Clinical Features of HSV Infection
Primary Clinical Manifestations
HSV infection presents with a spectrum of clinical features ranging from asymptomatic viral shedding to severe mucocutaneous disease, with most infected persons never recognizing symptoms suggestive of genital herpes. 1
Symptomatic Disease Patterns
- First clinical episodes may manifest as extensive disease requiring hospitalization, with painful genital ulcers, systemic symptoms, and prolonged viral shedding lasting 7-10 days or longer if untreated 2
- Recurrent episodes typically present with shorter duration and less severe symptoms, often preceded by prodromal symptoms (tingling, burning) before visible lesions appear 3
- Approximately 20% of HSV-2 seropositive persons remain completely asymptomatic and do not note any genital symptoms consistent with genital herpes 1
Anatomic Distribution
- HSV-2 traditionally causes anogenital infections, though HSV-1 is increasingly responsible for genital herpes 4
- HSV-1 classically causes orofacial infections (cold sores), but now accounts for a growing proportion of first-episode genital herpes 4
- Herpes proctitis presents with rectal pain, discharge, and ulcerative lesions requiring longer treatment courses (10 days) 1
Lesion Characteristics
- Vesicular lesions that progress to painful ulcers with erythematous bases 2
- Lesions may coalesce into larger ulcerations, particularly in immunocompromised hosts 1
- Healing typically occurs within 7-10 days for recurrent episodes, but primary episodes may require 2-3 weeks for complete resolution 2
Asymptomatic Viral Shedding
- Asymptomatic viral shedding occurs frequently and allows transmission even without visible lesions, representing a critical epidemiologic feature 3, 5
- Many cases of genital herpes are acquired from persons who do not know they have genital HSV infection or who were asymptomatic at the time of sexual contact 1
Special Population Considerations
Immunocompromised Patients
- HIV-infected and other immunosuppressed patients may have prolonged episodes with extensive disease requiring more aggressive and longer therapy courses 1
- Healing is slower among HIV-infected persons, and treatment failures occur more frequently, especially with shorter-course regimens 1
- Acyclovir-resistant strains are more common in immunocompromised populations, requiring alternative agents like foscarnet 1, 6
Severe Manifestations
- HSV encephalitis represents a life-threatening manifestation requiring IV acyclovir 2
- Disseminated HSV disease can occur in immunocompromised hosts and neonates 4
- Neonatal HSV infection carries significant morbidity and mortality 4
Diagnostic Approach
- Patients with symptoms consistent with genital herpes should undergo HSV-2 serologic testing to establish diagnosis, including those with classic or atypical genital symptoms 1
- Persons told they have genital herpes without virologic diagnosis have high pretest probability and should undergo HSV-2 serologic testing 1
- Viral culture and susceptibility testing should be obtained if lesions do not resolve within 7-10 days of appropriately dosed antiviral therapy, suggesting acyclovir resistance 2, 5
Recurrence Patterns
- HSV-2 causes more frequent recurrences than genital HSV-1, with a minority of infected persons experiencing frequent recurrent episodes (≥6 per year) 3
- Some patients have symptoms shortly after initial infection and then never again, while others develop chronic recurrent disease 1
- Recurrence frequency typically decreases over time in most patients 3