Herpes Simplex Infections
by Dr. H., Medical Director
What is Herpes?
Herpes is a virus, specifically “herpesvirus hominus”. Simplex is a sub-category of that family. Simplex falls into five categories, types 1, 2, 6, 7, and 8. Generally type I infects the mouth in humans and type II affects the genital tract, but there is a substantial overlap. Type 6 and 7 cause an infection of infancy and Type 8 has been associated with Kaposi’s Sarcoma which is seen in HIV.
Herpes simplex virus (HSV) has a vast presence in humans. It has been estimated that some 80-90% of humans experience oral herpes infections by the age of ten years old. Many will have an acute episode manifesting as infected gums and lips, causing high fevers, but most apparently have few if any symptoms. A substantial portion of the population has recurrent oral herpes infection, showing up as those nuisance little “cold sores” on lips and sides of the mouth, and occasionally elsewhere on the face.
Where is Herpes Found?
Herpes infects the nerve cells of the spinal cord of the pelvis (in the setting of genital herpes) and of the nerve ganglia serving the face at the base of the brain (in the setting of oral herpes). Herpes is a DNA-type virus, inserting its DNA directly into the dendritic nerve endings of the skin, which then leads along nerve fibers to the nucleus of the nerve cell. Once the viral information is inserted into the cell’s nucleus, this blending of viral genetic information with human genetic information is permanent. The nerve cell then becomes a factory for making more viral particles.
Thus, herpes is not a “skin infection”, but rather an infection of nerve cells, by way of the skin. It is not the “skin” that is infected but rather the nerve cell. When the infection becomes active again in the nucleus of the nerve cell, the viral particles flow back out, down the nerve, and out through little blisters that form in the skin. If the quantity of viral particles coming down the nerve cell isn’t enough to form a blister, then a number of viral particles can be excreted through the skin without any symptoms at all.
“Genital herpes” and “oral herpes” refer to the location where the herpes infection is found on the individual. Most genital herpes is caused by HSV-2, but can be caused by HSV-1 in as many as 30% of new cases. Oral herpes is most often caused by HSV-1, and only rarely by HSV-2. Because these locations are often associated with a particular type of herpes (which seem to “take hold” in those particular locations more easily), medical people, websites and literature often equate the location with the herpes type. You might find that people speak of genitally-located herpes infections as HSV-2 and orally-located herpes as HSV-1. However, humans can have either virus in either place, and in fact, potentially anywhere on the body.
Transmission of Herpes Virus:
Someone with an HSV-1 lesion on the mouth can certainly transmit the infection to a significant other through oro-genital contact with the genitalia of the other (oral sex), causing a recurrent HSV-1 lesion on the genitalia of the partner. Also, other sites of HSV infection can be produced, such as on a finger (the so-called “herpetic whitlow”) or elsewhere.
FIRST POINT: PEOPLE WHO HAVE SYMPTOMS OF HERPES INFECTIONS EITHER ON THE FACE OR ON THE GENITALIA SHOULD REFRAIN FROM ALLOWING THESE AREAS TO COME INTO CONTACT WITH A SIGNIFICANT OTHER DURING INTIMATECONTACT.
For discussion’s sake, I will call genital herpes infection “GHI” and I will call oral herpes infection “OHI”. I will refrain from calling GHI the more typical name “HSV-2″ for the reason discussed above. GHI affects about 20-25% of Americans, numbers exceeding probably 50 million Americans. Even though most other STDs are seen to be decreasing in their rate of new infections, GHI remains one of the fastest growing infectious diseases in the world in absolute numbers of cases. Probably Human Papillomavirus (HPV) infections outnumber GHI (see the article on HPV) in both growth rate and probably in absolute numbers.
Generally GHI is not considered to be extremely contagious. Casual contact on toilet seats, chairs, and similar sorts of workplace contact is almost certainly non-contagious, though debate exists on that issue. Anecdotal case reports of persons acquiring GHI through contact in hot tubs have been published. Obviously such matters would be very difficult to verify. The herpes virus does not survive outside the body for more than about 10 seconds, and although it can survive for slightly longer in warm, damp conditions, it dies very quickly once exposed to the air.
However, GHI IS contagious, typically through skin-to-skin contact with an infected area. The method of transmission is may occur through an active herpes blister on one person with a broken area of skin on the other person. For example, a male with an open blister could transmit the virus into the vagina of a female through a tiny abrasion in the vaginal mucosa of the female that could occur during intercourse. Similar modes of transmission can occur from female to male, male to male, and even female to female. Oral to oral transmission of either type of virus can also happen.
The virus may be transmitted to the penis, the vagina, the rectum, the mouth, and more rarely, the esophagus, the trachea, and even onto broken areas of skin anywhere on the body. The New England Journal of Medicine published a photograph of a herpes infection deep down inside the esophagus of a woman in April, 1999. Herpes simplex pneumonias have been reported. And, of course, the Herpes simplex infections of the brain in newborn babies who acquire infection during delivery are well known and can be medical disasters. Herpes simplex may also cause wide-spread rashes on the body with redness and swelling in these areas, reminiscent of measles.
Again, once the viral DNA has been transmitted to the receiving person’s nerve cells, the infection is permanent.
Viruses are very tiny, of course, far smaller than bacteria and far smaller than the cells of the human body. Viruses are so small that they can even slip through the tiny inter-cellular holes of the “lamb-skin” type of condom which are normally small enough to prevent sperm cells from getting through. Latex-type condoms are probably protective against viral particles getting through, provided the condom covers the affected area completely during the sex act. Viral particles from an active lesion can become liquid borne from inside the condom however and possibly leak out the base of the condom (SEE THE FIRST POINT ABOVE).
Herpes infections produce a number of different signs and symptoms. Traditional “first episode” herpes, most commonly described in women, are serious illnesses, with high fever, often large-sized outbreaks, and even inability to urinate. Hospitalizations are sometimes necessary, with urinary bladder catheterization, IV fluids, and intravenous anti-viral medications being required. Most people who present with infection don’t describe having such severe symptoms, however, showing up in the office or the ER with a cluster of small blisters surrounded by a red base showing up on the genitalia, in the case of GHI. Often the blisters have already ruptured, leaving behind a cluster of ulcers which scab over and require one to two weeks to heal.
SECOND POINT: DURING THE BLISTER AND ULCER PHASE, THE HERPES LESION CONTAINS AND LEAKS OUT BILLIONS OF VIRAL PARTICLES AND IS CONTAGIOUS TO ANY AREA OF BROKEN SKIN OR WET MUCOSA, INCLUDING THE EYE, THE MOUTH, THE ESOPHAGUS, THE TRACHEA, THE LUNGS, THE ANUS, THE URETHRA, AND THE VAGINA.
Herpes symptoms are often more subtle, however. Sometimes the skin will just be slightly reddened without obvious lesions. This area is probably contagious, though probably much less so than blistered areas. Sometimes the skin will form tiny red bumps that don’t blister, called “erythematous papules”. Sometimes there are no signs on the skin at all but rather a “prodrome” (sensory warning symptoms), such as urinary urgency, urinary frequency, AND/OR aching or tingling in the legs. Also, itching, burning, tingling, pain or pressure at a previous or potential outbreak site may occur.
Finally, many people with GHI (and probably OHI as well) produce viral particles even when they have no symptoms at all. These people are likely contagious even when they have no symptoms at all. This term is called “asymptomatic shedding” and is well described in the herpes literature.
Confusing the picture even more in women is that a herpetic lesion inside the vagina may only produce a vaginal discharge as an external symptom, resembling a yeast infection. It may be difficult without examining the patient to know which is which. So, some women with both chronic yeast infections and GHI may find themselves confused as to which problem is bothering them. These patients should be under the care of a gynecologist and should not attempt to self-medicate until the symptoms have been clearly explained.
It is vital to realize that viral shedding can occur from people who have acquired the infection asymptomatically. This means that people can acquire a herpes infection and have no symptoms, and later they can be shedding virus and therefore be contagious. Anna Wald showed, in the New England Journal of Medicine in 2000, that “most persons who have serologic [blood antibody] evidence of infection with herpes simplex virus (HSV) type 2 (HSV-2) are asymptomatic.” As the article stated they “conducted a prospective study to investigate genital shedding of HSV among 53 subjects who had antibodies to HSV-2 but who reported having no history of genital herpes, and compared their patterns of viral shedding with those in a similar cohort of 90 subjects with symptomatic HSV-2 infection. Genital secretions of the subjects in both groups were sampled daily and cultured for HSV for a median of 94 days. HSV was isolated from the genital mucosa in 38 of the 53 HSV-2 seropositive subjects (72 percent) who reported no history of genital herpes, and HSV DNA was detected by the polymerase-chain-reaction assay in cultures (PCR swab test) prepared from genital mucosal swabs in 6 additional subjects.”
The rate of subclinical (asymptomatic) shedding of HSV in the subjects with no reported history of genital herpes was similar to that in the subjects with such a history (3.0 percent vs. 2.7 percent). Of the 53 subjects who had no reported history of genital herpes, 33 (62 percent) subsequently reported having typical herpetic lesions; the duration of their recurrences in these subjects was shorter (median, three days vs. five days; (P value less than 0.001) and the frequency lower (median, 3.0 per year vs. 8.2 per year; (P value less than 0.001) than in the 90 subjects with previously diagnosed symptomatic infection. Only 1 of these 53 subjects had no clinical or virologic evidence of HSV infection.
Wald concluded that “seropositivity [testing positive in a blood test] for HSV-2 is associated with viral shedding in the genital tract, even in subjects with no reported history of genital herpes.” This means that people can be infected, that only their blood tests might be positive, that they may have no symptoms or few symptoms that are recognised as being caused by herpes, and yet that they may still be shedding virus…and may therefore be contagious.
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