Herpes simplex labialis after epidural or parenteral morphine: a randomized prospective trial in an Australian obstetric population

Pruritus, neuraxial morphine and recrudescence of oral herpes simplex and treatment: an educational review in obstetric patients

Neuraxial opioids are well known to cause itching, which may be challenging to treat. Neuraxial morphine has been demonstrated to cause recrudescent herpes simplex viruses (HSV-1), especially in women during labor and childbirth with neuraxial analgesia, and may be an occult etiology of refractory itching. This educational review summaries the clinical and epidemiological characteristics associated with recrudescent HSV-1 in patients treated with neuraxial opioids, especially morphine.

Possible Neonatal Herpes Simplex Virus (HSV) Acquired Postpartum from Maternal Oral HSV Reactivation after Neuraxial Morphine

In this report, we describe a case of a neonatal oral herpes simplex virus (HSV) infection possibly acquired from a mother who had oral HSV reactivation in association with neuraxial morphine. Neuraxial morphine is commonly administered for postpartum analgesia after cesarean delivery. While there is evidence that neuraxial morphine increases the risks of oral HSV reactivation in parturients, there has been no report of neonatal HSV infection directly acquired from a mother who had HSV recurrence from neuraxial morphine.

Management of HSV-1 encephalitis due to reactivation of HSV-1 during late pregnancy

A previously healthy 31-year-old G4P2 woman at 33 weeks of gestation was admitted as an emergency with a pyrexia of 39°C, vomiting, headache and neck stiffness associated with photophobia, phonophobia and visual and auditory symptoms. There were no heraldic signs of eclampsia. Polymerase chain reaction and testing for herpes simplex virus in the cerebrospinal fluid diagnosed herpes simplex-1 meningoencephalitis. Following acyclovir, the clinical course improved. Spontaneous vaginal delivery occurred at 39 weeks of gestation with epidural analgesia using ropivacaine. Mother and child were neurologically normal and healthy 15 months later. Early administration of acyclovir is essential to reduce the risk of neurological complications. After treatment and a negative polymerase chain reaction for herpes simplex virus in the cerebrospinal fluid, epidural analgesia with local anesthetic and sufentanil is possible.

Focused review: neuraxial morphine and oral herpes reactivation in the obstetric population

Neuraxial morphine administration is a common strategy for providing postcesarean delivery analgesia. Morphine delivered via this route increases the risk of herpes labialis (oral herpes) reactivation, a disease common in women of childbearing age. A primary concern is risk of transmission to the neonate from maternal reactivation. The benefits to the mother of this form of analgesia outweigh the risk of neonatal herpes acquired postpartum from maternal recurrence because serious neonatal morbidity from recurrent herpes has not been described.

DNA vaccine-encoded glycoprotein B of HSV-1 fails to protect chronic morphine-treated mice against HSV-1 challenge

The use of morphine has been demonstrated to increase susceptibility to infections. Herpes simplex virus type 1 (HSV-1) is a highly successful pathogen among immunocompromised individuals. In the present study, due to the importance of HSV vaccination in morphine abusers, the effects of chronic morphine exposure on the host response to a HSV-1 gB DNA-based vaccine have been investigated. The study is addressing an important aspect of vaccine development among the susceptible (immunocompromised) hosts. BALB/c mice were exposed to morphine over 11 days. They were then vaccinated with DNA vaccine or KOS strain as a live vaccine. The findings showed that the morphine-treated animals failed to respond to DNA vaccination evaluated by the anti-HSV gB antibody titer, delayed type hypersensitivity (DTH) and lethal HSV-1 challenge. Under the same conditions, the KOS vaccine showed a reduced Ab titer and DTH response in morphine-treated mice, but could protect mice against the lethal challenge and was safe for vaccination of morphine-treated animals.

Oral herpes simplex reactivation after intrathecal morphine: a prospective randomized trial in an obstetric population

There is now evidence for an association between the use of epidural morphine and reactivation of herpes simplex labialis (HSL). There are no studies that definitively demonstrate the relationship between HSL reactivation and spinal intrathecal morphine. To investigate this relationship, we randomized and prospectively studied 100 obstetric patients with a history of HSL undergoing cesarean delivery under spinal anesthesia. One group received intrathecal morphine plus IV morphine via patient-controlled analgesia (ITM+PCA group) for postoperative analgesia, and a second group received only IV morphine via patient-controlled analgesia for postoperative analgesia (PCA-only group). Patients were followed for a 30-day period. In the ITM+PCA group 19 (38%) patients had HSL reactivation whereas eight (16.6%) had HSL reactivation in the morphine PCA-only group (P = 0.028). The incidence of pruritus in the ITM+PCA group was also more frequent in the early postoperative period. Our data show HSL reactivation in both the ITM+PCA group and PCA-only morphine group, with a more frequent incidence in the ITM+PCA group.

Intrathecal opioids for combined spinal-epidural analgesia during labour

In <25 years, intrathecal administration of opioids (i.e. spinal analgesia) has evolved from an experimental model into an important therapy for obstetric analgesia and anaesthesia. A small dose of opioid delivered into the CSF provides almost immediate relief from labour pain with minimal risks to the mother and fetus. Careful attention, and prompt treatment when needed, can ameliorate the adverse effects of fetal bradycardia, respiratory depression and pruritus. The major limitation of intrathecal opioids for labour analgesia is the short duration of effect: 90-180 minutes under ideal circumstances. To address this problem, and to increase flexibility for anaesthesia as well as analgesia, the combined spinal-epidural (CSE) technique was developed. The CSE technique involves injection of drugs into the CSF and placement of an epidural catheter. An intrathecally administered opioid provides a rapid onset of labour analgesia without motor block or significant haemodynamic perturbation. The epidural catheter allows ongoing administration of medications to maintain labour analgesia and provides a means of delivering anaesthesia for operative delivery. This review will focus on intrathecally administered opioids as used as part of CSE analgesia. Considerable research has focused on the optimum dose of opioids when delivered intrathecally, with or without adjuncts, in the CSE technique. Fentanyl and sufentanil, two of the lipophilic synthetic opioids, have emerged as the most useful. Bupivacaine, a long-acting local anaesthetic, is often added to prolong the duration of analgesia, although this tends to increase the likelihood of motor blockade of the lower extremities. Comparisons of the CSE technique with standard epidural practices have shown that both are effective means of providing analgesia during labour. Controversy revolves around the incidence of fetal bradycardia following CSE and whether this phenomenon increases the rate of operative deliveries. The rapid onset of analgesia with intrathecally administered opioids must be balanced against the added risks of dural puncture and considered in the context of the whole duration of labour. Ultimately, the decision to choose a CSE technique depends on the experience of the anaesthesia provider and the local availability of drugs, equipment and monitoring capabilities.

Anesthetic management of the parturient with fever and infection

Fever is a common clinical problem in labor and delivery suites. It can result from a variety of infectious microorganisms, tissue trauma, malignancy, drug administration, and endocrine and immunologic disorders. Infection is the most common cause of fever, reflecting the effect of pyrogens on the hypothalamus. The diagnosis of infection in pregnancy often raises questions about the safety of regional anesthesia in febrile patients. Despite this concern, and lack of universal guidelines, it has now been well established that the presence of infection and fever in labor does not always contraindicate the administration of regional anesthesia.

Herpesviruses: emerging nosocomial pathogens?

BACKGROUND

Herpesviruses are ubiquitous pathogens that are known to cause infection in humans and animals. It is likely that more than 90% of adults have been infected by one or more herpesviruses. As hospitalized patients become increasingly immunosuppressed by virtue of illness or therapies, it is increasingly likely that human herpesvirus infection will become manifest in the hospital. Whether these manifestations represent manifestations of reactivated latent disease or true nosocomial infections is an open question.

METHODS

Review of the pertinent English-language literature.

RESULTS

There are eight known herpesviruses that cause disease in humans. Herpesviruses are double-stranded DNA viruses. The prototypical structure consists of an inner DNA core that is encased within a nucleocapsid that is icosahedral in configuration and consists of capsomere subunits. Herpesvirus infection generally occurs when virus is transmitted in oral secretions from an infected to a naive host. Clinical reactivation syndromes can occur in transplant patients, cancer chemotherapy patients, and patients with acquired immunodeficiency syndrome. Life-threatening infections are most closely associated with human herpesvirus-5 (cytomegalovirus), whereas the relationships between human herpesvirus-7 and clinical disease are largely undefined.

CONCLUSION

Clinical expressions of herpesvirus in surgical patients are not nosocomial infections, but are in the vast majority of cases the reactivation of latent infection. Reactivation disease can be lethal to the immunosuppressed host.

Recrudescent herpes labialis during and prior to early pregnancy

OBJECTIVES

To assess the experience of recrudescent herpes labialis (RHL) before and during early pregnancy.

METHODS

History of RHL prior to and during the first trimester of pregnancy was obtained from 3738 women attending at 10-15 weeks' gestation. The influence of age, ethnicity, socioeconomic group, smoking behavior, and alcohol intake on RHL was assessed.

RESULTS

1066 women (28.5%) reported a history of RHL lesions, with reduced incidence of RHL during pregnancy (0.111 lesions/subject per month) compared with outside pregnancy (0.19 lesions/subject per month) (P<0.0001). Those who did report lesions during pregnancy (n=296) experienced them at a higher monthly rate (0.41 lesions/subject per month) than before pregnancy (0.25 lesions/subject per month) (P<0.0001). RHL rate in early pregnancy was related solely to the previous rate of lesion recrudescence (P<0.001).

CONCLUSION

Pregnant women with a history of RHL report reduced incidence of RHL during pregnancy.

Treatment of mucocutaneous presentations of herpes simplex virus infections

Infections by herpes simplex virus (HSV) types I and II are diverse and quite frequent. After primary infection, the virus establishes a life-long latency in the sensory ganglia and recrudescences may occur at an unpredictable rate. Recurrent labial and genital herpes infections represent the majority of clinical manifestations of HSV infections. Their management is currently well established using evidence-based medicine data. Primary labial herpes is generally not treated with antivirals in otherwise healthy children, although intravenous aciclovir may be offered in severe primary infections, particularly in the immunocompromised patient. The decision whether or not to treat recurrent labial herpes should be evaluated individually and depends on the frequency and severity of relapses, the impairment of the quality of life, and the cost of therapy. Patients with mild disease may benefit from topical therapy, and those with severe and frequent recurrences may be considered for intermittent or long-term oral antiviral therapy. Primary genital herpes is treated with oral or intravenous antivirals, depending on the severity of the infection and associated symptoms. Recurrent genital herpes can be managed with episodic short courses of oral antivirals in patients whose recurrences are moderate to severe and rare, and have a clear prodrome. Patients with >5 episodes/year, severe recurrences or unrecognisable prodromes may be best managed with long-term suppressive antiviral prophylaxis. HSV is also responsible for a variety of other clinical manifestations, including herpetic whitlow, neonatal infection, disseminated and atypical cutaneous infections, traumatic herpes, eczema herpeticum, and HSV-associated erythema multiforme. HSV infection may also represent a complication following cosmetic procedures of the oro-facial region, surgical and dental interventions, sun exposure and burns. Precise treatment guidelines for these HSV infections are not firmly established.

The implications of HIV for the anaesthetist and the intensivist

The acquired immune deficiency syndrome has reached pandemic proportions. Anaesthetists should be aware of the implications of dealing with increasing numbers of both diagnosed and undiagnosed, symptomatic and asymptomatic, human immunodeficiency virus-infected patients in the fields of intensive therapy, operating theatre anaesthesia, obstetrics and pain management. With recent advances, important insights have been gained into the pathogenesis of human immunodeficiency virus. Molecular techniques allow quantification of viral burden, and together with CD4 T-lymphocyte count, prognosis and response to therapy can be evaluated. New drugs and therapeutic regimens have improved prognosis for those who are infected with the virus and vertical transmission of infection from mother to infant can be minimised. Should accidental occupational exposure to the virus occur, a prophylactic regimen of antiretroviral drugs can be administered in an attempt to prevent subsequent human immunodeficiency virus infection.

Opiates and infection

This review on the effects of opiate use on infectious diseases discusses the complete spectrum of infections in the opiate user, including those of the lung, the GI tract, the skin, the skeletal system, and the CNS. There is both increased prevalence and increased severity of bacterial and viral infections in injection drug users with the outcome of increased morbidity and mortality. The experimental administration of opiates has lead to a greater understanding of the effects on susceptibility to and progression of infectious diseases. Animal models of opiate dependence and infection are reviewed with specific attention to cases in which the opiate-mediated effects are harmful and in which cases they are beneficial.

A review of anatomical and immunological links between epidural morphine and herpes simplex labialis in obstetric patients

The anatomical basis for facial itch after epidural morphone is outlined. CNS nuclear events which reactivate latent herpes simplex and immune inhibition resulting in maternal mouth vesicles or neonatal infections are described. Morphine is hypothesized to affect these processes and facial itch is only a marker, not a trigger of this trigeminal opioid activity.