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Subscription Info For INFECTIONS in MEDICINE Photo ID Visual clues to the diagnosis of infectious disease Herpes Simplex: Initial and Recurrent Infections [Infect Med. 2009;26:145-147] Key words: Herpes simplex virus Herpes simplex virus type 2 Herpes simplex virus type 1 Herpes labialis H erpes simplex virus (HSV) infections are caused by 2 types of HSV: type 1 (HSV-1) and type 2 (HSV-2). Most cases of HSV infection are caused by HSV-2. Most persons with HSV-1 or HSV-2 infection have no or only minimal signs or symptoms. When signs do occur, they usually appear as one or more small blisters or sores on or around the mouth, lips, nose, face, genitals, and buttocks. HSV infections are very contagious and are spread by direct contact with the skin lesions. Herpes labialis is a common disease caused by infection of the mouth area with HSV-1. Most persons in the Figure 1 – An itchy, vesicular lesion was caused by an unusual case of herpes simplex virus United States are infected with HSV-1 type 1 infection. (Photo courtesy of David L. Kaplan, MD. Overview adapted from Dermclinic in Consultant. 2008;48:673-680.) by age 20 years. The blisters or sores associated with HSV infection may take 2 to 4 weeks to heal comof the vesicular lesion depicted here; the lesion recurred pletely the first time they occur. Typically, another outat the same site, and the physician initiated antiviral therbreak can appear weeks or months later at the same site, apy. A culture was positive for HSV-1. but it almost always is less severe and of shorter duration than the initial outbreak. Although HSV can remain in the Herpes simplex virus type 2 body indefinitely, the number of recurrent HSV infections Persons with HSV-2 infection are often unaware of their tends to decrease over a period of years. illness for several reasons. They may have become infected with HSV-2 during sexual contact with a person with Herpes simplex virus type 1 a genital HSV-2 infection who does not have visible sores Although lesions caused by HSV-1 infection typically apand may not know that he or she is infected. In addition, pear on the mouth, lips, nose, and face, they can develop they may never have signs and symptoms or may have anywhere on the skin. For example, a 25-year-old woman very mild signs that either they do not notice or they missought evaluation of an itchy lesion on her neck, shown take for such skin conditions as insect bites. However, if in Figure 1. Almost a year earlier, a similar lesion had signs and symptoms occur during the initial outbreak, occurred at the identical site after she had worked in they may be pronounced and may include sores, fever, the yard. Her physician had suspected rhus dermatitis at and swollen glands. the time and had prescribed a topical corticosteroid; the Figure 2 shows a pruritic eruption that was confined lesion had resolved. for several days to the buttocks of a 73-year-old woman. A diagnosis of HSV infection was made on the basis She was otherwise healthy. She was widowed and had May 2009 INFECTIONS in MEDICINE 145 0905IIM204689PIDlay 7/31/09 6:04 PM Page 146 PhotoID continued Figure 2 – This pruritic eruption on the buttocks of an elderly woman is an example of herpes simplex type 2 infection. (Photo courtesy of David L. Kaplan, MD. Overview adapted from Dermclinic in Consultant. 2008;48:673-680.) had no sexual contacts for many years. Antiviral therapy was started because the woman’s physician suspected HSV infection. A culture confirmed the diagnosis of HSV-2 infection. Additional information from the history revealed that the woman had been exposed to HSV-2 infection many years ago. Figure 3 depicts a tender eruption that was present on a 28-year-old woman’s posterior right thigh for 3 days. She had no history of a similar eruption. She was otherwise healthy but had had seasonal allergies as a child. Figure 3 – A tender blister on the posterior thigh of a 28-year-old woman is characteristic of herpes simplex virus type 2 infection. (Photo courtesy of David L. Kaplan, MD. Overview adapted from Dermclinic in Consultant. 2008;48:833-840.) 146 INFECTIONS in MEDICINE May 2009 Recently, she had started to use new brands of both soap and shaving cream. A culture identified HSV-2. Treatment with oral antivirals was started. The patient received counseling on being evaluated for other sexually transmitted infections as well as on the ramifications of genital HSV-2 infections. Herpes labialis Although initial herpes labialis may not cause symptoms or mouth ulcers, the virus remains in the nerve tissue of 0905IIM204689PIDlay 7/31/09 6:04 PM Page 147 Send Us Your Slides! Your contributions are invited: ImagesinInfectiousDisease Clinical photographs, tissue samples, photomicrographs, imaging studies. Send slides or high-quality Figure 4 – These painful vesicles that erupted suddenly and were accompanied by low-grade fever and a sore throat are characteristic of herpes labialis. (Photo courtesy of David L. Kaplan, MD. Overview adapted from Dermclinic in Consultant. 2008;48:1022-1028.) the face and may reactivate, producing recurrent cold sores, usually at the same site. Symptoms of primary herpes labialis may include a prodrome of fever, followed by a sore throat and mouth and submandibular or cervical lymphadenopathy. In children, gingivostomatitis and odynophagia are also observed. Painful vesicles develop on the lips, gingiva, palate, or tongue and are often associated with erythema and edema. The lesions ulcerate and heal within 2 to 3 weeks. A classic manifestation of herpes labialis is shown in Figure 4. After returning from a skiing trip to Colorado, a 24-year-old woman sought medical attention for an eruption of sudden onset on her lip. She also had a sore throat and low-grade fever. She was otherwise healthy, and her only medication was an oral contraceptive. ❖ prints. Please include a 1- or 2-paragraph description of what is shown, data about the patient (age, sex, clinical status), and anything unusual or unique about the image. For photomicrographs, please indicate magnification of original image. Photographs will be accepted for publication on the basis of subject matter, technical quality, and aesthetic quality. Contributors will receive an honorarium. Unused submissions will be returned. Please send your images to: May 2009 INFECTIONS in MEDICINE 147 [email protected] or CMPMedica LLC Images, Infections in Medicine 535 Connecticut Avenue Suite 300 Norwalk, CT 06854