Description

An in-depth report on the causes, diagnosis, treatment, and prevention of

herpes simplex.
Alternative Names

Genital herpes; Fever blisters; Cold sores; HSV-1; HSV-2

Diagnosis:

The herpes simplex virus is usually identifiable by its characteristic lesion: A

thin-walled blister on an inflamed base of skin. However, other conditions
can resemble herpes, and doctors cannot base a herpes diagnosis on visual
inspection alone. In addition, some patients who carry the virus may not
have visible genital lesions. Laboratory tests are essential for confirming
herpes diagnosis. These tests include virologic tests (which examine samples
of skin taken from the lesion) and serologic tests (blood tests that detect
antibodies).

In its 2006 guidelines for sexually transmitted diseases, the U.S. Centers for
Disease Control (CDC) recommends that both virologic and serologic tests
be used for diagnosing genital herpes. Patients diagnosed with genital
herpes should also be tested for other sexually transmitted diseases.

According to the CDC, up to 50% of first-episode cases of genital herpes are

now caused by herpes simplex virus 1 (HSV-1). However, recurrences of
genital herpes, and viral shedding without overt symptoms, are much less
frequent with HSV-1 infection than herpes simplex virus 2 (HSV-2). It is
important for doctors to determine whether the genital herpes infection is
caused by HSV-1 or HSV-2, as the type of herpes infection influences
prognosis and treatment recommendations.

Virologic Tests

Viral culture tests are made by taking a fluid sample, or culture, from the
lesions as early as possible, ideally within the first 3 days of appearance. The
viruses, if present, will reproduce in this fluid sample but may take 1 - 10
days to do so. If infection is severe, testing technology can shorten this
period to 24 hours, but speeding up the timeframe during this test may
make the results even less accurate. Viral cultures are very accurate if
lesions are still in the clear blister stage, but they do not work as well for
older ulcerated sores, recurrent lesions, or latency. At these stages the virus
may not be active enough to reproduce sufficiently to produce a visible
culture.
Polymerase chain reaction (PCR) tests are much more accurate than viral
cultures, and the CDC recommends this test for detecting herpes in spinal
fluid when diagnosing herpes encephalitis (see below). PCR can make many
copies of the virus ' DNA so that even small amounts of DNA in the sample
can be detected. PCR is much more expensive than viral cultures and is not
FDA-approved for testing genital specimens. However, because PCR is highly
accurate, many labs have used it for herpes testing.

An older type of virologic testing, the Tzanck smear test, uses scrapings
from herpes lesions. The scrapings are stained and microscopically examined
for the virus. Findings of specific giant cells with many nuclei or distinctive
particles that carry the virus (called inclusion bodies) indicate herpes
infection. The test is quick but accurate 50 - 70% of the time. It cannot
distinguish between virus types or between herpes simplex and herpes
zoster. The Tzanck test is not reliable for providing a conclusive diagnosis of
herpes infection and is not recommended by the CDC.

Serologic Tests

Serologic (blood) tests can identify antibodies that are specific to the virus
and its type, herpes virus simplex 1 (HSV-1) or herpes virus simplex 2
(HSV-2). When the herpes virus infects someone, their body ' s immune
system produces specific antibodies to fight off the infection. If a blood test
detects antibodies to herpes, it ' s evidence that you have been infected
with the virus, even if the virus is in a non-active (dormant) state. The
presence of antibodies to herpes also indicates that you are a carrier of the
virus and might transmit it to others.

Newer type-specific assays test for antibodies to two different proteins that
are associated with the herpes virus:

Glycoprotein gG-1 is associated with HSV-1

Glycoprotein gG-2 is associated with HSV-2

Although glycoprotein (gG) type-specific tests have been available since

1999, many of the older nontype-specific tests are still on the market. The
CDC recommends only type-specific glycoprotein (gG) tests for herpes
diagnosis.

Serologic tests are most accurate when administered 12 - 16 weeks after

exposure to the virus. Recommended tests include:

HerpeSelect. This includes two tests: ELISA (enzyme-linked

immunosorbent assay) or Immunoblot. They are both highly accurate
 in detecting both types of herpes simplex virus. Samples need to be
sent to a lab, so results take longer than the in-office Biokit test.
Biokit HSV-2 (also marketed as SureVue HSV-2). This test detects
HSV-2 only. Its major advantages are that it requires only a finger
prick and results are provided in less than 10 minutes. It is very
accurate, although slightly less so than the other tests. It is also less
expensive.

Western Blot Test. This is the gold standard for researchers with
accuracy rates of 99%. It is costly and time consuming, however, and
is not as widely available as the other tests.

False-negative (testing negative when herpes infection is actually present)

results can occur if tests are done in the early stages of infection. False-
positive results (testing positive when herpes infection is not actually
present) can also occur, although more rarely than false-negative. Your
doctor may recommend that you have the test repeated.

Doctors recommend serologic herpes tests especially for:

People who have had recurrent genital symptoms but no negative

herpes viral cultures
Confirming infection in people who have visible symptoms of genital
herpes

Determining if the partner of someone diagnosed with genital herpes

has acquired herpes

People who have multiple sex partners and who need to be tested for
different types of STDs

At this time, doctors do not recommend screening for HSV-1 or HSV-2 in the
general population.

Tests for Herpes Encephalitis

It may take a number of tests to diagnose herpes encephalitis.

Imaging Tests. Electroencephalography traces brain waves and can identify

about 80% of cases. Computed tomography or magnetic resonance imaging
scans may be used to differentiate encephalitis from other conditions.

Brain Biopsy. Brain biopsy is the most reliable method of diagnosing herpes
encephalitis, but it is also the most invasive and is generally performed only
if the diagnosis is uncertain.
Polymerase Chain Reaction (PCR). The polymerase chain reaction (PCR)
assay looks for tiny pieces of the DNA of the virus, and then replicates them
millions of times until the virus is detectable. This test can identify specific
strains of the virus and asymptomatic viral shedding. PCR identifies HSV in
cerebrospinal fluid and gives a rapid diagnosis of herpes encephalitis in most
cases, eliminating the need for biopsies. The CDC recommends PCR for
diagnosing herpes central nervous system infections.

Similar Conditions

Canker Sores (Aphthous Ulcers). Common canker sores (known medically

as aphthous ulcers) are often confused with the cold sores of herpes simplex
virus 1 (HSV-1). Canker sores frequently crop up singly or in groups on the
inside of the mouth or on or under the tongue. They are usually white or
grayish crater-like ulcers with a sharp edge and a red rim. They usually heal
in 2 weeks without treatment.

Canker sores (Aphthous ulcers) are very common. Typically, they are a
shallow ulcer with a white or whitish/yellow base surrounded by a reddish
border. This ulcer is seen in an individual with AIDS and is located in front
and just below the bottom teeth.

Thrush (Candidiasis). Candidiasis is a yeast infection that causes a whitish

overgrowth in the mouth. It is most common in infants but can appear in
people of all ages, particularly those with impaired immune systems.

Oral thrush
Click the icon to see an image of thrush.

Other conditions that may be confused with oral herpes include herpangina
(a form of the Coxsackie A virus), sore throat caused by strep or other
bacteria, and infectious mononucleosis.

Genital Disorders

Conditions that may be confused with herpes simplex virus 2 (HSV-2)

include bacterial and yeast infections, genital warts, herpes zoster
(shingles), molluscum (a virus disease which produces small rounded
swellings), scabies, syphilis, and certain cancers.

Urinary Tract Infections

In a few cases, HSV-2 may occur without lesions and resemble cystitis and
urinary tract infections.

Eye Injuries

Simple corneal scratches can cause the same pain as herpetic infection, but
these usually resolve within 24 hours and don't exhibit the corneal lesions
characteristic of herpes simplex.

Skin Disorders

Skin disorders that may mimic herpes simplex include shingles and chicken
pox (both caused by varicella-zoster, another herpes virus), impetigo, and
Stevens-Johnson syndrome, a serious inflammatory disease usually caused
by a drug allergy.

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