How to manage recurrent genital herpes in a female patient with a history of genital herpes, currently undergoing IVIG treatment for GBS?

Management of Recurrent Genital Herpes During IVIG Treatment for GBS

For this patient with recurrent genital herpes during IVIG therapy for GBS, initiate episodic antiviral treatment with valacyclovir 500 mg orally twice daily for 5 days, starting immediately at the first sign of recurrence. 1

Immediate Treatment Approach

• Start valacyclovir 500 mg orally twice daily for 5 days as soon as lesions appear, which is the CDC-recommended first-line episodic therapy for recurrent genital herpes 1

• Alternative regimens include acyclovir 400 mg orally three times daily for 5 days, acyclovir 800 mg orally twice daily for 5 days, or famciclovir 125 mg orally twice daily for 5 days 1

• Episodic therapy is most effective when started during the prodrome or within 1 day after onset of lesions 1

Critical Context: IVIG and Herpes Recurrence

• IVIG can paradoxically trigger HSV recurrences despite having some suppressive effects on genital herpes in research settings 2

• The recurrence during IVIG treatment does not indicate treatment failure of the IVIG for GBS—this is a known phenomenon where immune modulation can reactivate latent HSV-2 2

• One study showed IVIG at 400 mg/kg every fourth week actually reduced HSV recurrence frequency more effectively than intermittent acyclovir, but this was in a different clinical context than acute GBS treatment 2

Transition to Suppressive Therapy

After completing the current IVIG course for GBS, strongly consider daily suppressive antiviral therapy given this patient's demonstrated high recurrence pattern:

• Valacyclovir 1 gram orally once daily is the preferred suppressive regimen for patients with frequent recurrences (≥6 episodes per year) 1

• Alternative suppressive options include valacyclovir 500 mg orally once daily, acyclovir 400 mg orally twice daily, or famciclovir 250 mg orally twice daily 1

• Suppressive therapy reduces recurrence frequency by ≥75% and reduces asymptomatic viral shedding 1

• Suppressive therapy is safe for up to 6 years with acyclovir and 1 year with valacyclovir based on documented safety data 1

Monitoring and Follow-Up Strategy

• If lesions do not begin to resolve within 7-10 days of antiviral therapy, suspect acyclovir resistance and consider foscarnet 40 mg/kg IV every 8 hours as an alternative 1

• After 1 year of continuous suppressive therapy, consider discontinuation to reassess the patient's recurrence frequency 1

• Patients should be counseled to abstain from sexual activity when lesions or prodromal symptoms are present 1

Important Caveats

• Do not use topical acyclovir—it is substantially less effective than oral therapy 1

• The patient's history of developing GBS after initial HSV-2 infection is unusual but does not change herpes management 1

• Ensure the patient understands that antiviral medications control symptoms but do not eradicate the virus or prevent all recurrences 1

• Asymptomatic viral shedding can still occur even on suppressive therapy, potentially leading to transmission to sexual partners 1

• Condoms should be used during all sexual exposures with new or uninfected partners 1