Herpes virus

Introduction:
 The herpes viruses are large, enveloped DNA viruses.
 The herpes virus family contains over a hundred species that affect humans
and animals.
 They are characterized by their ability to establish latent infections,
enabling the virus to persist indefinitely within infected hosts and to
undergo periodic reactivation.
 They measures about 120-200 nm in diameter.
 They consist of four distinct structural elements a) DNA core, b) capsid, c)
tegument, and d) envelop.
 The DNA core consists of a linear double-stranded DNA molecule with
molecular weight varying from 125-229 kilobasepair.
 The core is surrounded by an icosahedral capsid containing 162
capsomeres.
 This is enclosed by a glycoprotein-containing envelope.
 Between the envelope and capsid is an amorphous structure called
tegument, which contains viral proteins and enzymes that initiate
replication.
 Envelope is the outermost component and is composed of lipids.
 It is derived from the modified host cell nuclear membrane through which
the naked virions project during replication.
 It carries surface spikes about 8 mm long.
 Herpesviruses replicate in the host cell nucleus, and both replication and
assembly occur in the nucleus.
 The herpes virus encodes for several glycoproteins that facilitate viral
attachment, fusion and immune evasion.
 The virus buds from nuclear membrane and is released by exocytosis and
cell lysis.
Classification:
 Herpesviruses are ubiquitous.
  All human herpesviruses are included in the family Herpesviridae, which is
divided into three subfamilies based on viral characteristics, pathogenesis
of the disease, and clinical manifestation of the disease-
Alphaherpesviruses, Betaherpesviruses and Gammaherpesviruses.

Herpes Simplex Viruses

Herpes simplex viruses (HSVs) are extremely host-adapted viruses that can cause
a wide variety of illness in infected human hosts. There are two types of the HSVs:
a) Herpes simplex virus type 1 ( HSV-1)- produces cold sores
b) Herpes simplex virus type 2 (HSV-2)- produces genital herpes

Both the types are closely related in their DNA homology, antigenic determinants,
and tissue tropism and disease symptoms, but differ in epidemiology.HSV-1 is
primarily transmitted by contact with infected saliva, whereas HSV-2 is
transmitted by contact or by genital tract infection to newborn from an infected
mother.
Virion characteristics:
Herpes simplex virus shows following features:
 The HSVs like other herpesviruses are large, enveloped, icosahedral viruses.
 Both HSV-1 and HSV-2 are structurally and morphologically similar. They,
however, are distinguished antigenically by using type-specific monoclonal
antibodies, restriction endonuclease patterns of their genome DNA, and
the site of lesions.
 The virus contains a dsDNA.The unique feature of the DNA genome is that it
encodes for as few as 80 polypeptides.
 Half of the proteins are required for replication of viruses.
 HSV encodes for at least 11 glycoproteins that serves as
a) Viral attachment proteins ( gB, gC, gD, gH),
b) Fusion proteins (gB),
c) Structural proteins,
d) Immune escape proteins ( gE, and gI), and
 e) Other fractions

Viability Characteristics:
 Like other enveloped viruses, HSVs are sensitive to treatment with acid,
alcohol, ether, chloroform, fat, bile salts, solvents, detergents and drying.
 They are readily inactivated in the conditions prevalent in the
gastrointestinal tract.
 They are heat labile and must be stored at -70 C ͦ .
Pathogenesis and Immunity:
HSV shows unique biological properties: neurovirulence, latency, And
reactivation.
  Neurovirulence: The viruses have to invade and multiply in the nervous
system.
 Latency: Establishment and maintenance of latent infection in the nerve
cell ganglion is the unique property of the virus.HSV-1 affects most
commonly the trigeminal ganglion, whereas HSV-2 affects the sacral nerve
root ganglion (S2-S5).
 Reactivation: Reactivation and replication of latent HSV can lead to overt or
convert recurrent infections and excretion of HSV. Reactivation can be
caused by a variety of stimuli, including fever, trauma, emotional stress,
sunlight, etc. In immunocompetent patients, HSV-1 reactivates more
frequently in the oral cavity rather than on the genital parts, HSV-2
reactivates eight to ten times more frequently in the genital parts as
compared to orolabial infection.
Pathogenesis of herpes simplex virus:
 Herpes simplex virus causes disease by direct cytopathologic effect.
 The infection is initiated by direct contact and depends on the infected
tissues whether oral, genital, or brain, etc.
 The infection occurs by inoculation of virus into susceptible mucosal
surfaces, such as the oropharynx, conjunctiva, or cervix or through small
abrasions on the skin.
 The virus infects cells of ectodermal origin, the cells coming in contact with
infected material, such as saliva or genital secretions.
 Virus replicate at the site of entry in the skin or mucous membrane.
 The neuroinvasiveness ( the ability of virus to invade the brain),
neurotoxicity ( Ability to multiply in the brain and destroy the brain), and its
latency ( ability to remain in a nonreplicating stage in thr dorsal root ganglia
of the central nervous system, or CNS) are the properties of HSV that
influence the course of infection in an infected host.
 The virus multiplies locally with cell-to-cell spread.
 The virus replicates in the infected cells at the base of the lesions and
infects the innervating neuron.
 Subsequently, the viruses travel by retrograde transport to the ganglion,
such as the trigeminal ganglion for HSV-1 and the sacral ganglion for HSV-2.
 The virus then returns back to the initial site of infection and may cause
inapparent infection or producue vesicular lesions.
 Thin- walled umbilicated vesicles- the roof of which breaks down, leaving
tiny superficial ulcers- are typical lesions caused by HSV.
 The vesicle heals without forming any scars.
 The vesicle fluid contains infectious virions.
 After this retrograde axonal flow from neurons, the viral genome become
latent in the ganglia, particularly those of the trigeminal (HSV-1) and sacral
(HSV-2) nerves.
 No viral particles are produced during this phase of latency.
 Also, latent infection in neurons does not cause any demonstable damage
in neurons.
 This latency phase may be reactivated periodically in some individuals,
causing recurrent oral and genital lesions.
 Various stimuli, such as physical or emotional stress, trauma, fever, and
sunlight can induce a recurrence in which the virus travels back down the
nerve, leaving lesions to develop at the skin, at the same spot each time.
 This stimuli trigger reactivation:
a) by facilitating viral replication in the nerve,
b) by inhibiting cell-mediated immunity (CMI) transiently,or
c) by inducing both the mechanisms.
Thus, recurrences or reactivation of infection can occur in the presence
of specific antibodies. However, the recurrent infections are more
localized, less severe, and of short duration than the primary infection,
due to presence of past memory immune responses.
Clinical symptoms:
Herpes simplex virus causes a wide variety of clinical manifestations. The clinical
manifestation depend on a) the age of patient b) immune status of the host c)
previous immunity of the patient to autologous or heterologues viruses, d)
antigenic type of the virus, and e) anatomical site of involvement.
Generally, HSV-1 produces lesions below the waist. HSV-1 infection is normally
associated with orofacial infections and encephalitis, whereas HSV-2 is associated
with genital infections. Primary infection with either virus is typically associated
with systemic signs, prolonged duration, increased severity of illness and more
complications.
A) HSV-1 infections: HSV-1 can cause a wide variety of clinical entities.these
include a) acute herpetic gingivostomatitis, b) acute herpetic
pharyngotonsillitis, c) herpes labialis, d) herpes encephslitis, e) eczema
herpeticum, and f) herpetic whitlow.
a) Acute herpetic gingivostomatitis: It is the manifestation of primary HSV-
1 infection occurring in children between 6 months and 5 years. Saliva
from infected child or an adult is the source of infection. This condition
has an incubation period of 3-6 days. This condition has an abrupt onset
with high temperature. Gingivitis is the most important manifestation
with marked lip swelling and erythematous and fragile gums. Vesicular
lesions appear on the oral mucosa, tongue and lips. These lesions
subsequently rupture and coalesce together, leaving behind ulcerated
plaques. The acute disease last for 5-7 days, and the symptoms subside
in 2 weeks. Viral shedding from the saliva may continue for 3 weeks or
more.
b) Acute herpeticphartngotonsillitis: HSV-1 causes pharyngitis and
tonsillitis in adults more frequently than gingivostomatitis. The condition
manifests as fever, malaise, headache, and sore throat. The vesicular
lesions on the tonsils and the posterior pharynx usually rupure to form
ulcers. Associated oral and labile lesions can be found in less thn 10% of
the patients.
c) Herpes labialis: It is the most common clinical manifestation of
recurrent HSV-1 infection. Pain, burning, and tingling sensation at the
site of infection are presenting features. An intraepidermal vesicle that
later becomes pustular and ulcerate is the typical lesions. Usually, two
or less recurrences manifest each year in most patients. But in some
patients, even monthly recurrence is seen.
d) Herpes encephalitis: It is an acute febrile disease that is usually caused
by HSV-1. This may be a manifestation of primary or recurrent infection
with the virus. The infection may have an insidious or an aburt onset.
Focal neurological manifestation, such as seizures, hemiparesis, aphasia,
and paresthesia may be seen during acute condition. In some patients,
the infection may rapidly progress from stupor to coma to death,
without having any localized neurological symptoms.
e) Eczema herpeticum: It is seen in children with active eczema. The
vesicular lesions appear briefly on previous eczematous areas with
extensive ulceration. Subsequently, the infection may be disseminated
 by blood to the adrenal glands, liver, and other organs, resulting in fatal
consequences.
f) Herpetic whitlow: It is an infection of the finger caused by entry of the
virus through cuts or abrasions on the skin. The condition often occurs in
doctors and nurses who are exposed to patients with HSV infection and
to patients who have genital infection. The vesicular lesions are usually
produced on the skin of the finger but may also be seen on the skin of
the head and neck.
B) HSV-2 infections: HSV-2 causes a) genital herpes, b) neonatal infection and
c) aseptic meningitis.
a) Genital herpes: It is mostly caused by HSV-2 but can also be caused by
HSV-1. The latter causes less than 10% of genital infections. Most
primary genital infections are asymptomatic. The clinical manifestations
of primary genital herpes caused by HSV-1 and HSV-2 are similar, but
recurrences are more common with HSV-2.
In symptomatic men, the herpetic vesicles appear in the
glans penis, the prepuce, shaft of the penis, and sometimes on the
scrotum, thighs, and buttocks. Herpetic proctitis involving the perianal
area and rectum are seen in the persons who engage in anal
intercourse. In women the vesicles appear on the external genitalia,
labia majora, labia minora, vaginal vestibule, and introitus. The vesicles
subsequently rupture, leaving behind extremely painful ulcers. Cervicitis,
urethitis, and dysuria may also be present in some women.
In both men and women, the primary infection may be associated
with constitutional symptoms, such as fever, headache, malaise, and myalgia. In
both the sexes, the ulcerative lesions persist from 4-15 days until crusting and re-
epithelizaton occur. The virus continue to shed in the ulcerative lesions for more
than 12 days.
Recurrent genital herpes are more common with HSV-2 as
compared to HSV-1. The condition is shorter in duration and less severe than the
primary genital herpes. Recurrent genital herpes in men may present as one or
more numbers of clustered vesicles on the shaft of penis, prepuce, or glans.
Relatively, pain is mild and urethritis is uncommon. The lesions heal in 7-10 day.
In women, the vesicular lesions are found on the labia majora, labia minora,or
 perineum. These lesions are very painful. Fever and constitutional symptoms are
uncommon. The lesions heal in 8-10 days.
b) Neonatal infections: It is a most serious and usually fatal disease caused
mostly by HSV-2. It usually occurs due to shedding of HSV-2 from the
cervix during vaginal delivery. It can also occur from an ascending in-
utero infection during a primary infection of the mother. The infection
can also be acquired postnatally from family members or hospital staff.
Since CMI is poorly developed in neonates, the virus causes a
disseminated disease without the involvement of liver, lung, as well the
organs of the CNS. The condition has a high mortality of 80%.
Progression of the infection to the CNS results in mental retardation or
neurological disabilities even with treatment, or may finally lead to
death.
c) Aseptic meningitis: It may occur as a complication of genital HSV-2
infection.

(It is important to understand that although someone may not have visible sores
or symptoms, they may still be infected by the virus and may transmit the virus to
others. Some of the symptoms associated with this virus include:

 blistering sores (in the mouth or on the genitals)

 pain during urination (genital herpes)
 itching
Additionally, one may experience many symptoms that are similar to the flu.
These symptoms can include fever, swollen lymph nodes, headaches, tiredness,
and lack of appetite. HSV can also spread to the eyes, causing a condition called
herpes keratitis. This can cause symptoms such as eye pain, discharge, and a gritty
feeling in the eye.)

Epidemiology:
Herpes simplex virus is distributed worldwide.
 Geographical distribution:
HSV-1 infection is more common than HSV-2 infection. By the age of 30
years, in a low socioeconomic status are seropositive. Serum antibodies to
HSV-2 begin to appear at puberty, correlating with degree of sexual
activity. The HSV-2 infection is a major problem in the United States. It has
been estimated that five of every 12 adults are infected, with up to1
million newly infected people added every day.
 Reservoir, source and transmission of infection:
Herpes simplex virus infections are exclusively human diseases. Humans
are the only natural reservoirs. No vectors are involved in transmission of
the disease. An infected person is a lifelong source and reservoir of the
virus. Vesicle fluid, saliva and vaginal secretions are the important sources
of infection for both types of HSV.
HSV-1 infection is transmitted orally through saliva. It is usually
transmitted by oral contact, such as by kissing or by sharing of the
toothbrushes or the other saliva contaminated items. The HSV infection
can also occur following mouth-to-skin contact, with the virus entering
through minor abrasions in the skin. Autoinoculation may also cause
infection of the eye.
Children are at risk for acquiring HSV-1 infection, whereas
sexually active people are at increased risk to HSV-2 infection. Medical and
paramedical staffs on coming in contact with oral and genital secretions
are at increased risk for acquiring herpetic whitlow. Immunocomprimed
individuals and neonates are at high risk for developing life-threatening
disseminated disease.

Laboratory Diagnosis:
 Specimens: These include saliva, vesicle fluid, conjunctival fluid, corneal
scraping, skin scrapings, and cerebrospinal fluid (CSF).
 Microscopy: Light microscopy of the stained infected cell may show
ballooning of cells, ground glass nuclei and eosinoplilic intranuclear
inclusions, and multinucleated giant cells. Electron microscopy can be used
 for direct demonstration of virions in the negatively stained smears of the
clinical specimens.
 Direct antigen detection: Direct enzyme immunoassay and direct
fluorescent antibody test are useful to demonstrate HSV antigens directly in
vesicular fluid, tissue smear, or biopsy.
 Isolation of the virus:
A definitive diagnosis of HSV infection is made by isolating the viruses in cell
cultures.
Cell cultures: For cultures, scrapings of skin vesicles and mucosal lesions are
collected, transferred immediately in a vial transport medium, and are
carried to microbiology laboratory. After inoculation, HSV produces
cytopathic effects (CPEs) within 1-3 days on HeLa cells, Hep-2 cella, and
human embryonic fibroblasts. These cells become enlarged and appeared
ballooned. Some virus strains, particularly HSV-2, cause fusion of infected
cells, leading to formation of syncytium. Immunofluorescent staining of
infected tissue cultures useful to confirm the diagnosis within 24 hours.
Polymerase chain reaction (PCR) is a useful tool to distinguish HSV-1 from
HSV-2. Isolated HSV can be typed by biochemical, immunological, and
molecular methods.
 Serodiagnosis:
Serodiagnosis is of little value for diagnosis of primary HSV infection. It is
mainly used for epidemiological studies. It is used only to determine
postexposure to HSV. It is not useful for diagnosing recurrent infections
because rise in antibody titer does not usually correlate with recurrent
disease. Also, the serological tests cannot distinguish between HSV-1 and
HSV-2 antibodies due to cross-reactivity.
 Other tests:
Tzanck smear:
 It is useful for the cytological identification of viruses in
the scraping obtained from the base of the vesicular
lesion.
 In this procedure, the vesicular lesion is aseptically
ruptures and the base of the lesion is scrapped with a
scalpel.
  The scraping from the base of the lesion is smeared on a
glass slide, air dried, fixed and usually stained with
Giesma or Wright stain.
 Demonstration of typical giant cell or Cowdry type A
intranuclear inclusion bodies in the stained smear is
diagnostic of HSV infection.
 This method shows variable sensitivity of 40-80% for
diagnosis of HSV.
Diagnostic methods Diagnostic features
1) Microscopy
Tzanck smear Presence of multinucleated giant cells
with faceted nuclei and homogenously
stained ground glass chromatin ( Tzanck
cells)
Light microscopy Eosinophilic intranuclear inclusions
Electron microscopy Virus particle
2) Direct antigen detection
Direct fluorescent antibody and HSV antigens directly in vesicular fluid,
direct enzyme immunoassay tissue smear, or biopsy
3) Cell culture
Culture on HeLa cells, Hep-2 Cytopathic effects within 1-3 days
cells and human embryonic
fibroblasts
4) Serology
ELISA, CFT and neutralization Not useful for primary infection, only used
test for seroepidemiological studies
5) Molecular diagnosis
DNA probe and PCR Detects viral genome directly in vesicular
fluid, skin scraping, CSF and other
specimens.
Table: Laboratory tests for diagnosis of herpes simplex virus infections
Treatment:
Herpes simplex virus infections are among other few non-HIV viral infections that
can be treated with antiviral therapy. Treatment with specific antiviral
chemotherapy is used to
  Pevent disease and recurrence,
 Treat the infection, and
 To reduce the clinical course of infection.
1)Acyclovir: It is a synthetic acyclic purine nucleotide analog, which is most
commonly used to treat HSV infectioin. Acyclovir is useful:
 To diminish shedding of viruses
 To decrease rate of clinical recurrences
 To suppress recurrent genital infections
Oral therapy with acyclovir is usually recommended for primary orolabial and
genital HSV infections, which are non-life-threatening. Intravenous acyclovir is
recommended for life-threatening and serious HSV infection, such as encephalitis,
infections in immunocompromised patients, and occasional severe orolabial or
genital cases.

2) Famciclovir and valacyclovir are other antiviral agents used against HSV.
These medications can help infected individuals reduce the risk of
spreading the virus to other people. The medications also help to lower the
intensity and frequency of outbreaks. These medications may come in oral
(pill) form, or may be applied as a cream. For severe outbreaks, these
medications may also be administered by injection.

Prevention and control:

 Prevention of genital HSV infection is difficult because most transmission
occurs during subclinical viral shedding.
 Nevertheless, abstinence from sexual intercourse while the patients have
prodromal symptoms or lesions or use of condoms may be useful.
 But these methods are not fully protective.
 Prevention of transmission of HSV from mother to infant is also difficult
due to presence of asymptomatic primary or recurrent genital infection.
 In such infected mothers, transmission can be prevented by avoiding
vaginal delivery and instead delivering by caesarian section.
 At present, no vaccine is available for use against HSV.