Herpes Simplex in Emergency Medicine Clinical Presentation
- Author: Rahul Sharma, MD, MBA, FACEP; Chief Editor: Steven C Dronen, MD, FAAEM more...
The typical incubation period from exposure to development of symptoms is 4 days but can range from 1-26 days. Prodromal symptoms of local pain, tingling, itching, and burning often precede development of the rash. Constitutional symptoms of fever, fatigue, myalgias, and headache often accompany the primary herpes simplex virus (HSV) infection.
Herpetic lesions usually begin as clusters of small bumps, then blisters, followed by open sores or ulcers. Lesions coalesce and usually heal over several weeks.
Local pain is a prominent and common complaint. Patients with genital herpes may also complain of pain in the groin area secondary to local adenopathy. Women often present with complaints of genital swelling, discharge, and dysuria.
Many primary infections are asymptomatic. Up to 80% of women with HSV-2 antibodies have no clinical history of infection. However, when primary infections are symptomatic, they are usually more severe than recurrent infections. Persons with asymptomatic genital HSV-2 infections still shed virus but less frequently than persons with symptomatic infections.
Recurrent lesions are common.
Patients may give a history that includes the following:
- Occupational exposure
- Herpetic whitlow, found in health care workers (especially medical or dental)
- Herpes gladiatorum on bodies of wrestlers
- Previous history of herpetic diseases
- Apparently undiagnosed episodes
- Occupational exposure
- Hematological malignancies
- Bone marrow
- Renal transplant
- Cardiac transplant
- Location varies
- May be very painful
- Tenesmus, itching with anal/perianal lesions
- Dysuria with genital lesions
- Sore throat with oral lesions
Constitutional symptoms (usually present with development of herpes lesions)
- General malaise
Prodromal symptoms (present in advance of herpes lesions)
Physical examination findings of HSV vary depending on location of the lesions.
Lesions coalesce and then heal over the next several weeks.
Tender bilateral lymphadenopathy occurs with genital lesions.
Skin infections (HSV-1 or HSV-2)
Herpetic whitlow or paronychia on the fingers of health care workers (not to be confused with abscess). This is usually is due to infection with HSV-1, but HSV-2 infections may be seen with digital-genital contact.
Herpes gladiatorum on the bodies of wrestlers and other sports that involve close physical contact. It has been estimated that in Division I National Collegiate Athletic Association (NCAA) wrestling, the incidence of herpes gladiatorum can be as high as 20-40%.
Genital lesions, especially urethral lesions, may cause transient urinary retention in women
Vesicles on eyelids
New psychiatric symptoms (indicative of encephalitis) - Confusion; seizures; meningeal signs (Recurrent lymphocytic meningitis [benign form of meningitis/encephalitis that may occur during primary HSV-2 infection])
Bell palsy (possible relationship with HSV-1)
HSV-1 is transmitted through direct contact with infected saliva or direct contact with contaminated utensils.
HSV-2 is usually acquired as an STD.
Maternal-fetal transmission-risk of transmission is greater in primary outbreak (30-50%) than with recurrent outbreaks (< 1%).
Recurrent disease (reactivation) due to certain stimuli: fever, physical or emotional stress, ultraviolet light exposure, or axonal injury
Mell HK. Management of oral and genital herpes in the emergency department. Emerg Med Clin North Am. 2008 May. 26(2):457-73, x. [Medline].
Biggs WS, Williams RM. Common gynecologic infections. Prim Care. 2009 Mar. 36(1):33-51, viii. [Medline].
Ahmad FA, Storch GA, Miller AS. Impact of an Institutional Guideline on the Care of Neonates at Risk for Herpes Simplex Virus in the Emergency Department. Pediatr Emerg Care. 2015 Aug 21. [Medline].
Amel Jamehdar S, Mammouri G, Sharifi Hoseini MR, Nomani H, Afzalaghaee M, Boskabadi H, et al. Herpes simplex virus infection in neonates and young infants with sepsis. Iran Red Crescent Med J. 2014 Feb. 16 (2):e14310. [Medline].
Tronstein E, Johnston C, Huang ML, Selke S, Magaret A, Warren T, et al. Genital shedding of herpes simplex virus among symptomatic and asymptomatic persons with HSV-2 infection. JAMA. 2011 Apr 13. 305(14):1441-9. [Medline].
[Guideline] Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep. 2006 Aug 4. 55:1-94. [Medline].
Frenkl TL, Potts J. Sexually transmitted infections. Urol Clin North Am. 2008 Feb. 35(1):33-46; vi. [Medline].
Pasternak B, Hviid A. Use of acyclovir, valacyclovir, and famciclovir in the first trimester of pregnancy and the risk of birth defects. JAMA. 2010 Aug 25. 304(8):859-66. [Medline].
Johnson R. Herpes gladiatorum and other skin diseases. Clin Sports Med. 2004 Jul. 23(3):473-84, x. [Medline].
Benedetti J, Corey L, Ashley R. Recurrence rates in genital herpes after symptomatic first-episode infection. Ann Intern Med. 1994 Dec 1. 121(11):847-54. [Medline].
Clark JL, Tatum NO, Noble SL. Management of genital herpes. Am Fam Physician. 1995 Jan. 51(1):175-82, 187-8. [Medline].
Cockerell C. Diagnosis and treatment of cutaneous herpes simplex virus infections. West J Med. 1996 Jun. 164(6):518-20. [Medline].
Hill J, Roberts S. Herpes simplex virus in pregnancy: new concepts in prevention and management. Clin Perinatol. 2005 Sep. 32(3):657-70. [Medline].
Hirsch MS. Herpes simplex virus. Mandell GL, ed. Mandell, Douglas, and Bennet's Principles and Practice of Infectious Diseases. 4th ed. Churchill Livingstone; 1995. 1336-45.
Holland-Hall C. Sexually transmitted infections: screening, syndromes, and symptoms. Prim Care. 2006 Jun. 33(2):433-54. [Medline].
Patel R, Rompalo A. Managing patients with genital herpes and their sexual partners. Infect Dis Clin North Am. 2005 Jun. 19(2):427-38, x. [Medline].
Rooney JF, Straus SE, Mannix ML. Oral acyclovir to suppress frequently recurrent herpes labialis. A double-blind, placebo-controlled trial. Ann Intern Med. 1993 Feb 15. 118(4):268-72. [Medline].
Whitley RJ, Gnann JW Jr. Acyclovir: a decade later. N Engl J Med. 1992 Sep 10. 327(11):782-9. [Medline].
Wu JJ, Pang KR, Huang DB. Advances in antiviral therapy. Dermatol Clin. 2005 Apr. 23(2):313-22. [Medline].
Patel EU, Frank MA, Hsieh YH, Rothman RE, Baker AE, Kraus CK, et al. Prevalence and factors associated with herpes simplex virus type 2 infection in patients attending a Baltimore City emergency department. PLoS One. 2014. 9 (7):e102422. [Medline].