Herpes Simplex Virus Cultures Research Articles

Variability in HSV Testing and Empiric Treatment in Febrile Infants

Source: Treasure JD, Shah SS, Hall M, et al for the Pediatric Research in Inpatient Settings Network and the Collaborative Antiviral Study Group. Variation in diagnostic testing and empiric acyclovir use for HSV infection in febrile infants. Hospital Pediatrics. 2021;11(9):922–930; doi.10.1542/hpeds.2020-003129Investigators from multiple institutions conducted a retrospective study to describe testing for herpes simplex virus (HSV) in febrile infants <60 days old, assess variation in testing and treatment across hospitals, and evaluate the effect of HSV testing on length of hospital stay (LOS) in these patients. For the study, data in the Pediatric Health Information System (PHIS) database were reviewed. PHIS includes administrative data such as demographics, diagnostic and procedure codes, and laboratory and pharmacy orders from encounters at pediatric hospitals. For the current study, data from 44 hospitals in 26 states and the District of Columbia were reviewed. Study participants were children ≤60 days old evaluated in the ED with an ICD-9 or ICD-10 code indicative of fever. Data abstracted on these children included use of HSV testing (culture or PCR), imaging and other diagnostic evaluations, hospital, demographics, orders for acyclovir, LOS, ICD-9 or ICD-10 codes for HSV infection, and severity of illness, as estimated in All Patient Refined-Diagnosis Related Groups (APR-DRG). The primary study outcome was rate of HSV testing, measured at the patient and hospital level. The hospital-level rates of acyclovir orders were also assessed. Secondary outcomes included rate of HSV infection in study patients. LOS was compared in study patients tested for HSV and those not tested using regression analyses and accounting for confounding variables such as age, hospital and APR-DRG estimated illness severity. Analyses were stratified by age (<22 days and 22–60 days).Data were analyzed on 24,534 ED encounters, including 6,027 (24.6%) patients <22 days old and 18,508 (75.4%) 22 to 60 days old. There were 108 children (0.44%) with a diagnostic code indicative of HSV infection, yielding rates of HSV disease of 1.08% for those <22 days old, and 0.23% for those 22 to 60 days of age. Rates of HSV testing were 39.4% and 12.0%, respectively, for children <22 and 22 to 60 days old. At the hospital level, the rate of HSV testing was 35.6% (interquartile range [IQR], 28% to 53%) for the younger age cohort, and 12% (IQR, 9% to 16%) for those 22 to 60 days old. There also was substantial variation in hospital-level rates of empiric acyclovir use (IQR, 68% to 90% for children <22 days old and 44% to 73% for those 22 to 60 days of age). The prevalence of additional testing also varied by age group and hospital. After adjusting for age, severity of illness and hospital, LOS was significantly longer in patients with HSV testing than in those not tested (mean LOS, 2.6 and 1.9 days, respectively; P <0.001).The authors conclude that substantial variation in diagnostic use of HSV testing in febrile infants ≤60 days old.Dr Winer has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.The diagnosis and care of potential meningitis/encephalitis in young infants with fever has continually evolved over time (See AAP Grand Rounds. 2010;24[2]:17). As hospitals have moved away from HSV culture and toward HSV PCR testing and the delay in obtaining results has shortened, the safety and cost-effectiveness calculations leading to optimal strategy continue to change.1Although the current investigators were limited in their ability to evaluate duration of empiric acyclovir in children for whom HSV testing is negative, this likely has shortened over time. The LOS was longer for patients who had HSV testing performed, likely related to clinical concern by the physicians that led to the decision to test in the first place.HSV testing continues to evolve, with many hospitals starting to use multiplex PCR array panels which test for multiple viral (including HSV), bacterial, and even fungal pathogens.2 Some evidence exists that initial CSF results are not sensitive enough to preclude a meningitis/encephalitis panel,3 but concerns also exist about overdiagnosis and overtreatment with universal use of these panels.Significant variability exists in the testing and empiric acyclovir usage in febrile infants. Patients tested for HSV have longer LOS than those for whom no test is performed.Fever in young infants is relatively common; neonatal HSV infection, relatively rare. Unfortunately, the results of the current study underscore the need for guidance to allow informed HSV diagnostic and therapeutic decisions. (See AAP Grand Rounds. 2018;39(5):56.)4

An Ulcerating Perineal Rash in an 8-month-old Girl.

An Ulcerating Perineal Rash in an 8-month-old Girl.

Characteristics of neonatal herpes simplex virus infections in Germany: results of a 2-year prospective nationwide surveillance study

ObjectiveTo assess incidence and burden of neonatal herpes simplex virus (HSV) infections and to explore possible transmission routes.MethodsA 2-year prospective nationwide surveillance study performed in 2017 and 2018. All German...

Case 2: Early-Onset Neonatal Sepsis in a Term Neonate

Case 2: Early-Onset Neonatal Sepsis in a Term Neonate

What is the True Etiology of “Recurrent Shingles”?

Purpose: To determine the true etiology of cases of putative recurrent shingles referred to a dermatology clinic. Methods: A prospective cohort study of patients aged 15-87 years with reported recurrent herpes zoster was conducted. Vesicular fluid and serology for herpes simplex 1, 2, and varicella zoster virus immunoglobulins were obtained from patients presenting with vesicles. Biopsies were obtained from patients with ambiguous presentations. Results: 44 patients (56%) had evidence of herpes simplex virus infection. 32% of patients had positive herpes simplex virus cultures or polymerase chain reaction sequencing, and 24% additional patients were diagnosed with presumptive simplex infection based on elevated antibody titers. 44% of patients had a diagnosis other than zoster or simplex. One individual had a positive viral culture for varicella zoster virus. 99% of patients who presented with suspected recurrent herpes zoster had no definitive evidence of varicella zoster virus reactivation. Conclusions: The most common diagnosis was herpes simplex infection. Our results suggest that true recurrent shingles in immunocompetent patients is rare.

Co-existence of Guillain-Barré syndrome and Behcet syndrome: A case report

A 40-year-old male patient was referred to our department with complains of recurrent oral ulcer for more than 20 years and vulvar ulcer for more than 10 years. He presented with a 3-month history of right external ophthalmoplegia. More than 10 days ago, the patient received ganglioside infusion. And one week ago, he developed numbness and pain of his lambs, and progressive myasthenia, accompanied by right blepharoptosis and dysuria. On exam, motor strength was graded 0/5 in the lower and the upper extremities. Deep tendon reflexes were diminished in extremities. His admission medical examination: hemoglobin (HGB), white cell and platelet counts were normal. C-reactive protein (CRP) was negative. Erythrocyte sedimentation rate (ESR) 53 mm/h. Antinuclear antibody (ANA), anti-dsDNA antibody, anti-Smith antibody, anti-cardiolipin antibody and human leucocyte antigen B51 were all within normal range. The etiological tests of influenza A pathogen, influenza B pathogen, parainfluenza virus, enterovirus and parvovirus were all negative. He tested positive for serum anti-GM1 IgG. Cerebrospinal fluid had a normal white cell count, an elevated protein content. Gram staining, culture and PCR detection for varicella-zoster virus, cytomegalovirus and herpes simplex virus were all negative. Antibodies associated with autoimmune encephalitis and paraneoplastic syndrome were negative in cerebrospinal fluid. Electromyography and nerve conduction studies showed a severe axonal damage affecting motor nerves. No obvious abnormalities were observed in his magnetic resonance imaging of brain and cavernous sinus. The patient was diagnosed with Behcet syndrome complicated with acute Guillain-Barre syndrome. He received intravenous methylprednisolone, intravenous immunoglobulin (IVIg) therapy, plasma exchange and rituximab treatment. After treatment, the patient's muscle strength of limbs was restored to grade 1, blepharoptosis and pain disappeared. The nervous system involvement of Behcet syndrome is relatively rare, especially combined with Guillain-Barre syndrome, which is easy to cause misdiagnosis. The treatment of Behcet syndrome complicated with acute Guillain-Barre syndrome includes the treatment of primary disease, plasma exchange and IVIg therapy. In addition, supportive treatment is very important for such patients. The focus of treatment is to avoid respiratory insufficiency, prevent deep vein thrombosis, monitor cardiac function and hemodynamics. Pain-relieving, physical exercise and psychological support are often under-recognized. The rehabilitation treatment is very important to improve the prognosis and quality of life of patients. What we need to learn is that when the symptoms and signs of the nervous system are difficult to be explained by neuro-Behcet syndrome alone, we should be alert to the possibility of other nervous system diseases.

Diagnosing Herpetic Genital Ulcers in a Resource-Limited Setting- What Works?

Aims: Globally, viral agents, especially herpes simplex virus (HSV), have overtaken the bacterial causes of genital ulcers. Very few laboratories in India, perform culture techniques and polymerase chain reaction (PCR) for diagnosis of genital ulcers. This study aimed to establish the utility of existing tests, which are cheaper and need less technical expertise, when compared to newer tests such as PCR.&#x0D; Study Design: This cross sectional study was carried out to determine the aetiology of genital ulcers, with emphasis on diagnosis of herpetic ulcers, using newer and more accurate methods of diagnosis and evaluating their performance by comparing against viral culture as gold standard test.&#x0D; Place and Duration of the Study: The study was carried out over a period of one year in the Apex Regional Sexually Transmitted Diseases (STD) Centre at Safdarjung Hospital, New Delhi and the Department of Microbiology, AIIMS, New Delhi.&#x0D; Methodology: Fifty three patients with genital ulcers were included in the study. Specimens from ulcers were taken for various tests, including Giemsa stain, ELISA for HSV-1 &amp; 2, PCR and Viral culture for HSV.&#x0D; Results: HSV was identified in 31 of 53 cases (58.5%), including 03 cases of HSV-1, and 28 cases of HSV-2. Sensitivity and specificity of PCR was 90.0% and 84.85%, respectively. Viral culture positivity was 37.7%.&#x0D; Conclusion: Genital herpes is associated with an increased risk of Human Immunodeficiency Virus (HIV) acquisition, and clinical manifestations are diverse; hence a presumptive diagnosis should be confirmed by reliable laboratory tests. Nucleic acid amplification tests (NAAT) are the most sensitive methods for direct detection of HSV. The extensive validation of these tests allows for their application in routine laboratory settings with consistency and greater diagnostic accuracy. When standardised and used, PCR is a highly reproducible, rapid and labour efficient method for HSV detection.

Case 1: A Term Male Infant with Hypoglycemia and Hyperbilirubinemia as Initial Presentation

A white male infant is born at term via spontaneous vaginal delivery to a 28-year-old woman at an outside facility. The parents do not have a consanguineous relationship, and the mother has had no pregnancy or delivery complications. The neonate weighs 3,170 g (11th–25th percentile), with a head circumference of 33.5 cm (4th–10th percentile) and length of 54.5 cm (76th–90th percentile). His skin is pale and multiple cafe-au-lait spots are found on his torso and extremities. He has micrognathia with an elongated head shape, a prominent occiput, and a flat anterior fontanelle. He is admitted to the NICU for hypoglycemia and receives antibiotics for 48 hours while sepsis is ruled out. Herpes simplex virus, cytomegalovirus, and peripheral blood cultures are negative. He continues to have refractory hypoglycemia and further tests reveal significant elevated γ-glutamyl transpeptidase (GGT) relative to mildly elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT), elevated direct hyperbilirubinemia, and mildly prolonged coagulation studies. Abdominal ultrasonography findings are normal. At 6 days of age, he begins to feed poorly so a nasogastric tube is placed for enteral feeds. The following day he is transferred to our facility for specialty consultation because of persistent hyperbilirubinemia and significantly elevated GGT. Upon admission to our unit he is noted to be an alert, active infant with normal male genitalia, but has bronze-colored skin and a large anterior fontanelle. His laboratory findings on admission reveal the following: sodium, 136 mEq/L (136 mmol/L); potassium, 6.9 mEq/L (6 mmol/L); chloride, 19 mEq/L (19 mmol/L); AST, 138 U/L (2.3 μkat/L); ALT, 97 U/L (1.6 μkat/L); …

Utility of Surface and Blood Polymerase Chain Reaction Assays in Identifying Infants With Neonatal Herpes Simplex Virus Infection.

Of 27 neonates with herpes simplex virus, DNAemia was observed in 100% with disseminated disease, 57% with central nervous system disease and 28% with skin, eye, mouth disease, suggesting DNAemia occurs frequently in these infants. Herpes simplex virus culture and polymerase chain reaction were performed on surface specimens from 13/27 infants, and ~50% tested positive only by polymerase chain reaction, suggesting the superiority of this technique.

S59. Response to immunotherapy in antibody-negative autoimmune epilepsy

Introduction Autoimmune epilepsy has been linked to a number of neural specific antibodies and the diagnosis is generally established by identifying one of these antibodies. Recognizing an autoimmune etiology is important because the mainstay of treatment is immunotherapy rather than anti-seizure drugs. However, antibodies may not always be detected and a clinical response to immunotherapy can support the diagnosis. We present a patient who showed significant improvement after immunotherapy even though no antibodies were detected. Methods Case report. Results 79 year old woman with history of breast cancer developed tremors, cognitive issues and generalized tonic-clonic seizures. MRI brain was unremarkable. EEG revealed frontal- temporal sharp waves and diffuse slowing. Cerebrospinal fluid (CSF) showed lymphocytic pleocytosis and raised protein. She gave a history of tick exposure and family members had Lyme disease. Lyme screening assay was positive for IgG, but IgM was negative. Testing for Epstein Barr virus, cytomegalovirus, herpes simplex virus, toxoplasma, Neurosyphilis, Gram stain and fungus culture was negative. Paraneoplastic panel (serum and CSF) and autoimmune panel including NMDA, GAD, and AMPA receptors were also negative. Heavy metal screening for arsenic, mercury, lead and copper was negative. Neuron specific enolase and 14-3-3 studies were unremarkable. Her seizures responded to fosphenytoin, and she was later switched to levetiracetam. She was treated with a course of ceftriaxone for presumed Neuroborreliosis. She improved clinically and was discharged. One month later, the patient returned with worsening tremors, cognitive dysfunction and seizures. She underwent extensive testing for etiology including MRI and CSF studies, which were unremarkable. Paraneoplastic/autoimmune panel was again negative. EEG showed temporal sharp waves and slowing. CT chest/abdomen/pelvis revealed a lung mass concerning for a malignancy. The patient was presumed to have a paraneoplastic syndrome due to history of cancer and new left upper lung mass, and was treated with IVIG. She had significant clinical improvement with resolution of seizures, and improvement in tremors and cognitive dysfunction. She is currently status post 7 treatments of IVIG without any relapse for >6 months. EEG was repeated and revealed resolution of slowing and sharp wave activity. Conclusion Although extensive testing for paraneoplastic and autoimmune antibodies was negative in our patient, the significant clinical and EEG response to immunotherapy with IVIG confirmed the diagnosis of autoimmune epilepsy. Since not all antibodies have been described and not all the described antibodies have commercially available testing, negative results do not exclude the possibility of autoimmune epilepsy. A trial of immunotherapy is warranted in such cases, if there is strong clinical suspicion.

A systematic review of oral herpetic viral infections in cancer patients: commonly used outcome measures and interventions.

To review the literature for outcome measures for oral viral infections in cancer patients. A secondary aim was to update the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) clinical practice guidelines for the management of oral viral infections in cancer patients. Databases were searched for articles published in the English language, 1981-2013. Studies that met the eligibility criteria were reviewed systematically. The data about the outcome measures were classified according to the aim of the study: prevention, treatment, or non-interventional. The results of interventional studies were compared to the 2010 MASCC/ISOO publication. Multiple clinical and laboratory tests were used to measure oral viral infections, with great variability between studies. Most of the studies were about Herpes Simplex Virus (HSV). The outcome measure that was most commonly used was the presence of HSV infection diagnosed based on a combination of suggestive clinical presentation with a positive laboratory result. HSV culture was the most commonly reported laboratory outcome measure. Acyclovir and valacyclovir were consistently reported to be efficacious in the management of oral herpetic infections. No new data on the quality of life and economic aspects was found. Considering the variability in outcome measures reported to assess oral herpetic infections the researcher should select carefully the appropriate measures based on the objective of the study. Acyclovir and valacyclovir are effective in the management of oral herpetic infections in patients receiving treatment for cancer. Studies on newer anti-viral drugs may be useful to address the issue of anti-viral resistance.

Multiplex PCR testing for nine different sexually transmitted infections.

Current sexually transmitted infection (STI) testing is not optimal due to delays in reporting or missed diagnoses due to a lack of comprehensive testing. The FilmArray® (BioFire Diagnostics, LLC, Salt Lake City, Utah) is a user-friendly, fully automated, multiplex PCR system that is being developed for rapid point-of-care use. A research-use-only STI panel including multiple PCR primer sets for each organism was designed to detect Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema pallidum, Trichomonas vaginalis, Mycoplasma genitalium, Ureaplasma urealyticum, Haemophilus ducreyi, and herpes simplex virus (HSV) types 1 and 2. Standard clinical testing included Gram stain, nucleic acid amplification, wet mount examination, herpes simplex virus culture, and syphilis IgG. Standard clinical tests were not available for all the organisms tested by the FilmArray STI panel. Two hundred and ninety-five clinical specimens from 190 subjects were directly compared to standard testing. Urine (n = 146), urethral/cervical swabs (31), oral swabs (60), rectal swabs (43), and ulcer swabs (15) were tested. Among the tested samples, FilmArray detected C. trachomatis in 39 (13%), N. gonorrhoeae in 20 (7%), T. vaginalis in nine (3%), HSV 1 in five (2%), HSV 2 in five (2%), U. urealyticum in 36 (12%), M. genitalium in eight (3%), and T. pallidum in 11 (4%). Concordance between the FilmArray STI panel and standard nucleic acid amplification testing for C. trachomatis was 98% and for N. gonorrhoeae was 97%. Multiplex PCR STI testing has the potential to improve public health by providing rapid, sensitive, and reliable results within the clinic or nearby laboratory.

Weighing Evidence and Art: A Challenging Case of Early-Onset Atypical Kawasaki Disease

A 3-month-old previously healthy boy first presented to the emergency department (ED) with a 2-day history of diarrhea, severe dehydration, and fussiness with apneic spells. He also had developed a maculopapular rash on his extremities and trunk that had almost completely resolved on presentation to the ED and had conjunctival erythema with discharge. Several children at home had “pink eye” the same week the infant became ill. From the ED, he was admitted to the PICU, where he was intubated. Although his initial laboratories were unremarkable (white blood cell [WBC] count 11.0 k/uL, 39% neutrophils, platelets 342 k/uL), he also underwent an extensive septic workup (including blood cultures, urine culture, cerebrospinal fluid analysis and culture, herpes simplex virus and enterovirus cultures, respiratory viral panel by polymerase chain reaction, respiratory culture, and influenza A/B direct antigen detection tests) along with empirical treatment with antibiotics for a total of 5 days. These laboratory and imaging studies (serial chest x-rays, head computed tomography scan) were not clinically significant. He defervesced for a 48 hours, but still experienced low-grade fever (Tmax 38.3°C) and intermittent episodes of irritability. After 8 days of hospitalization, he was discharged from the hospital after apparent resolution of most of his symptoms. At his follow-up outpatient pediatric visit 4 days after discharge, 12 days since the onset of his illness, he was afebrile and clinically quiet. ### Question Is there objective evidence that this patient had Kawasaki disease (KD) on initial visit? ### Discussion Tomisaku Kawasaki described the criteria for diagnosing KD in 1967.1 The criteria require presence of fever for duration of ≥5 days along with 4 of the 5 following physical findings without an alternative explanation:

Development and clinical evaluation of a novel fully automated qualitative PCR assay for the diagnosis of anogenital herpes simplex virus infection

Molecular detection of viral infections has the potential to improve microbial diagnostics, particularly with the emergence of rapid automated systems. We describe the design of the IDbox fully automated cassette-based system for nucleic acid extraction and real-time PCR amplification and perform a clinical evaluation for the diagnosis of genital herpes simplex infections. At optimal cutoff values determined by receiver-operator curves, the IDbox showed sensitivities of 94.9% (95% confidence interval [CI] 84.9–98.7%) and 97.0% (95% CI 88.5–99.5%) and specificities of 96.7% (95% CI 91.2–98.9%) and 97.3% (95% CI 91.9–99.3%) relative to herpes simplex virus culture and PCR, respectively. We discuss relevant design characteristics and approaches used for each step of the analytical process to enhance assay sensitivity and provide accurate results in the presence of potential cross-reactive organisms and interfering substances.

Creating a Molecular Atmosphere, Phase 5

As mentioned in previous articles in this series, product inserts are available with most FDA-approved assays. These product inserts contain information about the product as well as explain processes and procedures approved by the manufacturer of the assay. Included in these procedures are quality control (QC) recommendations. Some FDA-approved assays have QC material included in the packaging of test materials; others suggest from whom to purchase the quality control material and provide recommendations on how to use it. For all of the assays that we perform on the Infinity (Thermo Fisher Scientific, Waltham, MA) instrument, we routinely perform external QC on new lots and new shipments. All of these assays are FDA-approved, qualitative, and include a built-in internal control for every patient test that is performed. Because the internal control is present, we are not required to perform external QC procedures with every patient specimen. The external controls used for these assays are purchased from a manufacturer and can be used directly or after a simple dilution is made. The assays we perform on the SmartCycler (Cepheid, Sunnyvale, CA) are laboratory developed; therefore, control materials are not commercially available in ready-to-use form. Clinical Laboratory Standards Institute (CLSI) and College of American Pathologist (CAP) guidelines suggest that laboratorians ensure that a control is present throughout the entirety of a patient testing procedure. If an internal control cannot be present from start to finish, external-control material must be included in every patient-testing procedure. For herpes simplex virus (HSV) external control, we purchase stock virus from a manufacturer. We grow the virus in shell vials, in a similar manner that we would use for controls when setting up HSV cultures. This growth of virus in shell vials takes anywhere from 3 to 5 days to yield a 90% or greater cytopathic effect (CPE). … [↵][1]* To whom correspondence should be addressed. E-mail: stephanie.e.wallace{at}osfhealthcare.org [1]: #xref-corresp-1-1

Herpes Simplex Virus Duodenitis Accompanying Crohn's Disease

Herpes simplex virus (HSV) is a recognized cause of gastrointestinal infection in immunodeficient patients. Although a few cases of HSV gastritis and colitis in immunocompromised patients have been reported, there are no reports of HSV duodenitis in patients with Crohn's disease (CD). A 74-year-old female was admitted with general weakness and refractory epigastric pain. She had been diagnosed with CD three years ago. Esophagogastroduodenoscopy (EGD) revealed diffuse edematous and whitish mucosa with multiple erosions in the duodenum. Considering the possibility of viral co-infection, cytomegalovirus (CMV) immunohistochemical staining, PCR, and cultures of duodenal biopsies were performed, all of which were negative with the exception of the isolation of HSV in culture. After administration of intravenous acyclovir for 1 week, follow-up EGD showed almost complete resolution of the lesions and the patient's symptoms improved. In CD patients with refractory gastro-intestinal symptoms, HSV, as well as CMV, should be considered as a possible cause of infection, so that the diagnosis of viral infection is not delayed and the appropriate antiviral treatment can be initiated.

Type-Specific Identification of Anogenital Herpes Simplex Virus Infections by Use of a Commercially Available Nucleic Acid Amplification Test

Herpes infections are among the most common sexually transmitted infections (STI), but diagnostic methods for genital herpes have not kept pace with the movement toward molecular testing. Here, we describe an FDA-approved molecular assay that identifies and types herpes simplex virus (HSV) infections for use in routine clinical settings. Paired samples from anogenital lesions were tested using the BD ProbeTec HSV Q(x) (HSVQ(x)) system, HSV culture and, a laboratory-developed PCR assay. Family planning, obstetrics/gynecology (OB/GYN), or sexually transmitted disease (STD) clinics in the United States served as recruitment sites. Sensitivity and specificity estimates, head-to-head comparisons, measures of agreement, and latent-class analyses were performed to provide robust estimates of performance. A total of 508 participants (174 men and 334 women) with anogenital lesions were included; 260 HSV-2 and 73 HSV-1 infections were identified. No differences in test performance based on gender, clinic type, location of the lesion, or type of lesion were observed. The sensitivity of HSV-2 detection ranged from 98.4 to 100% depending on the analytical approach, while the specificity ranged from 80.6%, compared to the less sensitive culture method, to 97.0%, compared to PCR. For HSV-1, the sensitivity and specificity ranges were 96.7 to 100% and 95.1 to 99.4%, respectively. This assay may improve our ability to accurately diagnose anogenital lesions due to herpes infection.

Intrauterine Herpes Simplex Virus Infection in a Monochorionic Twin Gestation.

Herpes simplex virus (HSV) of the newborn affects 1 in 3200 [1] live births in the United States, and can be acquired by the intrauterine or intrapartum route, or postnatally. Intrauterine or congenital infection represents the rarest form (5% of cases) [2] and frequently has devastating consequences such as congenital brain malformation and severe neurocognitive impairment leading to fetal or neonatal death [3]. Here we present two cases of fatal intrauterine HSV infection in monochorionic twin infants. CASE A 21-year-old secundigravida mother with twin gestation of 26-4/7 weeks presented with spontaneous rupture of membranes of clear amniotic fluid 11 hours prior to delivery. She had negative prenatal laboratory studies for hepatitis B, syphilis, human immunodeficiency virus (HIV), and an unknown group B streptococcus status. Her sexually transmitted infection history included chlamydia trachomatis infection treated during early pregnancy and no history of HSV in herself or her sexual partner. A structural survey 1 week prior to delivery revealed severe hydrops and hydranencephaly in the first twin, and moderate hydrocephalus in the second twin. The mother was afebrile, well-appearing, and reported no history of recent illness or genital lesions before or during either of her pregnancies. Both mother and father refused HSV serologic testing. The first twin boy was delivered via cesarean section with Apgar scores of 1, 2, and 3, at 1, 5, and 10 minutes, respectively. The infant was apneic, unresponsive to resuscitation efforts, and died shortly after birth. On autopsy, gestation was shown to be monochorionic–monoamniotic, and the placenta had evidence of acute chorioamnionitis; however, it was not tested for the presence of HSV. The intracranial cavity was composed of hemorrhagic fluid and fragments of parenchymal tissue with extensive necrosis and chronic inflammation, consistent with meningoencephalitis, and the liver was calcified and necrotic. Viral immunostaining revealed the presence of HSV in the adrenal gland and brain parenchyma, and no virus was detected in the liver. No viral cultures were performed on autopsy tissue due to formalin fixation, and surface cultures for HSV were not performed. The second twin boy had Apgar scores of 5, 7, and 8 at 1, 5, and 10 minutes, respectively. He was immediately intubated for respiratory distress, received inotropes and intravenous fluids for hypotension, and was given ampicillin and gentamicin for presumed sepsis. At 5 hours of life, vesicular skin lesions on the neck were noted on physical examination (PE). PE was otherwise unremarkable. HSV studies were sent from the skin lesion (neck), mucosal surfaces (eyes, mouth, rectum), and cerebrospinal fluid (CSF), and empiric acyclovir 20 mg/kg every 8 hours was started. Initial white blood cell (WBC) count, platelet count, liver function, and serum electrolytes were normal. The CSF revealed 111 WBC/mm 3 with a lymphocytic predominance, 7600 red blood cells/mm 3 , protein 1245 mg/dL, and glucose 21 mg/dL. Blood and CSF bacterial cultures were sterile. Toxoplasma immunoglobulin M antibody, cytomegalovirus (CMV), and parvovirus B-19 polymerase chain reaction (PCR) yielded negative results. PCR was positive for HSV type 2 (HSV-2) and negative for HSV type l from all five tested sites.

Herpes Simplex Virus Type 1 is the Leading Cause of Genital Herpes in New Brunswick

Little is known about the role of herpes simplex virus (HSV) type 1 (HSV1) in the epidemiology of genital herpes in Canada. Data on herpes viral cultures for two consecutive years obtained from L'Hôpital Dr GL Dumont, which performs all the viral culture testing in New Brunswick, were reviewed. It was hypothesized that HSV1 was the main cause of genital herpes in New Brunswick. Samples of genital origin sent to the laboratory for HSV culture testing between July 2006 and June 2008 were analyzed. Samples from an unspecified or a nongenital source were excluded from analysis. Multiple positive samples collected from the same patient were pooled into a single sample. HSV was isolated from 764 different patients. HSV1 was isolated in 62.6% of patients (male, 55%; female, 63.8%). HSV1 was isolated in 73.2% of patients 10 to 39 years of age and in 32% of patients ≥40 years of age. The difference in rates of HSV1 infection between the 10 to 39 years of age group and the ≥40 years of age group was statistically significant (P<0.001 [χ(2)]). In a similar Canadian study performed in Nova Scotia, HSV1 was recovered in 53.7% of positive cultures (male, 36.7%; female, 58.1%). The rates of HSV1 infection reported by this study and the present study were significantly different (P<0.001 [χ(2)] for male, P=0.012 for female). In New Brunswick, HSV1 is the dominant type of HSV isolated in samples collected from a genital site. Significant rate differences were demonstrated between the groups 10 to 39 years of age and ≥40 years of age. Little is known about the role of herpes simplex virus (HSV) type 1 (HSV1) in the epidemiology of genital herpes in Canada. Data on herpes viral cultures for two consecutive years obtained from L’Hôpital Dr GL Dumont, which performs all the viral culture testing in New Brunswick, were reviewed. It was hypothesized that HSV1 was the main cause of genital herpes in New Brunswick. Samples of genital origin sent to the laboratory for HSV culture testing between July 2006 and June 2008 were analyzed. Samples from an unspecified or a nongenital source were excluded from analysis. Multiple positive samples collected from the same patient were pooled into a single sample. HSV was isolated from 764 different patients. HSV1 was isolated in 62.6% of patients (male, 55%; female, 63.8%). HSV1 was isolated in 73.2% of patients 10 to 39 years of age and in 32% of patients ≥40 years of age. The difference in rates of HSV1 infection between the 10 to 39 years of age group and the ≥40 years of age group was statistically significant (P<0.001 [χ2]). In a similar Canadian study performed in Nova Scotia, HSV1 was recovered in 53.7% of positive cultures (male, 36.7%; female, 58.1%). The rates of HSV1 infection reported by this study and the present study were significantly different (P<0.001 [χ2] for male, P=0.012 for female). In New Brunswick, HSV1 is the dominant type of HSV isolated in samples collected from a genital site. Significant rate differences were demonstrated between the groups 10 to 39 years of age and ≥40 years of age.

A Case of Cutaneous Endometriosis following Vulvar Injury

Background Cutaneous endometriosis of the vulva following traumatic injury is rare. Case A 15-year-old presented to the emergency department complaining of vulvar swelling with painful papules and URI symptoms, 11 months after suffering a vulvar abrasion. She was admitted to the hospital for pain control and empiric antiviral therapy for a suspected herpes outbreak, although final herpes simplex virus (HSV) cultures were negative. She continued to experience similar episodic vulvar symptoms, and biopsy and surgical resection of the lesions revealed cutaneous endometriosis. Conclusion Although the vulva is a rare site for endometriosis, it should always remain a differential diagnosis when painful vulvar lesions are present.