Clinical Manual for Management of the HIV-Infected ... - myCME.com

Herpes Simplex, Mucocutaneous
Background
Herpes simplex virus (HSV) types 1 and 2 cause both
primary and recurrent oral and genital disease. HSV
usually appears as a vesicular eruption of the mucous
membranes of the oral or perioral area, vulva, perianal
skin, rectum, and occasionally the inguinal or buttock
areas. The eruption develops into tender or painful
ulcerated lesions that are frequently covered with a
clear yellow crust. In some patients, however, the typical
painful vesicular or ulcerative lesions may be absent.
Persons with HIV disease and low CD4 counts have
more frequent recurrences of HSV and more extensive
ulcerations than HIV-uninfected people. Persistent
HSV eruption (>1 month) is an AIDS-indicator
diagnosis.
S: Subjective
The patient may complain of eruption of red, painful
vesicles or ulcers (“fever blisters”) with or without an
exudate in the mouth, on the genitals, or in the perianal
area. The patient may complain of burning, tingling, or
itching before eruption of the lesions.
The vesicles will rupture and ulcerate, generally
crusting over and healing in approximately 7-14 days.
The lesions may be pruritic and are often painful. As
immunosuppression progresses, the lesions may recur
more frequently, grow larger or coalesce, and become
chronic and nonhealing.
Perform a history, asking the patient about the
symptoms above, duration, associated symptoms, and
history of HSV or similar symptoms.
O: Objective
Look for punctate, grouped vesicular or ulcerative
lesions on an erythematous base on the mouth, anus, or
external genitals, or are visible on speculum or anoscopic
examination. When immunosuppression is severe,
lesions may coalesce into large painful ulcerations that
spread to the skin of the thighs, lips, face, or perirectal
region. Recurrent lesions may start atypically, first
appearing as a fissure, pustule, or abrasion.
A: Assessment
Section 6—Disease-Specific Treatment | 6–45
A partial differential diagnosis includes:
♦
♦
♦
♦
♦
♦
Oral aphthous ulcers
Chancroid
Syphilis
Cytomegalovirus
Candidiasis
Drug-related eruption
P: Plan
Diagnostic Evaluation
The diagnosis of HSV is usually based on the clinical
appearance and symptoms, without laboratory testing.
If the diagnosis is uncertain, obtain a specimen from a
freshly opened vesicle or the base of an ulcer for culture
confirmation. Note that lesions that are >72 hours
old or are beginning to resolve may not show HSV in
culture.
Polymerase chain reaction (PCR) is also a sensitive
diagnostic test for detection of herpes DNA in
ulcerative lesions, but is more expensive and less widely
available than viral culture.
If culture is not available, perform a Tzanck smear by
staining scrapings from the base of the lesion with
Giemsa or methylene blue to reveal multinucleated
giant cells. Note that this test is fairly insensitive.
If cultures are negative and there is a high suspicion of
HSV infection, skin may be taken from the edge of the
ulcer for biopsy. Biopsy material may also be cultured.
Single serologic tests that detect HSV-1 or HSV-2
antibodies can determine whether a patient has ever
been infected with herpes, and a 4-fold or greater rise
in antibody titer between acute and convalescent serum
specimens may diagnose primary HSV. However, only
about 5% of persons with recurrences will develop a 4fold
rise in titer.
Strongly consider checking for syphilis with a rapid
plasma reagin (RPR) or Venereal Disease Research
Laboratory (VDRL) test in any patient who presents
with genital, anal, or oral ulceration.