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Penis and scrotum
Infectious disorders
Herpes simplex virus
Reviewers: Antonio Cubilla, M.D. and Alcides Chaux, M.D. (see Author/Reviewers page)
Revised: 18 February 2010, last major update February 2010
Copyright: (c) 2002-2010, PathologyOutlines.com, Inc.
Definition
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● Sexually transmitted disease, usually caused by Herpes simplex virus 2 (HSV2) and HSV1, which are DNA viruses
Terminology
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● The Herpesviridae family has at least 8 viruses known to infect man: HSV1, HSV2, Epstein Barr virus (EBV), Cytomegalovirus (CMV), Varicella Zoster Virus (VZV), Human herpes virus 6 (exanthum subitum or roseola infantum), Human herpes virus 7 and Human herpes virus 8 (Kaposi's sarcoma-associate herpes virus)
Epidemiology
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● Sexually transmitted; spreads by direct contact with lesions
● Also spreads by asymptomatic shedding when no lesion is apparent
Sites
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● Genital region, mouth; also other areas
Etiology
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● Although historically caused mainly by HSV2, now 5-30% of primary outbreaks of genital herpes are caused by HSV1
● Blisters contain large number of viral particles and are very contagious
Clinical features
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● HSV infection is the most common cause of genital ulceration (BJU Int 2002;90:498)
● Multiple (6-10) small (1-2 mm) papules and macules, followed by vesicles that rupture and cause painful ulcers, usually at tip of penis or on shaft
● Atypical presentations include fissures, furuncles, linear excoriations and ulcerations
● In immunocompromised patients, especially those HIV-positive, ulcerations can be deep and persistent
● Blisters occur around anus in men who have sex with men
● Usually diagnosed clinically, with confirmation by culture, direct fluorescent antibody, skin biopsy, PCR for viral DNA
● Primary outbreak: occurs 3-14 days after exposure; patients usually asymptomatic but rarely have systemic symptoms of fever, headache, muscle ache, fatigue, swollen and tender lymph nodes
● After infection, viral genome remains in latent state in nuclei of sensory neurons for life
● Recurrences: may not occur at all, or up to 40 years after primary outbreak, usually milder than initial outbreak
Treatment
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● Antiviral drugs reduce frequency, duration and severity of outbreaks, and asymptomatic shedding
● Antiviral medications include aciclovir (Zovirax), valaciclovir (Valtrex), famciclovir (Famvir) and penciclovir (Wikipedia)
Clinical images
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Multiple vesicles and ulcerations on surface Cluster of vesicles on same red base
Lesions in later Atypical lesions Crusting lesion
stage of healing resembling erosions resembling scabies
Micro description (Histopathology)
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● Multinucleated giant cells with ground glass nuclei due to intranuclear virus
● More common at interface between ulcerated and non-ulcerated areas
● Intraepithelial vesicles contain rounded acantholytic keratinocytes
● Keratinocytes show viral cytopathic changes of ground-glass nuclei, nuclear molding and multinucleated giant epithelial cells
● Well-defined acidophilic inclusions can also be seen
Micro images
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Intraepidermal vesicle Focal ulceration Multinucleated giant cells at edge of ulcer
Multinucleated giant cells with inclusions From lung HSV2 antibody highlights virus
in cells at interface
Other images: multinucleated giant cells with inclusions (vulva)
Cytology images
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Multinucleated giant cells with Multinucleated cells with intranuclear inclusions
ground glass nuclei and nuclear molding – cervicovaginal (Thin Prep)
Positive stains
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● HSV1 or HSV2
Electron microscopy images
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Drawing Image-negative stain Enveloped, linear, double-stranded DNA
Herpesviruses have an envelope surrounding an icosahedral capsid, approximately 100nm in diameter, which contains the dsDNA genome; when the envelope breaks and collapses away from the capsid, negatively stained virions have a typical "fried-egg" appearance (University of South Carolina)
Additional references
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End of Penis and scrotum > Infectious disorders > Herpes simplex virus
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