All patients with genital, anal or perianal ulcers should be evaluated with a serologic test for syphilis in addition to a diagnostic evaluation for genital herpes. In settings where chancroid is prevalent, a test for Haemophilus ducreyi should also be performed. Specific tests for evaluation of genital, anal, or perianal ulcers Includes syphilis serology and darkfield examination HSV culture and PCR are preferred serologic testing for type-specific HSV antibody. No FDA-cleared PCR test for syphilis or chancroid is available in the U.S.; however, such testing can be performed by clinical laboratories that have developed their own tests and conducted a Clinical Laboratory Improvement Amendment (CLIA) verification study. Healthcare providers frequently must patients before test results are available, because early treatment decreases the possibility of ongoing transmission and because successful treatment of genital herpes depends on prompt initiation of therapy. 40] Lesson V: Patient Management 41] Principles of Management of Genital Herpes Counseling about the natural history of genital herpes, sexual and perinatal transmission, and methods to reduce transmission is integral to clinical management. Antiviral chemotherapy offers clinical benefits to most symptomatic patients and is the mainstay of management. Partially controls symptoms and signs of herpes episodes when used to treat first clinical and recurrent episodes, or when used as daily suppressive therapy Does not eradicate latent virus and does not affect risk, frequency, or severity of recurrences after drug is discontinued 42] Antiviral Therapy for HSV HSV systemic antiviral chemotherapy includes three oral medications: Acyclovir (ACV) Valacyclovir (Valine of acyclovir) — high oral bioavailability Famciclovir (Penciclovir prodrug) — high oral bioavailability Topical antiviral treatment is of minimal clinical benefit and is not recommended. 43] Management of Clinical Episode of Genital Herpes Many patients with first episode of herpes present with mild clinical manifestations, but later develop severe or prolonged symptoms. Therefore, patients with initial genital herpes should receive antiviral therapy.
Roberta’s Laboratory Results HSV gG-based type-specific serologies: HSV-1 negative; HSV-2 positive NAAT for Chlamydia trachomatis: negative NAAT for Neisseria gonorrhoeae: negative RPR: nonreactive HIV antibody test: negative Pregnancy test: positive 4. What would you tell Roberta about her HSV infection, based on clinical manifestations and test results? Roberta most likely has an asymptomatic or unrecognized genital herpes infection. She does have evidence of exposure to HSV-2, but reports no symptoms or previous clinical episodes. Up to two-thirds of patients with identified “asymptomatic” HSV-2 infection may actually have symptomatic infection that is mild or simply unrecognized as genital herpes. Most patients with asymptomatic or unrecognized genital HSV infections will still shed virus intermittently in the genital tract. Patients such as Roberta should be taught to recognize signs and symptoms of genital herpes. She should inform her obstetric provider(s) about her HSV-2 infection status and assess whether any signs or symptoms of infection develop at the onset of labor. The risk for transmission of HSV-2 to a neonate is low (less than 1%) among women who have acquired HSV-2 infection before the second half of pregnancy. Women without symptoms of genital herpes or its prodrome and without signs of herpetic lesions on careful examination at the onset of labor can deliver vaginally. Although cesarean section does not completely eliminate the risk for HSV transmission to the infant, women with recurrent genital herpetic lesions at the onset of labor should deliver by cesarean section to prevent neonatal HSV infection. 5. Would routine viral cultures during Roberta's pregnancy be recommended? No. The results of viral cultures during pregnancy of women with or without visible herpetic lesions do NOT predict viral shedding at the time of delivery, and therefore routine viral cultures of pregnant women with recurrent genital herpes are NOT recommended. [Slide 73] Partner Management Sex partner and exposure information Franklin Patterson First sexual exposure: Sixteen months ago Last sexual exposure: One month ago