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Herpes B Clinical Presentation

  • Author: Sowmya Nanjappa, MD; Chief Editor: Pranatharthi Haran Chandrasekar, MBBS, MD  more...
Updated: May 06, 2016


Following potential exposure to herpes B virus in humans, the wound and the at-risk individual should be monitored because of the potential for severe infection, a protocol involving the exposing primate (see Lab Studies). An incubation period of 2-30 days has been described, with progression of symptoms over 7-10 days.

Early symptoms (variably present) may include the following:

  • Pain or pruritus at exposure site
  • Vesicles or ulcers at or near exposure site
  • Local lymphadenopathy

Intermediate symptoms (variably present) may include the following:

  • Fever
  • Malaise
  • Diffuse myalgias
  • Headache
  • Numbness or paraesthesias at or near exposure site
  • Nausea and/or abdominal pain
  • Persistent hiccups

Late manifestations may include the following:

  • Persistent headache
  • Alteration of mentation
  • Focal neurological symptoms


Findings of herpes B virus infection primarily include progressive neurologic deterioration that suggests a multifocal hemorrhagic encephalitis or encephalomyelitis. This finding contrasts with the temporal lobe localization of herpes simplex encephalitis. The progression of signs and symptoms may be modified by early antiviral therapy. Asymptomatic human herpes B virus infection is rare, if not nonexistent. Typical physical signs include the following:

  • Meningismus
  • Confusion progressing to coma
  • Brain stem findings, which may include the following: Diplopia, dysarthria, dysphagia, cerebellar signs (including ataxia), cranial nerve palsies
  • Signs of meningoencephalomyelitis, which may include the following: Seizures, hemiparesis or hemiplegia, progressive ascending paralysis, transverse myelitis
  • Non–central nervous system signs, which may include the following: conjunctivitis or chorioretinitis, sinusitis


Information regarding the epidemiology and transmission of herpes B virus in primates is vital in order to understand how to prevent this high-mortality infection.

Macaques transmit the herpes B virus to each other through oral, ocular, or genital contact of mucous membranes or lesioned skin. The herpes B virus can be shed asymptomatically, including through bodily fluids (eg, semen, mother's milk, saliva, perhaps even in aerosol form). The animal stools could also conceivably transmit the herpes B virus. In captive macaques, transmission may often occur during routine colony management protocols involving tube sharing, common instrumentation, or contaminated gloves. Animals usually become infected as juveniles, at the onset of sexual activity; however, younger animals can become infected through contact with another virus-shedding animal. For example, a nursing mother has repeated opportunities to transmit herpes B virus in buccal or conjunctival fluids to a nursing infant during grooming.

Conclusively determining transmission pathways may not be possible because most human cases of herpes B virus infection involve individuals who regularly work with monkeys, thus providing many potential means of exposure. Suspected transmission modes include monkey bites, monkey scratches, or cage scratches; direct contamination of a preexisting wound with macaque saliva; respiratory exposure to aerosol macaque saliva; mucosal splash exposure; cuts sustained from culture bottles containing macaque kidney cells; needle-stick injuries following needle use in macaques; and cleaning a rhesus macaque skull without gloves. In addition, one apparent case of human-to-human herpes B virus transmission involved a woman with dermatitis on her finger; she touched her husband's herpetiform lesion (resulting from a monkey bite).[3]

Given the myriad potential transmission pathways and abundance of macaques in contact with people, the fact that relatively few documented cases of B virus infection occur in humans may seem surprising. Nevertheless, although most macaques test positive for herpes B virus antibodies, only a small percentage (ie, 0-2%) shed the virus at any given time. In most animals, the human B virus is latent in the trigeminal ganglia and becomes reactivated only when the macaque experiences psychological stress, pharmacological stress, or diminished immunocompetence.[4]

The widely observed pattern of increasing frequency with age suggests that horizontal transmission is far more common than vertical transmission (ie, mother to offspring). Whether this horizontal transmission occurs most commonly via oral or genital contact, including sexual behavior, is unresolved.

Contributor Information and Disclosures

Sowmya Nanjappa, MD Assistant Member, Department of Internal Medicine, Moffitt Cancer Center; Assistant Professor of Medicine, Department of Internal Medicine and Department of Oncologic Sciences (Joint Appointment), University of South Florida Morsani College of Medicine

Sowmya Nanjappa, MD is a member of the following medical societies: American Association of Physicians of Indian Origin, American College of Physicians, American Medical Association, Infectious Diseases Society of America, Society of Hospital Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Charles V Sanders, MD Edgar Hull Professor and Chairman, Department of Internal Medicine, Professor of Microbiology, Immunology and Parasitology, Louisiana State University School of Medicine at New Orleans; Medical Director, Medicine Hospital Center, Charity Hospital and Medical Center of Louisiana at New Orleans; Consulting Staff, Ochsner Medical Center

Charles V Sanders, MD is a member of the following medical societies: American College of Physicians, Alliance for the Prudent Use of Antibiotics, The Foundation for AIDS Research, Southern Society for Clinical Investigation, Southwestern Association of Clinical Microbiology, Association of Professors of Medicine, Association for Professionals in Infection Control and Epidemiology, American Clinical and Climatological Association, Infectious Disease Society for Obstetrics and Gynecology, Orleans Parish Medical Society, Southeastern Clinical Club, American Association for the Advancement of Science, Alpha Omega Alpha, American Association of University Professors, American Association for Physician Leadership, American Federation for Medical Research, American Geriatrics Society, American Lung Association, American Medical Association, American Society for Microbiology, American Thoracic Society, American Venereal Disease Association, Association of American Medical Colleges, Association of American Physicians, Infectious Diseases Society of America, Louisiana State Medical Society, Royal Society of Medicine, Sigma Xi, Society of General Internal Medicine, Southern Medical Association

Disclosure: Received royalty from Baxter International for other.

Chief Editor

Pranatharthi Haran Chandrasekar, MBBS, MD Professor, Chief of Infectious Disease, Program Director of Infectious Disease Fellowship, Department of Internal Medicine, Wayne State University School of Medicine

Pranatharthi Haran Chandrasekar, MBBS, MD is a member of the following medical societies: American College of Physicians, American Society for Microbiology, International Immunocompromised Host Society, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

Larry I Lutwick, MD Professor of Medicine, State University of New York Downstate Medical School; Director, Infectious Diseases, Veterans Affairs New York Harbor Health Care System, Brooklyn Campus

Larry I Lutwick, MD is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Thomas J Marrie, MD Dean of Faculty of Medicine, Dalhousie University Faculty of Medicine, Canada

Thomas J Marrie, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Society for Microbiology, Association of Medical Microbiology and Infectious Disease Canada, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Brian Hogan, MD, MPH MPH&TM, Fellow in Infectious Diseases, Brooke Army Medical Center, San Antonio Uniformed Services Health Education Consortium

Disclosure: Nothing to disclose.


Robert O Deaner, PhD Assistant Professor, Department of Psychology, Grand Valley State University

Disclosure: Nothing to disclose.

Jason F Okulicz, MD Assistant Professor of Medicine, Uniformed Services University of the Health Sciences; Staff, Infectious Disease Service, Brooke Army Medical Center

Jason F Okulicz, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

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This is a photo of long-tailed macaques socializing in the wild. The long-tailed macaque, Macaca fascicularis, is a major reservoir for the herpes B virus. (Photo courtesy of Carel van Schaik)
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