History, Assessment, and Examination for Suspected HSV in a 45-Year-Old Active Duty Male

History Taking

A comprehensive sexual and symptom history is essential to establish the diagnosis and guide management of suspected HSV infection. 1

Lesion characteristics: Ask specifically about vesicular (fluid-filled blisters) or ulcerative lesions on the penis, buttocks, perineum, or thighs 1
Timing and progression: Document when lesions first appeared, whether they started as redness followed by papules then vesicles, and if they have progressed to ulcers or crusts 1
Pain and dysuria: Query about painful urination, which may occur even after treatment for other STIs like gonorrhea or nongonococcal urethritis 1
Prodromal symptoms: Ask about tingling, burning, or itching sensations that preceded visible lesions (prodrome typically occurs 1-2 days before lesions) 2
Duration: Determine if this is a first episode (typically lasts 10-14 days) or recurrent episode (typically <10 days) 1

Previous episodes: Document any history of recurrent vesicular or ulcerative genital skin lesions, as this suggests recurrent rather than primary infection 1
HIV status: Critical to assess, as HSV lesions are more common, severe, and prolonged in HIV-infected patients 1
Immunosuppression: Ask about any conditions or medications that compromise immune function 1
Prior HSV diagnosis: Determine if the patient has ever been diagnosed with oral or genital herpes 3

Recent sexual contacts: Document sexual activity within the past 2-10 days (typical incubation period) or up to 4 weeks 1
Partner symptoms: Ask if any sexual partners have had similar lesions or known HSV infection 1
Number and gender of partners: Important for risk stratification and partner notification 1
Condom use: Document consistency of barrier protection 1
Other STI screening: Ask about symptoms or recent testing for other sexually transmitted infections, as co-infection is possible 1

The physical examination must focus on identifying characteristic HSV lesions while excluding other causes of genital ulceration. 1

Inspect the penis: Look for vesicles (clear fluid-filled blisters), ulcers, or crusted lesions on the shaft, glans, or prepuce 1
Examine the urethral meatus: Check for erythema, discharge, or lesions at the opening; gently insert a swab 0.5-2 cm to collect urethral exudates if indicated 1
Assess surrounding areas: Examine the scrotum, perineum, buttocks, and thighs for lesions, as HSV can affect these sites 1
Palpate inguinal lymph nodes: Tender lymphadenopathy is common in primary HSV infection 1
Document lesion characteristics: Note the number, size, distribution, and stage (vesicular, ulcerative, or crusted) of all lesions 1

Oral cavity: Examine for oral lesions, as HSV-1 can cause both oral and genital disease 4
Skin: Check for disseminated vesicular rash, which would indicate severe disease requiring hospitalization 1
Neurological assessment: If the patient reports headache, altered mental status, or focal neurological symptoms, consider HSV encephalitis and perform a complete neurological examination 5

Laboratory confirmation is essential because clinical diagnosis alone leads to both false positive and false negative results. 1

Viral culture or PCR: Open vesicles with a sterile needle, collect fluid with a swab, and either apply to a microscope slide for immunofluorescence or place in transport media for viral culture or nucleic acid amplification testing (NAAT) 1
Type-specific testing: Request HSV-1 and HSV-2 differentiation, as this has important prognostic implications—genital HSV-1 recurs much less frequently than HSV-2 (1.3 recurrences/year vs. much higher for HSV-2) 6, 4
Timing matters: Collect specimens as early as possible, ideally within 48-72 hours of lesion onset, as viral shedding decreases rapidly 1

Limited role in acute diagnosis: Type-specific HSV IgG antibodies take 2-12 weeks to develop after infection, so serology cannot diagnose acute infection 3
Use for asymptomatic partners: Serology may help identify asymptomatic infection in sexual partners for counseling purposes 1
Avoid in low-risk asymptomatic patients: Testing asymptomatic individuals without lesions or known exposure has limited clinical benefit and requires careful pre-test counseling 3

Co-infection testing: Test for syphilis (Treponema pallidum), as it can cause similar genital ulcers and may co-exist with HSV 1
HIV testing: Offer HIV testing, as HSV facilitates HIV transmission and HIV affects HSV disease severity 1
Other STIs: Consider testing for gonorrhea, chlamydia, and other sexually transmitted infections based on risk factors 1

Do not rely on clinical diagnosis alone: The clinical appearance of genital ulcers is unreliable—always obtain laboratory confirmation 1
Do not delay specimen collection: Waiting beyond 72 hours significantly reduces the sensitivity of viral culture and PCR 5
Do not use topical acyclovir: It is substantially less effective than oral therapy and should not be used 1, 7
Do not assume HSV-2 based on genital location: Among sexually active adults, new genital HSV-1 infections are as common as new oropharyngeal HSV-1 infections 4
Do not forget to assess for severe disease: Ask about and examine for signs of disseminated infection (widespread rash, respiratory symptoms, altered mental status), which requires immediate hospitalization and IV acyclovir 1, 2

Occupational implications: Document any impact on duty status or deployment readiness 1
Partner notification: Military health systems may have specific protocols for partner notification and contact tracing 1
Confidentiality: Ensure the patient understands confidentiality protections and any mandatory reporting requirements 1