Pediatric emergency medicine trisk 2145 2145
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has primary HSV infection. Nonprimary HSV infection refers to a patient who
develops a genital infection with HSV-1 who has pre-existing antibodies to HSV2 or vice versa. Recurrent infections occur when there is reactivation of HSV and
the lesions are the same serotype as the serum antibodies. Patients with primary
infections tend to have significant systemic and local signs and symptoms, though
some patients may be asymptomatic or have mild symptoms. When present,
systemic symptoms include headache, fever, myalgias, and malaise. Local
symptoms include painful lesions that may also be pruritic, dysuria, and tender
lymphadenopathy. Lesions tend to last 2 to 3 weeks. Nonprimary infections tend
to be less severe with fewer lesions. Recurrent infections are typically less severe
than primary infections, are usually unilateral with a shorter duration of
symptoms (resolve within 5 to 10 days), and may be preceded by a prodrome of
tingling or pain in the legs, buttocks, or genitalia. Local symptoms are more
common than systemic symptoms in recurrent disease.
Patients will classically present with painful, shallow, tender ulcers that may
contain a vesicular component. Other etiologies of genital ulcerations include
syphilis which tends to be a painless ulcer and chancroid which tends to be a
deep, purulent ulcer with very tender lymphadenopathy. Nonsexually transmitted
conditions can also cause acute genital ulcers and are usually self-limited and can
occur in sexually inactive females. They have been associated with Epstein–Barr
virus infection as well as other viral and bacterial infections. Noninfectious
causes of genital ulcers including autoimmune conditions such as Behỗet
syndrome and Crohn disease can also occur and should be included in the
differential diagnosis.
Diagnosis of HSV made by history and physical examination alone may be
inaccurate; therefore, diagnosis should be confirmed by laboratory testing. HSV
IgG can be tested via a type-specific ELISA test, which has good sensitivity and
specificity when Western blotting is used as a reference assay. Polymerase chain
reaction (PCR) of an active lesion should be sent as well. PCR is rapid, typespecific, and sensitive and has largely replaced viral culture in the diagnosis of
HSV. Viral culture is least sensitive of the available methods and requires several
days prior to diagnosis, making this option less desirable. PCR testing is also the
test of choice for cerebrospinal fluid testing. Tzanck testing is insensitive and
difficult to interpret and should not be relied upon for the diagnosis of HSV.
