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Snapshot
  • A 22-year-old man presents to his primary care physician for a sore throat and oral lesions. He said his symptoms began a few days ago and have progressively worsened. Initially, his symptoms were associated with fever and submandibular lymphadenopathy. He endorses having sexual intercourse with multiple female partners without the use of condoms. Physical examination is notable for a perioral papulovesicular lesion without any genital lesions. 
Introduction
  • Classification
    • an enveloped, double-stranded linear DNA virus from the Herpesviridae family  
  • Epidemiology
    • incidence
      • more commonly affects the oral mucosa
  • Transmission
    • respiratory secretions
    • saliva
  • Pathogenesis
    • herpes simplex virus (HSV) 1 inoculates the mucosal surfaces of skin and makes its way to the sensory dorsal root ganglion, where it lies dormant
      • reactivation of HSV 1 from dormancy leads to vesicle formation, pustulations, ulcerations, and scabbing involving the mucosa of the
        • face
        • mouth
        • lips
        • oropharynx
        • eye
    • various triggers can reactivate HSV 1 from dormancy
      • emotional stress
      • immunodeficiency
      • fever
      • menstruation
      • sunlight
      • trigeminal nerve manipulation
      • dental extractions
  • Associated conditions
    • HSV encephalitis 
    • Bell palsy
    • erythema multiforme
    • ezcema herpeticum
    • esophagitis
  • Prognosis
    • lesions are typically self-limiting in healthy patients
    • herpetic episodes are more severe and have a longer duration in immunocompromised patients
Presentation
  • Symptoms/physical exam
    • gingivostomatitis 
    • keratoconjunctivitis
    • esophagitis
    • fever
    • pharyngitis
    • painful vesicular lesions
Studies
  • Making the diagnosis
    • this is a clinical diagnosis based on the patient's history and appearance perioral papulovesicular lesions 
  • Tzank smear
    • demonstrates multinucleated giant cells (intranuclear eosinophilic Cowdry A inclusions)
      • seen in HSV 1, HSV 2, and VZV infections
  • Real-time HSV PCR assay
    • confirms the diagnosis
Differential
  • Aphthous ulcers 
    • differentiating factors
      • these ulcers are never preceded by vesicles and only appear on nonkeratinized mucosal surfaces (e.g., inner surfaces of the lips and buccal mucosa
Treatment
  • Medical
    • acyclovir, famciclovir, or valacyclovir
      • indications
        • immunocompromised patients
        • patients with frequent outbreaks
Complications
  • HSV encephalitis
  • Pneumonitis
  • HSV esophagitis
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Questions (4)
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(M1.MC.15.75) A 5-year-old boy is brought to his pediatrician by his mother with complaints of a sore mouth and fevers over the past several days. The mother reports that she noted blisters on the inside of the boy's mouth, prompting her to bring him to the office for evaluation. His vital signs are as follows: T 38.9 C, HR 102, BP 100/65, RR 22, SpO2 99%. Physical examination reveals the findings shown in Figure A and is also notable for palpable cervical lymphadenopathy. Infection with which of the following organisms is responsible for this patient's presentation? Tested Concept

QID: 106724
FIGURES:
1

Herpes simplex virus type 1

62%

(30/48)

2

Herpes simplex virus type 2

0%

(0/48)

3

Epstein-Barr virus

12%

(6/48)

4

Coxsackie A virus

17%

(8/48)

5

Human herpes virus type 6

4%

(2/48)

M 2 D

Select Answer to see Preferred Response

(M1.MC.15.75) A 26-year-old female presents to her family physician with concern for a lesion that recently developed on her lip (Figure A). She states that a similar episode occurred 'a year or so ago', and the lesion gradually dissipated over a few days without any treatment. She denies any recent sick contacts but does report that she has been under a good amount of stress recently at work to meet various deadlines for a project she is working on. Which of the following best describes the infecting organism in this patient's presentation? Tested Concept

QID: 106737
FIGURES:
1

Positive sense, single-stranded RNA virus

25%

(41/164)

2

Negative sense, single-stranded RNA virus

15%

(24/164)

3

Nonenveloped virus

12%

(20/164)

4

Host cell nuclear membrane-derived envelope

30%

(50/164)

5

Host cell plasma membrane-derived envelope

8%

(13/164)

M 1 D

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Evidence (2)
Topic COMMENTS (2)
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