Herpes is the most common viral infections of man. Infection with herpes simplex virus (HSV) is 90%, 20% of the world’s population have clinical signs of infection. Genital herpes – sexually transmitted chronic relapsing viral infection.
Etiology and Pathogenesis
The causative agent of the disease is herpes simplex virus serotypes, HSV-1 and HSV-2, most HSV-2. HSV is large enough (diameter 200 nm), DNA-containing, volatile external environment and rapidly killed by drying, heating, disinfectants action.
Infection occurs through sexual contact from an infected partner, are not always aware of their infection. HSV stands with the sperm, so you may transfer agent for artificial insemination. In recent epidemiological significance is oral-genital route of infection. Contagiousness of women reaches 90%. Domestic mode of transmission (through toiletries, clothes) is unlikely, though not eliminated. HSV infection can be transmitted from a sick mother to the fetus transplacental and intrapartum. During pregnancy, HSV can lead to miscarriage, fetal death and malformation of its development (microcephaly, heart defects, retinal dysplasia, microphthalmia, etc.).
The virus enters the body through mucosal damage reproductive organs, urethra, rectum and skin. In the place of deployment, where there are blisters, HSV enters the bloodstream and lymphatic system, settling in the internal organs and nervous system. The virus can also penetrate through the nerve endings of the skin and mucous membranes in the ganglia of the peripheral and central nervous system, which persists for life. Periodically migrate between ganglia (for genital herpes is a ganglion of the lumbar and sacral parts of the sympathetic chain) and the surface of the skin, the virus causes clinical signs of disease recurrence. Manifestation of herpes virus infection contribute to reduction in immunoreactivity, hypothermia or hyperthermia, chronic diseases, menstruation, surgery, physical or mental injury, and alcohol intake. HSV, having neyrodermotropizmom, affects the skin and mucous membranes (face, genitals), central (meningitis, encephalitis) and peripheral (gangliolity) nervous system, eyes (keratitis, conjunctivitis).
Classification
Clinically distinguish the first episode of illness and recurrences of genital herpes, as well as the typical course of infection (with herpes), atypical (without lesions) and the virus carrier.
Clinic
The incubation period is 3-9 days. The first episode of the disease occurs more rapidly than subsequent recurrences. Following a short prodromal period, accompanied by local pruritus and hyperesthesia, the clinical picture unfolds. A typical course is accompanied by extra-genital herpes symptoms (viraemia, intoxication) and genital (the local manifestation of the disease) symptoms. By extragenital symptoms include headache, fever, chills, myalgia, nausea, malaise. Usually these symptoms disappear with the advent of blisters on the perineum, the skin of the vulva, vagina, the cervix (genital symptoms). Vesicles 2-3 mm in size surrounded by a plot hyperemic edematous mucosa. After 2-3 days of existence, they opened with the formation of ulcers covered with grayish-yellow pus (due to secondary infection) bloom. Patients complain of pain, itching, burning at the site of lesion, severity of the lower abdomen, dysuria. When expressed manifestations of the disease are marked low-grade fever, headache, increase in peripheral lymph nodes.
The acute period of herpes infection lasts 8-10 days, after which the visible symptoms disappear.
At present, the frequency of atypical form of genital herpes has reached 40-75%. These forms of the disease have blurred over without herpes lesions and are accompanied by not only the skin and mucous membranes, and internal genital organs. There have been complaints of itching and burning sensation in the lesion, leukorrhea, not amenable to antibiotic therapy, recurrent erosions and leukoplakia of the cervix, habitual miscarriage, infertility. Herpes of the upper genital tract is accompanied by symptoms of nonspecific inflammation. Patients concerned about recurrent pain in the lower abdomen, a common therapy does not give the desired effect.
In all forms of the disease suffer from nervous system, which is manifested in neuropsychiatric disorders – lethargy, irritability, poor sleep, depressed mood, reduced working capacity.
The relapse rate depends on the immunobiological resistance of microorganism and ranges from 1 per 2-3 years, up to 1 times every month.
Diagnosis of genital herpes based on data from medical history, complaints, data of objective inspection. Recognition of typical forms of the disease usually presents no difficulty, since vezikuleznaya rash has the characteristic symptoms. However, one should distinguish between ulcers after opening herpetic vesicles from syphilitic ulcers, heavy, pain-free, with smooth edges. Diagnosis of atypical forms of genital herpes is extremely complex.
Used highly sensitive and specific laboratory diagnostic methods: the cultivation of the virus in cell culture of chick embryo (the “gold standard”) or detection of viral antigen by enzyme immunoassay, immunofluoresence, immunoperoxidase method, polymerase chain reaction (PCR). Material for research is detachable from herpetic vesicles, vagina, cervix, urethra. A simple definition of antibodies in the serum to the virus is not an accurate diagnostic criterion because it reflects only the infection with HSV, including not only the genital. Diagnostic value of the first episode of the disease has a fourfold increase in titers of specific IgG in paired serum of patients with an interval of 10-12 days, and to identify gM. Diagnosis
installed only on the basis of serological tests, may be erroneous.
Treatment
Sexual partners of patients with genital herpes should be screened for HSV, while clinical signs of infection – to treat. To the disappearance of the manifestations of the disease must abstain from sex or use condoms.
Since at present there are no methods of elimination of HSV from the body, the goal of treatment is to suppress virus replication during acute disease and the formation of a persistent immunity to prevent a recurrence of herpes infection.
Recommended schemes of antiviral therapy first clinical event (TSNIKVI and the Russian Association of Obstetricians and Gynecologists, 2001):
- Acyclovir 200 mg orally 5 times a day for 5-10 days;
- Valacyclovir 500 mg orally 2 times a day for 5-10 days.
At relapse of the disease or prescribe acyclovir, valacyclovir for the same schemes, but a duration of 10 days.
Alternative regimens:
- Glycyrrhizic acid as a spray vaginally 2-3 times a day for 6-10 days, the skin of the vulva 6 times a day, 5-10 days;
- Vidarabin 10% gel to the affected areas 4 times a day, 7 days;
- Riodoksol 0,25-1% ointment for 5-10 days;
- 3-5% acyclovir ointment 5 times per day 5-10 days.
An integrated approach involves the use of non-specific (T-activin, timalin, thymogen, Myelopid standard scheme) and specific (antiherpetic gamma globulin, herpes vaccine) immunotherapy. An extremely important link in the treatment of herpes is a correction of interferon system as the main barrier to the introduction of viral infections in the body. A good effect is given inducers of synthesis of endogenous interferon: Poludan as applications on the affected mucous membranes; cycloferon 0,25 g intramuscularly or 0,3-0,6 g orally at 1-2-4-6-8-11-14 – 17-20-23rd day Neovir 250 mg intramuscularly every 48 h, 5-7 injections; amiksin 250 mg 1 time a day 2 days, then 125 mg every other day for 3-4 weeks. As replacement therapy using interferon drugs – viferon in rectal suppositories, reaferon intramuscularly, etc.
In addition, recommends that local application of antiseptics to prevent secondary purulent infection.
In order to prevent recurrence of herpetic use of the vaccine, immune drugs interferonogeny as well:
- Acyclovir 400 mg orally 2 times a day;
- Valacyclovir 500 mg 1 time per day;
- Glycyrrhizinic acid, 2 times a day in the morning on the skin of the vulva and intravaginally for 8-10 days before menstruation.
The duration of therapy is determined individually.
Treatment of pregnant women are compulsory on these schemes. Caesarean section in the prevention of neonatal herpes is shown only when herpes on the genitals or in the first clinical episode in the mother during the last month before the birth. In other cases, delivery is possible through the birth canal.
The criteria for treatment efficacy believe the disappearance of clinical manifestations of disease (relapse), the positive dynamics of specific antibodies.
