A 4-year-old girl is brought to her pediatrician’s office because of fever and sores in her mouth for the past 2 days. The child is alert, playful and fully oriented, and her doctor notes that she has crusting on her outer lips (Figure 114-1A). The mother pulls back the child’s upper lip to show how her daughter’s gums are inflamed (Figure 114-1B). There are small ulcers on the tip of the tongue (Figure 114-2A) and when the lower lip is pulled down there are obvious ulcers on the mucosa (Figure 114-2B). The doctor easily diagnoses primary herpes gingivostomatitis and determines that the child is drinking fluids but not eating. Her mucous membranes are moist and there are no signs of dehydration. The doctor recommends giving fluids that are nonacidic and somewhat cold (anything that will be tolerated). Oral acyclovir suspension is prescribed three times daily for 7 days. The following day the child the child became afebrile and was tolerating fluids and food better. Within 1 week, she was fully better and able to go back to preschool.
HSV affects more than 1/3 of the world’s population, with the 2 most common cutaneous manifestations being orolabial herpes (Figures 114-1 and 114-2) and genital (Figures 114-3 and 114-4).1
HSV-1 infections are transmitted via saliva and are common in children, although primary herpes gingivostomatitis can be observed at any age. Children are most often infected by five years of age with infection rates ranging from 20 to 40 percent depending upon the geographic location and socioeconomic status of the family.2 Orolabial herpes is the most prevalent form of herpes infection in children and often affects children younger than 5 years of age. The duration of the untreated illness is 2 to 3 weeks, and oral shedding of virus may continue for as long as 23 days.1
Acute herpetic gingivostomatitis (Figures 114-1 and 114-2) is a manifestation of primary HSV-1 infection that most often occurs in children aged 6 months to 5 years. Adults may also develop acute gingivostomatitis, but it is less severe and is often associated with a posterior pharyngitis. Infected saliva from an adult or another child is the mode of infection. The incubation period is 3 to 6 days.3
HSV-2 infections generally affect the genitals but may occur in neonates associated with maternal outbreak at delivery, with an incidence of about 1 in 3000 births.4 Genital HSV-2 infections most commonly occur once sexual activity begins, often in adolescence. HSV-2 genital infections in children can be an indication of sexual abuse.5
The Centers for Disease Control and Prevention (CDC) reports that at least 50 million persons in the US have genital HSV-2 infection (Figures 114-3 and 114-4).6 Over the past decade, the percentage of Americans with genital herpes infection in the US has remained stable. Most persons infected with HSV-2 have not been diagnosed with genital herpes.6
Genital HSV-2 infection is more common in women (approximately 1 out of 5 women 14 to 49 years of age) than in men (approximately 1 out of 9 men 14 to 49 years of age). Transmission from an infected male to his female partner is believed to be more likely than from an infected female to her male partner.6
Cross-sectional data from the 2003 to 2004 US National Health and Nutrition Examination Survey (NHANES) shows 24 percent of female adolescents (aged 14 to 19 years) had laboratory evidence of infection with human papillomavirus (HPV, 18%), Chlamydia trachomatis (4%), Trichomonas vaginalis (3%), herpes simplex virus type 2 (HSV-2, 2%), or Neisseria gonorrhoeae. Among girls who reported ever having had sex, 40 percent had laboratory evidence of one of the four STDs, most commonly HPV (30%) and chlamydia (7%).7
Herpetic whitlow is an intense painful infection of the hand involving the terminal phalanx of one or more digits (Figures 114-5 and 114-6). In the US, the estimated annual incidence is 2.4 cases per 100,000 persons.8
FIGURE 114-6
Herpes whitlow on the left third finger of a 6-month-old child. The mother is demonstrating the lesions on the finger, which are grouped pustules with an erythematous base. The child and mother had a history of recurrent cold sores on the lip and this second primary lesion was most probably from self-innoculation while sucking the finger. A Tzanck prep showed multinucleated giant cells. Viral culture showed HSV1. (Image used with permission from Robert Brodell, MD.)
HSV belongs to the family Herpesviridae and is a double-stranded DNA virus.
HSV exists as 2 separate types (types 1 and 2), which have affinities for different epithelia.8 Seventy to ninety percent of HSV-2 infections are genital, whereas 70 to 90 percent of those caused by HSV-1 are oral–labial.
HSV enters through abraded skin or intact mucous membranes. Once infected, the epithelial cells die, forming vesicles and creating multinucleated giant cells.
Retrograde transport into sensory ganglia leads to lifelong latent infection.1 Reactivation of the virus may be triggered by immunodeficiency, trauma, fever, and UV light.
Genital HSV infection is usually transmitted through sexual contact. When it occurs in a preadolescent, the possibility of abuse must be considered.
Evidence indicates that 21.9 percent of all persons in the US, 12 years or older, have serologic evidence of HSV-2 infection, which is more commonly associated with genital infections.4
As many as 90 percent of those infected are unaware that they have herpes infection and may unknowingly shed virus and transmit infection.9
Primary genital herpes has an average incubation period of 4 days, followed by a prodrome of itching, burning, or erythema.
With both types, systemic symptoms are common in primary disease and include fever, headache, malaise, abdominal pain, and myalgia.10 Recurrences are usually less severe and shorter in duration than the initial outbreak.1,10
Herpetic whitlow occurs as a complication of oral or genital HSV infection and in medical personnel who have contact with oral secretions (Figures 114-5 and 114-6).
Toddlers and preschool children are susceptible to herpetic whitlow if they have herpes labialis and engage in thumb-sucking or finger-sucking behavior (Figure 114-6).
Like all HSV infections, herpetic whitlow usually has a primary infection, which may be followed by subsequent recurrences. The virus migrates to the peripheral ganglia and Schwann cells where it lies dormant. Recurrences observed in 20 to 50 percent of cases are usually milder and shorter in duration.
Herpes can remain dormant in nerves, including the trigeminal nerve and recur subsequently (Figures 114-7 to 114-10).
Maternal–fetal transmission of HSV is associated with significant morbidity and mortality. Manifestations of neonatal HSV include localized infection of the skin, eyes, and mouth, central nervous system (CNS) disease, or disseminated multiple organ disease (Figure 114-11). The CDC and the American College of Obstetricians and Gynecologists recommend that cesarean delivery should be offered as soon as possible to women who have active HSV lesions or, in those with a history of genital herpes, symptoms of vulvar pain, or burning at the time of delivery.11
FIGURE 114-7
Recurrent herpes simplex virus on the cheek of a 14-year-old boy. He gets this about once a year since age 8 months. This recurrence started 5 days ago. HSV1 remains dormant in the trigeminal ganglion of V2 between outbreaks. (Used with permission from Ross Lawler, MD.)
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