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Herpes


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Herpes

digital illustration of the herpes virus
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What is herpes?

Herpes is the name of a group of viruses that cause painful blisters and sores. The most common viruses are:
  • Herpes zoster – causes chickenpox and shingles
  • Herpes simplex virus (HSV) type 1 and type 2 – causes cold sores or fever blisters around the mouth and sores on the genitals (sexual organs).
Genital herpes is a sexually transmitted infection (STI). Once you are infected, you have the virus for the rest of your life.

Symptoms of herpes

Many people who get herpes never have symptoms. Sometimes the symptoms are mild and are mistaken for another skin condition. If you experience symptoms, they may include:
  • painful sores in the genital area, anus, buttocks, or thighs
  • itching
  • painful urination
  • vaginal discharge
  • tender lumps in the groin.
During the first outbreak (called primary herpes), you may experience flu-like symptoms. These include body aches, fever, and headache. Many people who have a herpes infection will have outbreaks of sores and symptoms from time to time. Symptoms are usually less severe than the primary outbreak. The frequency of outbreaks also tends to decrease over time.

Stages of infection

Once you have been infected with the virus, you’ll go through different stages of infection.

Primary stage

This stage usually starts 2 to 8 days after you’re infected. Usually, the infection causes groups of small, painful blisters. The fluid in the blisters may be clear or cloudy. The area under the blisters will be red. The blisters break open and become open sores. You may not ever notice the blisters, or they may be painful. It may hurt to urinate during this stage. You may run a fever, feel achy, and have other flu-like symptoms.
While most people have a painful primary stage of infection, some don’t have any symptoms at all. They may not even know they’re infected.

Latent stage

During this stage, there are no blisters, sores, or other symptoms. The virus is traveling from your skin into the nerves near your spine.

Shedding stage

In the shedding stage, the virus starts multiplying in the nerve endings. If these nerve endings are in areas of the body that make or are in contact with body fluids, the virus can get into those body fluids. This could include saliva, semen, or vaginal fluids. There are no symptoms during this stage, but the virus can be spread during this time.

Recurrences

Many people have blisters and sores that come back after the first herpes attack goes away. This is called a recurrence. Usually, the symptoms aren’t as bad as they were during the first attack.
Stress, being sick, or being tired may start a recurrence. Being in the sun or having your menstrual period may also cause a recurrence. You may know when a recurrence is about to happen because you may feel itching, tingling, or pain in the places where you were first infected.

What causes herpes?

The virus that causes genital herpes is usually spread from one person to another during vaginal, oral, or anal sex. The virus can enter your body through a break in your skin. It can also enter through the skin of your mouth, penis, vagina, urinary tract opening, or anus. Herpes is most easily spread when blisters or sores can be seen on the infected person. But it can be spread at any time, even when the person who has herpes isn’t experiencing any symptoms.
Herpes can also be spread from one place on your body to another. If you touch sores on your genitals, you can carry the virus on your fingers. Then you can pass it onto other parts of your body, including your mouth or eyes.
A pregnant woman should tell her doctor if she has genital herpes, or if she has ever had sex with someone who had it. If you have an active genital herpes infection at or near the time of delivery, you can pass it to your baby. When the baby passes through the birth canal, it may come in contact with sores and become infected with the virus. This can cause brain damage, blindness, or even death in newborns.
If you have an active herpes outbreak when you go into labor, your doctor may do a cesarean section (C-section). Then the baby won’t have to go through the birth canal and be exposed to the virus.

How is herpes diagnosed?

Your doctor will do a physical exam and look at the sores. He or she can do a culture of the fluid from a sore and test it for herpes. Blood tests or other tests on the fluid from a blister can also be done.

Can herpes be prevented or avoided?

The best way to prevent getting herpes is to not have sex with anyone who has the virus. It can be spread even when the person who has it isn’t showing any symptoms. If your partner has herpes, there is no way of knowing for sure that you won’t get it.
There is no time that is completely safe to have sex and not spread herpes. If you have herpes, you must tell your sex partner. You should avoid having sex if you have any sores. Herpes can spread from one person to another very easily when sores are present.
You should use condoms every time you have sex. They can help reduce the risk of spreading herpes. It is still possible to spread or get herpes if you are using a condom.

Herpes treatment

If you think you have herpes, see your doctor as soon as possible. It is easier to diagnose when there are sores. You can start treatment sooner and perhaps have less pain with the infection.
There is no cure for herpes. But medicines can help. Medicines such as acyclovir and valacyclovir fight the herpes virus. They can speed up healing and lessen the pain of herpes for many people. They can be used to treat a primary outbreak or a recurrent one.
If the medicines are being used to treat a repeat outbreak, they should be started as soon as you feel any tingling, burning, or itching. They can also be taken every day to prevent recurrences. Acyclovir also comes in a cream to put on sores during the primary stage or during recurrences.

What if I have herpes and become pregnant?

If you have genital herpes and are pregnant, be sure to tell your doctor. He or she will give you an antiviral medicine. This will make it less likely that you will have an outbreak at or near the time you deliver your baby. If you do have an outbreak of genital herpes at the time of delivery, your doctor will most likely deliver your baby by C-section. With a C-section, the risk of giving herpes to your baby is small.

What if I get herpes during pregnancy?

If you have your first genital herpes outbreak during pregnancy, tell your doctor. He or she may want to treat you with an antiviral medicine. The risk of your baby getting herpes is much higher if you have your first genital herpes outbreak near the time of delivery.
It is important to avoid getting herpes during pregnancy. If your partner has herpes and you do not have it, be sure to use condoms during sexual intercourse at all times. Your partner could pass the infection to you even if he is not currently experiencing an outbreak. If there are visible sores, avoid having sex completely until the sores have healed.

Living with herpes

It’s common to feel guilty or ashamed when you are diagnosed with herpes. You may feel that your sex life is ruined or that someone you thought you could trust has hurt you. You may feel sad or upset. Talk to your family doctor about how you’re feeling.
Keep in mind that herpes is very common. About 1 in 6 adults have it. Herpes may get less severe as time goes by. You can help protect your sex partner by not having sex during outbreaks and by using condoms at other times.

Tips on dealing with herpes

  • Talk to your doctor if you think you may have herpes.
  • Remember that you’re not alone. Millions of people have herpes.
  • Keep yourself healthy and limit your stress.
  • Don’t touch your sores.
  • Tell your sex partner and use condoms.

Tips to soothe the pain

  • Take aspirin, acetaminophen (Tylenol) or ibuprofen (Advil, Motrin).
  • Place lukewarm or cool cloths on the sore place.
  • Take lukewarm baths. (A woman may urinate in the tub at the end of the bath if she is having pain urinating. This may help dilute the urine so it doesn’t burn the sores so badly.)
  • Keep the area dry and clean.
  • Wear cotton underwear.
  • Wear loose-fitting clothes.

Questions to ask your doctor

  • What is the best treatment for me?
  • Is it safe to have unprotected sex if I don’t have any sores?
  • Can I give myself genital herpes if I also have oral herpes?
  • What is the best way to prevent herpes outbreaks?
  • If I give my baby herpes, is there any treatment?
  • Are there any side effects to my treatment?
  • Can I live a normal life with herpes?
  • Am I at risk of developing any other diseases?
  • Are there any support groups in my area?
  • Can I give someone else herpes even if I’m not having an outbreak?

Resources

U.S. National Library of Medicine, Genital Herpes
Centers for Disease Control and Prevention, Genital Herpes
U.S. Department of Health and Human Services, Office on Women’s Health, Genital herpes
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This information provides a general overview and may not apply to everyone. Talk to your family doctor to find out if this information applies to you and to get more information on this subject.
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Is it herpes, syphilis, or something else?


By Sharon Adler, MD, MPH
May 18, 2007
Clinical Feature

Is it herpes, syphilis, or something else?

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Genital ulcers could be one of many sexually transmitted diseases or an infection that is not transmitted by sex. An expert walks you through a case.
This is the first of a three-part series on sexually transmitted diseases. Part 2 will appear in the June issue.
A 30-year-old man presents with mildly painful sores that have been present on his penis for three days. He had no symptoms before the lesions appeared, and he has never had similar genital lesions before. The patient has no other symptoms and otherwise feels well. He has no significant medical history and no drug allergies.
Examination of the penile shaft reveals multiple shallow ulcerations with some exudate. Minimal bilateral inguinal lymphadenopathy is nontender. The remainder of his genital exam is unremarkable.
Q: What patient information should be obtained to assist in making a diagnosis?
A complete sexual history is particularly important in patients presenting with genital complaints. This patient reveals that his partners are male and that in the past three months he has had sex with three men, two of whom are new partners. He gives and receives oral sex and engages in insertive anal sex. He uses condoms for anal sex, but not with his primary boyfriend. Results of his latest HIV test four months ago were negative. His only prior sexually transmitted disease (STD) was gonorrhea (urethral) five years ago. His boyfriend is HIV negative and doesn’t have any STD symptoms. The patient denies any drug use and occasionally uses alcohol.
Q: Given your patient’s sexual history and genital findings, should you perform further examination?
Yes. All patients being evaluated for STDs should have an exam that includes: skin, oral cavity, lymph nodes, and genitals. An anal exam should be done if there is a history of any type of anal sex. Any patient with lesions suspicious for syphilis should have a neurologic exam focusing on cranial nerves and motor and sensory deficits. This patient’s history of receptive oral sex and multiple partners accompanied by genital lesions, possibly from an STD, necessitate further physical exam.
Examination of the patient’s skin is unremarkable and without rash. Oropharyngeal exam is within normal limits; no mucous patches or ulcerative lesions are found. There is no lymphadenopathy.
Q: What is your differential diagnosis?
The differential for genital ulcers is broad and includes genital herpes, syphilis, and chancroid, along with other less common STD causes of genital ulcer (lymphogranuloma venereum, granuloma inguinale, and acute HIV infection) and non-STD causes of genital ulcer (including candidiasis, psoriasis, trauma, Reiter’s syndrome, Behçet’s syndrome, fixed-drug eruption, and scabies). Co-infections can occur. In approximately 25% of patients, no etiology is found. Based on this patient’s sexual history, he is at high risk for a sexually transmitted infection.
Q: What laboratory tests should be done?
Tests for herpes and syphilis are warranted. Herpes viral culture of the lesion(s) is recommended. Polymerase chain reaction (PCR), which is more sensitive, can also be used, but it is more expensive and is not FDA-approved for diagnosing genital lesions. If neither culture nor PCR testing is available, a direct fluorescent antibody test can be used. (Other antigen detection methods do not distinguish between herpes simplex virus [HSV]-1 and HSV-2 and are not recommended.) Type-specific glycoprotein G serologic testing for HSV-2 can be considered if genital lesions are crusted or if direct testing of the lesion is negative. Keep in mind that it may take up to four months for any of these serologic tests to be positive after initial infection.
With regard to syphilis, direct assessment of the genital ulcer(s) with darkfield microscopy exam or direct fluorescent antibody toTreponema pallidum is reliable, though access to these tests is frequently limited. Serologic testing with a nontreponemal syphilis test, a rapid plasma reagin test (RPR), or a Venereal Disease Research Laboratory (VDRL) test, are also acceptable alternatives. Both tests are nonspecific and measure an antibody to a cardiolipin that is present in other inflammatory conditions.
A specific treponemal test, such as the T. pallidum agglutination assay (TP-PA) or the fluorescent treponemal antibody absorption test (FTA-ABS), is necessary to confirm a syphilis diagnosis when using RPR or VDRL as the first screening test. Most laboratories will automatically perform the treponemal tests on all positive RPR or VDRL samples. The sensitivity of RPR or VDRL tests in early primary syphilis is 74%-87%, so a negative test does not rule out syphilis, particularly if the lesion has been present for only a few days.
Additional testing to assess for chancroid is not necessary in this case. This would be considered if the patient had traveled to an endemic area or exchanged sex for drugs or money.

Q: Are there other laboratory tests that should be done?
Sexually active men who have sex with men (MSM) should be screened for urethral gonorrhea and chlamydia, rectal gonorrhea and chlamydia (if engaging in receptive anal sex), and pharyngeal gonorrhea (if engaging in oral receptive sex). An HIV test should be performed even though his latest test was just four months ago. Presentation with a new STD indicates possible concurrent HIV exposure.
Q: What is your presumptive diagnosis?
This case of an MSM with multiple mildly painful, shallow genital ulcers and nontender inguinal lymphadenopathy demonstrates the challenges of diagnosing the cause of genital ulcers. The presentation is consistent with herpes, which classically appears as multiple shallow lesions with exudate. However, if these were primary lesions, one would expect them to be more painful and accompanied by tender regional lymphadenopathy and systemic symptoms. Recurrent herpes is another possibility, though it typically has fewer lesions.
This patient’s lesions are not classic for syphilis, which typically presents as a solitary, painless indurated ulcer with nontender, bilateral lymphadenopathy. Atypical presentations of syphilis (and herpes) do occur, particularly in HIV-infected persons. The lesions are not consistent with chancroid, which classically presents as painful deep ulcer(s) with ragged edges and tender, inguinal lymphadenopathy that may suppurate. A non-STD etiology can be considered, although given this man’s sexual history, STDs should first be excluded.
Q: Does the current epidemiology of herpes, syphilis, and chancroid influence your presumptive diagnosis?
Yes. In the United States, genital herpes is the most common cause of STD-related genital ulcers among sexually active adults, followed by syphilis. Chancroid is rare in this country. Even though syphilis is not as common as herpes, rates of primary and secondary syphilis among MSM have been increasing since 2001. Factors associated with high rates of syphilis among MSM are HIV coinfection, high-risk sexual behavior, methamphetamine use, and meeting sexual partners via the Internet. The fact that this patient is an MSM engaging in high-risk sex should raise your suspicion of syphilis.
Q: What is your management strategy?
Presumptive treatment for syphilis, herpes, or both is often necessary for patients with genital ulcers. In general, patients with classic syphilis lesions or those at high risk for syphilis should be offered presumptive syphilis treatment. Those with a classic presentation of vesicles or prodrome consistent with herpes should be offered herpes treatment. Also, patients at risk for being lost to follow-up should be treated for syphilis, given the serious sequelae of untreated syphilis and risk of transmission to partners. In this patient, empiric treatment for syphilis is recommended despite the atypical presentation. He is at sufficient risk for syphilis given his sexual orientation and high-risk behavior. Penicillin G benzathine (Bicillin L-A) is the only recommended regimen for early syphilis. Errors in use of other preparations of penicillin G benzathine (particularly Bicillin C-R) have been documented, so caution to avoid such errors should be exercised. The patient is told that malaise, fever, arthralgias, and other flulike reactions can occur within 24 hours. He is also warned that syphilis can be transmitted orally as well as ano-genitally, and he is encouraged to consistently use condoms.
Q: Should you contact your local health department to report this possible syphilis case?
Yes. Nationally, syphilis is a reportable condition, and presumptive cases generally should be reported. For specifics, check with your locality. Your local health department will generally provide assistance in partner management for confirmed cases.
Q: Is there any further follow-up necessary for this patient?
Yes. The patient returns one week later and his lesions are resolving. His lab results reveal a reactive RPR with titer of 1:256 and a reactive confirmatory TP-PA. All other tests (i.e., herpes culture, gonorrhea, chlamydia, and HIV) are negative. The health department has already contacted him to obtain information on his partners so they can be evaluated and treated.
This patient should have repeat RPR tests at six and 12 months to ensure adequate response to treatment, which is reflected by a fourfold drop in his RPR titer.
Annual screening with a nontreponemal serology test (RPR or VDRL) is recommended after adequate treatment response. MSM with ongoing risk for syphilis should have more frequent screening, with some experts recommending intervals of three to six months. The patient in this case was counseled about his risk for STDs and the importance of STD screening.

This case demonstrates both an atypical presentation of syphilis that could be easily misdiagnosed as herpes and the importance of syphilis testing for all patients with genital ulcers. The case also shows that knowledge of current STD epidemiology is important when assessing patients with genital ulcers and why clinicians should have a low threshold for presumptive treatment of syphilis in MSM with such lesions.
For more about genital ulcer disease and syphilis, visit the National Network of Prevention Training Centers’ (NNPTC) online case series (www.stdhivtraining.org/nnptc). To find out about STD training, go to the NNPTC Web site (www.depts.washington.edu/nnptc).
For a list of references used in this article, contact the editor via e-mail (editor@clinicaladvisor.com) or telephone (646.638.6077).

Dr. Adler, a family physician by training, is a clinical instructor at the California STD/HIV Prevention Training Center in Oakland. She would like to thank colleagues Heidi Bauer, MD, MS, MPH, Helene Calvet, MD, and Linda Creegan, MS, FNP, for their assistance.

From the May 2007 Issue of Clinical Advisor »
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Antibiotics for Syphilis

Examples

Penicillin is the antibioticClick here to see more information. most commonly used to treat syphilisClick here to see more information.. Penicillin is usually given as a shot (injection).
If you are allergic to penicillin, your doctor may prescribe another antibiotic in early stages of syphilis, such as doxycycline, tetracycline, ceftriaxone, or azithromycin. Or he or she may desensitize you so that you can safely take penicillin. Later stages of syphilis may require treatment with penicillin.
Penicillin is the only antibiotic that should be used during pregnancy. If you are pregnant and think you may be allergic to penicillin, discuss your allergy with your doctor.

How It Works

Antibiotics destroy the bacteria that cause syphilis.

Why It Is Used

Antibiotics are needed if you have a positive blood test for syphilis during routine screening or have symptoms suggestive of syphilis. Exposed sex partners of a person with syphilis and babies born to women who have syphilis also need treatment.
The amount of antibiotics used and how often the medicine is taken are based on the stage of the illness. For example, if neurosyphilis is present, you will need to receive antibiotics for 10 days to 2 weeks.

How Well It Works

Treatment with penicillin cures most cases of syphilis in any stage. Antibiotics prevent further complications of syphilis but may not reverse damage that has already occurred.
A follow-up exam and a blood test for cure should be done at 6 and 12 months after the antibiotics are given (and may be done at 24 months after latent syphilis) to be sure the infection is cured.
If human immunodeficiency virus (HIVClick here to see more information.) infection was also present at the time of treatment, follow-up exams and blood tests should be done at 3, 6, 9, 12, and 24 months.1
Syphilis passed to a baby from the mother (congenital syphilis) may be prevented if the woman is treated before the 16th to 18th weeks of her pregnancy. Treatment after 16 to 18 weeks will cure the infection and stop the damage to the baby. But it may not reverse damage already caused by the infection.

Side Effects

All medicines have side effects. But many people don't feel the side effects, or they are able to deal with them. Ask your pharmacist about the side effects of each medicine you take. Side effects are also listed in the information that comes with your medicine.
Here are some important things to think about:
  • Usually the benefits of the medicine are more important than any minor side effects.
  • Side effects may go away after you take the medicine for a while.
  • If side effects still bother you and you wonder if you should keep taking the medicine, call your doctor. He or she may be able to lower your dose or change your medicine. Do not suddenly quit taking your medicine unless your doctor tells you to.
Call 911 or other emergency services right away if you have:
  • Trouble breathing.
  • Swelling of your face, lips, tongue, or throat.
Call your doctor if you have:
  • Hives.
  • Severe belly pain or cramps.
  • Decreased urine.
  • Depression.
  • Nausea or vomiting.
  • Unusual bleeding or bruising.
Common side effects of this medicine include:
  • Diarrhea.
  • Headache.
  • Sore mouth or tongue.
  • Vaginal itching or discharge.
A Jarisch-Herxheimer reaction is a fairly common reaction to antibiotic treatment of syphilis that involves fever and headache. It may occur up to 8 hours after the first treatment of early syphilis. The reason the Jarisch-Herxheimer reaction occurs is not clear. But it may be caused by the toxins released from the syphilis bacteria as they are destroyed by antibiotics. A Jarisch-Herxheimer reaction is not the same as an allergic reaction to penicillin.
See Drug Reference for a full list of side effects. (Drug Reference is not available in all systems.)

What To Think About

Antibiotic treatment can cure syphilis. And it can prevent complications. The complications of tertiary-stage or congenital syphilis may not be reversed with treatment. But the progression of the disease will be stopped.
Penicillin is the preferred drug for treating syphilis. And penicillin is the standard therapy for the treatment of neurosyphilis, congenital syphilis, or syphilis acquired or detected during pregnancy. But other antibiotics (such as ceftriaxone) may be used.

Taking medicine

Medicine is one of the many tools your doctor has to treat a health problem. Taking medicine as your doctor suggests will improve your health and may prevent future problems. If you don't take your medicines properly, you may be putting your health (and perhaps your life) at risk.
There are many reasons why people have trouble taking their medicine. But in most cases, there is something you can do. For suggestions on how to work around common problems, see the topic Taking Medicines as Prescribed.

Advice for women

If you are pregnant, breast-feeding, or planning to get pregnant, do not use any medicines unless your doctor tells you to. Some medicines can harm your baby. This includes prescription and over-the-counter medicines, vitamins, herbs, and supplements. And make sure that all your doctors know that you are pregnant, breast-feeding, or planning to get pregnant.

Checkups

Follow-up care is a key part of your treatment and safety. Be sure to make and go to all appointments, and call your doctor if you are having problems. It's also a good idea to know your test results and keep a list of the medicines you take.
Complete the new medication information form (PDF)Click to view external link(What is a PDFClick here to see more information. document?) to help you understand this medication.

References

Citations

  1. Centers for Disease Control and Prevention (2010). Syphilis section of Sexually transmitted diseases treatment guidelines, 2010. MMWR, 59(RR-12): 1–110. Available online: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5912a1.htm?s_cid=rr5912a1_w.
Last Revised: May 14, 2012
Author: Healthwise Staff
Medical Review: Sarah Marshall, MD - Family Medicine & Devika Singh, MD, MPH - Infectious Disease



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Syphilis

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Diagnosis

Syphilis can be diagnosed by testing samples of:
  • Blood. Blood tests can confirm the presence of antibodies that the body produces to fight infection. The antibodies to the bacteria that cause syphilis remain in your body for years, so the test can be used to determine a current or past infection.
  • Cerebral spinal fluid. If it's suspected that you have nervous system complications of syphilis, your doctor may also suggest collecting a sample of cerebrospinal fluid through a procedure called a lumbar puncture (spinal tap).
Through the Centers for Disease Control and Prevention, your local health department offers partner services, which will help you notify your sexual partners that they may be infected. That way, your partners can be tested and treated and the spread of syphilis can be curtailed.

Treatment

When diagnosed and treated in its early stages, syphilis is easy to cure. The preferred treatment at all stages is penicillin, an antibiotic medication that can kill the organism that causes syphilis. If you're allergic to penicillin, your doctor will suggest another antibiotic.
A single injection of penicillin can stop the disease from progressing if you've been infected for less than a year. If you've had syphilis for longer than a year, you may need additional doses.
Penicillin is the only recommended treatment for pregnant women with syphilis. Women who are allergic to penicillin can undergo a desensitization process that may allow them to take penicillin. Even if you're treated for syphilis during your pregnancy, your newborn child should also receive antibiotic treatment.
The first day you receive treatment you may experience what's known as the Jarisch-Herxheimer reaction. Signs and symptoms include a fever, chills, nausea, achy pain and headache. This reaction usually doesn't last more than one day.

Treatment follow-up

After you're treated for syphilis, your doctor will ask you to:
  • Have periodic blood tests and exams to make sure you're responding to the usual dosage of penicillin
  • Avoid sexual contact until the treatment is completed and blood tests indicate the infection has been cured
  • Notify your sex partners so that they can be tested and get treatment if necessary
  • Be tested for HIV infection
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