syphilis at delivery. Rates of prevalent and incident HSV-2 and recently acquired syphilis were compared between cases and controls.

FINDINGS

Overall prevalence of maternal HSV-2 and active syphilis at delivery were 82.5% [95% confidence interval (CI), 80.6-84.5] and 4.0% (95% CI, 3.0-5.1), respectively. Prevalent HSV-2 was associated with increased intra-partum MTCT [adjusted odds ratio (OR), 1.50; 95% CI, 1.09-2.08]. The proportion of intra-partum transmissions potentially attributable to prevalent HSV-2 infection was 28.4% (95% CI, 7.3-44.7). Maternal infection with active syphilis at delivery was not associated with intra-partum MTCT (unadjusted OR, 0.89; 95%CI, 0.49-1.59; adjusted OR, 0.64; 95% CI, 0.34-1.20).

INTERPRETATION

HSV-2 infection is common among HIV-1-positive women and is associated with an increased risk of intra-partum MTCT. More than 25% of intra-partum MTCT may be attributable to maternal HSV-2 co-infection. Active maternal syphilis at the time of delivery is not associated with intra-partum MTCT risk.

Oral and vulvar changes in pregnancy

The endocrinologic, immunological, and vascular changes that occur during pregnancy are far-reaching. These systemic factors produce profound local impact on the physiology and pathology of the oral cavity, vagina, and vulva. Physiological changes can be expected and tolerable or of such severity that they are viewed as pathological. Existing disease can be exacerbated and dermatoses specific to pregnancy can erupt. Each of these conditions can pose potentially challenging treatment considerations.

Herpes simplex virus in pregnancy: new concepts in prevention and management

Genital herpes simplex virus (HSV) infection is one of the most common viral sexually transmitted diseases in the United States. It is estimated that 45 million adolescents and adults are infected with genital HSV. Most genital herpes infections in the United States are caused by HSV type 2 (HSV-2), and 25% to 30% of women of reproductive age have HSV-2 antibodies. What is more striking is that genital herpes is frequently under-recognized, and that only 5% to 10% of these women have a history of genital herpes. Because such a small percentage of women are aware of being infected with HSV, the risk of maternal transmission of this virus to the fetus or newborn is a significant health issue.

Type-specific screening for asymptomatic herpes infection in pregnancy: a decision analysis

OBJECTIVE

To evaluate the merits of serum screening for herpes simple virus (HSV) in pregnant women with no history of prior HSV infection.

DESIGN

Clinical decision analysis.

POPULATION

Hypothetical cohort of pregnant women in first trimester with no clinical history of HSV infection.

METHODS

We used decision analysis techniques to compare three strategies for antepartum screening for HSV in women with no history of infection: (1) universal screening; (2) targeted screening in women estimated to be at high risk for infection; and (3) current care (no screening). For the screening strategies, we considered screening at 35 weeks of gestation, with prophylactic antiviral therapy for seropositive women. For all women, we assumed caesarean delivery in the setting of symptomatic infection at delivery. We performed a literature review of English-language publications to derive probability estimates for the rate of HSV seropositivity in asymptomatic pregnant women, and the risks of symptomatic HSV infection and asymptomatic shedding at the time of delivery. We determined the modification of rates of viral shedding, symptomatic lesions and caesarean section with the use of prophylactic suppression therapy for seropositive women based on available data. We chose neonatal herpes with severe sequelae, neonatal death, as well as caesarean delivery as clinically relevant outcomes.

MAIN OUTCOME MEASURES

Number of cases of neonatal death, neonatal HSV with severe sequelae, neonatal HSV with moderate sequelae, patients screened, patients treated and caesarean section with each strategy.

RESULTS

Universal maternal screening reduced the total number of deaths and severe sequelae secondary to neonatal HSV. Universal screening required treatment of 3849 women to prevent one case of neonatal death or disease with severe sequelae from HSV. Targeted screening of high risk women treatment of 2277 women to prevent one death or case of severe disease. Universal screening reduced the rate of neonatal HSV attributable to recurrent HSV by 79.3%. Caesarean delivery was reduced with both screening strategies. We used one-way sensitivity analyses to evaluate the robustness of our model.

CONCLUSIONS

Maternal screening reduced the number of cases of neonatal HSV. Screening also reduced the rate of caesarean delivery. However, employing universal screening will likely result in a significant expenditure of medical resources because the number needed to treat to avert a single case of neonatal herpes is high.

Prenatal testing for infectious disease

Prenatal testing for infectious diseases is performed frequently and for a variety of indications. The purpose of this article is to review the maternal and fetal infections that pose diagnostic concerns. Recent advances in diagnostic testing (such as avidity testing) is included. Testing issues focus on the diagnosis of maternal and fetal infection.

A double-blind, randomized, placebo-controlled trial of acyclovir in late pregnancy for the reduction of herpes simplex virus shedding and cesarean delivery

OBJECTIVE

The purpose of this study was to assess the efficacy of acyclovir in the reduction of herpes simplex virus culture and polymerase chain reaction positivity and cesarean delivery.

STUDY DESIGN

Women with recurrent genital herpes simplex virus were randomized to acyclovir 400 mg three times daily or placebo from 36 weeks of gestation until delivery. A subset of daily specimens for herpes simplex virus culture and DNA polymerase chain reaction was self-collected. Analyses used chi(2), Fisher exact, and Mann-Whitney U tests.

RESULTS

Lesions occurred at delivery among 11 of 78 women (14%) who received placebo and 4 of 84 women (5%) who received acyclovir (P =.08). Herpes simplex virus culture and polymerase chain reaction positivity near delivery occurred in 7% and 34% women in the placebo group and 0 and 2% in the acyclovir group (P =.03 and <.01, respectively). Cesarean delivery for herpes simplex virus occurred in 8 of the women (10%) in the placebo group and in 3 of the women (4%) in the acyclovir group (P =.17). Despite reductions in herpes simplex virus detection, 6% of the women who received acyclovir had herpes simplex virus detected by polymerase chain reaction on >20% of days. Neonatal outcomes were similar between groups.

CONCLUSION

Acyclovir significantly reduced, but did not eliminate, herpes simplex virus lesions and detection in late pregnancy.

Diagnosis and treatment of herpes simplex infection during pregnancy

When pregnant women acquire primary herpes simplex genital infections or experience recurrent infections around the time of delivery, the risk of transmitting the disease to their newborns is significant. This perinatal transmission can result in a serious neonatal illness. Issues surrounding screening, treatment, and mode of delivery to prevent perinatal transmission often are confusing and controversial. Nurses delivering care to childbearing women and their newborns must be aware of the current information to give accurate and helpful information and support. Nurses also need to understand the effect this disease has both physiologically and psychosocially on women with primary infections, recurrent infections, and women at risk of acquiring the infection during pregnancy.

Comparative performance of herpes simplex virus type 2-specific serologic assays from Meridian Diagnostics and MRL diagnostics

MRL Diagnostics and Meridian Diagnostics have recently designed herpes simplex virus type 2 (HSV-2)-specific enzyme immunoassays for HSV-2 antibody detection. Blood donor sera were assayed for HSV-2 antibodies by both methods. The sensitivity, specificity, and efficiency were 97.9, 95.4, and 95.9% for the MRL assay and 83.2, 98.2, and 95.5% for the Meridian assay, respectively.

Sensitive method for detection of human herpesviruses 6 and 7 in saliva collected in field studies

To facilitate studies of the epidemiology and natural history of human herpesviruses 6 and 7 in infants, a practical method for collecting and quantifying the DNA of these viruses was developed. Saliva was collected using small strips of filter paper, and virus was detected using a real-time quantitative fluorescent-probe PCR assay. The sensitivity and specificity of this method even after prolonged drying of the specimens compared favorably to those of our traditional method of collecting and assaying saliva.

Detecting urethral and prostatic inflammation in patients with chronic prostatitis

OBJECTIVES

Diagnosis of urethral and prostatic inflammation can represent a challenge. We compare the accuracy of diagnostic methods for detecting inflammation in lower urinary specimens/samples.

METHODS

A standardized protocol was used to evaluate urethral smear, first-void urine (VB1), midstream urine (VB2), expressed prostatic secretions (EPS), and postmassage urine (VB3) in urologic patients with no symptoms or signs of urethritis who were attending our prostatitis clinic.

RESULTS

Of 235 subjects, 60 (26%) had leukocytes detected by the Gram-stained urethral smear, 44 (18%) by the VB1, and only 14 (6%) by the VB2. Compared with the urethral swab, VB1 had 0% to 22% sensitivity and 81% to 98% specificity, and VB2 had 8% to 11% sensitivity. Of 83 subjects with prostatic inflammation, the EPS detected 63 (76%) and the VB3 detected 68 (82%).

CONCLUSIONS

VB1 or VB2 examinations had low sensitivity for detecting urethral inflammation. Examining both the EPS and VB3 proved best for detecting prostatic fluid inflammation. Combining the urethral smear with lower urinary tract localization ("four-glass test") represents an optimal approach for detecting urethral and prostatic inflammation.

Herpes simplex virus DNA in amniotic fluid without neonatal infection

Twenty-one pregnant women were studied to determine the distribution of herpes simplex virus (HSV): 10 had symptomatic genital herpes, including 1 with primary cervical HSV infection, and 11 had asymptomatic genital herpes. Samples from vesicles, the cervix, and amniotic fluid (AF) were analyzed with 2 separate polymerase chain reaction (PCR) tests and with viral culture. For newborns, clinical examinations and pharyngeal HSV cultures were performed, and cord blood IgM antibodies to HSV were measured. HSV DNA was present in the AF of 3 women with symptomatic HSV infection, but all cultures were negative. HSV was detected more often with PCR than with culture, in both vesicle and cervical samples. For the asymptomatic group, all AF samples were negative, whereas 4 cervical samples were positive by PCR (none were positive by culture). All isolates were HSV type 2. All infants were healthy, and none had cord blood IgM antibodies to HSV, including those with PCR-positive AF.

Herpes simplex virus infection of the uterine cervix--relationship with a cervical factor?

OBJECTIVE

To determine the prevalence of genital herpes simplex virus (HSV) in women of reproductive age and to evaluate a potential relation of asymptomatic HSV shedding with a cervical factor.

DESIGN

Prospective study.

SETTING

Outpatient infertility clinic of a university hospital.

PATIENT(S)

Randomly chosen asymptomatic women (n = 1,262) with a median age of 30 years.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Prevalence of cervical HSV, cervical index parameters, and other variables of CM quality, including CM penetrability in vivo and in vitro.

RESULT(S)

The prevalence of HSV infection of the uterine cervix was 5.2% (identified with cell culture). There was a tendency toward increased viscosity of the CM in HSV-positive women, but no significant relation with the other variables of CM quality (amount, spinnbarkeit, ferning, cervical appearance, and cellularity of the CM), or with the summarized Insler score or the cervical index according to World Health Organization guidelines. Postcoital testing and the in vitro penetration test, using either partners' or donors' semen, showed that the penetrability of the CM did not differ significantly between women with and without cervical HSV shedding. Asymptomatic cervical HSV infection was not significantly associated with bacterial colonization of the lower genital tract, with leukocyte counts in cervical secretions, with the pH of the CM or the vaginal fluid, or with antisperm antibodies in the CM.

CONCLUSION(S)

The results suggest that in asymptomatic women under controlled endocrine conditions, cervical HSV infection is not a significant cause of impaired quality and penetrability of the CM.

Prevalence of herpes simplex type 2 antibodies and a clinical history of herpes in three different populations in Campinas City, Brazil

OBJECTIVES

To determine the seroprevalence of herpes simplex virus type 2 (HSV-2) antibodies and the relation between the history of clinical herpes and the presence of type-specific HSV-2 antibodies in three different populations from the city of Campinas City, Brazil.

POPULATION AND METHODS

One hundred and one college students, 96 patients with sexually transmitted diseases (STD), and 102 women at delivery were interviewed and blood samples were collected. Total HSV (HSV-1 and HSV-2) antibodies were screened by enzyme-linked immunosorbent assay (ELISA) and type-specific HSV-2 antibodies were detected by Western blot assay.

RESULTS

Herpes simplex virus antibodies were detected in 66.3% of the students, 97.1% of the women at delivery, and 99.0% of the STD patients. Type-specific HSV-2 antibodies were detected in 6.9% of the students, 22.6% of the women at delivery, and in 53.1% of the STD patients. History of genital herpes was reported by none of the students, by one of the women at delivery, and by 11 of 51 (21.6%) STD patients who were HSV-2 seropositive. Four of the 45 (8.9%) seronegative STD patients reported a history of genital herpes.

CONCLUSION

The prevalence of HSV-2 infection in Campinas City can be significantly affected by the characteristics of the population studied, as was shown in previous studies. The sensitivity of the history of genital herpes was low in the present series, stressing that prophylactic measures for vertical and horizontal transmission of HSV-2 should not be based only on a positive history of genital ulcers.

Herpes simplex virus

Herpes simplex virus (HSV) infection is prevalent worldwide. Herpes labialis, caused predominantly by HSV-1, and herpes vulvovaginitis, caused predominantly by HSV-2, may result in significant morbidity and mortality for infected neonates exposed during delivery. The diagnosis of HSV infection is made by serological testing, viral culture, or polymerase chain reaction. Women with primary herpes vulvovaginitis exhibit a painful vesicular rash which is self-limited but may be followed by multiple recurrences. Women at greatest risk to transmit HSV to their neonates are those who experience their first episode of HSV during the latter stage of pregnancy. If infected, their neonates may have localized skin, eye and mucosal lesions, invasive central nervous system infection, or disseminated disease. Because of the potentially devastating outcome for a baby infected with HSV, pregnant women with active HSV lesions at delivery should be offered a cesarean section. Still, many neonates who are infected with HSV are born to women with asymptomatic HSV shedding. Therefore, prevention of HSV during pregnancy is exceedingly important.

Polymerase chain reaction in the detection of microbes in amniotic fluid

Intra-amniotic infection during pregnancy can be caused by bacteria, viruses or protozoa, Toxoplasma gondii for example. Bacterial intrauterine infections are connected with premature birth, premature rupture of fetal membranes, and infective complications of both the mother and the newborn. Viral infections and Toxoplasma gondii can cause fetal malformations and illness with serious sequelae to the infant or fetal death in utero. Determining the causative agent is important and often greatly affects the prognosis of the newborn. Amniotic fluid is in most cases easily and safely obtainable during the second and third trimester and can be used in several microbiological assays. These include bacterial and viral cultures, Gram staining, quantitative assays for immunoglobulins or cytokines, and polymerase chain reaction (PCR) for detecting microbial DNA. This review concentrates on broad-spectrum or universal bacterial PCR for detection of bacterial DNA in amniotic fluid and on PCR assays for certain clinically important viruses and for Toxoplasma gondii.

Vertical transmission of viral infections

A variety of congenital viral infections are responsible for a large proportion of the mortality and morbidity in infancy and childhood. Vertical transmission may occur during primary maternal infection or during chronic or recurrent infection, with different implications for counselling and testing in pregnancy. Strategies for the diagnosis and prevention of mother-to-child transmission differ according to the timing and mechanisms involved. As demonstrated by hepatitis B research in the past and human immunodeficiency virus today, multicenter cohort studies and clinical trials are a key to developing effective interventions.

Pathogenesis of HSV and CMV Infections in Pregnancy

Human herpesvirus (HHSV) and human cytomegalovirus (HCMV) infections during pregnancy are a major concern of public health because of the risk for severe sequelae for the fetuses and the neonates and because primary infections, reinfections and reactivations can be asymptomatic. The risk for neonatal herpes is mostly congenital, while the risk for HCMV infection is either prenatal or congenital. Screening exposed women has not brought definite solutions but is currently being evaluated. Among pregnant women with active infection, evaluation of the fetus for contamination and thus for the risk for severe immediate or long-term sequelae for neonates is the major goal. Diagnostic tools are available, cell culture still being the gold standard, and polymerase chain reaction (PCR) being currently evaluated for its contribution to diagnosis of active infection. Consensus for screening pregnant women as well as achievement of antiviral vaccines are the most urgent intervention strategies to develop in the near future.