Increasing proportion of herpes simplex virus type 1 among women and men diagnosed with first-episode anogenital herpes: a retrospective observational study over 14 years in Melbourne, Australia

Six-year Study on Mucocutaneous Herpes Simplex Virus Infections at the Largest Tertiary Teaching Hospital in Portugal

Herpes simplex virus (HSV) infections are widespread among humans. Their diagnosis is predominantly clinical, but its laboratory confirmation is increasingly encouraged. We conducted a 6-year retrospective, observational study of polymerase chain reaction (PCR) confirmed mucocutaneous HSV infections in the largest Portuguese tertiary teaching hospital. Throughout this period, a total of 947 PCR herpesvirus tests in mucocutaneous swabs were performed, 448 of which tested positive (266 for HSV). Regarding the PCR-confirmed mucocutaneous HSV infections, HSV-1 was the main cause of orolabial herpes and HSV-2 of genital herpes. A significant proportion of patients were immunocompromised, demonstrating the risk for herpesvirus infection and reactivation in this setting. HSV-1 genital herpes was more common in women, younger individuals and had a lower rate of recurrences. This study demonstrates the variable clinical spectrum of HSV infections, and the importance of their laboratory confirmation, as the recognition of the specific pathogen may determine optimal management and prognosis.

Trends in infections detected in women with cervicitis over a decade

Objectives

There is a growing body of evidence that in the absence of Chlamydia trachomatis and/or Neisseria gonorrhoeae, Mycoplasma genitalium and bacterial vaginosis (BV) are associated with cervicitis. We aimed to describe infections detected among cervicitis cases over a decade and establish how commonly M. genitalium and BV were detected among non-chlamydial/non-gonococcal cases to inform testing and treatment practices.

Methods

We conducted a retrospective case-series to determine the number of cervicitis cases diagnosed with genital infections (C. trachomatis, N. gonorrhoeae, M. genitalium and BV) among women attending the largest public sexual health service in Australia from 2011 to 2021. We determined the proportion of cervicitis cases with one or more genital infections detected, and trends in testing and detection of each infection over time.

Results

Over a decade 813 cervicitis cases were diagnosed; 421 (52%, 95%CI: 48%-55%) had no infection detected; 226/729 (31%, 95%CI: 28%-35%) had BV, 163/809 (20%, 95%CI: 17%-23%) C. trachomatis, 48/747 (6%, 95%CI: 5%-8%) M. genitalium, and 13/793 (2%, 95%CI: 1%-3%) N. gonorrhoeae. Of the 665 (82%) cases tested for all four infections, 268 (40%) had one infection and 73 (11%) had >1 infection detected. Of the 517/665 (78%) non-chlamydial/non-gonococcal cases, 164 (32%) had BV and 16 (3%) had M. genitalium as the sole infections detected; a further 13 cases (3%) were co-infected with BV and M. genitalium. The proportion of cases tested for BV (90%) did not change overtime, but detection increased from 32% to 45% (Ptrend < 0.001). The proportion of cases tested for M. genitalium increased from 84% in 2011 to 96% in 2019 (Ptrend = 0.006), with M. genitalium-detection in cervicitis increasing from 3% to 7% (Ptrend = 0.046).

Conclusions

In our study population, chlamydia or gonorrhoea were not detected in ∼75% of cervicitis cases; 1 in 3 of these cases had BV and/or M. genitalium, and both increased in prevalence over time. These data highlight the need for clinicians to consider BV and M. genitalium when assessing and managing cervicitis.

Herpes Simplex Type 1 as the Predominant Cause of Genital Herpes in College Students

BACKGROUND

Genital herpes etiology has been shifting to include a greater proportion of herpes simplex virus type 1 (HSV-1) infection in the last few decades. A prior study published in 2003 found that 48.9% of infections in a college health population were HSV-1.

METHODS

We evaluated the number of positive HSV polymerase chain reaction test results obtained from anogenital sites from undergraduate and graduate students from 2013 to 2022 in a college health clinic setting and analyzed the number caused by HSV-1 and HSV type 2 and compared by sex. This was then compared with the prior study from 1993 to 2001.

RESULTS

We received 691 (of 2685 samples) positive polymerase chain reaction results for HSV of both types in the period analyzed. Overall, 600 (86.8%) of these were HSV-1, and 520 (75.2%) were in female patients. The prior study in 1993 to 2001 found that 48.9% (244 of 675) of all positive test results were HSV-1; we observed an increase in the percentage of positive HSV-1 over all positive test results of 1.8 ( χ2 = 16.548; P < 0.001).

CONCLUSIONS

Our study shows that 86.8% of the positive genital HSV test results from 2013 to 2022 were HSV-1. This shows that most positive HSV test results in this setting are now HSV-1, a substantial increase from the previous study in our clinic.

Impaired endocytosis and accumulation in early endosomal compartments defines herpes simplex virus-mediated disruption of the nonclassical MHC class I-related molecule MR1

Presentation of metabolites by the major histocompatibility complex class I-related protein 1 (MR1) molecule to mucosal-associated invariant T cells is impaired during herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2) infections. This is surprising given these viruses do not directly synthesise MR1 ligands. We have previously identified several HSV proteins responsible for rapidly downregulating the intracellular pool of immature MR1, effectively inhibiting new surface antigen presentation, while preexisting ligand-bound mature MR1 is unexpectedly upregulated by HSV-1. Using flow cytometry, immunoblotting, and high-throughput fluorescence microscopy, we demonstrate that the endocytosis of surface MR1 is impaired during HSV infection and that internalized molecules accumulate in EEA1-labeled early endosomes, avoiding degradation. We establish that the short MR1 cytoplasmic tail is not required for HSV-1-mediated downregulation of immature molecules; however it may play a role in the retention of mature molecules on the surface and in early endosomes. We also determine that the HSV-1 US3 protein, the shorter US3.5 kinase and the full-length HSV-2 homolog, all predominantly target mature surface rather than total MR1 levels. We propose that the downregulation of intracellular and cell surface MR1 molecules by US3 and other HSV proteins is an immune-evasive countermeasure to minimize the effect of impaired MR1 endocytosis, which might otherwise render infected cells susceptible to MR1-mediated killing by mucosal-associated invariant T cells.

Revisiting the therapeutic potential of homeopathic medicine Rhus Tox for herpes simplex virus and inflammatory conditions

BACKGROUND

Herpes simplex virus type-1 and type-2 cause a viral disease named Herpes. Genital herpes is mainly caused by HSV-2 with symptoms of painful and itchy blisters on the vagina, cervix, buttocks, anus, penis, or inner thighs with blisters that rupture and convert into sores. The homeopathic remedy Rhus Tox has been widely used to treat herpes and has shown invitro anti-inflammatory effects in previous studies.

PURPOSE

The presented review focuses on relapses and harmful effects caused by acyclovir in modern medicine and the probable antiherpetic activity of Rhus Tox on HSV infection based on its pathophysiology, preclinical findings, on primary cultured mouse chondrocytes, mouse cell line MC3T3e1 and a comparative study of Natrum Mur with Rhus Tox on HSV infection.

STUDY DESIGN

The design of the study focuses mainly on the descriptive data available in various literature articles.

METHOD

Databases such as PubMed, Google Scholar, Medline and ScienceDirect were used to search the articles. Articles are selected from 1994 to 2022 focusing solely on the competence of Rhus Tox against herpes. Keywords used for the study are antiviral, Herpes, Rhus Tox, in vitro and homeopathy.

RESULTS

The review includes fifteen articles, including 4 full-text articles on HSV, 6 in vitro studies of homeopathic compounds performed on the herpes virus, and 5 articles based on the pathophysiology and effects of Rhus tox. The review article proposes the anti-inflammatory and antiviral action of the homeopathic remedy Rhus Tox which can be used in crisis conditions when the physician doubts the simillimum, as it prevents further outbreaks of HSV infection.

CONCLUSION

The homeopathic medicine Rhus Tox has no cytotoxicity observed under in vitro conditions and can be used to treat herpes infection. Further studies are needed to confirm the results under in vitro and in vivo conditions as well as in clinical trials.

Ten-Year Trend in Emergency Department Visits for Sexually Transmitted Infections among Adolescents: A Retrospective Cross-Sectional Study in Italy

Sexually transmitted infections (STIs) are frequently underdiagnosed, representing a serious public health concern, especially during adolescence and in more vulnerable communities.

AIM

to describe the last ten years of emergency department (ED) visits for STIs among adolescents.

METHODS

a retrospective cross-sectional observation was carried out in the Piedmont region in Italy. Data were retrieved through the Italian National Information System database. ED visits related to specific ICD-9-CM codes carried out on 11 to 19-year-old youths between 2011 and 2020 were investigated. Age-specific, crude, and standardized rates and admission ratios, with 95% confidence intervals (CIs), were calculated to estimate the STI trend.

RESULTS

from a total of 1,219,075 ED visits, 339 were related to STIs, representing an increasing ratio of 28 per 100,000 visits, primarily in females. Most infections occurred in girls (83.5%) and among 17 to 19-year-olds (71.5%). A drop in both ED visits and STI cases was observed in 2020. Genital Herpes and Genital Warts were more frequent in girls while Gonorrhea was more frequent in boys.

CONCLUSIONS

the increasing trend of ED visits for STIs, particularly in girls, represents an emerging relevant public health issue that needs to be urgently tackled.

Diagnosis and Management of Genital Herpes: Key Questions and Review of the Evidence for the 2021 Centers for Disease Control and Prevention Sexually Transmitted Infections Treatment Guidelines

Genital herpes, caused by herpes simplex virus (HSV) type 1 or type 2, is a prevalent sexually transmitted infection (STI). Given that HSV is an incurable infection, there are important concerns about appropriate use of diagnostic tools, management of infection, prevention of transmission to sexual partners, and appropriate counseling. In preparation for updating the Centers for Disease Control and Prevention (CDC) STI treatment guidelines, key questions for management of genital herpes infection were developed with a panel of experts. To answer these questions, a systematic literature review was performed, with tables of evidence including articles that would change guidance assembled. These data were used to inform recommendations in the 2021 CDC STI treatment guidelines.

[Herpes simplex factors: Literature review]

Herpes simplex virus, after the first infection, can remain dormant in the lymph nodes and reactivate at any time due to certain factors and/or stimuli causing effects in the patient. The purpose of this literature review is to update scientific information on the factors that predispose to the reactivation of herpes simplex virus. A comprehensive literature review was conducted in the LILACS, SciELO, PubMed, Scopus and the following keywords were used: herpes simplex, reactivation, latency and risks. A factor is reactivation by immunosuppression due to the intake of immunosuppressants or oncological therapy. Another factor is psychological stress, in which the hormones released act on mediating signs of reactivation. Sun exposure that reactivates the virus in infected neurons and infection in pregnant women can trigger complications in the fetus and delivery.

Two Sides to Every Story: Herpes Simplex Type-1 Viral Glycoproteins gB, gD, gH/gL, gK, and Cellular Receptors Function as Key Players in Membrane Fusion

Herpes simplex virus type-1 (HSV-1) and type-2 (HSV-2) are prototypical alphaherpesviruses that are characterized by their unique properties to infect trigeminal and dorsal root ganglionic neurons, respectively, and establish life-long latent infections. These viruses initially infect mucosal epithelial tissues and subsequently spread to neurons. They are associated with a significant disease spectrum, including orofacial and ocular infections for HSV-1 and genital and neonatal infections for HSV-2. Viral glycoproteins within the virion envelope bind to specific cellular receptors to mediate virus entry into cells. This is achieved by the fusion of the viral envelope with the plasma membrane. Similarly, viral glycoproteins expressed on cell surfaces mediate cell-to-cell fusion and facilitate virus spread. An interactive complex of viral glycoproteins gB, gD/gH/gL, and gK and other proteins mediate these membrane fusion phenomena with glycoprotein B (gB), the principal membrane fusogen. The requirement for the virion to enter neuronal axons suggests that the heterodimeric protein complex of gK and membrane protein UL20, found only in alphaherpesviruses, constitute a critical determinant for neuronal entry. This hypothesis was substantiated by the observation that a small deletion in the amino terminus of gK prevents entry into neuronal axons while allowing entry into other cells via endocytosis. Cellular receptors and receptor-mediated signaling synergize with the viral membrane fusion machinery to facilitate virus entry and intercellular spread. Unraveling the underlying interactions among viral glycoproteins, envelope proteins, and cellular receptors will provide new innovative approaches for antiviral therapy against herpesviruses and other neurotropic viruses.

Rational Design of Live-Attenuated Vaccines against Herpes Simplex Viruses

Diseases caused by human herpes simplex virus types 1 and 2 (HSV-1 and HSV-2) affect millions of people worldwide and range from fatal encephalitis in neonates and herpes keratitis to orofacial and genital herpes, among other manifestations. The viruses can be shed efficiently by asymptomatic carriers, causing increased rates of infection. Viral transmission occurs through direct contact of mucosal surfaces followed by initial replication of the incoming virus in skin tissues. Subsequently, the viruses infect sensory neurons in the trigeminal and lumbosacral dorsal root ganglia, where they are primarily maintained in a transcriptionally repressed state termed "latency", which persists for the lifetime of the host. HSV DNA has also been detected in other sympathetic ganglia. Periodically, latent viruses can reactivate, causing ulcerative and often painful lesions primarily at the site of primary infection and proximal sites. In the United States, recurrent genital herpes alone accounts for more than a billion dollars in direct medical costs per year, while there are much higher costs associated with the socio-economic aspects of diseased patients, such as loss of productivity due to mental anguish. Currently, there are no effective FDA-approved vaccines for either prophylactic or therapeutic treatment of human herpes simplex infections, while several recent clinical trials have failed to achieve their endpoint goals. Historically, live-attenuated vaccines have successfully combated viral diseases, including polio, influenza, measles, and smallpox. Vaccines aimed to protect against the devastation of smallpox led to the most significant achievement in medical history: the eradication of human disease by vaccination. Recently, novel approaches toward developing safe and effective live-attenuated vaccines have demonstrated high efficacy in various preclinical models of herpetic disease. This next generation of live-attenuated vaccines has been tailored to minimize vaccine-associated side effects and promote effective and long-lasting immune responses. The ultimate goal is to prevent or reduce primary infections (prophylactic vaccines) or reduce the frequency and severity of disease associated with reactivation events (therapeutic vaccines). These vaccines' "rational" design is based on our current understanding of the immunopathogenesis of herpesviral infections that guide the development of vaccines that generate robust and protective immune responses. This review covers recent advances in the development of herpes simplex vaccines and the current state of ongoing clinical trials in pursuit of an effective vaccine against herpes simplex virus infections and associated diseases.

Genital HSV-1 DNA detection is associated with a low inflammatory profile in HIV-uninfected South African women

OBJECTIVES

Genital herpes simplex virus (HSV) infections are common in South Africa and worldwide. While HSV-2 is known to cause genital lesions, HSV-1 is better known to cause oral infections. Due to the global rise in genital HSV-1 infections, we aimed to compare the genital cytokine environment associated with HSV-1 and HSV-2 infections and their relation to the proinflammatory genital immune environment associated with HIV risk in African women.

METHODS

HSV-1 and HSV-2 DNA were detected by quantitative real-time PCR in menstrual cup specimens collected from 251 HIV-negative women participating in the CAPRISA 083 study in Durban, South Africa. HSV shedding was defined as detection at >150 copies/mL. Forty-eight cytokines were measured in genital fluid by multiplexed ELISA, and multivariable regression models determined associations between genital cytokines and HSV DNA detection.

RESULTS

HSV-1 DNA detection (24/251 (9.6%)) and shedding (13/24 (54.2%)) was more common than HSV-2 (detection in 14/251 (5.6%), shedding in 0/14). None of the women with detectable HSV had evidence of genital lesions. HSV-2 DNA detection was associated with increased interleukin (IL)-18 and decreased cutaneous T-cell attracting chemokine concentrations, but only in univariable analysis. By contrast, in both univariable and multivariable analyses, the detection of HSV-1 DNA was associated with reduced concentrations of granulocyte-colony stimulating factor, IL-7, IL-4, platelet-derived growth factor-ββ and five proinflammatory cytokines associated with HIV risk: IL-6, IL-1β, macrophage inflammatory protein (MIP)-1α, MIP-1β and tumour necrosis factor-α.

CONCLUSIONS

That HSV-1 DNA was more commonly detected and shed than HSV-2 emphasises the need for clinical screening of both viruses, not just HSV-2 in young women. Efforts to reduce genital inflammation may need to consider implementing additional strategies to mitigate a rise in HSV replication.

[The role of herpesviruses in development of diseases of the urogenital tract and infertility in women]

This review presents the data on the spreading of all known human herpesviruses (НHVs) in female urogenital tract. According to the WHO almost 500 million people worldwide suffer from genital infection caused by НHVs. НHVs were detected in various inflammatory diseases of female upper and lower genital tract (vaginitis and cervicitis), in extrauterine pregnancy (in fallopian tubes), in infertility (cervical channel, endometrium and ovaries). Herpes simplex virus 1 (HSV‑1) was identified for the first time in oocytes after failed in vitro fertilization (IVF). НHVs produce negative effect on the entire reproductive process from conception to childbirth. It was established that HSV, cytomegalovirus (CMV) and human herpesvirus 6 (HHV-6) markedly increase the risk of spontaneous abortion, preterm birth and stillbirth. Intrauterine НHV infection is a major cause of congenital malformations. Data on humoral and cell immunity in genital herpesvirus infections (НHVI) are also reviewed. Intravaginal HSV‑2 infection changes cell composition of vaginal mucosa, i.e., together with cells mobilized from the blood, protective role is performed by resident memory T‑cells (TRM), natural killer cells (NK‑cells) and regulatory T‑cells (Treg) whose function consists in maintaining the balance of the activities of lymphocytes. Constant НHVI spreading is largely explained by transition of primary infection to potentially reactivating latent form, since latent virus is unavailable to immune recognition and medicines. The genome editing system CRISPR/Cas9 can recognize and modify not only active but also latent viruses. The promising pilot results with the use of this system offer the possibility of developing innovative technologies for НHV elimination and НHVI eradication.

A HSV1 mutant leads to an attenuated phenotype and induces immunity with a protective effect

Herpes simplex virus type 1 (HSV1) is a complicated structural agent with a sophisticated transcription process and a high infection rate. A vaccine against HSV1 is urgently needed. As multiple viral-encoded proteins, including structural and nonstructural proteins, contribute to immune response stimulation, an attenuated or deficient HSV1 vaccine may be relatively reliable. Advances in genomic modification technologies provide reliable means of constructing various HSV vaccine candidates. Based on our previous work, an M6 mutant with mutations in the UL7, UL41, LAT, Us3, Us11 and Us12 genes was established. The mutant exhibited low proliferation in cells and an attenuated phenotype in an animal model. Furthermore, in mice and rhesus monkeys, the mutant can induce remarkable serum neutralizing antibody titers and T cell activation and protect against HSV1 challenge by impeding viral replication, dissemination and pathogenesis.

Herpes Simplex Virus Type 1 Interactions with the Interferon System

The interferon (IFN) system is one of the first lines of defense activated against invading viral pathogens. Upon secretion, IFNs activate a signaling cascade resulting in the production of several interferon stimulated genes (ISGs), which work to limit viral replication and establish an overall anti-viral state. Herpes simplex virus type 1 is a ubiquitous human pathogen that has evolved to downregulate the IFN response and establish lifelong latent infection in sensory neurons of the host. This review will focus on the mechanisms by which the host innate immune system detects invading HSV-1 virions, the subsequent IFN response generated to limit viral infection, and the evasion strategies developed by HSV-1 to evade the immune system and establish latency in the host.

Time Trends in First-Episode Genital Herpes Simplex Virus Infections in an Urban Sexually Transmitted Disease Clinic

BACKGROUND

Genital herpes simplex virus type 1 (HSV-1) has emerged as the leading cause of first-episode genital herpes among specific populations in the United States, such as adolescents, young adult women, and men who have sex with men (MSM). We examined trends in the etiology of first-episode genital herpes diagnoses over time in a sexually transmitted disease (STD) clinic population.

METHODS

Using an electronic database, we identified persons diagnosed as having first-episode genital herpes at Public Health - Seattle & King County STD Clinic from 1993 to 2014 and compared risk factors for genital HSV-1 versus herpes simplex virus type 2 (HSV-2) infection.

RESULTS

Of 52,030 patients with genital ulcers, 3065 (6.15%) had first-episode genital herpes infection: 1022 (33.3%) with HSV-1 and 2043 (67.7%) with HSV-2. Overall, 1154 (37.7%) were women, the median age was 28 years (interquartile range, 24-36 years), 1875 (61.2%) patients were white, and 353 (11.5%) were MSM. The number of patients diagnosed as having first-episode genital HSV-2 declined on average by 5.5 persons per year, from 208 in 1993 to 35 in 2014 (change of -5.6 per year; 95% confidence interval [CI], -6.9 to -4.1), whereas HSV-1 diagnoses remained stable at approximately 50 per year (change of 0.2; 95% CI, -0.4 to 0.9). In a multivariate model, persons diagnosed as having first-episode genital HSV-1 rather than genital HSV-2 infection were more likely to be younger (age <30 years [relative risk {RR}, 1.38; 95% CI, 1.22-1.55]), white (RR, 3.16; 95% CI, 2.57-3.88), and MSM (RR, 1.50; 95% CI, 1.31-1.71).

CONCLUSIONS

We observed a significant decrease in the frequency of first-episode genital HSV-2 and a stable number of first-episode genital HSV-1 infections in a STD clinic over the last 2 decades.

The global and regional burden of genital ulcer disease due to herpes simplex virus: a natural history modelling study

Introduction

Herpes simplex virus (HSV) infection can cause painful, recurrent genital ulcer disease (GUD), which can have a substantial impact on sexual and reproductive health. HSV-related GUD is most often due to HSV type 2 (HSV-2), but may also be due to genital HSV type 1 (HSV-1), which has less frequent recurrent episodes than HSV-2. The global burden of GUD has never been quantified. Here we present the first global and regional estimates of GUD due to HSV-1 and HSV-2 among women and men aged 15-49 years old.

Methods

We developed a natural history model reflecting the clinical course of GUD following HSV-2 and genital HSV-1 infection, informed by a literature search for data on model parameters. We considered both diagnosed and undiagnosed symptomatic infection. This model was then applied to existing infection estimates and population sizes for 2016. A sensitivity analysis was carried out varying the assumptions made.

Results

We estimated that 187 million people aged 15-49 years had at least one episode of HSV-related GUD globally in 2016: 5.0% of the world's population. Of these, 178 million (95% of those with HSV-related GUD) had HSV-2 compared with 9 million (5%) with HSV-1. GUD burden was highest in Africa, and approximately double in women compared with men. Altogether there were an estimated 8 billion person-days spent with HSV-related GUD globally in 2016, with 99% of days due to HSV-2. Taking into account parameter uncertainty, the percentage with at least one episode of HSV-related GUD ranged from 3.2% to 7.9% (120-296 million). However, the estimates were sensitive to the model assumptions.

Conclusion

Our study represents a first attempt to quantify the global burden of HSV-related GUD, which is large. New interventions such as HSV vaccines, antivirals or microbicides have the potential to improve the quality of life of millions of people worldwide.

Genital Infection With Herpes Simplex Virus Type 1 and Type 2 in Valencia, Spain: A Retrospective Observational Study

INTRODUCTION AND OBJECTIVE

The epidemiology of genital herpes has changed in recent years with an increase in the incidence of herpes simplex virus type 1 (HSV-1) infection. The aim of this study was to analyze the clinical and epidemiological characteristics of patients diagnosed with genital herpes.

MATERIAL AND METHODS

A retrospective observational study was designed. All patients diagnosed with genital herpes between January 2016 and January 2019 in a Sexually Transmitted Infections Unit (ITS) in Valencia, Spain, were included.

RESULTS

We identified 895 STI diagnoses. Of these, 126 (14%) were genital herpes; 68 (54%) of these cases were in women and 58 (46%) in men. Diagnosis was confirmed by molecular detection of HSV DNA in 110 cases (87.3%). Of these, 52 were cases of HSV-1 infection (47.3%) and 58 were HSV-2 infection (52.7%). HSV-2 was more common in men (69.5%), while HSV-1 was more common in women (59.3%). In the subgroup of women, mean age at diagnosis was 26 years for HSV-1 and 34 years for HSV-2 (P=.015). Recurrent genital herpes rates were 13% for HSV-1 and 40% for HSV-2.

CONCLUSIONS

There has been an increase in the number of cases of genital herpes caused by HSV-1 in our setting, with young women in particular being affected. This has important prognostic implications because genital herpes caused by HSV-1 is less likely to recur.