DRG Category: 606
Mean LOS: 5.9 days
Description: Medical: Minor Skin Disorders With Major Complication or Comorbidity
There are two types of herpes simplex virus (HSV): type 1 and type 2. HSV-1 causes infection above the waist, such as “cold sores” that occur on the mouth. This type may occur in the genital area as a result of oral-genital sexual practices. After the initial infection, the virus is dormant, but the patient is a carrier and likely to have recurrent infections. Events that trigger recurrences are sun exposure, fever, menses, stress, and lack of sleep. The virus is inactivated at room temperature, and humans are the only carriers.
HSV-2 causes lesions in the genital area and is a common sexually transmitted infection (STI). In the primary episode, multiple blisterlike, painful vesicles erupt on the vulva, perineum, cervix, tip or shaft of the penis, or perianal area within 3 to 5 days after the initial exposure. The virus then becomes dormant and resides in the nerve ganglia of the affected area. Repeated outbreaks can happen at any time, but most patients have less severe regular recurrences that are more likely to occur during menses, pregnancy, or times of illness and stress. The more severe the primary outbreak, the more frequent the recurring infections. The Centers for Disease Control and Prevention estimates that one in six people in the United States ages 14 to 19 years have HSV-2 genital infection.
HSV-2 is associated with significant complications. Active HSV is associated with spontaneous abortion in the first trimester of pregnancy and an increased risk of preterm labor after 20 weeks' gestation. If a patient has active herpes around the time of the estimated date of delivery, cesarean section is the preferred method of delivery. Infected infants can develop the following signs and symptoms after an incubation period of 2 to 12 days: fever, hypothermia, jaundice, seizures, poor feeding, and vesicular skin lesions. When people have HSV-2 lesions, studies have shown that they are at risk for infection with HIV. Experts suggest that this risk occurs because the T cells that are part of the body's reaction to HSV-2 create an environment conducive to HIV proliferation. As a result, scientists note that HIV replicates three to five times faster in tissues that have healed from an HSV-2 infection as compared to normal tissue.
HSV infection occurs through attachment by receptors to human cells after close personal contact with an infected person, usually through a mucosal surface such as the oropharynx, cervix, or conjunctiva or through contact with cracks in the skin. The virus also attaches to sensory neurons, leading to latency (the infection can reappear during times of physiological stress). HSV-1 is particularly attracted to the oral mucosa, and HSV-2 is particularly attracted to the genital epithelium. Pregnant women can transmit the herpes virus to the fetus, especially during a primary outbreak. Transmission can occur when the membranes rupture or during a vaginal delivery, but transplacental transmission is extremely rare. Asymptomatic transmission is very uncommon.
Heritable immune responses could be protective or increase susceptibility.
HSV-1 is usually acquired during childhood when children come in contact with oral secretions of others with the infection. By age 30 years in the United States, 50% of people with higher socioeconomic status are seropositive for HSV-1, and 80% of people with lower socioeconomic status are positive. HSV-2 affects one in five men and one in four women. Because teenagers are engaging in sexual activity earlier than ever before, they have a higher risk today than in the past of contracting HSV-2; the number of adolescents with HSV-2 is therefore increasing. Because there is no cure for herpes, recurrent outbreaks of HSV occur over a lifetime.
HSV-2 is more prevalent in Black persons (seroprevalence of 45%) and Hispanic persons (seroprevalence of 22%) than in White persons (seroprevalence of 17%). Men who have sex with men are at higher risk for infection with HSV, with infections of both the oropharynx and genito-anal tract, than men who do not have sex with men.
HSV is present around the globe, and the global prevalence of HSV infections is increasing with more than 23 million new cases a year. Just as in the United States, around the globe there are increasing numbers of people who are seropositive for HSV-2.
PLANNING AND IMPLEMENTATION
Collaborative
Because HSV is not curable, treatment focuses on relieving the symptoms. The drug of choice to treat a primary infection of HSV-1 or HSV-2 is acyclovir.
| Medication or Drug Class | Dosage | Description | Rationale |
|---|
| Antiviral | Depends on the drug and whether the outbreak is primary or recurrent | Penciclovir (Denavir); acyclovir (Zovirax); valacyclovir (Valtrex); famciclovir (Famvir) | Relieves symptoms, decreases viral shedding (acyclovir is contraindicated during pregnancy); daily dosage for primary episodes is slightly lower than for recurrent infections; some physicians may order chronic suppressive drug therapy, where acyclovir is taken for up to 6 mo |
Other Drugs: Antipyretics, analgesics, viscous lidocaine
Independent
Instruct the patient to take all medication ordered, even if symptoms recede before the medication is used up. For comfort during the outbreak, patients may take prescribed analgesics or use warm soaks with Epsom salts or sitz baths. Lesions can be cleaned with Betadine. Encourage patients to wear loose clothing and cotton underwear and to avoid ointments that contain cortisone and petroleum because they slow healing and promote the growth of the virus. Encourage exercise, good nutrition, and stress reduction to decrease the number of recurrent outbreaks (Box 1).
Inform patients that for persons with HSV-2, the risk of acquiring HIV is likely more than double than for persons without HSV-2. Help patients understand that this is a minor problem with which they will be inconvenienced from time to time. Adherence to strict guidelines when active lesions are present allows patients to have normal sexual relationships. Healthcare workers with active herpes are prohibited from working with immunosuppressed patients or in a nursery setting because of the complications that result in the neonate if HSV transmission occurs.
Evidence-Based Practice and Health Policy
Marcocci, M., Napoletani, G., Protto, V., Kolesova, O., Piacentini, R., Donatella, D., Lomonte, P., Grassi, C., Palamara, A., & De Chiara, G. (2020). Herpes simplex virus-1 in the brain: The dark side of a sneaky infection. Trends in Microbiology, 28, 808–820.
- After infection, HSV-1 remains alive but resting in sensory nerves, but a variety of stresses can induce reactivation of the virus, which spreads and replicates to the site of primary infection (usually the lips or eyes). Viral particles can also reach the brain, causing herpes simplex encephalitis. This infection is usually clinically asymptomatic but has recently been correlated with the production of biomarkers of Alzheimer disease.
- The authors highlight three issues that need to be studied: (1) identification of the biomarkers in people with recurrent infections; (2) understanding of the virus- and host-related factors determining the frequency and extent of virus spread to the brain; (3) identification of strategies to limit virus reactivation and diffusion to the brain; and (4) evaluation of their potential to prevent neurodegenerative damage.