Herpes Simplex Virus

2013

Herpes simplex virus (HSV) is a member of the human herpes virus group that includes, for example, herpes simplex virus-1, herpes simplex virus-2, and Epstein-Barr virus (EBV). Herpes simplex virus is a recurrent viral infection that remains dormant in the nervous system with periods of reactivation characterized by individual or multiple clusters of fluid-filled vesicles at specifically affected sites. Herpes simplex virus-1 and -2 are the main types of herpes virus seen in general clinical practice. Herpes simplex virus-1 typically manifests above the waist and is referred to as Herpes labialis because of it primarily appearing on the lips in the form of “cold sores.” Herpes simplex virus-2, Herpes genitalis, typically appears on the genitals, although it also produces skin lesions. The vesicles rupture, leaving small, sometimes painful ulcers, which generally heal without scarring, although recurrent lesions at the same site may cause scarring. Coinfection with herpes simplex virus-1 and -2 increases the frequency of herpes simplex virus-2 outbreaks. Orogenital sex can lead to cross-contamination of these sites, with oral herpes being more likely transmitted to the genitals than the other way around. The incubation period for herpes simplex virus-1 is 3 to 7 days and 3 to 5 days for herpes simplex virus-2.

Approximately 75% of individuals in the United States are infected with herpes simplex virus-1, and about 25% with herpes simplex virus-2, with an estimated incidence of 500,000 to 1 million new cases annually. Independent predictors of herpes simplex virus-2 infection include sex (women are more likely to become infected and have more frequent outbreaks, whereas men are more likely to transmit infection), race (rates are higher among African Americans and Mexican Americans), increased age, less education, poverty, cocaine use, and multiple sexual partners. Since the late 1970s, seroprevalence has quintupled among white teenagers and doubled among whites in their twenties. The virus is spread through contact with the lesions and through viral shedding. Sexual contact is the primary method of contamination; however, kissing and other contact with sores or shed virus in an asymptomatic individual can lead to infection. Casual contact, such as sharing of a drinking glass or cigarette has also been known to lead to infection. Ninety percent of affected individuals are unaware they have herpes. Herpes simplex virus-2 infection significantly increases susceptibility to HIV infection.

Immunologic changes of pregnancy, particularly depression of T-cell response, appear to make pregnant women more susceptible to a number of viral infections, including herpes simplex virus. Primary herpes outbreaks in pregnancy, especially during the third trimester, pose great danger to a newborn, causing significant morbidity and mortality. Antibodies to herpes simplex virus-2 have been detected in about 20% of pregnant women, with only about 5% aware they have herpes (see Herpes Simplex Virus in Pregnancy).

Prevention is always the best treatment. Practicing safe sex on all occasions regardless of whether lesions are visible, and avoiding contact with active lesions is essential. Herpes simplex virus may be shed in the saliva and genital secretions of asymptomatic individuals. Active lesions shed between 100 and 1000 times the amount of virus. Minor injury, for example, irritation from vaginal Candida infection, may increase the likelihood of viral transmission. Condoms do not guarantee protection, but do significantly reduce herpes simplex virus-2 transmission, especially to women. The virus is commonly passed from a person who does not know they have the virus because they have never had any symptoms.

Pathophysiology

Herpes simplex virus travels along the peripheral nerve axons to the nerve cell bodies in the dorsal root ganglia and can exist in the paraspinous ganglia indefinitely, sometimes in a completely inactive state. The virus can be reactivated and begin replicating in response to such factors as stress, depression, and anxiety, trauma to mucosa, fever, exposure to ultraviolet light (sun exposure), menstruation, poor sleep, spicy food, immunodeficiency, and other unknown factors. Migration to mucosal surfaces by way of the peripheral sensory nerves can lead to a cutaneous outbreak of lesions, which are often painful. Although the virus usually becomes dormant after an outbreak and before the next outbreak, if it occurs, an infected person, even if asymptomatic, can still pass the virus to another person. Asymptomatic viral “shedding” is common and occurs in cycles. Therefore, transmission of infection is possible at any time regardless of the presence of active lesions. The possibility of transmission between an infected and uninfected person in a monogamous relationship increases at the rate of about 10% a year. Women who have regular herpes outbreaks, or who have a sexual partner who has active outbreaks, should have routine Pap smears because herpes may predispose women to cervical cancer. Recent research suggests possible long-term consequences of harboring chronic herpes simplex virus infection, such as development of rheumatoid arthritis.

Symptoms of Herpes

Diagnosis

When a patient presents with clusters of painful vesicles and inflammation of the surrounding area, herpes should be considered. The standard test for herpes simplex virus infections is viral culture of vesicular fluid. Direct immunofluorescent staining with conjugated monoclonal antibodies to herpes simplex virus is faster, more expensive, and only about 80% to 90% as accurate as viral culture. Polymerase chain reaction (PCR) is the most accurate and most expensive test.

Diagnosis in the neonate can be difficult at first because symptoms are sometimes nonspecific (e.g., fever, lethargy), with no other outward signs of infection. Less than 50% of newborns with disseminated disease or encephalitis have skin lesions. If diagnosis is delayed, damage to the CNS or internal organs can be significant.

Conventional Treatment Approaches

Antiviral therapy with drugs that selectively inhibit viral replication including acyclovir, famciclovir (Famvir), and valacyclovir (Valtrex) is the standard treatment. Acyclovir has been on the market for over 20 years, and has a reasonable safety profile, even when given during pregnancy. Teratogenicity has not been demonstrated, even during the first trimester. Famciclovir and valacyclovir are more absorbable and higher blood levels can be sustained, although their safety, especially during pregnancy, has not been as thoroughly tested as acyclovir. Studies suggest that prophylactic administration of acyclovir during pregnancy can reduce shedding, shorten the duration of shedding, and reduce the cesarean rate, although these were small and not conclusive. The usual dose of acyclovir is 60 mg per kg of body weight per day in three doses intravenously for 14 days for localized skin disease, and 21 days for more severe infections. Acyclovir has been associated with numerous side effects in its various dosage forms, including nausea and vomiting, diarrhea, headache, dizziness, fatigue, skin rash, edema, inguinal lymphadenopathy, anorexia, leg pain, medication taste, and sore throat from short-term oral administration, and nausea and vomiting, diarrhea, headache, dizziness, insomnia, irritability, depression, rash, acne, hair loss, arthralgia, fever, palpitations, sore throat, muscle cramps, menstrual abnormalities, and lymphadenopathy with long-term use.

Herpes Simplex Virus In Pregnancy

It is estimated that 20% to 25% of pregnant women have genital herpes. With recurrent herpes, less than 0.1% of babies will contract the infection. Primary herpes outbreaks pose a much greater risk to the fetus / neonate with transmission rates as high as 50%. In asymptomatic cases the risk of transmission at birth is about 0.04%; in symptomatic cases, the risk is about 5%.

Primary herpes infection in pregnancy is associated with miscarriage, premature labor, intrauterine growth retardation, and neonatal infection. Neonatal infection most frequently occurs during labor and is associated with increased neonatal death, brain damage, seizures, cerebral palsy, blindness, and deafness. Neonatal herpes affects about 1 in 15,000 newborns and the prognosis for disseminated disease with encephalitis is poor. Because 90% of cases of neonatal herpes are a result of direct contact with lesions in the birth canal, cesarean section is routinely performed as the mode of delivery in active herpes outbreaks at the time of labor. Neonates are treated acyclovir or vidarabine, but this treatment is less effective once the infection has spread to the brain and internal organs.

More recently, experiments have looked at using acyclovir for herpes prophylaxis in late pregnancy. Treatment has been shown to reduce recurrences after a primary infection, and reduce asymptomatic viral shedding as well as need for cesarean delivery; however, prophylaxis only partly prevents neonatal herpes infection, because it is not applicable to patients with no known clinical history but may excrete the virus.

The Botanical Practitioner’s Perspective

Botanical Treatment Protocol for Recurrent Herpes Simplex Virus

Nutritional Considerations

Additional Therapies

Chronic stress has the most significant impact on recurrent herpes simplex virus, even more so than acute stress. Regular practice of mind-body therapies that help to relieve stress are important in the prevention of recurrent herpes simplex virus for many patients. Examples include meditation, yoga, biofeed-back, and massage.

Treatment Summary For Herpes

  • • Observe safe sex and common hygienic safety practices to reduce the likelihood of transmission of infection
  • • Reduce exposure to avoidable common stressors that trigger outbreaks, for example, excessive sunlight exposure
  • • Minimize unavoidable chronic stress and practice stress reduction techniques such as yoga and meditation
  • • Regulate hormones and reduce stressors related to menstruation if outbreaks are cyclically related
  • • Use adaptogens and nervines for improving immune and stress response
  • • Use antivirals internally and topically to prevent recurrence and reduce frequency of outbreaks
  • • Use topical astringents, anti-inflammatories, analgesics, and vitamin E to speed healing and reduce pain
  • • Reduce dietary arginine and increase lysine
  • • Supplement with zinc and vitamin C
  • • Pregnant women should make every effort to avoid outbreaks late in the third trimester, and should be evaluated for herpes infection in late pregnancy to be sure there are no active lesions during a vaginal birth.

What to expect with botanical treatment of herpes:

Patients can expect to shorten the duration, frequency, and severity of herpes outbreaks in as quickly as 24 hours with aggressive topical treatment in outbreaks that are caught early. Prevention of recurrence of herpes can be achieved quickly with the addition of dietary and lifestyle modifications accompanied by nervine, adaptogen, and antiviral therapy, internally and topically as appropriate and indicated. Some patients may continue to experience periodic and infrequent outbreaks during times of heightened stress, but these can largely be ameliorated with adherence to botanical and dietary protocol. Some patients experience complete remission of the virus, and may go indefinitely, even more than a decade, without a sign of an outbreak.

Case History: Herpes Simplex Virus-2 In Pregnancy