HERPES SIMPLEX

GENITALIS
 The Herpesvirus Family
Alphaherpesviruses
• Herpes simplex virus type 1 (HSV-1) - causes sores around the mouth and lips
• Herpes simplex virus type 2 (HSV-2) - main cause of genital herpes
• Varicella-zoster virus (VZV)- causes chickenpox and herpes zoster (shingles)

Betaherpesviruses
• Cytomegalovirus (CMV)
• Human herpesvirus 6 (HHV-6)
• Human herpesvirus 7 (HHV-7)

Gammaherpesviruses
• Epstein-Barr virus (EBV)
• Human herpesvirus 8 (HHV-8)
 Herpes Simplex Virus 1 and 2
• HSV-2
- Almost entirely genital; oral infections rare
- >95 % of recurrent genital herpes
- More frequent asymptomatic shedding than HSV-1
- Very low, if any, risk of HSV-1 acquisition
• HSV-1
- Mostly orolabial (cold sores, fever blisters)
- Increasing proportion of cases of primary genital herpes,
especially in younger sexually active patients
- Shorter initial and recurrent outbreaks than HSV-2
- Infrequent recurrences and asymptomatic shedding
- Continued risk for HSV-2 acquisition
 Reservoir and mode of transmission
• Reservoir:
Infected Humans

• Mode of transmission: (during presence of lesions)

Direct sexual contact
oral – genital
oral – anal
anal - genital
(During pregnancy and birth)
Mother – to – fetus
Mother – to - neonate
 Characteristics
• In general, herpex simplex infections are characterized by a
localized primary lesion, latency, and a tendency to localized
recurrence.
• Principal sites:
women – cervix and vulva
*** with recurrent disease affecting the vulva, perineal skin,
legs and buttocks.
men – penis, anus and rectum
• Symptoms:
• tingling, itching, sorenes
• Small patch of redness and then a group of small painful blisters
 Laboratory diagnosis
• Genital herpes is diagnosed by observation of characteristic
cytologic changes in tissue scrapings or biopsy specimens, and the
presence of multinucleated cells with intranuclear inclusions, and
confirmation by immunodiagnostic and molecular diagnostic
procedures.
 Patient Care
• Use Standard Precautions for hospitalized patients; add Contact
Precautions for severe disseminated or primary mucocutaneous
herpes.

• ***mucocutaneous herpes - lesions may appear anywhere on the

skin or mucosa
• Treatment:
• First episode treatment:
• Acyclovir 400 mg three times a day for 7-10 days
− Valacyclovir (Valtrex) 1000 mg twice a day for 7-10 days
− Famciclovir (Famvir) 250 mg three times a day for 7-10 days
GONORRHOEA
• Gonorrhea (Greek, “flow of seed”) is attributed to Galen (130 A.D.),
who is said to have believed that urethral exudate in males with
gonorrhea was semen.
• In 1879, Neisseria gonorrhoeae was demonstrated by Neisser in
stained smears of urethral, vaginal, and conjunctival exudates,
making gonococcus 2nd identified bacterial pathogen following
discovery of Bacillus anthracis.
• First cultured in vitro by Leistikow in 1882
• Effective antimicrobial therapy in form of sulfonamides was first
applied in 1930s.
 N. Gonorrhoeae
• gram negative
• nonmotile
• non-spore forming diplococci
Steps in pathogenesis
• 1. Adherence :- initial event , N. gonorrhoeae adhere to mucosal
cells , mediated by pili, Opa, and other surface proteins.
• 2. Invasion :-Organism is then pinocytosed by epithelial cells, which
transport gonococci from mucosal surface to subepithelial spaces.
• 3. Tissue damage :-Progressive mucosal cell damage and
submucosal invasion are accompanied by a vigorous neutrophil
response, submucosal microabscess formation, and exudation of
purulent material into lumen of the infected organ.
• 4. Dissemination:- ability to resist the killing activity of antibodies
and complement in normal human serum is closely related to the
ability of gonococci to cause bacteremic illness with or without
septic arthritis
URETHRAL INFECTION IN MEN
• Acute anterior urethritis is most common in men.
• incubation period ranges from 1 to 14 days or even longer;
however, majority of men develop symptoms within 2–5 days, as
was the case in 36 (82%) of 44 men with uncomplicated gonorrhea
in one of few studies in which time of exposure could be clearly
defined.
• Predominant symptoms are urethral discharge or dysuria
• initially scant and mucoid or mucopurulent in appearance, in most
males urethral exudate becomes frankly purulent and relatively
profuse within 24 hours of onset.
• Dysuria usually begins after onset of discharge
UROGENITAL INFECTION IN WOMEN
• Primary site:- endocervical canal
• Urethral colonization :- 70–90% of infected women, but is
uncommon in absence of endocervical infection.
• Infection of Bartholin’s gland ducts is also common.
• Most common symptoms are those of most lower genital tract
infections in women: increased vaginal discharge, dysuria,
intermenstrual uterine bleeding, and menorrhagia.
RECTAL INFECTION
• Rectal mucosa is infected in 35–50% of women with gonococcal
cervicitis. Only rectum is involved in 5% women.
• 40% in homosexual men.
• Symptoms range from minimal anal pruritus, painless mucopurulent
discharge (often manifested only by a coating of stools with
exudate), or scant rectal bleeding, to symptoms of overt proctitis,
including severe rectal pain, tenesmus, and constipation.
PHARYNGEAL INFECTION
• 3–7% of heterosexual men, 10–20% of heterosexual women, and 10–
25% of homosexually active men.
• acute pharyngitis or tonsillitis and occasionally is associated with
fever or cervical lymphadenopathy.
• >90% are asymptomatic
INFECTION OF OTHER SITES
• Gonococcal conjunctivitis is rare.
• Primary cutaneous infection i.e. localized ulcer of genitals,
perineum, proximal lower extremities, or finger is rare.
 TREATMENT
Uncomplicated Gonococcal
infection of cervix, urethra and
rectum
• Single dose of Tab. cefixime
400mg, Inj. Ceftriaxone 125 mg
IM, tab. Ciprofloxacin 500mg,
tab. Ofloxacin 400mg, or tab.
Levofloxacin 250mg
PLUS
• If chlamydial infection is not
ruled out- tab. Azithromycin 1 g
single dose or tab. Doxycyclin
100mg BID x 7days.
Uncomplicated Gonococcal
infection of pharynx
• Single dose of Inj. Ceftriaxone
125 mg IM, or tab. Ciprofloxacin
500mg
PLUS
• If chlamydial infection is not
ruled out- tab. Azithromycin 1 g
single dose or tab. Doxycyclin
100mg BID x 7days
HEPATITIS B
Prototype member of the Hepadnaviridae family

DNA virus

Outer lipoprotein envelope with 3 glycoproteins – Hep B surface antigens (HBsAg)

Viral nucleocapsid protein - Hep B core antigen (HBcAg)

Soluble nucleocapsid protein-Hepatitis B e antigen (HBeAg)

 Primary Infection
Incubation Period 4-10 weeks

During the prodromal period, patient may have a serum sickness-like syndrome.

Constitutional symptoms, anorexia, nausea, RUQ discomfort and jaundice.

30 % develop icteric hepatitis.

70% develop anicteric or subclinical hepatitis

.
0.5-1% develop fulminant liver failure.

Symptoms and jaundice disappear in 1-3 months, though fatigue may persist.
 Infection in Children vs. Adults
Children
In neonates, the immature immune system does not recognize a difference between the virus
and the host.
Cellular immune responses to hepatocyte-membrane HBV proteins do not occur.
Risk of developing chronic HBV infection is 90% in infants born to HBeAg positive mothers.
In children under 5, risk is 25-30%.

Adults:
Tend to have a more vigorous immune response.
Less than 5% of those infected develop continual viremia and persistent infection
Indications for Therapy
Acute Hepatitis
One trial demonstrated no biochemical or clinical benefit in patients treated with Lamivudine
vs. placebo in 12 months.

General Rule:
Coagulopathy INR>1.5
Persistent symptoms or marked jaundice (bilirubin >10 mg/dl) for more than 4 weeks after presentation
Fulminant Hepatic Failure
Concomitant infection with Hep C or D