#133 Herpes for Everyone with Robert Bettiker MD

December 24, 2018 | By Kate Grant

Welcome Herpes to the Family! 

Master the diagnosis and management of Genital Herpes with tips from expert, Robert Bettiker MD . Topics include: the natural history, diagnosis & screening guidelines for genital herpes; cold sores; options for primary and recurrent episodes including prophylaxis; and consideration of specific populations including symptomatic and asymptomatic patients, pregnancy and MSM (men who have sex with men). We also discuss partner notification and treatment.

Full show notes available at http://thecurbsiders.com/podcast. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com.

Credits

Written and produced by: Kate Grant MBChB DipGUMed

Images by: Kate Grant MBChB DipGUMed

Hosts: Stuart Brigham MD, Paul Williams MD, Matthew Watto MD

Guest: Robert Bettiker MD

Time Stamps

• 00:00 Disclaimer, guest bio, intro
• 01:50 Guest one liner, memorable teaching moment and a few failures
• 10:50 Intro to herpes
• 12:25 Case 1: Genital herpes in a married man
• 15:42 Overview of testing options
• 18:50 Marital counseling in Herpes
• 22:18 Prophylaxis in serodiscordant partners and asymptomatic shedding
• 25:08 Case 2: Severe outbreak of genital herpes in a young woman
• 31:50 Case 3: Young male with recent exposure to herpes
• 38:45 Herpes 1 (HSV1) versus Herpes 2 (HSV2)
• 44:12 Case 4: Herpes in pregnancy
• 50:45 Do topical agents work for herpes
• 55:05 Take home points
• 56:10 Outro
• 57:52 Stuart shares a PUN!

Herpes Clinical Pearls

Make the sexual history routine. Get comfortable with a common script that you ask your patients, and do not be deterred by an initial vague answer.  

Transmission of genital herpes: No need to worry if both partners are seropositive for HSV2 IgG. Consider daily suppressive valacyclovir in serodiscordant couples since asymptomatic shedding is common and condom use alone cannot provide reliable protection.

Counseling: Avoid sexual intercourse during prodromal symptoms (eg tingling, burning) and during active outbreaks.

HSV1 vs HSV2: Typically, HSV1 causes cold sores and HSV2 causes genital herpes. BUT, both viruses can cause oral or genital infection. Having antibodies to HSV1 or HSV2 may confer partial protection against the other virus (Xu J Inf Disease 2002).

Routine screening for herpes is not recommended by the CDC. Therefor, do not test patients unless they have a potential exposure (CDC STD Facts – Genital Herpes). NOTE: UK guidelines differ. 

Herpes in pregnancy: Seropositive women without a primary or recurrent anogenital Herpes outbreak during pregnancy pass protective IgG antibodies to the neonate and suppressive therapy with acyclovir is not recommended. Most sources recommend suppressive therapy with acyclovir starting at 36 weeks “for all women who present with a genital HSV lesion anytime during pregnancy, whether with a primary, nonprimary first-episode, or recurrent infection” (Riley UpToDate.com Genital herpes simplex virus infection and pregnancy 2018).

Memorable Quotes from Dr Bettiker

“We have to process through our own emotions and be aware that we bring them home.”

“I have learned so much about people’s marriages through this virus.”

“Topical agents work…as long as you give them with pills.”

“If you have herpes, you can…welcome it to the family.”

Herpes In-Depth Show Notes

ALL STI guidelines for USA and UK can be accessed through the following links

USA https://www.cdc.gov/std/default.htm

British guidelines

Routinizing the sexual history

Dr Bettiker notes that Doctors are bad at talking about sex. It’s easy to take a sexual history when a patient presents with a genital complaint. BUT, it’s also important to make routine sexual history part of everyday practice (see show notes for The Curbsiders #127 STI)

Sexual health History taking guideline for men/women (appropriate for any country) https://www.bashhguidelines.org/media/1078/sexual-history-taking-guideline-2013-2.pdf

Genital Herpes

Incubation

Primary infection 2 days to 2 weeks (CDC STD Facts – Genital Herpes)

Transmission

After direct skin to skin contact with an infectious lesion on an infected individual. It cannot be caught from toilets,swimming pools, towels etc.

Recurrent herpes

After the primary infection, the virus becomes latent in a sensory nerve root ganglion and recurrent episodes occur when the HSV1/HSV2 virus reactivates. Usually the blisters recur in the site of the primary infection. Each time it reactivates, there is viral shedding, whether symptomatic or asymptomatic.

Recurrence rates

HSV2 typically 4 times per year. HSV1 typically 1 time per year. (Benedetti Ann Int Med 1994; WHO HSV Fact Sheet)

Case 1: A married man with herpes

42 yo M who is married. He’s had five urinary tract infections despite negative cultures. Physical exam shows small ulceration near the urethral meatus.

Differential diagnosis = herpes, syphilis, and penile cancer.

Diagnosis = Take a viral swab for PCR from the ulcer, or de-roof the vesicle and swab the ulcer base.

Treatment = Valacyclovir (check out the CDC’s Free STD Tx Guide App for specifics)

What about their marriage?

Did he bring this into the marriage? Does his wife already have herpes too? We should test her as well. Send herpes IgG antibodies. If positive, then she has nothing to worry about.

A bit more on testing

Culture: Herpes will grow within about 48 hours. It is specific, but not sensitive.

PCR: Send a swab. Excellent sensitivity.

Serology: IgM will be negative and IgG will be positive in recurrent cases.

Preventing herpes transmission in serodiscordant couples

Avoid sex if prodromal symptoms of herpes or an ulcer is present.

Asymptomatic shedding can occur with very low levels of virus present on the skin. This represents a big risk for transmission since patient “feel sexy” and let down their guard.

Chronic valacyclovir can decrease viral shedding and prevent transmission in serodiscordant couples.

What about “belts and suspenders” aka barrier protection and antivirals?

The CDC site notes, “consider suppressive antiviral therapy as part of a strategy to prevent transmission, in addition to consistent condom use and avoidance of sexual activity during recurrences.” (CDC STD Facts – Genital Herpes)

Case 2: Primary HSV2

A young woman with severe pain, urinary retention and widespread ulcers on her vulva.

Primary HSV2

Can present as widespread painful lesions on area exposed. Sacral nerve involvement can cause a few months of bowel and bladder dysfunction. Sometimes this requires urethral catheterization.

Treatment

valacyclovir, viscous lidocaine, urethral catheterization and pain medication- check out the CDC’s Free STD Tx Guide App for specifics.

Counseling

Many people have more than four HSV2 outbreaks in the first year. Subsequently, patients experience about one less outbreak each year until the virus “burns itself out” -Dr Bettiker.  Early treatment with valacyclovir during outbreaks can shorten, or even abort symptoms. Consider daily valacyclovir if frequent recurrences occur.

Was her partner cheating?

It is often impossible to know when a partner’s infection was acquired. In our case, the woman’s boyfriend may have been infected years ago. Therefor, infidelity cannot be proven.

Case 3

A 25 yo M with multiple encounters of unprotected sex with male partners wants STI testing. He later finds out that one of his recent partners has herpes. He asks to be tested for “everything”.

Baseline and follow up testing

Routine post-exposure STI testing should include Hep C, Hep B, gonorrhea, chlamydia, HIV and syphilis. Dr Bettiker does not routinely send HSV serologies for these patients.

At the moment, we cannot tell if our patient has acquired a new HSV infection from this encounter. Baseline serologic testing can identify a preexisting HSV infection if he has HSV IgG antibodies.

Screening for Herpes

Routine screening for herpes is not recommended by the CDC. Therefor, do not test patients unless they have a potential exposure.

Counseling and prevention

Dr Bettiker recommends, “throw condoms all over him” and offer him preexposure prophylaxis for HIV (The Curbsiders #41 HIV preexposure prophylaxis).

HSV1 vs HSV2

HSV1 – Dr Bettiker recommends we “Call it the cold sore virus” to decrease patient anxiety.

HSV1 (cold sore virus) vs HSV2 (genital ulcers). Dr Bettiker reminds us that, “they cause more severe disease if infecting their ‘proper place’”. Having antibodies to HSV1 will protect against HSV1 infection elsewhere in the body (WHO – HSV facts), may have partial protection against acquisition of HSV2 (Xu J Inf Disease 2002). Prior HSV1 infection increases the likelihood that an infection with HSV-2 will be subclinical (Xu J Inf Diseases 2002).

Case 4

A 20 yo woman at 10 weeks gestation presents with her first herpes outbreak.

Treatment

Acyclovir- check out the CDC’s Free STD Tx Guide App for specifics.

Suppressive therapy

Most sources recommend suppressive therapy with acyclovir starting at 36 weeks “for all women who present with a genital HSV lesion anytime during pregnancy, whether with a primary, nonprimary first-episode, or recurrent infection”. In HSV seropositive women with prior herpes infection, but no active genital lesions during pregnancy, suppressive therapy is not recommended (Riley UpToDate.com Genital herpes simplex virus infection and pregnancy 2018).

Labor

Vaginal birth is okay if no active anogenital lesions at time of delivery. Perform a C-section if any active lesions of the genitals or perineum.

NOTE: Active lesions are “virus factories” and can overwhelm the protective IgG antibodies transmitted from mother to  the neonate. Thus, vaginal delivery should be avoided when active lesions are present. Virus levels are very low during asymptomatic shedding. Therefore, in the absence of an active outbreak during pregnancy, IgG antibodies can prevent transmission to the neonate. -Dr Bettiker

Other counseling on herpes

Period of Abstinence:

• Advise no sex if a patient has known herpes, and a clear prodrome (eg itching/tingling).
• No sex when active genital lesions are present.
• Condoms may be used to reduce risk, but cannot protect enough skin to provide total protection.

Risk reduction counseling

• Reduce number of partners.
• Get routine STI screening.
• Use condoms every time.
• Get partners tested.
• Test for HIV, other STIs.
• Discuss pre-exposure prophylaxis PrEP for HIV.

Role of oral sex:

Remind the patient that Herpes and other STIs can be transmitted through oral contact as well.

Goals and Learning Objectives

Goals

Listeners will develop a both a practical and evidence based approach to the management of Genital Herpes.

Learning objectives

After listening to this episode listeners will…

1. Interpret the results of diagnostic testing for Herpes.
2. Diagnose Herpes using history, appearance of lesions, ulcer swabs and the role of serology testing.
3. Counsel, and treat pregnant the pregnant women with herpes
4. Prevent neonatal herpes
5. Incorporate a routine, thorough sexual history into regular practice.
6. Explain the differences between HSV1 and HSV2
7. Counsel patients and their partners about herpes
8. For this episode, listeners are strongly encouraged to check Guidelines for USA and UK/Europe, because there are importance epidemiological differences in treatment regimens and routine screening recommendations in different populations.

Disclosures

Dr Bettiker reports no relevant financial disclosures. The Curbsiders report not relevant financial disclosures.

Links

Links from the show

Forbes Top 5 Noise cancelling headphones 2018 https://www.forbes.com/sites/forbes-finds/2018/07/02/bluetooth-noise-cancelling-headphones/#2c2fcae83b48

Helpful PDF How to take a self swab (endocervical/penile) for non-ulcer STIs Swab_Collection_Guide.pdf

Permalink URL:

Citation for guest CV:

Bettiker, Robert. Guest, expert. #133 Herpes for Everyone. The Curbsiders Internal Medicine Podcast http://thecurbsiders.com. December 24, 2018. URL http://thecurbsiders.com/podcast/133-herpes-everyone-robert-bettiker-md