True or false? State whether the following are true or false regarding genital herpes.a) HSV1 is more commonly associated with genital herpes than HSV2.b) Genital herpes is always symptomatic.c) It presents as a single painless ulcer.d) Acyclovir reduces the recurrence of genital herpes.e) Risk of transmission of HSV to the baby is low if it is recurrent genital herpes in a pregnant mother.
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I now have all the information needed to answer all five questions comprehensively. Here is the full breakdown:
Genital Herpes - True or False
a) HSV-1 is more commonly associated with genital herpes than HSV-2.
FALSE
HSV-2 remains the predominant cause of genital herpes overall. However, this picture is changing: HSV-1 now accounts for >50% of first-episode genital herpes in women under 25 in high-income countries, and in young women and men who have sex with men (MSM) under 25. In women over 25 and men of all ages, HSV-2 is still the most common cause. So while the statement has some truth in specific subgroups, as a general rule it is false - HSV-2 predominates across all ages and sexes.
- Andrews' Diseases of the Skin, p. 801; Campbell-Walsh Urology, p. 2490
b) Genital herpes is always symptomatic.
FALSE
Only ~57% of new HSV-2 infections are symptomatic. Many infected individuals have totally asymptomatic infection, unrecognized outbreaks, or subclinical recurrences. In fact, only 10-25% of HSV-2 seropositive persons ever have recognized genital herpes. Asymptomatic viral shedding occurs on ~10% of days even in those who have never had a recognizable lesion, making them unknowing sources of transmission.
- Andrews' Diseases of the Skin, p. 809; Campbell-Walsh Urology, p. 2490
c) It presents as a single painless ulcer.
FALSE - on two counts:
- Not single: Genital herpes classically presents as grouped (multiple) vesicles on an erythematous base, progressing to multiple ulcers. Lesions are often bilaterally symmetric in primary disease.
- Not painless: The ulcers are characteristically painful. Pain and dysuria are the major complaints. (A single painless ulcer is the classic description of primary syphilis.)
Atypical presentations do occur (fissures, furuncles, vulvar erythema), but the hallmark is multiple painful lesions.
- Campbell-Walsh Urology, p. 2507; Creasy & Resnik's Maternal-Fetal Medicine, p. 2006
d) Acyclovir reduces the recurrence of genital herpes.
TRUE
Suppressive (daily) acyclovir therapy significantly reduces the frequency of recurrences. Preexposure acyclovir prophylaxis (400 mg twice daily) reduces the overall risk of recurrence by ~73%. Long-term suppression with acyclovir (or its prodrug valacyclovir) is a well-established indication - patients have been safely maintained on daily suppression for over 10 years with no evidence of significant toxicity. Suppressive therapy beginning at 36 weeks gestation is specifically recommended in pregnant women with recurrent genital herpes to reduce recurrence at delivery.
- Goodman & Gilman's Pharmacological Basis of Therapeutics; Katzung's Basic and Clinical Pharmacology, p. 1351
e) Risk of transmission of HSV to the baby is low if it is recurrent genital herpes in a pregnant mother.
TRUE
The risk of neonatal transmission differs dramatically by maternal infection type:
- Primary genital HSV acquired near delivery: risk of neonatal transmission is 25-60%
- Recurrent, clinically evident genital HSV: risk is only 1-2%
- Asymptomatic recurrent infection at the time of vaginal delivery: in one study, 0 of 34 infants were infected
The low risk in recurrent infection is due to pre-existing maternal type-specific antibodies, which cross the placenta and provide partial neonatal protection, along with the lower viral load shed during recurrences. The key danger is primary HSV acquired near term, not recurrent disease.
- Creasy & Resnik's Maternal-Fetal Medicine, p. 2023
Summary Table
| Statement | Verdict |
|---|---|
| a) HSV-1 more common in genital herpes | False (HSV-2 predominates overall; HSV-1 leads only in first-episodes in young women) |
| b) Always symptomatic | False (~43% of new infections are asymptomatic) |
| c) Single painless ulcer | False (multiple, painful - single painless ulcer = syphilis) |
| d) Acyclovir reduces recurrence | True |
| e) Low transmission risk to baby in recurrent infection | True (1-2% vs 25-60% in primary infection) |
Herpes simplex virusa) causes persistent infectionb) type I is spread by respiratory secretionc) causes encephalitisd) infection is treated with acyclovirc) infection can be prevented by live attenuated vaccine
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Herpes Simplex Virus - True or False
a) HSV causes persistent infection
TRUE
After primary infection, both HSV-1 and HSV-2 establish persistent/latent infection in sensory ganglia - HSV-1 in the trigeminal ganglia and HSV-2 in the sacral root ganglia. The viral DNA persists indefinitely in the ganglia without producing infectious virions (true latency). Reactivation is triggered by stimuli such as sunlight, physical/emotional stress, fever, trauma, or immune suppression, causing the virus to travel anterograde down axons back to epithelial surfaces and produce recurrent disease. This lifelong latency is the hallmark of all herpesviruses.
- Sherris & Ryan's Medical Microbiology, p. 791; Tintinalli's Emergency Medicine
b) HSV type 1 is spread by respiratory secretions
FALSE
HSV-1 is spread primarily by direct contact with infected oral secretions or mucocutaneous surfaces - classically through kissing, sharing utensils, or direct skin-to-skin contact. It is not spread by the respiratory (airborne/droplet) route. This distinction is important: respiratory spread implies airborne transmission (like influenza or measles), which does not apply to HSV. Asymptomatic oral shedding allows transmission even in the absence of visible lesions.
- Textbook of Family Medicine 9e
c) HSV causes encephalitis
TRUE
HSV-1 is the most common cause of fatal sporadic encephalitis worldwide. It characteristically causes hemorrhagic necrosis of the temporal lobe, beginning unilaterally before potentially spreading to the contralateral side. Clinical features reflect temporal lobe involvement: fever, headache, altered consciousness, behavioral changes, aphasia, and seizures. CSF shows lymphocytic pleocytosis with mildly elevated protein and normal glucose. Diagnosis is confirmed by HSV PCR of CSF. MRI (more sensitive than CT) shows temporal lobe abnormalities.
- Without treatment, mortality exceeds 70% and fewer than 10% of patients return to normal function.
- Goldman-Cecil Medicine
d) Infection is treated with acyclovir
TRUE
Acyclovir is the mainstay of treatment for HSV infections across all clinical scenarios:
-
HSV encephalitis: IV acyclovir 10 mg/kg every 8 hours for 14-21 days - reduces mortality from >70% down to 10-25%
-
Genital herpes (first episode): oral acyclovir 200-400 mg three times daily for 7-10 days
-
Neonatal HSV: IV acyclovir 20 mg/kg every 8 hours for 14-21 days
-
Suppressive therapy: oral acyclovir reduces recurrence frequency by ~73%
-
Its prodrug valacyclovir achieves higher bioavailability and is now preferred in many settings.
-
Goldman-Cecil Medicine; Katzung's Basic and Clinical Pharmacology
e) Infection can be prevented by a live attenuated vaccine
FALSE
There is no licensed vaccine for HSV-1 or HSV-2, live attenuated or otherwise. Despite decades of research (including trials of subunit vaccines like GEN-003 and various glycoprotein-based candidates), no vaccine has achieved sufficient efficacy for regulatory approval. Prevention currently relies on behavioural measures (condom use, avoiding contact during active outbreaks) and chemoprophylaxis (suppressive antiviral therapy to reduce transmission). Note: the only licensed herpesvirus vaccines are for VZV (varicella/Zostavax/Shingrix) - not for HSV.
- Fitzpatrick's Dermatology; Sherris & Ryan's Medical Microbiology
Summary Table
| Statement | Verdict | Key Point |
|---|---|---|
| a) Causes persistent infection | True | Latency in trigeminal (HSV-1) and sacral (HSV-2) ganglia - lifelong |
| b) HSV-1 spread by respiratory secretions | False | Spreads by direct contact with oral secretions, not airborne |
| c) Causes encephalitis | True | Most common cause of fatal sporadic encephalitis; hemorrhagic temporal lobe necrosis |
| d) Treated with acyclovir | True | Drug of choice for all forms of HSV disease |
| e) Prevented by live attenuated vaccine | False | No licensed HSV vaccine exists (unlike VZV) |
Varicella zoster virusa) has several serotypesb) patients are contagious from 2 days before the onset of rash until about 7 days laterc) persist in the anterior horn cells of the spinal corda) infection can be prevented by screening by pap smearb) infection in the mother around the time of delivery can cause severe varicella in newborns
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Varicella zoster virus, persist in the anterior horn cells of the spinal cord . True or false
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