The diagnosis of genital herpes - beyond culture: An evidence-based guide for the utilization of polymerase chain reaction and herpes simplex virus type-specific serology

Applicability of molecular assays for detection and typing of herpes simplex viruses in encephalitis cases

Herpes simplex viruses (HSVs) cause a latent infection in humans which is mainly associated with characteristic cold sores or fever blisters and genital blisters. Large segments of the world population are suffering from the HSV infection and early diagnosis as well as treatments are needed to avoid further complications. HSV surveillance is very sparse, especially from developing countries including India. The aim of the present study is to develop and evaluate molecular assays for rapid detection and typing of HSV. In the present study, viral DNA was extracted from cerebro-spinal fluid from HSV suspected encephalitis patients. The conventional multiplex PCR for HSV-1 and HSV-2 was optimized and their comparative analysis was done with Real-Time qPCR for detection and typing of HSV. Out of 137 clinical samples, eleven samples (8.03%) were diagnosed as HSV positive by Real-Time qPCR while ten (7.3%) by conventional multiplex PCR which were further typed as subtyping HSV-1 (nine) and HSV-2 (two). Real-Time qPCR is highly sensitive and able to detect 9.4 × 10¹ to 3.1 × 10⁶ copies/ml of HSV DNA. Conventional PCR was found to be having 99.21% specificity with 100% sensitivity. The positive predictive value was 90.91% whereas negative predictive value was 100%. Logistic regression indicates blisters with pain and skin rash as the most significant symptoms associated with HSV infection. The present study could be applied for rapid, specific, sensitive and cost-effective diagnosis of HSV-1 and HSV-2 thereby helpful in better patient management through early detection and treatment of HSV.

Sexually transmitted infections - laboratory diagnosis

The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field in order to standardize producers to assist the reasoning and decision-making of doctors. The information provided through this project must be assessed and criticized by the physician responsible for the conduct that will be adopted, depending on the conditions and the clinical status of each patient.

[Genital herpes and pregnancy: Serological and molecular diagnostic tools. Guidelines for clinical practice from the French College of Gynecologists and Obstetricians (CNGOF)]

OBJECTIVES

To describe serological and molecular tools available for genital and neonatal herpes, and their use in different clinical situations.

METHODS

Bibliographic investigations from MedLine database and consultation of international clinical practice guidelines.

RESULTS

Virological confirmation of genital herpes during pregnancy or neonatal herpes must rely on PCR (Professional consensus). HSV type-specific serology (IgG) will allow determining the immune status of a patient (in the absence of clinical lesions). However, there is currently no evidence to justify universal HSV serological testing during pregnancy (Professional consensus). In case of genital lesions in a pregnant woman that do not report any genital herpes before, it is recommended to perform a virological confirmation by PCR and HSV type-specific IgG in order to distinguish a true primary infection, a non-primary infection associated with first genital manifestation, from a recurrence (Grade C). HSV IgM is useless for diagnosis of genital herpes (Grade C). If a pregnant woman has personal history of genital herpes but no lesions, whatever the gestational age, it is not recommended to perform genital sampling nor serology (Professional consensus). In case of recurrence, if the lesion is characteristic of herpes, virological confirmation is not necessary (Professional Agreement). However, if the lesion is not characteristic, virological confirmation by PCR should be performed (Professional consensus). At birth, HSV PCR samples should be collected as soon as neonatal herpes is suspected (symptomatic neonate) (best before beginning antiviral treatment but must not delay the treatment), or after 24hours of life in case of asymptomatic neonate born to a mother with herpes lesions at delivery (Professional consensus). Clinical samples for virological confirmation should include at least blood and a peripheral location. In case of clinical manifestations of herpes in the neonate, first samples PCR positive, preterm birth, or maternal primary infection or non-primary infection associated with first genital manifestation at delivery, CSF should also be collected as well as samples of lesions in the neonate if present (Professional consensus). Sampling should be repeated in case of PCR negative but strong evidence of neonatal herpes (Professional consensus). HSV serology is useless for diagnosis of neonatal herpes (Grade C).

CONCLUSIONS

Virological confirmation for diagnosis of genital herpes during pregnancy or neonatal herpes must rely on PCR. PCR assays available in France are very reliable. Specific IgG are dedicated to restricted indications.

Herpes simplex virus 1 and 2 educational assessment of young adults in rural southwest Virginia

Purpose

Herpes simplex virus 2 (HSV-2) causes genital herpes, one of the most common sexually transmitted infections (STIs) in the U.S. HSV-1, commonly associated with cold sores, is increasing as a cause of genital herpes. Abstinence-only sexual health classes, commonly taught in Virginia, generate young adults who are under-educated in sexual health, increasing STI risks. College students in southwest Virginia were surveyed to assess comprehensiveness of high school health education regarding HSV-1 and HSV-2 and to identify students’ preferred methods for STI education.

Methods

To obtain data on knowledge of HSV, comprehensiveness of sexual health education in high school, and preferred learning methods, 237 college students participated in an online questionnaire and 28 students were interviewed using structured interviews.

Results

Questionnaire and interview data indicated that Family Life Education classes need to include more comprehensive information on prevention, viral transmission, and differences between HSV-1 and HSV-2. The majority of total respondents (both the questionnaire and interview) (65%) reported non-comprehensive high school sexual health education. The majority of interview (79%) and questionnaire (55%) respondents wished they had learned more about herpes and other STIs in high school. Education preferences of both interviewed and surveyed respondents included interactive internet programs or games, more realistic lectures, and learning about STIs later in high school when students reported greater sexual activity.

Conclusion

Our results indicate that more comprehensive sexual health education is needed and wanted by students in southwest Virginia. More relevant educational programs should be implemented for VA high school students utilizing technology and interactive methods to improve student engagement in sexual health education.

Implications and contribution

These studies provide information on knowledge of herpes simplex viruses among college students, comprehensiveness of sexual health education received in high schools, and preferred methods to learn about HSV and other STIs. These studies inform the facilitation of improved health education practices and programs for high school and college students.

Multicenter Evaluation of Meridian Bioscience HSV 1&2 Molecular Assay for Detection of Herpes Simplex Virus 1 and 2 from Clinical Cutaneous and Mucocutaneous Specimens

Herpes simplex virus (HSV) causes acute and relapsing symptoms characterized by ulcerative lesions. Laboratory diagnosis of HSV in cutaneous or mucocutaneous lesions has historically been performed with the use of viral cell culture systems; however, these tests are laborious and suffer decreased sensitivity for advanced-stage lesions. The recent availability of FDA-cleared moderately complex assays has resulted in the increased use of molecular diagnostics for the routine detection of HSV in superficial swab specimens. We performed a clinical evaluation of the recently FDA-cleared illumigene HSV 1&2 loop-mediated isothermal amplification (LAMP) assay (Meridian Bioscience, Cincinnati OH) for the detection and differentiation of HSV-1 and HSV-2 in cutaneous and mucocutaneous swab specimens. A total of 1,153 clinical swab specimens were collected and tested at 7 different clinical centers. Each specimen was tested for the presence of HSV-1 and HSV-2 using the illumigene assay, and results were compared to those of the enzyme-linked virus-inducible system (ELVIS) as the reference method. Overall, the illumigene assay demonstrated a sensitivity and specificity of 94.8% and 95.5%, respectively, for the detection of HSV-1. Detection of HSV-2 was similar, with a sensitivity of 98.9% and a specificity of 95.5%. Discrepant analysis was performed using an alternative molecular test (AmpliVue HSV1+2 assay; Quidel Molecular, San Diego, CA) on 91/99 specimens that were recorded as false positive (FP) or false negative (FN) compared to the reference method. In total, 57/78 (73%) FP and 9/13 (69%) FN illumigene results were supported by the AmpliVue result. The illumigene HSV 1&2 assay demonstrated high sensitivity and specificity to detect and differentiate HSV in clinical specimens and identified 57 additional specimens that were positive for HSV compared to culture. The use of LAMP eliminates the need for the cycling of temperatures and provides results in less than 60 min, with approximately 2 min of hands-on time per specimen.

Chancroid, lymphogranuloma venereum, granuloma inguinale, genital herpes simplex infection, and molluscum contagiosum

Chancroid, lymphogranuloma venereum, and granuloma inguinale may be considered as tropical venereal diseases. These diseases were a major diagnostic and therapeutic challenge in past centuries. Currently, patients with these bacterial infections that are endemic to the tropics occasionally consult with dermatologists in temperate climates. Due to the increasing frequency of travel to the tropics for tourism and work, as well as the increasing number of immigrants from these areas, it is important for dermatologists practicing in temperate climates to be familiar with the dermatologic manifestations of such infections, to be prepared to diagnose these diseases, and to treat these patients. All three "tropical" infections respond well to prompt and appropriate antimicrobial treatment, although herpes progenitalis still cannot be cured, and the number of people infected keeps growing; moreover, genital herpes can be transmitted by viral shedding before and after the visual signs or symptoms. Acyclovir, valacyclovir, and famciclovir can shorten outbreaks and make them less severe or even stop them from happening. There is currently no etiologic treatment for molluscum contagiosum, and the majority of treatment options are mechanical, causing a certain degree of discomfort. The molluscum contagiosum virus, unlike the other infectious agents mentioned, does not invade the skin.

Clinical practice in prevention of neonatal HSV infection: a survey of obstetrical care providers in Alberta

OBJECTIVE

To identify the current practice patterns of physicians providing prenatal care in Alberta with respect to prevention of neonatal herpes simplex virus (HSV) infection.

METHOD

A 22-item questionnaire was mailed to all obstetricians and family physicians providing obstetrical care in Alberta. The questionnaire included demographic and practice details, and details of management of patients with a history or symptoms of HSV lesions, including practice in prescribing antiviral therapy, recommending elective Caesarean section, and ordering serology. Two reminders were mailed as necessary.

RESULTS

Responses were received from 89 obstetricians (57%) and 94 family physicians (54%). Antiviral therapy was prescribed for the prevention of neonatal HSV infection in the third trimester by 97% of obstetricians versus 84% of family physicians (P = 0.007), with acyclovir being the most commonly prescribed agent. Caesarean section was offered "most of the time" to women with primary HSV infection in the third trimester by 65% of physicians, to women with prodromal symptoms during the intrapartum period by 57% (no significant differences between groups), and to women with HSV lesions by 92% of obstetricians and 82% of family physicians (P = 0.032). Women with a negative HSV history but whose partner had known HSV were offered serological testing "most of the time" by 30% of physicians (no significant difference between groups).

CONCLUSION

Despite the encouraging survey results, obstetrical providers should be encouraged to offer Caesarean section to women with a primary HSV infection in the third trimester and to offer serological testing in discordant couples. These simple strategies can help to prevent neonatal HSV infection and its long-term consequences.

Evaluation of the HerpeSelect Express rapid test in the detection of herpes simplex virus type 2 antibodies in patients with genital ulcer disease

BACKGROUND

A rapid point-of-care test with high sensitivity and specificity is required in order to fulfill the need for early detection and screening of Herpes simplex virus type 2 (HSV-2) infection among patients with genital ulcer disease (GUD), for better management and control of virus transmission.

METHODS

The goal of this study is to evaluate the performance of the commercially available HerpeSelect Express rapid test in comparison with three ELISA assays: HerpeSelect ELISA, Kalon HSV-2 glycoprotein G2 assay, and monoclonal antibody blocking enzyme immunoassay, which was used as the gold standard for the detection of HSV-2 antibodies.

RESULTS

This study showed high sensitivity (ranging from 82.6 to 100%) and specificity (100%) of the HerpeSelect Express rapid test when compared to the three ELISA assays. The agreement between the HerpeSelect Express rapid test with the three ELISAs ranged from 93.3 to 100%.

CONCLUSION

The HerpeSelect Express rapid test has adequate sensitivity and specificity for confirming HSV-2 infection in patients with GUD, indicating its suitability for epidemiological studies.

Light microscopy, culture, molecular, and serologic methods for detection of herpes simplex virus

Herpes simplex virus 1 (HSV-1) and 2 (HSV-2) cause a variety of human diseases, ranging from acute to chronic and mild to severe. The absence of curative therapy results in lifelong carriage marked by recurrent outbreaks and allows transmission of the virus to uninfected individuals. Nonspecific lesions, variable presentation, and chronic carriage necessitate the use of different laboratory testing methods appropriate for each presentation. A thorough understanding of the performance characteristics and limitations of available tests is critical for selection of the appropriate test and interpretation of results. Clinical sensitivity, specificity, and selection of the appropriate methodology is paramount to avoid misdiagnosis and guide therapy. In this article we review the different methods for detection and typing of HSV, including light microscopy, culture, serology, and nucleic acid-based tests. We discuss the strengths and weaknesses of each method for diagnosing HSV infection, cite performance characteristics, and review appropriate clinical uses.

A miniaturized and integrated gel post platform for multiparameter PCR detection of herpes simplex viruses from raw genital swabs

Herpes simplex virus (HSV) is one of the most prevalent viruses, with acute and recurrent infections in humans. The current gold standard for the diagnosis of HSV is viral culture which takes 2-14 days and has low sensitivity. In contrast, DNA amplification by polymerase chain reaction (PCR) can be performed within 1-2 h. We here describe a multiparameter PCR assay to simultaneously detect HSV-1 and HSV-2 DNA templates, together with integrated positive and negative controls, with product detection by melting curve analysis (MCA), in an array of semi-solid polyacrylamide gel posts. Each gel post is 0.67 μL in volume, and polymerized with all the components required for PCR. Both PCR and MCA can currently be performed in one hour and 20 min. Unprocessed genital swabs collected in universal transport medium were directly added to the reagents before or after polymerization, diffusing from atop the gel posts. The gel post platform detects HSV templates in as little as 2.5 nL of raw sample. In this study, 45 genital swab specimens were tested blindly as a preliminary validation of this platform. The concordance of PCR on gel posts with conventional PCR was 91%. The primer sequestration method introduced here (wherein different primers are placed in different sets of posts) enables the simultaneous detection of multiple pathogens for the same sample, together with positive and negative controls, on a single chip. This platform accepts unprocessed samples and is readily adaptable to detection of multiple different pathogens or biomarkers for point-of-care diagnostics.

Seroprevalence and risk factors for herpes simplex virus infection in a population of HIV-infected patients in Canada

OBJECTIVE

To determine the seroprevalence of herpes simplex virus infection in a population of HIV-infected individuals in Canada.

METHODS

HIV-infected patients attending 5 infectious disease clinics for follow-up care were approached to participate in the study. After informed consent was obtained, subjects completed a questionnaire documenting HIV-risk behavior, duration of infection, history of oral and/or genital herpes, and treatment for HIV and/or genital herpes. Blood for HSV type-specific serology was drawn and tested by enzyme-linked immunosorbent assay (Focus Diagnostics HerpeSelect HSV-1, HSV-2 enzyme-linked immunosorbent assay IgG). Equivocal samples were repeated and any discrepant results were resolved with Western blot.

RESULTS

Six hundred twenty-nine HIV-infected individuals participated. The mean age was 43.9 years, 74.7% were Canadian born and 72.3% were men. The majority of foreign-born subjects were black (endemic) and women. The seroprevalence of HSV-1 and HSV-2 was 78.1% and 54.6%, respectively. Women were 2.7 times more likely to be HSV-2 seropositive, non-Canadian-born participants were 2.0 times more likely to be HSV-2 seropositive, and nonwhite subjects were 3.2 times more likely to be seropositive. Men who had sex with other men had the lowest seroprevalence of HSV-2. Only 30.3% of HSV-2 positive subjects reported a history of genital herpes.

CONCLUSIONS

A significant proportion of HIV-infected subjects attending 5 infectious disease clinics in Canada are coinfected with HSV. Routine type-specific HSV-2 testing should be introduced to direct education regarding symptoms, signs, and transmission reduction of genital herpes and perhaps ultimately HIV-1. Knowledge of HSV serostatus would also provide an opportunity to consider antiviral therapy.

Using centralized laboratory data to monitor trends in herpes simplex virus type 1 and 2 infection in British Columbia and the changing etiology of genital herpes

OBJECTIVES

Understanding the regional epidemiology of genital Herpes Simplex Virus (HSV) infections is important for clinical and public health practice, due to the increasing availability of type-specific serologic testing in Canada and the contribution of genital HSV-2 infection to ongoing HIV transmission. We used centralized laboratory data to describe trends in viral identifications of genital HSV in BC and assess the utility of these data for ongoing population surveillance.

METHODS

Records of viral identifications (1997-2005) were extracted from the Provincial Public Health Microbiology & Reference Laboratory database. Classification as genital or other site was based on documented specimen site. We conducted a descriptive analysis of trends over time, and calculated odds of HSV-1 infection among individuals with genital herpes.

RESULTS

Of 48,183 viral identifications, 56.8% were genital, 10.0% were peri-oral and 9.1% cutaneous; site was unknown for 22.9%. Among genital identifications, HSV-1 infection was more likely in females, younger age groups, and later time periods. The proportion of genital herpes due to HSV-1 increased over time from 31.4% to 42.8% in BC.

CONCLUSIONS

Our analysis of population-level laboratory data demonstrates that the proportion of genital herpes due to HSV-1 is increasing over time in BC, particularly among women and younger age groups; this has implications for clinical practice including the interpretation of type-specific serology. Provincial viral identification data are useful for monitoring the distribution of genital HSV-1 and HSV-2 infections over time. Improving clinical documentation of specimen site would improve the utility of these data.

The diagnosis of genital herpes - beyond culture: An evidence-based guide for the utilization of polymerase chain reaction and herpes simplex virus type-specific serology

Accurate identification of persons with genital herpes is necessary for optimal patient management and prevention of transmission. Because of inherent inaccuracies, clinical diagnosis of genital herpes should be confirmed by laboratory testing for the causative agents herpes simplex virus type 1 (HSV-1) and HSV type 2 (HSV-2). Further identification of the HSV type is valuable for counselling on the natural history of infection and risk of transmission. Laboratory methods include antigen detection, culture, polymerase chain reaction (PCR) and conventional and type-specific serology (TSS). PCR has, by far, the greater sensitivity and should be the test of choice for symptomatic cases. HSV-2 TSS is indicated for patients with genital lesions in whom antigen detection, culture or PCR fail to detect HSV, and for patients who are asymptomatic but have a history suggestive of genital herpes. HSV-2 TSS is further indicated for patients infected with HIV. HSV-2 TSS along with HSV-1 TSS may be considered, as appropriate, in evaluating infection and/or immune status in couples discordant for genital herpes, women who develop their first clinical episode of genital herpes during pregnancy, asymptomatic pregnant women whose partners have a history of genital herpes or HIV infection, and women contemplating pregnancy or considering sexual partnership with those with a history of genital herpes. The above should be performed in conjunction with counselling of infected persons and their sex partners.

Evaluation of a novel serology algorithm to detect herpes simplex virus 1 or 2 antibodies

BACKGROUND

Herpes simplex virus (HSV)-type specific serology (TSS) testing has been commercially available for nearly a decade. Guidelines on appropriate use of such testing exist, including Canadian-based recommendations. Despite this, most Canadian laboratories do not offer HSV-type specific serology and many provide only nontype-specific HSV serology tests.

METHODS

At the Alberta Provincial Laboratory, HSV TSS is performed using the following algorithm (termed the Alberta algorithm). Eligible specimens are first tested with a nontype-specific kit (Behring Enzygnost IgG). If positive, sera are then tested using the Focus HerpeSelect-2 assay to establish HSV-2 infection. If the HerpeSelect-2 result is negative, the result is reported as anti-HSV-1 positive. In this study we sought a validation of the Alberta algorithm by testing 344 serum samples with the Behring Enzygnost IgG assay, the type specific Focus HerpeSelect 1 and 2 assays, and by Western blot (WB).

RESULTS

Taking the WB as a gold standard, the Behring Enzygnost IgG assay showed a sensitivity of 94% and a specificity of 100%, whereas the Alberta algorithm had a sensitivity of 92% and a specificity of 97% for the detection of HSV-2 antibodies, and a sensitivity of 94% and a specificity of 100% for the detection of HSV-1 antibodies in HSV-2 negative sera. Focus HerpeSelect 1 and HerpeSelect 2 sensitivities against WB were 88% and 91%, whereas specificities were 95% and 97% for HSV-1 and HSV-2, respectively.

CONCLUSIONS

The Alberta algorithm was at least equivalent to HerpeSelect 1 and 2 in detecting anti-HSV antibodies. Although sensitivity and specificity were higher, the differences were not statistically significant.