The diagnosis of herpes simplex is suspected in patients who complain of lesions in the form of grouped vesicles on an erythematous base which then become pustules, erosion, and ulceration at the ruptured vesicles. Before lesions appear, patients generally experience prodromal symptoms such as malaise, anorexia, fever and lymphadenopathy.

Supporting examinations such as the Tzank test or PCR can be considered to confirm the diagnosis in cases where the lesion is atypical.

ANAMNESIS

Symptoms will appear between three days and one week after exposure to the Herpes Simplex Virus (HSV). Patients will generally experience prodromal symptoms typical of the virus, such as malaise, anorexia, fever, lymphadenopathy, localized pain, burning or throbbing before the appearance of the lesion.

The patient will then complain of the appearance of grouped vesicles on an erythematous base. These vesicles will then become pustules, erosion and ulceration at the ruptured part of the vesicle. Within 2 to 6 weeks, the lesion will be covered by crusting and the symptoms will disappear.

RECURRENT INFECTIONS

In Recurrent Herpes Simplex, symptoms are usually milder. Reactivation generally depends on the body's immunity, although the frequency of reactivation will decrease with age.

Several physiological and environmental factors that can stimulate viral reactivation are fever, exposure to Ultraviolet light, menstruation, stress or trauma. In orolabial herpes, recurrent infections generally attack the vermillion border area of the lips.

GENITALIS HERPES

In Genital Herpes, clinical manifestations that can be identified from the anamnesis include the classic syndrome in the form of the appearance of a group of bilateral erythematous papules, vesicles or ulcers on the patient's external genitalia, perianal area or buttocks which appear within 4-7 days after sexual exposure. This classic syndrome only appears in 10–25% of cases of primary infection.

Patients generally complain of genital pain and itching. 80% of cases in women report dysuria. Constitutional symptoms, such as fever, headache, myalgia and malaise are also often present.

After 2-3 weeks, new lesions will appear and old lesions will turn into pustules which then merge into ulcers, scab, then heal. Lesions on the genital mucosa may form ulcers without prior vesicle formation. Atypical presentations of HSV type 2 may include small erosions and fissures, as well as dysuria or urethritis, without the appearance of skin lesions.

PHYSICAL EXAMINATION

Physical examination of orolabial herpes will show cold sores or fever blisters in the form of vesicles that appear in groups over erythematous areas. This lesion will feel very painful. HSV-1 lesions have a predilection for the mouth and lips.

In Genital Herpes, the appearance of painful vesicles or ulcer-shaped lesions may appear similar to chancroid or syphilis. Apart from that, inguinal lymphadenopathy can also be found. Lesions in the urethra can cause complaints in the form of transient urinary retention in women.

SUPPORTING INVESTIGATION

The diagnosis of herpes simplex can be made clinically. In situations where it is difficult to determine the diagnosis of whether a lesion or ulcer on the genitalia is caused by HSV infection or not, supporting examinations can be considered.

1. Culture

HSV can be well confirmed by virus isolation. Results can be obtained after inoculation for 48 hours. Immunofluorescence staining of cell culture tissue can be used to differentiate HSV types 1 and 2.

2. Tzank Test

We can observe the characteristics of cytological changes caused by HSV through the Tzank test. However, this procedure cannot differentiate between HSV types 1 and 2. Multinucleated giant cells and epithelial cells containing eosinophilic intranuclear inclusion bodies indicate HSV infection.

3. Polymerase Chain Reaction (PCR)

The examination is carried out by checking for the presence of HSV DNA in the specimen using the polymerase chain reaction (PCR) method. PCR is more sensitive than culture and is preferred for detecting HSV infection in the ocular and central nervous system.

4. Serological examination

Serologic testing is frequently performed, but its clinical benefit is limited. A positive serological examination cannot determine whether the infection is acute or not.

●  Anti-HSV1 IgM examination

The Anti-HSV1 IgM examination detects IgM antibodies against HSV1. IgM antibodies are antibodies that first appear in the blood when an infection occurs and will disappear within a few months. The Anti-HSV1 examination requires a blood sample taken from a vein in the arm.

Benefits of Examination:

The anti-HSV1 IgM examination is useful for detecting new infections caused by the Herpes Type 1 virus (which attacks the body from the waist up in the form of lesions generally in the area around the mouth).

● Anti-HSV1 IgG examination

The Anti-HSV1 IgG examination detects IgG antibodies against HSV1. IgG antibodies are antibodies that appear after IgM and can remain for life. The Anti-HSV1 examination requires a blood sample taken from a vein in the arm.

Benefits of Examination:

This examination is useful for detecting past infections, but a significant increase in anti-HSV1 IgG within a certain time interval indicates an active or new infection. Negative IgG indicates that a person has never been exposed to HSV or their body has not been able to produce HSV antibodies.

● Anti-HSV2 IgM examination

The Anti-HSV2 IgM examination detects IgM antibodies against HSV2. IgM antibodies are antibodies that first appear in the blood when an infection occurs and will disappear within a few months. This examination is highly recommended for women who are pregnant or planning to become pregnant soon; women who are newly/currently pregnant, if previous results are negative or have never been examined, should ideally be monitored every 3 months; and newborns whose mothers were infected during pregnancy. This examination requires a blood sample taken from a vein in the arm.

Benefits of Examination:

The anti-HSV2 IgM examination is useful for detecting new infections caused by the Herpes virus type 2 (which attacks the body from the waist down in the form of lesions generally in the genital area). This examination is not recommended in patients who are asymptomatic, because it can give false positive results.

● Anti-HSV2 IgG examination

The Anti-HSV2 IgM examination detects IgM antibodies against HSV2. IgM antibodies are antibodies that first appear in the blood when an infection occurs and will disappear within a few months. This examination is highly recommended for women who are pregnant or planning to become pregnant soon; women who are newly/currently pregnant, if previous results are negative or have never been examined, should ideally be monitored every 3 months; and newborns whose mothers were infected during pregnancy. This examination requires a blood sample taken from a vein in the arm.

Benefits of Examination:

The anti-HSV2 IgM examination is useful for detecting new infections caused by the Herpes virus type 2 (which attacks the body from the waist down in the form of lesions generally in the genital area). This examination is not recommended in patients who are asymptomatic, because it can give false positive results.

Author: dr. Nurmalia Purnama Sari, Sp.PK., M.Sc., Med (Doctor in Charge of PRAMITA Clinical Laboratory Branch Jl. Veteran No. 173 Palembang)