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Key Features

Essentials of Diagnosis

  • Grouped vesicles on an erythematous base, typically in or around the mouth or genitals

  • Tender regional adenopathy is common with primary infection

  • Fever and malaise with primary infection

  • Recurrent episodes in many patients

General Considerations

  • There are two types of herpes simplex virus (HSV)

  • Type 1 (HSV-1)

    • Causes most cases of oral, skin, and cerebral disease in older children

    • Latent infection is routinely established in sensory ganglia during primary infection

    • Recurrences may be spontaneous or induced by external events (eg, fever, menstruation, or sunlight) or immunosuppression

    • Transmission is by direct contact with infected secretions

    • Primary infection is subclinical in 80% of cases and causes gingivostomatitis or genital disease in the remainder

  • Type 2 (HSV-2)

    • Transmitted sexually

    • Produces mild, nonspecific symptoms

    • Recurrent episodes are due to reactivation of latent HSV

Clinical Findings

  • Gingivostomatitis

    • High fever, irritability, and drooling occur in infants

    • Multiple oral ulcers are seen on the tongue and on the buccal and gingival mucosa, occasionally extending to the pharynx

    • Pharyngeal ulcers may predominate in older children and adolescents

    • Diffusely swollen red gums that are friable and bleed easily are typical

    • Cervical nodes are swollen and tender

    • Duration is 7–14 days

  • Vulvovaginitis or urethritis

    • Vesicles or painful ulcers on the vulva, vagina, or penis and tender adenopathy are typical

    • Systemic symptoms (fever, flu-like illness, myalgia) are common with the initial episode

    • Painful urination is frequent, especially in females

    • Primary infection lasts 10–14 days before healing

  • Cutaneous infections

    • Direct inoculation onto cuts or abrasions may produce localized vesicles or ulcers

    • A deep HSV infection on the finger (called herpetic whitlow) may be mistaken for a bacterial felon or paronychia

  • Recurrent mucocutaneous infection

    • Recurrent oral shedding is asymptomatic

    • Perioral recurrences often begin with a prodrome of tingling or burning limited to the vermillion border, followed by vesiculation, scabbing, and crusting around the lips over 3–5 days

    • Recurrent intraoral lesions are rare

    • Fever, adenopathy, and other symptoms are absent

  • Keratoconjunctivitis

    • Produces photophobia, pain, and conjunctival irritation

    • Dendritic corneal ulcers may be demonstrable with fluorescein staining

    • Stromal invasion may occur

  • Encephalitis

    • Unusual in infants outside the neonatal period

    • In older children, can follow a primary infection but usually represents reactivation of latent virus

    • Sudden onset is associated with fever, headache, behavioral changes, and focal neurologic deficits and/or focal seizures

  • Neonatal infections

    • May be acquired by ascending spread prior to delivery (< 5% of cases)

    • However, occurs most often at the time of vaginal delivery from a mother with genital infection

    • Some infants (45%) have infection limited to the skin, eye, or mouth

    • Other infants are acutely ill, presenting with jaundice, shock, bleeding, or respiratory distress (20%)

    • Some infected infants exhibit only neurologic symptoms at 2–3 weeks after delivery: apnea, lethargy, fever, poor feeding, or persistent seizures


Laboratory Findings


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