Predictors of Herpes Simplex Virus Type 2 Antibody Positivity Among Persons With No History of Genital Herpes

Heterogeneous cutaneous findings associated with intrauterine HSV infection: A case series and literature review

BACKGROUND/OBJECTIVE

Herpes simplex virus (HSV) infection acquired in utero may present with non-vesicular dermatologic findings in affected newborns, which may pose a diagnostic dilemma. We aimed to describe and assess the range of non-vesiculobullous skin lesions that neonates with intrauterine HSV infection may manifest at birth.

METHODS

We collected a multicenter case series and conducted a literature review of neonates with intrauterine HSV infection presenting with non-vesiculobullous cutaneous lesions.

RESULTS

Twenty-two cases were reviewed, including six managed clinically by members of our team and 16 identified in the literature. Four (18%) were associated with twin pregnancies, and thirteen (59%) cases occurred in premature infants. Only four (18%) mothers had a documented history of HSV infection. Twelve (55%) cases resulted in poor outcomes, including long-term neurologic sequelae or death. Cutaneous manifestations included erosions, ulcerations, crusted papules or plaques, calcinosis cutis, excoriations, macules (erythematous, hypopigmented, or hyperpigmented), cutaneous atrophy, contractures, and bruising. About one-third of neonates developed new-onset vesicular lesions within a week of birth; in each of these cases, accurate diagnosis and therapy were delayed until appearance of vesicles.

CONCLUSIONS

The range of dermatologic findings associated with intrauterine HSV is extremely broad, and the various morphologies present at birth likely reflect different stages of the ongoing evolution of an HSV infection that began in utero. Clinicians should have a low threshold for HSV testing in premature neonates born with atypical cutaneous lesions, since early detection and treatment of HSV may reduce morbidity and mortality from systemic complications.

Low acceptance of HSV-2 testing among high-risk women

We evaluated the acceptability of a community-based herpes simplex virus type 2 (HSV-2) screening programme for at-risk women and assessed factors related to uptake of point of care HSV-2 testing. One hundred recently arrested women (median age 34 years) were recruited from a community court handling lower-level misdemeanour cases in Indianapolis, Indiana. Individuals completed a survey assessing factors related to HSV-2 screening intentions and were offered point of care HSV-2 testing. Rates of HSV-2 infection in this population are high; 61.1% of women tested were positive. The majority (81%) accepted a prescription for suppressive therapy. Women in this sample indicated that HSV-2 screening is an important component of health care but were unwilling to pay the US$10 it cost to be tested. To encourage this and other high-risk populations to be screened for HSV-2, public health resources will be needed to help individuals overcome cost-related barriers to care.

A Comparison of One Year of Episodic or Suppressive Treatment of Recurrent Genital Herpes With Valacyclovir

OBJECTIVES

We conducted this study to compare episodic and suppressive therapy for genital herpes about disease characteristics, disease burden, and psychologic impact.

STUDY DESIGN

The authors conducted a randomized, open-label, 1-year treatment trial.

RESULTS

Forty subjects were randomized to episodic therapy with valacyclovir (500 mg twice daily for 5 days) and 40 to suppressive therapy (500 mg daily). Subjects in the episodic arm experienced more outbreaks (7.87 +/- 4.65) than those in the suppressive arm (1.59 +/- 1.93) (P <0.001). Subjects in the episodic arm also had significantly more days with pain and lesions (6.5 +/- 7.3) than those in the suppressive arm (1.1 +/- 3.3) (P < 0.001), and other quantitative measures of disease burden also favored the suppressive arm. Both treatment groups had significant improvements in their recurrent genital herpes quality-of-life scores from baseline that persisted throughout the study; however, there was no significant difference between the treatment arms in these scores.

CONCLUSIONS

Suppressive therapy of recurrent genital herpes with valacyclovir has a greater impact on measures of disease frequency and burden than episodic therapy. However, both treatment strategies lead to significant improvements in recurrent genital herpes quality-of-life scores. Both treatment strategies benefit patients with recurrent genital herpes.

Herpes simplex virus infections in preterm infants

OBJECTIVE

Neonatal herpes simplex virus infections cause significant neonatal mortality and morbidity, but the course and prognosis in preterm infants is not well documented. We performed a retrospective review of herpes simplex virus infections at out institution within the first 30 days after birth in infants who were born at <37 weeks to help better define the symptoms and signs of herpes simplex virus infections in preterm infants and to assist in prognosis.

METHODS

Hospital databases were reviewed to identify culture- or polymerase chain reaction-proven cases of herpes simplex virus-1 or herpes simplex virus-2 infections that occurred in preterm newborns between 1989 and 2003. Maternal and neonatal histories, clinical features, and laboratory results were reviewed systematically.

RESULTS

Ten preterm singletons and a set of twins were infected with herpes simplex virus-2 during the first month after birth. No mother had herpes simplex virus lesions at delivery, but a history of genital herpes simplex or other sexually transmitted infections was prevalent among the mothers. Infants presented with either disseminated disease or encephalitis. All infants with disseminated disease (n = 9) died, whereas the 3 infants with encephalitis survived. All infants in the cohort developed respiratory distress, and consistent with the prominence of respiratory symptoms, viral cultures of the respiratory tract were consistently positive. Ten of 12 infants received acyclovir, but despite treatment within 48 hours of symptoms, infants with disseminated disease deteriorated rapidly and died. Two of 3 infants who received high-dosage (60 mg/kg per day) acyclovir survived.

CONCLUSIONS

Herpes simplex virus infections in preterm infants usually present during the first 2 weeks of life with respiratory distress and a high incidence of disseminated disease. Viral respiratory cultures have a high yield for documentation of infection. The morbidity of herpes simplex virus in this population may be attributable to a relatively immature immune system in this population. Additional studies are necessary to delineate the evolution of herpes simplex virus disease in preterm infants and the role of antiviral therapy in mitigating the sequelae of herpes simplex virus infections in this population.

Herpes Virus Type 2 Infection and Genital Symptoms in Primary Care Patients

OBJECTIVE

We aimed to identify whether genital symptoms were associated with unrecognized herpes simplex virus type 2 (HSV-2) infection in a primary care population.

STUDY DESIGN

Five thousand four hundred fifty-two individuals aged 18 to 59 seeking general care at 36 suburban medical offices in 6 U.S. cities were tested for HSV-2 antibody and asked about 10 types of genital symptoms. In patients with no known history of genital herpes, we assessed whether HSV-2 infection was independently associated with symptoms.

RESULTS

HSV-2 infection was associated with increases in reports of "sores, blisters, ulcers, crusts, or small cuts/slits" in men [adjusted odds ratio (OR), 1.79; 95% CI, 1.24-2.58] and with increases in reports of "redness, irritation, or a rash" among women (adjusted OR, 1.50; 95% CI, 1.06-2.11). HSV-2 was not significantly associated with other types of genital symptoms.

CONCLUSIONS

Primary-care physicians should consider unrecognized HSV-2 infection as a potential cause of some common genital symptoms.

Genital Herpes Complicating Pregnancy

Approximately 22% of pregnant women are infected with herpes simplex virus (HSV)-2, and 2% of women will acquire HSV during pregnancy. Remarkably, up to 90% of these women are undiagnosed because they are asymptomatic or have subtle symptoms attributed to other vulvovaginal disorders. Diagnosis of genital herpes relies on laboratory confirmation with culture or polymerase chain reaction assay of genital lesions and type-specific glycoprotein G-based serologic testing. Neonatal herpes is the most severe complication of genital HSV infection and is caused by contact with infected genital secretions at the time of labor. Maternal acquisition of HSV in the third trimester of pregnancy carries the highest risk of neonatal transmission. Despite advances in the diagnosis and treatment of neonatal herpes, little change in the incidence or serious sequelae from this infection has occurred. As such, prevention of the initial neonatal infection is critically important. Obstetricians are in a unique position to prevent vertical HSV transmission by identifying women with genital lesions at the time of labor for cesarean delivery, prescribing antiviral suppressive therapy as appropriate, and avoiding unnecessary invasive intrapartum procedures in women with genital herpes. Enhanced prevention strategies include identification of women at risk for HSV acquisition during pregnancy by testing women and possibly their partners for HSV antibodies and providing counseling to prevent transmission to women in late pregnancy.

Factors Predicting the Acceptance of Herpes Simplex Virus Type 2 Antibody Testing Among Adolescents and Young Adults

BACKGROUND

The rates and determinants of acceptance of herpes simplex virus type 2 (HSV-2) testing have not been adequately studied.

OBJECTIVES

The objective of this study was to identify factors associated with acceptance of HSV-2 antibody testing in individuals with no history of genital herpes.

STUDY

We conducted a cross-sectional survey study followed by the offer of free HSV-2 serologic testing at an urban sexually transmitted disease (STD) clinic, 2 general adult medical clinics, an urban university campus, and an urban adolescent medicine clinic. A total of 1199 individuals aged 14 to 30 years completed the survey and were offered testing.

RESULTS

A total of 68.4% accepted HSV-2 testing. Factors independently associated with acceptance were female sex, older age, having an STD history, having 1 or more sexual partners in the last 6 months, perceived vulnerability to HSV-2 infection, and perceived benefits of HSV-2 testing. Fear of needles predicted rejection of testing, as did attending a general medical clinic versus an STD clinic and nonwhite race.

CONCLUSION

There is a substantial interest in HSV-2 antibody testing across a variety of settings. Those at greatest behavioral and historic risk for HSV-2 infection, women, and persons whose health beliefs are consistent with testing are more likely to accept serologic testing when it is offered.