QuestionMy son, 19 years old, has a very painful tongue and roof of the mouth (palet?). His tongue feels very hot and firey. It is difficult for him to eat and he can't taste very well. He has a few raised pimples which are red with a couple of white cancker sores as well. It is difficult to explain but we would like help if possible. Does this sound like something you have seen before? If so, what helps heal it and take it away? Please advice something........this is his second time getting these symptoms in about 2 months. We asked a doctor about herpes but did not think that was it. He had no clues. Can you help?
Thank you in advance.
AnswerDoes this sound like something you have seen before?
Yes, it is oral herpes simplex
If so, what helps heal it and take it away?
Yes, acyclovir 800mg twice daily usually helps my patients.
------------------
Viral disease with many manifestations, usually seen as painful vesicles that often occur in clusters on skin, cornea, or mucous membranes; may occur as encephalitis, pneumonia, or disseminated infection. Usual course of primary disease is 2 weeks; duration of recurrences varies; viral shedding in recurrence is briefer than with primary disease. Newborns or individuals with immune compromise are at risk for major morbidity or mortality.
System(s) affected: Skin/Exocrine, Nervous
Genetics: N/A
Incidence/Prevalence in USA:
29.2/100,000 office visits/year
Widespread; 0.65-20% of adults may be excreting HSV1 or HSV2 at any given time
Prevalence of antibodies varies from 30% in higher socioeconomic strata to 100% in lower socioeconomic strata; 20,000-70,000/100,000
Predominant age: All ages
Predominant sex: Male = Female
SIGNS AND SYMPTOMS
Vesicles - usually cluster and open as painful ulcerated lesions, often with erythematous base
Primary disease classic variations include:
Herpetic whitlow: localized primary infection on a finger with intense itching and pain, followed by vesicles that may coalesce with swelling, erythema, and may mimic pyogenic paronychia; neuralgia and axillary adenopathy sometimes; heals over 2-3 weeks without incision. Primary inoculation of other abraded skin can occur (e.g., herpes gladiatorum in wrestlers).
Primary herpetic gingivostomatitis and pharyngitis: first infection with HSV1 usually in early childhood; incubation from 2-12 days, then fever, sore throat, pharyngeal edema and erythema; small vesicles develop on pharyngeal and oral mucosa, rapidly ulcerate and increase in number to involve soft palate, buccal mucosa, tongue, floor of mouth, and often lips and cheeks; tender gums may bleed; fetid breath, cervical adenopathy; fever, general toxicity, poor oral intake, and drooling contribute to dehydration; autoinoculation of other sites may occur; resolves in 10-14 days with slower resolution of adenopathy
Primary genital herpes: see Herpes, genital topic
Primary herpes keratoconjunctivitis: by HSV1 usually; can present as unilateral conjunctivitis with regional adenopathy, as blepharitis with vesicles on lid margin, as keratitis with dendritic lesions or with punctate opacities; lasts 2-3 weeks but systemic involvement prolongs process
Recurrent diseases from endogenous reactivation include:
Herpes labialis: recurrent lesions on lips with HSV1, usually less than one recurrence per six months, but 5-25% may have more than one attack per month; precipitating events may be sunlight, fever, trauma, menses, stress; prodrome of pain, burning, itching may last 6-48 hrs before vesicles appear, often at vermilion border with increased pain; will ulcerate and crust within 48 hrs; heals within 8-10 days generally; may have local adenopathy
Ocular herpes: may recur as keratitis, blepharitis, or keratoconjunctivitis; may have dendritic ulcers, decreased corneal sensation, less visual acuity; uveitis may cause permanent visual loss
Recurrent genital herpes (herpes progenitalis): see Herpes, genital topic
CAUSES
Herpes simplex virus, a DNA virus of two major types: HSV1 and HSV2; most often HSV1 is associated with oral lesions and HSV2 with genital lesions but reverse occurs also
RISK FACTORS
Immune compromise (brief as with occurrence of other illness or stress, or more chronic as with chemotherapy, malignancy, or AIDS)
Newborns - if exposed to actively infected mother via birth canal or if exposed to case in nursery (insufficient maternal passive antibody transfer); risk greatest for neonate of mother with active primary H. simplex infection
Prior HSV infection
Sexual intercourse with infected person (condoms can help prevent but location of some lesions may permit spread even with condoms)
Occupational exposure (medical/dental risk more for HSV1 whitlow and general community to HSV2 whitlow)
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
Impetigo - straw-colored vesicles that crust
Aphthous stomatitis - grayish, shallow erosions with ring of hyperemia, usually only anterior in mouth and lips
Herpes zoster - unilateral dermatome distribution
Syphilitic chancre - usually painless ulcer
Herpangina - vesicles predominate on anterior tonsillar pillars, soft palate, uvula and oropharynx but not more anteriorly on lips or gums (usually caused by group A Coxsackievirus)
Stevens-Johnson syndrome
Other causes of Kaposi's varicelliform eruption are varicella and Coxsackievirus A16
LABORATORY
Tzanck smear shows multinucleated giant cells often with intranuclear inclusions (scrape material from lesion onto slide, fix with ethanol or methanol, stain with Giemsa or Wright preparation; alternatively spray slide with cytological fixative and stain as for Pap smear)
Herpes simplex virus culture - only half of true positives available in 2 days; rest may take 6 days or longer to be positive; not considered as reasonable means to follow activity of recurrent disease near labor and delivery
Drugs that may alter lab results: N/A
Disorders that may alter lab results: Varicella (herpes zoster) has identical findings on Tzanck smear
PATHOLOGICAL FINDINGS
Multinucleated giant cells with 2-15 nuclei per cell with eosinophilic inclusion bodies within nuclei; intraepithelial edema (ballooning degeneration) and intracellular edema; brain biopsy (in encephalitis) has hemorrhagic necrosis of gray and white matter with acute and chronic inflammation, thrombosis and fibrinoid necrosis of parenchymal vessels, and intranuclear inclusions in astrocytes, oligodendroglia, and neurons
SPECIAL TESTS
Clinically available antibody tests do not reliably distinguish between HSV-1 and HSV-2, but initially high titers or less than a fourfold rise of titers between acute and convalescent sera may help rule-out a primary infection
IgM HSV antibodies may appear in first 4 weeks of life in infected infants
IMAGING
N/A
DIAGNOSTIC PROCEDURES
Occasionally biopsy is needed
Screen for other sexually transmitted diseases with primary genital herpes
TREATMENT
APPROPRIATE HEALTH CARE
Outpatient
GENERAL MEASURES
Limited skin lesions (as in recurrent herpes labialis) may benefit from early unroofing of vesicles and application of Campho-Phenique
Intermittent cool moist dressings with Domeboro or Burow's solution
Inability to void from severe periurethral lesions may be remedied by pouring a cup of warm water over genitals while urinating or sitting in a warm bath to urinate
Children with gingivostomatitis may require IV hydration
Extensive skin disease (as with neonates or with eczema herpeticum) may require vigorous volume replacement
SURGICAL MEASURES
N/A
ACTIVITY
No restrictions
DIET
Avoid acidic foods with gingivostomatitis
PATIENT EDUCATION
Avoid contact with immunocompromised
Wash hands often
Genital herpes: avoid sexual contact while disease is active; discuss condom benefits and limits and reinforce benefits of mutually monogamous sexual relations.
Reassure and reduce stigma
MEDICATIONS
DRUG(S) OF CHOICE
Acyclovir
Primary genital herpes: 400 mg po tid or 200 mg po x 5 doses daily for 7-10 days
Recurrent genital herpes: 800 mg bid or 200 mg po x 5 doses daily for 5 days; for chronic suppression in persons with frequent recurrences - 400 mg bid
Neonatal herpes simplex or encephalitis: 20 mg/kg IV over 1 hour q8h x 14-21 days
Primary herpes gingivostomatitis, recurrent herpes labialis and other HSV skin infections: 200 mg po q4h x 5 doses daily for 10 days
Penciclovir (Denavir)
Oroherpes recurrence: 1% cream q2h while awake for 4 days
Valacyclovir (Valtrex): better bioavailability orally than acyclovir, is converted to acyclovir; indicated for use only in immunocompetent
Primary genital herpes: 1 gm po bid for 7-10 days
Recurrent genital herpes: 500 mg po bid for 3-5 days; chronic suppression 1 g po q/day (10 or more recurrences per year) or 500 mg po q/day (9 or less recurrences per year)
Famciclovir (Famvir): is converted to penciclovir, with longer intracellular half-life and higher levels than acyclovir
Primary genital herpes: 250 mg po tid for 7-10 days
Recurrent genital herpes: 125 mg po bid for 5 days; chronic suppression 250 mg po bid
Contraindications: Acyclovir, valacyclovir, or famciclovir: Hypersensitivity or intolerance
Precautions:
Reduce dosage in renal insufficiency for acyclovir, valacyclovir and famciclovir
Acyclovir may produce encephalopathic reactions, particularly in the elderly
Valacyclovir: Thrombotic thrombocytopenia purpura/hemolytic uremic syndrome (TTP/HUS) reported in some immunocompromised persons in trials on high doses (8 grams daily) for CMV suppression
Pregnancy - see Miscellaneous section
Significant possible interactions: Probenecid with IV acyclovir, possibly probenecid with valacyclovir can reduce renal clearance and elevate antiviral drug levels
ALTERNATIVE DRUGS
Foscarnet: Drug of choice for acyclovir-resistance in immunocompromised persons with systemic HSV; 40 mg/kg IV q8h (assume valacyclovir and famciclovir resistance also if acyclovir resistance occurs)
Other topicals:
Ophthalmic preparations for herpes keratoconjunctivitis: Acyclovir, vidarabine (Vira-A), idoxuridine and trifluorothymidine; refer to ophthalmologist
FOLLOWUP
PATIENT MONITORING
Observe for disappearance of lesions and resolution of systemic manifestations
PREVENTION/AVOIDANCE
See Patient Education
POSSIBLE COMPLICATIONS
Herpes encephalitis - brain biopsy may be needed for diagnosis; herpes pneumonia; aseptic meningitis; herpes viremia
EXPECTED COURSE/PROGNOSIS
Good for treatment of recurrent episodes. Expect frequent recurrences.
MISCELLANEOUS
ASSOCIATED CONDITIONS
Erythema multiforme
AGE-RELATED FACTORS
Pediatric: Previously described
Geriatric: Decreased immunological competence of old age may increase risk
Others: N/A
PREGNANCY
May give acyclovir orally for first episode genital herpes or severe recurrent herpes. Give IV for severe or complicated disease.
Risk of viral shedding at delivery from asymptomatic recurrent genital HSV low (1.6%); not predicted by monitoring cultures
Attack rate for neonatal HSV is 30-50% if primary maternal genital HSV present at time of delivery and < 1% for recurrent genital HSV at time of delivery. Avoid fetal scalp electrodes if maternal history of genital HSV.
C-section and/or acyclovir indicated if any active genital lesions (or prodrome) present at time of delivery; consider if primary genital herpes occurred within 4 wks of expected delivery
Obtain HSV cultures (urine, stool, CSF, eyes, throat) of neonates exposed to primary maternal genital HSV at delivery; treat with acyclovir if clinically ill, cultures positive, CSF abnormal
Neonates with possible exposure to HSV with signs of infection: lethargy, poor feeding, fever, or lesions; admit, culture; treat immediately with IV acyclovir if HSV illness suspected
SYNONYMS
N/A
ICD-9-CM
054.0 Eczema herpeticum
054.9 Herpes simplex, any site
771.2 Neonatal herpes simplex
054.9 Herpes labialis
