Genital Herpes Simplex Virus Herpes Overview Genital HSV is a recurrent viral STD. Most cases of genital herpes are caused by HSV-2, however, there are increasing rates of infection with HSV-1. Herpes may be diagnosed in the primary, non-primary, or recurrent stage. Since it is sometimes asymptomatic, diagnosis may be delayed. Primary: First time of infection, no antibodies are present. Non-primary: Infection with either HSV-1 or HSV-2, but with pre-existing antibodies to the other strain. Recurrent: reactivated HSV infection, antibodies to that strain are present. Presentation Primary infection: Lasts on average 19 days with variable presentation, symptoms begin 2-10 days after infection. Signs and symptoms may include: genital vesicles/ulcers with an erythematous base, flu like symptoms, genital pain, and painful urination. Primary infections are often asymptomatic, leading to a delay in diagnosis and increased transmission rates. Non-primary infection: Similar symptoms as primary infection, but less severe Recurrent: Lasts on average 10 days, recurrence frequency usually correlates with the length and severity of the primary infection, as well as the overall immune status of the patient. Transmission and Prevention Genital HSV is transmitted during sexual contact when lesions are present. However, many cases of transmission occur when lesions aren’t present, but the patient is in the viral shedding phase, since patients may not know they have an infection. Prevention strategies include barrier protection and chronic antiviral therapy for already affected individuals who are sexually active with uninfected persons. Diagnosis and Treatment Screening is not routinely performed. Diagnosis: PCR is very sensitive and specific, and is usually the test of choice. Direct fluorescent antibody can be used as a rapid test, as well as viral culture and serology. Treatment includes oral antivirals, most commonly acyclovir (cheap!), famciclovir, or valacyclovir for 1-5 days. Although recurrence may still occur, the duration and severity of outbreaks can be lessened. Treatment is most efficacious within 72 hours of symptoms. Genital HSV During Pregnancy and Vertical Transmission HSV may be passed to an infant via the placenta or during a vaginal delivery. Risk of this is increased if the mother is experiencing a primary or non-primary infection during labor, and is much lower for recurrent infections. This is due to protection of the baby by the mother’s antibodies, and lower ulcer burdens in recurrent infections. Women with diagnosed HSV should be placed on prophylactic antiviral therapy beginning at 36 weeks (acyclovir 400mg TID), and cesarean section should be considered if the woman has a confirmed primary infection, visible lesions, or prodromal symptoms. HSV is not present in breastmilk, and mothers may breastfeed as long as no ulcers are present on the breast. Neonatal HSV includes vesicular lesions, CNS disease, and disseminated disease. Treatment is IV acyclovir. ZikaZika Overview Zika is a mosquito borne virus most prevalent in Central and South America, Central Africa, and Southeast Asia. In the US, there is some threat of Zika in Texas and Florida, as well as in patients who have recently visited areas with endemic Zika. Presentation Symptoms of Zika are nonspecific, and only present in about ¼ of infected patients. The most common symptoms include arthralgias, fever, rash, and conjunctivitis. Long term complications include Guillain-Barre, encephalitis, and neuropsychiatric conditions. Transmission and Prevention Zika is transmitted by bites from an infected mosquito, sexual contact (semen and female genital tract secretions), blood transfusions, and from mother to fetus. Primary prevention includes use of mosquito nets and sprays, and practicing either abstinence or using barrier protection during intercourse with an affected person. The CDC recommends men use protection for at least 6 months after infection or exposure, and women use protection for at least 8 weeks. Diagnosis and Treatment Diagnosis is typically made via a history of potential exposure along with PCR or serology. Treatment for Zika is supportive with symptoms control mainly aimed at pain and fever with acetaminophen, and fluids to prevent dehydration. Zika and Pregnancy Zika transmission during pregnancy: maternal circulation ? placenta ? fetal circulation ? fetal brain All pregnant women should be asked about potential exposure and symptoms at prenatal visits. Symptomatic women and asymptomatic women with ongoing exposures should receive Zika NAT and Zika IgM testing. Associated birth defects are more common when the mother is infected in the 1st trimester and include microcephaly, hydrops fetalis, miscarriage, eye and ear abnormalities, and various neurologic conditions. However, the prevalence of these conditions is unknown. In known affected mothers, serial ultrasounds may be used to screen fetuses for anomalies. Involvement of MFM, infectious disease, and abortion services should be discussed with the patient. Pregnant women with Zika may undergo either vaginal deliveries or cesarean sections, depending on other pregnancy complications. Breastfeeding is encouraged.