Editing Sexually Transmitted Infections (section)

===== Herpes =====
* '''Most common cause of genital ulcers'''
* '''Caused by the herpes simplex virus, a double-stranded DNA virus'''
** '''HSV-1 causes mainly oral infections but now accounts also for 5-30% of first episodes of genital HSV infections'''
** '''HSV-2 causes the majority of genital herpes and is transmitted by sexual contact'''
* Females are more susceptible to HSV-2 infection and are more likely to have symptomatic infections. Most HSV-2 transmission thus occurs from individuals who do not know they are infected
* '''HSV-2 infection seems to protect against HSV-1 infection, but HSV-1 gives only a small amount of protection from infection with HSV-2'''
* '''Pathophysiology'''
** HSV initiates replication in epithelial cells at the site of entry, damages the cells, and enters the ends of peripheral sensory nerves. Once in the nerve cell body, HSV enters a latent state
** Recurrence and reactivation of virus occur with transportation in the peripheral nerves back to the mucosal or skin surface.
*** '''Events that trigger reactivation of HSV include local trauma such as surgery or ultraviolet light, immunosuppression, or fever'''
** '''Incubation period: 4-7 days after sexual intercourse'''
* '''Diagnosis and Evaluation'''
** '''History and Physical Exam'''
*** '''History'''
**** '''Patients have pain, burning, or itching, and 80% of women report dysuria.'''
**** '''Other associated symptoms include flu-like symptoms, fever, headache, malaise, and myalgias.'''
**** '''Possible complications include aseptic meningitis and autonomic dysfunction that can lead to urinary retention'''
*** '''Physical Exam'''
**** '''The classic first presentation of primary herpes is clusters of erythematous papules and vesicles on the external genitalia that do NOT follow a neural distribution'''
**** '''Tender inguinal and femoral lymph nodes may be present.'''
**** '''Over the next 2- 3 weeks, 75% of patients have new lesions, which can progress to vesicles and pustules and can coalesce into ulcers before crusting and healing'''
**** '''Primary genital HSV-1 infection cannot be distinguished from HSV-2 infection on clinical examination alone, but requires laboratory testing.'''
**** Insert figure
*** '''Labs'''
**** '''Options: NAAT or cell culture of a lesion'''
***** '''NAAT is preferred''' due to increased sensitivity, and viral cultures are limited by the rate of viral shedding that can be intermittent and, therefore, cause false-negative results
**** '''While the Tzanck preparation has historically been used, it should not be solely relied upon as it is non-specific and insensitive.'''
**** '''In patients with no active lesions, serology must be used; specific immunoglobulin G (IgG) testing can distinguish the two types of HSV'''
** '''Recurrent episodes'''
*** '''Genital HSV-1 recurs much less frequently than genital HSV-2 infections'''
*** '''HSV recurrences decrease after the first year'''
** '''Management'''
*** '''Treatment for a first clinical episode should be started on clinical grounds before laboratory confirmation of diagnosis.'''
*** '''Currently available medications do not eradicate the virus, but aim to reduce the signs and symptoms of infection and prevent new lesions.'''
**** '''Treatment of recurrent episodes reduces their severity and duration'''.
***** Oral therapy within 24 hours of the first signs or symptoms of recurrence increases the chance of resolving a recurrence without lesions
*** '''Options (3): -clovir'''
***# '''Acyclovir'''
***#* May be needed for those with neurologic complications, those unable to take oral medications, or those with widespread disease (e.g., immunocompromised patients)
***# '''Valacyclovir'''
***# '''Famciclovir'''
*** '''Treatment is usually 7 to 10 days''' but should be extended if lesions are not adequately healed
*** '''Lesions heal in 5-10 days in the absence of antiviral treatment'''