What are the symptoms and treatment of acute herpes simplex virus?

Symptoms of Acute Herpes Simplex Virus

The primary symptoms of acute herpes simplex virus infection include painful vesicular lesions that progress to ulcers, often accompanied by prodromal symptoms such as fever, malaise, and regional lymphadenopathy.

Clinical Manifestations

Prodromal Phase

• Tingling, burning, or itching sensation at the site of infection (1-2 days before visible lesions) 1
• Systemic symptoms including fever, malaise, headache, and myalgia (present in 67% of primary infections) 2
• Regional lymphadenopathy (80% of primary infections) 2

Active Lesion Phase

1. Orolabial HSV (typically HSV-1)

   • Grouped vesicles on erythematous base on lips or perioral area 3
   • Progression from papules to vesicles, then ulcers, and finally crusts 4
   • Lesions typically last 7-10 days in immunocompetent hosts 1
   • May involve oral mucosa with painful erosions 5

2. Genital HSV (typically HSV-2, but can be HSV-1)

   • Multiple painful vesicles on genital mucosa or skin 1
   • Lesions evolve to ulcers that may be bilateral in primary infection 2
   • Primary episodes last approximately 19 days; recurrent episodes last about 10 days 2
   • Associated with dysuria (63% of primary infections) 2
   • Urethral or cervical involvement may occur 2

3. Ocular HSV

   • Unilateral involvement with conjunctival injection 4
   • Watery discharge and mild follicular reaction 4
   • Possible palpable preauricular lymph node 4
   • Can progress to keratitis if untreated 4

4. Atypical Presentations

   • Herpes barbae: folliculocentric vesicles in beard area 5
   • Herpetic whitlow: painful vesicles on fingers 3
   • Herpes gladiatorum: lesions on areas of skin-to-skin contact during wrestling 3
   • Nodular lesions that may be mistaken for bacterial infections 6

Differences Between Primary and Recurrent Episodes

Primary Infection

• More severe and prolonged symptoms 2
• Multiple, bilaterally distributed lesions 2
• Higher rate of systemic symptoms 2
• Longer duration (average 19 days) 2
• Higher risk of complications 2

Recurrent Episodes

• Milder symptoms with unilateral distribution 2
• Fewer lesions that heal more quickly (average 10.1 days) 2
• Systemic symptoms uncommon 2
• 25% may be asymptomatic 2
• Triggered by stress, sunlight, or physiologic factors 1

Complications

• Aseptic meningitis (8% of primary infections) 2
• Secondary bacterial infections 5
• Sacral autonomic nervous system dysfunction (2%) 2
• Extragenital lesions (20%) 2
• Secondary yeast infections (11%) 2
• Ocular complications: keratitis, corneal scarring, vision impairment 4
• Urogenital complications: urinary retention, dysuria 1

Special Considerations

Immunocompromised Patients

• More severe and prolonged symptoms 1
• Possible extensive, deep, nonhealing ulcerations in patients with CD4+ counts <100 cells/μL 1
• Higher risk of acyclovir-resistant infections 1

Neonates

• Neonatal HSV infection is life-threatening and requires immediate consultation with a pediatrician 4

Diagnostic Approaches

• Clinical appearance of grouped vesicles on erythematous base 3
• Tzanck smear showing multinucleated giant cells 5
• Viral culture, PCR, or direct fluorescent antibody testing for confirmation 3
• Serologic testing to determine previous exposure 3

Differential Diagnosis

• Aphthous ulcers
• Varicella-zoster virus infection
• Acute paronychia
• Bacterial infections
• Pemphigus vulgaris
• Behçet syndrome 3

Understanding these symptoms is crucial for early diagnosis and appropriate management of herpes simplex virus infections, which can significantly improve patient outcomes and quality of life.