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Snapshot
  • A 22-year-old man presents to an urgent care clinic for a severe painful genital ulcer. His symptoms are associated with fever, headache, myalgias, and dysuria. He has a medical history of asthma. Social history is significant for having multiple recent sexual partners while not using condoms. Physical examination is significant for a genital ulcer with associated tender inguinal lymphadenopathy. A polymerase chain reaction returns positive for HSV2 infection.
Introduction
  • Classification
    • an enveloped, linear, double-stranded DNA virus from the Herpesviridae family
  • Epidemiology
    • incidence
      • most cases of recurrent genital herpes are caused by HSV2
  • Transmission
    • sexual contact
    • perinatal
  • Pathogenesis
    • HSV2 inoculates in the mucous membrane or skin after close contact with the skin or genital secretions of a patient with viral shedding
      • cytolytic replication occurs in the epithelial cells where the virus enters, which then travels to the sensory dorsal root ganglia, where it lies dormant
  • Prognosis
    • immunocompromised patients have more severe herpetic episodes with frequent viral reactivation
Presentation
  • Symptoms/physical exam
    • painful genital ulcers  
    • dysuria
    • fever
    • inguinal lymphadenopathy
Studies
  • Making the diagnosis
    • based on the patient's history and physical exam, which is confirmed by laboratory testing
  • Confirmatory testing includes
    • viral culture
    • polymerase chain reaction (PCR)
    • direct fluorescence antibody
    • serological testing
  • Tzank smear
    • demonstrates multinucleated giant cells (intranuclear eosinophilic Cowdry A inclusions)
      • seen in HSV1, HSV2, and VZV infections
Differential
  • Chancre
    • differentiating factor
      • abnormal VDRL and RPR testing
Treatment
  • Medical
    • acyclovir, famciclovir, or valacyclovir  
      • indications
        • immunocompromised patients
        • patients with frequent outbreaks
Complications
  • Neonatal herpes
  • Disseminated vesicular rash

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Questions (4)
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(M1.MC.15.71) A 25-year-old female presents to the gynecologist with the following lesions (Figure A). She reports having had unprotected sex with several partners in the past six months. A Tzanck smear (Figure B) was performed from one of the lesions. The physician prescribes oral acyclovir to decrease the duration and severity of the outbreak. In which of the following locations/cell types does the agent of this outbreak establish a latent infection?

QID: 106497
FIGURES:
1

Sacral nerve ganglion

48%

(205/430)

2

Dorsal root ganglion

32%

(136/430)

3

Trigeminal nerve ganglion

11%

(47/430)

4

B cells

3%

(14/430)

5

CD4+ T cells

3%

(13/430)

M 1 C

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Evidence (1)
EXPERT COMMENTS (6)
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