Can Herpes Simplex Virus (HSV) cause cervicitis?

HSV as a Cause of Cervicitis

Yes, herpes simplex virus (HSV) can cause cervicitis, particularly during primary HSV-2 infection, though it is not among the most common causes. 1

Etiology of Cervicitis

Cervicitis is characterized by inflammation of the cervix, typically presenting with:

• Purulent or mucopurulent endocervical exudate
• Easily induced endocervical bleeding
• Leukorrhea (>10 WBC per high power field on microscopic examination)

The most common causative organisms include:

1. Chlamydia trachomatis (most frequent)
2. Neisseria gonorrhoeae (second most frequent)
3. Trichomonas vaginalis
4. Herpes simplex virus (especially primary HSV-2 infection)
5. Mycoplasma genitalium (emerging evidence)
6. Bacterial vaginosis (associated with cervicitis)

In the majority of cervicitis cases, however, no specific organism is isolated, particularly in women at lower risk for STIs (e.g., women over 30 years) 1.

HSV-Related Cervicitis

Clinical Presentation

HSV cervicitis can present in various ways:

• Typical presentation includes cervical inflammation with mucopurulent discharge
• May occur with or without concurrent external genital lesions
• Can occasionally present as a cervical mass mimicking cervical cancer 2, 3
• Often asymptomatic, particularly in women with intrauterine contraceptive devices 4

Diagnostic Considerations

When HSV cervicitis is suspected:

• Look for characteristic vesicular lesions on the cervix (may not always be present)
• Consider testing for HSV using the most sensitive methods available
• Nucleic Acid Amplification Tests (NAATs) are preferred when available
• Viral culture from cervical lesions can confirm diagnosis
• Serological testing for HSV-1 and HSV-2 antibodies may help determine prior exposure

The 2006 CDC guidelines note that "although HSV-2 infection has been associated with cervicitis, the utility of specific testing (i.e., culture or serologic testing) for HSV-2 in this setting is unclear." 1

Diagnostic Approach for Cervicitis

For women presenting with cervicitis, the following testing is recommended:

• Test for C. trachomatis and N. gonorrhoeae using NAATs (highest sensitivity)
• Evaluate for bacterial vaginosis and trichomoniasis
• Consider HSV testing if vesicular lesions are present or there's a history of genital herpes
• Finding of >10 WBC in vaginal fluid (in absence of trichomoniasis) may indicate endocervical inflammation caused by C. trachomatis or N. gonorrhoeae 1

Clinical Implications

HSV cervicitis is clinically significant because:

• It may increase risk of HIV acquisition and transmission
• It can be mistaken for cervical malignancy in rare cases 2, 3
• It may lead to upper genital tract infection if not properly diagnosed and treated
• Asymptomatic cases may go undetected but still be infectious

Treatment Considerations

While the CDC guidelines don't provide specific treatment recommendations for HSV cervicitis alone, standard antiviral therapy for genital herpes would apply:

• Acyclovir, valacyclovir, or famciclovir are the mainstays of treatment
• Treatment duration depends on whether it's a primary infection or recurrence
• Partners should be evaluated and treated if symptomatic

Key Points to Remember

• HSV (particularly HSV-2) is a recognized but not predominant cause of cervicitis
• Most cases of cervicitis have no identifiable organism
• Consider HSV in the differential diagnosis, especially with vesicular lesions
• HSV cervicitis can occasionally present atypically as a cervical mass
• Proper diagnosis requires appropriate laboratory testing
• Concurrent testing for other STIs is essential due to frequent co-infections