Rosen & Barkin's 5-Minute Emergency Medicine Consult (341 page)

• Most common cause of severe sporadic encephalitis in the western world
  
• Usually from HSV-1 reactivation disease
  

May or may not have known history of exposure to HSV-1 or HSV-2

Vesiculoulcerative lesions in orofacial or genital area

• Up to 60–80% of babies who develop neonatal HSV are born to mothers without history of genital herpes
  
• Vesicular skin lesions may or may not be present on initial exam
  
• Primary genital disease of the mother increases risk of transmitting virus to fetus
  
• Most primary infections occur during childhood; symptomatic in only 5–10% of children
  
• Orofacial disease is most likely to present as gingivostomatitis in children younger than 5 yr of age
  
• Whitlow may be caused by thumb-sucking children with oral herpes
  

• Herpes encephalitis:
  
  • Lumbar puncture if herpes encephalitis is considered
    
• Herpes ophthalmicus:
  
  • Fluorescein exam if ocular herpes is a concern
    

• Orofacial:
  
  • Presumptive diagnosis made by history and exam
    
  • If definitive diagnosis is necessary (e.g., systemic disease, child abuse):
    
    • Viral culture or polymerase chain reaction (PCR) testing of swabs from vesicles
      
  • PCR is the most accurate and reliable method for detecting the virus
    
    • Fluorescent antibody detection of antigen; serum antibody studies
      
    • Scrapings for Tzanck smear or Papanicolaou stain
      
    • Skin biopsy if hyperkeratotic or lichenoid lesions
      
• Eye:
  
  • Dendritic corneal lesions by fluorescein exam
    
  • Swab of affected area for viral culture or fluorescent antibody detection
    
• CNS/encephalitis:
  
  • Lumbar puncture with CSF pleocytosis and negative bacterial antigens
    
  • CSF PCR
    
  • MRI/CT (abnormalities in temporal lobe may be visualized)
    
  • EEG diagnostic if spike and waves in temporal region
    

• Lesion scrapings can be sent for culture or PCR testing
  
• Tzanck smear demonstrating multinucleated giant cells, atypical keratinocytes, and large nuclei
  
• Serum testing has limited ED use
  
• ELISA testing may demonstrate HSV antibodies, determining past exposure only
  
• Requires 2 wk to >3 mo to detect seroconversion
  

• Orofacial and skin:
  
  • Bacterial pharyngitis
    
  • Mycoplasma pneumoniae pharyngitis
    
  • Stevens–Johnson syndrome
    
  • Herpes zoster
    
  • Varicella
    
  • Pemphigus
    
  • Contact or chemical dermatitis
    
  • Impetigo
    
  • Syphilis
    
• Eye:
  
  • Conjunctivitis: Viral, bacterial, or allergic
    
  • Herpes zoster ophthalmicus
    
  • Scleritis/episcleritis
    
  • Angle-closure glaucoma
    
  • Corneal abrasion
    

TREATMENT

• Maintain universal precautions.
  
• Pain control
  

Protect airway in comatose or obtunded patients with suspected CNS disease

• Orofacial/gingivostomatitis:
  
  • Primary disease in healthy children is generally not treated
    
  • Primary disease in normal host with mild disease requires only supportive treatment with hydration and analgesia
    
  • Severe disease or immunocompromised patients: IV or oral acyclovir, valacyclovir, or famciclovir
    
  • Oral acyclovir is first-line medication
    
  • If recurrent disease, oral antivirals are most helpful if started with prodrome or at 1st sign of lesion:
    
    • Reduces lesions and symptoms by 1–2 days
      
  • Consider prophylaxis in patients with more than 6 episodes per year; history of herpes-associated erythema multiforme or herpes gladiatorum; upcoming intense sun exposure or stress; perioral/intraoral surgery; cosmetic facial procedures:
    
    • Prophylaxis reduces frequency and severity of herpes labialis and may help decrease asymptomatic shedding, leading to decreased transmission
      
    • Does not cure or terminate the disease
      
    • When prophylaxis is stopped, most patients have recurrences
      
• Skin (other than orofacial or genital):
  
  • May be treated with oral acyclovir
    
  • Antibiotics if secondary bacterial infection
    
  • Do not incise and drain
    : May lead to spread of infection
    
• Eye:
  
  • Oral acyclovir and topical antiviral therapy with trifluridine or vidarabine
    
  • Vidarabine ointment for children
    
  • Do not treat with steroids
    : May cause increased viral replication
    
  • Ophthalmology consult
    

Acyclovir has been used to suppress genital herpes near end of pregnancy and appears safe, but is not FDA approved

• Acyclovir:
  
  • Orofacial and skin: 400 mg PO TID for 7–10 days or 5–10 mg/kg IV (5–10 mg/kg) q8h for 7–14 days
    
  • Pediatric mucocutaneous primary infection: 40–80 mg/kg PO in 3–4 div. doses for 5–10 days; max. dose 1 g/d
    
  • Eyes for suppression therapy: 400 mg PO BID
    
  • Encephalitis: 60 mg/kg/24h IV div. q8h for 14–21 days
    
• Famciclovir:
  
  • Primary orofacial: 250 mg PO TID for 7–10 days (immunocompetent), 500 mg PO BID for 7–10 days (immunocompromised)
    
• Trifluridine:
  
  • Adults and peds older than 6 yr: 1 drop of 1% ophthalmic ointment to eye q2h while awake (max. 9 drops per day) for at least 10 days and then taper under ophthalmology consultation
    
• Valacyclovir:
  
  • Adults primary mucocutaneous: 1,000 mg PO BID for 7 days
    
  • Adult recurrent mucocutaneous (nongenital): 500 mg PO BID for 3 days
    
• Vidarabine:
  
  • Adults or peds older than 2 yr: Topical 0.5 in ribbon of 3% ophthalmic ointment to eye 5 times per day
    
• Recurrent mucocutaneous herpes:
  
  • Acyclovir: 400 mg PO TID for 5 days
    
  • Famciclovir: 1,000 mg PO BID for 1 day
    
  • Valacyclovir: 500 mg PO BID for 3 days
    
• Long-term prophylaxis:
  
  • Acyclovir: 400 mg PO BID
    
  • Valacyclovir: 500 mg PO daily
    
  • Famciclovir: 250 mg PO BID
    

FOLLOW-UP

• Encephalitis, disseminated disease, dehydration
  
• Severe local or disseminated disease in immunocompromised host
  
• Neonatal HSV
  
• ICU vs. ward based on toxicity and need for airway support
  
• Ophthalmology consult vs. admission for ocular involvement
  

Uncomplicated local disease

• Suppressive treatment options
  
• Herpes infection during pregnancy
  

Skin/genital infection:

• Follow-up with the patient’s primary doctor to discuss risks and benefits of suppressive therapy
  

• Failure to consider herpes simplex encephalitis in patients whom you have a concern for meningitis/encephalitis
  
• Failure to consider ocular herpes in patients presenting with eye pain, decreased vision, and/or lesions on nose
  
• Failure to warn patients about the risk of transmission to others especially during outbreaks and for 1–2 wk thereafter
  
• Failure to warn patients to avoid touching the lesions during outbreaks to prevent spread of the lesions to other body areas
  

• Cernik C, Gallina K, Brodell RT. The treatment of herpes simplex infections: An evidence based review.
  Arch Intern Med
  . 2008;168:1137–1144.
  
• Chayavichitsilp P, Buckwalter JV, Krakowski AC, et al. Herpes simplex.
  Pediatr Rev
  . 2009;30:119–130.
  
• Habif, YP. Warts, herpes simplex, and other viral infections.
  Clin Dermatol.
  2010;5:454–490.
  
• Mell HK. Management of oral and genital herpes in the emergency department.
  Emerg Med Clin North Am
  . 2008;26:457–473.
  
• Workowski KA, Berman S. Centers forDisease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010.
  MMWR Recomm Rep.
  2010;59:1–110.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Genital Herpes
  
• Varicella
  
• Zoster
  

CODES