Viral Genetics Modulate Orolabial Herpes Simplex Virus Type 1 Shedding in Humans

BACKGROUND

Orolabial herpes simplex virus type 1 (HSV-1) infection has a wide spectrum of severity in immunocompetent persons. To study the role of viral genotype and host immunity, we characterized oral HSV-1 shedding rates and host cellular response, and genotyped viral strains, in monozygotic (MZ) and dizygotic (DZ) twins.

METHODS

A total of 29 MZ and 22 DZ HSV-1-seropositive twin pairs were evaluated for oral HSV-1 shedding for 60 days. HSV-1 strains from twins were genotyped as identical or different. CD4+ T-cell responses to HSV-1 proteins were studied.

RESULTS

The median per person oral HSV shedding rate was 9% of days that a swab was obtained (mean, 10.2% of days). A positive correlation between shedding rates was observed within all twin pairs, and in the MZ and DZ twins. In twin subsets with sufficient HSV-1 DNA to genotype, 15 had the same strain and 14 had different strains. Viral shedding rates were correlated for those with the same but not different strains. The median number of HSV-1 open reading frames recognized per person was 16. The agreement in the CD4+ T-cell response to specific HSV-1 open reading frames was greater between MZ twins than between unrelated persons (P = .002).

CONCLUSION

Viral strain characteristics likely contribute to oral HSV-1 shedding rates.

Recent approval of Xerese in Canada: 5% acyclovir and 1% hydrocortisone topical cream in the treatment of herpes labialis

Herpes labialis is a frequently occurring viral infection of the lips and oral mucosa. Recurring lesions are induced by viral reactivation and replication, but the symptoms leading to morbidity, such as pain and inflammation, are immune-mediated. The introduction of 5% acyclovir/1% hydrocortisone in a topical cream (Xerese™) represents a therapeutic strategy directed at both of these pathogenic processes. Applied at the onset of prodromal symptoms, this combination treatment has a good safety profile and is more effective in reducing healing time than antiviral or anti-inflammatory agents alone. Although it was US FDA-approved for herpes labialis in 2009, Xerese™ has only recently been approved for use in Canada in October 2013. Herein, we review the basic science and clinical studies that support the efficacy of this topical combination acyclovir-hydrocortisone product in treating herpes labialis and examine its safety profile, as well as touch upon other therapies that have been shown to be effective in treating this common viral condition.

[Cycloferon and management of herpes virus infection]

The treatment of patients with various forms of herpes requires a complex approach with using chemo- and immunotropic drugs. The use of Cycloferon, an interferon inductor (12.5% injection solution, 150 mg tablets or 5% liniment) was shown efficient. It had antiviral and immunotropic action in the mono- and combination therapy of herpes simplex of the skin and mucosa, genital herpes, ophthalmoherpes, herpes zoster, infectious mononucleosis. Cycloferon lowered the level and period of the disease clinical signs, prolonged the remission, corrected the immunity shifts, prevented the complications. The results of the study presented a conclusive proof for recommending such a use of Cycloferon in wide medical practice.

[Using cycloferon in the complex treatment of herpetic infection in patients with atopic dermatitis]

Clinical efficacy of including cycloferon liniment in combined treatment of herpetic infection in a group of 40 patients with atopic dermatitis has been analyzed. It is concluded that the administration of cycloferon favors dynamic disappearance of general infectious syndrome, reduces timeline of rash as well as length of local inflammation, accelerates epithelization of erosions (on the average 1.2 - 1.4 times, p < 0.05), decreases frequency of recurrent infections, and reduces the level of pro-inflammatory cytokines in the blood of patients.

Recurrent infections in patients with nickel allergic hypersensitivity

Nickel (Ni) is the most common contact allergen among the general population in the industrialized world. Ni has been shown to exhibit immunomodulatory, if not immunotoxic, effects in several experiments conducted on humans and on rodents. This study tests the incidence of different infectious diseases in 100 patients with Ni hypersensitivity and compares it to data from 100 healthy volunteers. One hundred subjects with Ni hypersensitivity were enrolled. A group of 100 matched healthy volunteers with negative European standard patch test were enrolled as healthy controls. In patients with Ni hypersensitivity a higher incidence of recurrent herpes labialis (RHL), urinary tract infections (RUTI), genital candidiasis, and upper respiratory tract infections (RURTI) was detected. Fifteen patients with nickel allergic hypersensitivity (NAH) followed a Ni-poor diet. After a one-year diet a net reduction of incidence of RHL was found. Indeed, the number of episodes of RHL per year decreased from 6 +/- 2.75 to 2.4 +/- 1.2. Conversely, among the matched control group with NAH following a normal daily dietary nickel intake the RHL number did not show any statistically significant changes (6.1 +/- 1.7 vs 6 +/- 1.5 ). In conclusion, our study demonstrates a higher incidence of recurrent infections among patients with NAH. A low-Ni diet reduces the number of RHL episodes per year.

Variation in the WBC differential count and other factors associated with reporting of herpes labialis: A population-based study of adults

Reactivation of latent herpes virus has been linked to triggers of mild immunosupression, such as stress or UV-exposure. Despite having predictive value in severe immunodeficiency, the white blood cell (WBC) differential count has not been examined in relation to risk of herpes reactivation in population studies. The WBC differential count and other risk factors for herpes labialis were examined in 5687 adults (ages 18-64) from the Third National Health and Nutrition Examination Survey, who had WBC 3.5-11 x 10(6) cells mL(-1) and reported no acute infections in the past month. The association between self-reported herpes labialis in the past year and the WBC differential count was modeled, adjusting for age, sex, race/ethnicity, education, smoking, upper respiratory infections (URI), and HSV-1 antibodies. Herpes labialis was significantly associated with white race/ethnicity, being a nonsmoker, and frequent URI. Compared with the highest quartile, being in the lowest quartile of granulocytes was associated with herpes labialis, adjusted odds ratio=1.82 (95% confidence interval 1.20, 2.28). At the same time, there was a trend towards an inverse association of lower lymphocyte count and herpes labialis. These findings suggest that moderate differences in the WBC differential count are related to reactivation of HSV-1. Prospective studies may help to show whether such differences indicate susceptibility to loss of latency or represent a consequence of reactivated infection.

An update on short-course intermittent and prevention therapies for herpes labialis

Infection with herpes simplex virus (HSV) has increased in prevalence worldwide over the past two decades, making it a major public health concern. Approximately 90% of recurrent HSV type 1 (HSV-1) infections manifest as non-genital disease, primarily as orofacial lesions known as herpes labialis. Improvements in our understanding of the natural history of herpes labialis support the rationale for early treatment (during the prodrome or erythema stages) with high doses of antiviral agents in order to maximize drug benefit. When evaluating the efficacy of different antiviral and anti-inflammatory agents in clinical trials, episode duration, lesion healing time, reduction in maximum lesion size and the proportion of aborted lesions should be used as the most reliable measures of therapeutic efficacy. There has also been considerable research into the most beneficial treatment for recurrent episodes of herpes labialis in immunocompetent individuals. Data from clinical studies confirm that short-course, high-dose oral antiviral therapy should be offered to patients with recurrent herpes labialis to accelerate healing, reduce pain and most likely increase treatment adherence. Optimal benefits may be obtained when these oral antiviral agents are combined with topical corticosteroids, but more research is needed with this combination. Patients undergoing facial cosmetic procedures (i.e.facial resurfacing) are at risk of HSV reactivation, but further data are required on the actual risk according to the specific procedure. Aciclovir, valaciclovir and famciclovir all provide effective prophylaxis against HSV-1 reactivation following ablative facial resurfacing. However, no definitive recommendations can be made regarding prophylactic therapy for minimally invasive procedures at present.

A comparative study between viral isolation and indirect immunofluorescence in the diagnosis of herpes simplex virus

Fifty patients with oral ulcers were studied clinically and investigated for the detections of Herpes Simplex Virus (HSV) through virus isolation from their lesions (vesicles and ulcers) and detection of the presence of antiviral antibodies (both, IgM and IgG) in their sera using the indirect immunofluorescene (IIF) technique. The results of this study proved that virus isolation is the most reliable method for diagnosis, though the use of antibody serological tests could be a useful adjunct to virus isolation in situations where a rapid laboratory diagnosis is needed. Oral Herpes Simplex virus infection can be viewed, in the main, as a trivial disorder causing patients minor physical discomfort. The prevalence of HSV may be high in innocent infections, as high as 1/3 of the population. However, HSV infection and its complications with troublesome recurrences may make the problem worse. The apparent increase in HSV infection over recent years may be partly due to increased publicity about the disease, the current antiviral treatment, the inclusion of both primary and recurrent cases in clinic follow up and the increased use of viral cultures for diagnosis. The aim of this work is to share in the study of the detection of HSV through virus isolation and detection of antiviral antibodies using IIF technique, as well as the evaluation of the diagnosis by the above mentioned methods.

Intimate male partner violence impairs immune control over herpes simplex virus type 1 in physically and psychologically abused women

OBJECTIVE

Intimate partner violence (IPV) against women is a worldwide problem and a cause of significant distress and threat to health. Studies have focused mainly on mental health, and few have considered the effect on physiological systems. The aim of this research was to determine whether IPV also compromises the immune system, as evidenced by a decrease in immune regulation over herpes simplex virus type 1 (HSV-1), the latent virus that causes cold sores.

METHODS

Physically abused (N = 47) and psychologically abused women (N = 27) were compared with nonabused control women (N = 37). Information about sociodemographic characteristics, lifetime history of victimization, and mental health status (depression, anxiety, and posttraumatic stress disorder) was obtained through structured interviews. Salivary samples were collected on two occasions, and the capacity to neutralize live HSV-1 virus was tested with a bioassay. In addition, salivary levels of HSV-1-specific antibody and total IgA were determined by enzyme-linked immunosorbent assay.

RESULTS

Physically abused women had the lowest virus neutralization, significantly below the other two groups, with the psychologically abused group intermediate. HSV-1-specific antibody also tended to be lower in physically abused women, but these values were not directly correlated with virus neutralization, suggesting that loss of other antiviral factors accounted for the reduced bioactivity. The effect of IPV on immune function was not mediated directly by mental health status.

CONCLUSION

These findings confirm that the stressful disturbance associated with IPV has important physiological consequences, which could impair health by increasing the likelihood of viral reactivation and reducing the ability to suppress virus proliferation.

High Frequency of Detection of Herpes simplex Virus DNA in the Oral Cavity of Patients with Eczema herpeticum

BACKGROUND

It has been reported that herpes simplex virus (HSV) DNA was detected in the oral cavity of patients with herpes labialis under various conditions such as during oral surgery.

OBJECTIVE

The frequency of detection of oral HSV DNA was compared between first or recurrent episodes of eczema herpeticum and recurrent type herpes labialis.

PATIENTS AND METHODS

Oral swabs were collected from 7 patients with eczema herpeticum and 9 with herpes labialis. The detection of oral HSV DNA was performed by the polymerase chain reaction method.

RESULTS

Oral HSV DNA was detected in 6 out of 7 patients (86%) with eczema herpeticum and 3 of 9 (33%) with herpes labialis.

CONCLUSIONS

The high frequency of oral HSV DNA detection in eczema herpeticum suggests that subclinical herpetic lesions may develop in the oral cavity of patients with a first episode of eczema herpeticum or may occur during asymptomatic oral HSV shedding in people with recurrent eczema herpeticum.

The role of dendritic cells in immune responses against vaginal infection by herpes simplex virus type 2

Herpes simplex virus type 2 is a leading cause of genital ulcers that affects more women than men worldwide. Recent evidence indicates that protective immunity can be generated by specialized dendritic cells in the female genital mucosa. This article aims to provide an overview of the effector immunity required for protection from genital herpes, and to discuss the mechanism by which specific subsets of dendritic cells mediate induction of adaptive immunity following genital infection with herpes simplex virus type 2 in vivo.

Immunological properties of a DNA plasmid encoding a chimeric protein of herpes simplex virus type 2 glycoprotein B and glycoprotein D

A DNA plasmid containing a chimeric sequence encoding both herpes simplex virus type 2 (HSV-2) glycoprotein B (gB) and glycoprotein D (gD) external domains (pcgDB) was used to immunize BALB/c mice against genital HSV-2 infection. To determine the efficacy of this vaccine, groups of mice immunized with the pcgDB plasmid were compared with animals immunized with plasmids corresponding to the individual proteins (pcgBt or pcgDt), administered separately or in combination (pcgBt + pcgDt). We studied the response of the different mouse groups to viral challenge by analyzing clinical disease (vaginitis), serum antibody levels, as well as lymphoproliferative responses and cytokine production by spleen cells. Increased IFN-gamma levels correlated with prolonged survival in mice immunized with the plasmid pcgDB, relative to mice immunized with plasmids coding for the individual proteins alone or in combination. Our results show that immunization with the plasmid encoding the chimeric protein is advantageous over separate proteins. These findings may have important implications for the development of multivalent DNA vaccines against HSV and other complex pathogens.

T cell immunity to herpes simplex viruses in seronegative subjects: silent infection or acquired immunity?

During the course of investigating T cell responses to HSV among volunteers entering trials of investigational genital herpes vaccines, 6 of the 24 immunocompetent subjects with no prior history of oral/labial or genital herpes possessed HSV-specific T cell immunity but, by multiple determinants of even the most sensitive serological assays, remained seronegative to HSV-1 and -2. Of these six immune seronegative (IS; HSV-seronegative with HSV-specific T cell responses) subjects, two had transient HSV-specific T cell responses, while four had CD4(+) and CD8(+) T cell responses directed at HSV that persisted for up to 4 years. CD4(+) T cell clones were isolated that recognized and had high binding affinities to epitopes in HSV-2 tegument proteins. All six IS subjects had potential sexual exposure to an HSV-2-infected sexual partner. Oral and genital mucosal secretions were sampled and tested for the presence of infectious HSV and HSV DNA. No evidence of HSV was detected in >1500 samples obtained from these IS subjects. The identification of persistent T cell responses to HSV in seronegative subjects is a novel finding in the herpesvirus field and suggests either undetected infection or acquired immunity in the absence of infection. Understanding the basis of these acquired immune responses may be critical in developing effective vaccines for genital herpes.

Salivary defense factors in herpes simplex virus infection

Saliva may contribute to a lowering of the infectious herpes simplex virus (HSV) dose during transmission and consequently abrogate infection or lead to decreased reactivation. To test this hypothesis, we assayed saliva for innate defense factors, immunoglobulin content, and the capacity to interfere with HSV infection. Serum or salivary anti-HSV IgG levels did not correlate with control of recurrent labial herpes (RLH) and were significantly higher in subjects with RLH compared with asymptomatic seropositive subjects. Although no differences in levels or output rate of innate defense factors between the groups were observed, the salivary neutralizing activity correlated with lactoferrin and hypothiocyanite concentrations in the asymptomatic seropositive group. Our results suggest that saliva contains factors, in addition to anti-HSV immunoglobulins, that neutralize HSV and may indirectly contribute to the control of RLH.

Herpes simplex virus-specific immune responses in subjects with frequent and infrequent orofacial recrudescences

BACKGROUND

Following the primary infection of the orofacial region with herpes simplex virus (HSV) type 1, the virus remains latent in the ganglia for the lifetime of the host but can reactivate at intervals and cause recrudescent lesions. The frequency of these episodes varies considerably from one individual to another.

OBJECTIVES

To compare immune responses in two groups of subjects: those with frequent orofacial lesions, defined as 10 or more per year (n = 12), and those with infrequent lesions, defined as three or fewer per year (n = 20).

METHODS

Plasma and peripheral blood mononuclear cells were collected from each individual for the series of immunological tests listed in the following results section.

RESULTS

Although IgG titres specific for HSV, measured by enzyme-linked immunosorbent assay (ELISA), were not different between the two groups, there was a significantly higher HSV-specific IgE titre in the frequent group. The percentages of CD3-, CD4- and CD8-positive cells in peripheral blood, assessed by flow cytometry, and the in vitro lymphoproliferative response to the non-specific mitogen concanavalin A, did not differ between the two groups. T-cell responses to HSV were assessed by in vitro lymphoproliferation with tritiated thymidine incorporation and subsequent calculation of the stimulation index; cytokine production [interferon (IFN)-gamma and interleukin (IL)-10] into the culture supernatant as a result of the stimulation was measured by ELISAs. The mean +/- SEM stimulation index was 4.1 +/- 0.2 in the subjects with frequent lesions and 11.8 +/- 3.1 in the subjects with infrequent lesions, a difference that was significant. The mean IL-10 concentrations found in the subjects with frequent and infrequent lesions were 154 and 110 pg mL-1, respectively, a difference that did not reach significance. However, the IFN-gamma production was significantly lower in the subjects with frequent lesions compared with those with infrequent lesions: mean 835 and 1679 pg mL-1, respectively.

CONCLUSIONS

Thus, from the HSV-specific T-cell proliferation, IFN-gamma production and IgE results, patients who experience frequent recrudescences may tend towards the production of T-helper 2 cytokines in response to the virus, which may lead, in turn, to less effective control of viral replication in the periphery following reactivation from latency.

[Prevention of recurrence of herpes with poliovaccine]

In the course of 20 years in collaboration with dermatologists and doctors attending adolescents 75 patients were treated suffering for at least four years from 10 relapses of herpes labialis or genitalis every year. The usual treatment mitigated only temporarily their complaints but had no effect on the frequency of relapses. Two thirds of the patients had immunological examinations, in half of them shortage of IgA was found. Only 12 subjects had during comprehensive immunological examinations normal results. After 3-4 years immunomodulation with poliovaccine in rare instances combined with other immune preparations, the condition improved in 67 of 69 patients (97%), in two (3%) it remained unaltered. The procedure involved restricted exposure to tobacco smoke, alcohol, UV rays and sleep deficiency. After a comprehensive immunological examination immunomodulation with levamisol was started. This was followed by the administration of 2-3 drops of poliovaccine, at first every month, when the complaints receded the interval of vaccine administration was prolonged. When the complaints persisted the immunity of the organism was promoted by protection from influenza (vaccination, Remantadin) and other respiratory infections (Isoprinosin, Modimunal) and the general resistance was reinforced (Biostim). The mentioned procedure should be reserved for subjects with herpes persisting for a long time and with frequently relapsing herpes.

BAC-VAC, a novel generation of (DNA) vaccines: A bacterial artificial chromosome (BAC) containing a replication-competent, packaging-defective virus genome induces protective immunity against herpes simplex virus 1

This study aimed to exploit bacterial artificial chromosomes (BAC) as large antigen-capacity DNA vaccines (BAC-VAC) against complex pathogens, such as herpes simplex virus 1 (HSV-1). The 152-kbp HSV-1 genome recently has been cloned as an F-plasmid-based BAC in Escherichia coli (fHSV), which can efficiently produce infectious virus progeny upon transfection into mammalian cells. A safe modification of fHSV, fHSVDeltapac, does not give rise to progeny virus because the signals necessary to package DNA into virions have been excluded. However, in mammalian cells fHSVDeltapac DNA can still replicate, express the HSV-1 genes, cause cytotoxic effects, and produce virus-like particles. Because these functions mimic the lytic cycle of the HSV-1 infection, fHSVDeltapac was expected to stimulate the immune system as efficiently as a modified live virus vaccine. To test this hypothesis, mice were immunized with fHSVDeltapac DNA applied intradermally by gold-particle bombardment, and the immune responses were compared with those induced by infection with disabled infectious single cycle HSV-1. Immunization with either fHSVDeltapac or disabled infectious single cycle HSV-1 induced the priming of HSV-1-specific cytotoxic T cells and the production of virus-specific antibodies and conferred protection against intracerebral injection of wild-type HSV-1 at a dose of 200 LD(50). Protection probably was cell-mediated, as transfer of serum from immunized mice did not protect naive animals. We conclude that BAC-VACs per se, or in combination with genetic elements that support replicative amplification of the DNA in the cell nucleus, represent a useful new generation of DNA-based vaccination strategies for many viral and nonviral antigens.

Immune, stress, and mood markers related to recurrent oral herpes outbreaks

This was a prospective and longitudinal study designed to compare daily mood states and weekly changes in plasma levels of immune and neuroendocrine markers with recurrent herpes labialis lesion recurrences during a 3-month period among 9 subjects. Results from a paired t test showed that there was a significant decrease in plasma levels of natural killer cells and serum levels of epinephrine from the week before recurrent herpes labialis lesion occurrence (T1,9 = 2.70; p < 0.05) to the week of recrudescence (T1,9 = 2.41; p < 0.05). On the other hand, in the week before recrudescence the number of natural killer cells was 58 units higher than the overall group mean for natural killer cell level (227 units). In the week before outbreak, elevated natural killer cell numbers were associated with a mood of discontentment (r = 0.64; p = 0.05). Elevated levels of epinephrine averaged across the 12 weekly blood draws were significantly correlated with higher scores on affect intensity (r = 0.72; p < 0.05). This study provides new data on the pattern of changes in stress, mood states, and immune and neuroendocrine markers associated with the recurrence of perioral herpes lesions. Putative mechanisms linking neuroendocrine and immune function are discussed.

Oral recrudescent herpes simplex virus infection

OBJECTIVE

The objective of this study is to determine the frequency of involvement of different intraoral sites by oral recrudescent herpes simplex virus in immunocompromised patients and whether keratinized intraoral sites are always affected by this virus.

STUDY DESIGN

The records of 30 hospitalized patients who had oral ulcers culture positive for herpes simplex virus were reviewed for the location of oral ulcers, febrile episodes, and medical diagnoses.

RESULTS

The data revealed that oral recrudescent herpes simplex virus may involve any intraoral site in immunocompromised patients with nonkeratinized sites representing approximately half of all sites; this is more frequent than has been previously reported. Twenty-six (86.7%) of 30 patients had no evidence of herpes labialis, and 13 (43.3%) of 30 patients were afebrile.

CONCLUSION

It is recommended that all oral ulcers, in immunocompromised patients should be cultured for herpes simplex virus regardless of their location. Early diagnosis reduces patient morbidity because effective treatment in the form of acyclovir is readily available.

Relationship between antibodies to herpes simplex virus (HSV) and symptoms of HSV infection

To determine the relationship between antibodies to herpes simplex virus (HSV) types 1 and 2 and diagnosis of orolabial and genital herpes, a cross-sectional survey was done among 869 sexually transmitted disease clinic attendees and 1594 blood donors in London. Among clinic attenders, the prevalence of HSV-1 infection was 59.5% and that of HSV-2 infection was 22.7%, and among blood donors the prevalence was 44.6% and 7.6%, respectively. The sensitivity and specificity of a diagnosis of oral herpes for the presence of HSV-1 antibody was almost identical in the 2 groups (clinic attendees: sensitivity, 33.1%, and specificity, 91.4%; blood donors: sensitivity, 32.3%, and specificity, 94.3%). A diagnosis of genital herpes was less sensitive for antibody for HSV-2 among donors than among clinic attenders (P < .001); however, the specificity was similar in the 2 populations (clinic attendees: sensitivity, 32.1%, and specificity, 96.6%; blood donors: sensitivity, 17.5%, and specificity, 99.5%). False-positive clinical histories were also relatively common (clinic attenders, 12%; donors, 6%). The sensitivity of the diagnosis of genital herpes would be improved if accurate serologic assays for detection of HSV type-specific antibodies were more widely available.

Orally administered HSV-specific transfer factor (TF) prevents genital or labial herpes relapses

Forty-four patients suffering from genital (22) and labial (22) herpes were orally treated with HSV-1/2-specific transfer factor (TF). TF was obtained by in vitro replication of a HSV-1/2-specific bovine dialysable lymphocyte extract. Treatment was administered bi-weekly the first 2 weeks, and then weekly for 6 months, most patients received 2-3 courses. The total observation period for all patients before treatment was 26,660 days, with 544 relapses, and a relapse index of 61.2, whereas the cumulative observation period during and after treatment was 16,945 days, with a total of 121 relapsing episodes and a cumulative RI of 21.4 (P < 0.0001). Results were equally significant when the 2 groups of patients (labial and genital) were considered separately. These observations confirm previous results obtained with bovine HSV-specific TF, and warrant further studies to establish HSV-specific TF as a choice of treatment for preventing herpes recurrences.

Th1/Th2-like immunity and resistance to herpes simplex labialis

To investigate potential immunologic mechanisms of resistance to recurrent herpes simplex labialis, we assayed serum antibody titers and cultured peripheral blood mononuclear cell (PBMC) cytokine production among patients with a history of frequent episodes (H+S+), herpes simplex virus (HSV)-seropositive individuals without a history of herpes labialis (H-S+) and HSV-seronegative persons (H-S-). In addition, H+S+ patients were exposed to experimental ultraviolet radiation (UVR) on the lips and the immunologic assay results compared among those who developed experimental lesions and those who did not. H+S+ patients were found to have higher median serum titers of HSV antibody and trends to lower levels of HSV-specific PBMC IFN-gamma and IL-2 than H-S+ control patients (123 vs 66, P = 0.04; 424 vs 548 pg/ml, P = 0.08; 14 vs 26 pg/ml, P = 0.14, respectively). Correlation of the results with the occurrence of experimental lesions showed the inverse: the subgroup of H+S+ patients with UVR-induced lesions had lower titers of antibody and trends to higher levels of IFN-gamma and IL-2 than H+S+ patients who could not be induced (93 vs 149, P = 0.02; 501 vs 347 pg/ml, P = NS; 26 vs 11 pg/ml, P = NS, respectively). The size and duration of UVR-induced lesions showed positive correlations with IFN-gamma and IL-2 levels (r = 0.60-0.67, P = 0.02-0.04). Although the small number of patients limited the power of this study, the overall pattern of the findings suggests that a Th1-like cytokine response (IFN-gamma and IL-2 production) may be associated with resistance to naturally occurring episodes of herpes labialis. The development and severity of experimental UVR-induced herpes labialis appears to be regulated differently and may involve an immunopathologic mechanism.

A review of anatomical and immunological links between epidural morphine and herpes simplex labialis in obstetric patients

The anatomical basis for facial itch after epidural morphone is outlined. CNS nuclear events which reactivate latent herpes simplex and immune inhibition resulting in maternal mouth vesicles or neonatal infections are described. Morphine is hypothesized to affect these processes and facial itch is only a marker, not a trigger of this trigeminal opioid activity.

Seventeen years of application of herpes vaccines in Bulgaria

This study reports on our experience with whole herpes simplex vaccines in Bulgaria for a period of 17 years. More than 1,500 immunized patients with herpes ophtalmicus showed a reduction of the recovery period, reduced number of the recurrences and reduced risk of visual damage. More than 14,000 patients suffering from other forms of herpes diseases for a longer period showed reduced recovery period and recurrence frequency in over 95% of the cases. Whole vaccines were well tolerable with no side effects. This report emphasizes the usefulness of whole herpes vaccines.

The herpes-specific immune response of individuals with herpes-associated erythema multiforme compared with that of individuals with recurrent herpes labialis

Infection with herpes simplex virus (HSV) is the most common precipitating factor in the development of erythema multiforme (EM). It is not known why only a few of the many individuals who experience recurrent HSV infection also develop herpes-associated EM (HAEM), although a difference in the HSV-specific immune response has been postulated. The purpose of this study was to compare the HSV-specific immune response of individuals with HSV infection alone with that of individuals with HAEM. There were 21 patients in each of the two groups. Four parameters of the HSV-specific immune response were examined: (1) anti-HSV IgG titers were measured by ELISA; (2) antibody neutralization was assessed using a plaque assay; and (3) antibody-dependent complement-mediated cytotoxicity, and (4) antibody-dependent cellular cytotoxicity were investigated using a previously described in vitro HSV-specific cytotoxicity assay. No statistically significant differences were detected between the two patient groups. Thus, a difference in these HSV-specific immune mechanisms does not explain the development of HAEM in some individuals with recurrent HSV infection.

The temporal relationship of psychosocial stress to cellular immunity and herpes labialis recurrences

This study used a prospective single-subject study design and time series analysis for repeated measures data to investigate the hypothesis that variations in psychosocial stress are associated with changes in cellular immunity in a study subject with recurrent herpes labialis. A study subject who was antibody positive for HSV-1 but reported no clinical manifestations of disease served as a control. Psychosocial stress, as measured by a questionnaire; cellular immunity, as measured by the monoclonal antibodies CD4 (OKT4), which defines the helper/inducer subset of T lymphocytes; and CD8 (OKT8), which defines the suppressor/cytotoxic subset, were measured weekly over the 32-week study period. Analysis of data using bivariate time series (ARIMA) demonstrated significant inverse correlations between stress level scores and percent CD4 helper/inducer T lymphocytes in both subjects. In the study subject with recurrent herpes simplex labialis, a Mann-Whitney U statistic determined that the percent of CD4 in the early stages of a recurrence were significantly lower than the percent of CD4 at other times when blood samples were drawn. The data presented are repeated measures on two individuals with positive antibodies to the herpes simplex virus, one with recurrent herpes and one without a history of recurrent herpes. Relevance for stress research is discussed.

HLA antigens associated with susceptibility to herpes simplex virus infection

HLA antigen frequencies in 150 patients with recurrent herpes simplex virus infection and 176 normal Iraqi controls were studied. Highly significant increased frequencies of HLA-A1, -B5 and -DR1 were found in patients as compared to control individuals. The frequencies of HLA-A3 and -A23 were also significantly increased in patients. When we subdivide the patients into groups according to rate of recurrence of symptomatic infection or ELISA reading of antibody titre no preferential association of HLA antigens with any particular subgroup is apparent. These results were compared with published findings for other ethnic populations and found to be compatible with them.

Lymphoproliferative Responses in Recrudescent Orofacial Herpetic Infections

The relationship between antibody (Ab) and lymphoproliferative responses to herpes simplex virus (HSV) and recrudescent orofacial HSV lesions were investigated in 65 patients. All had HSV-specific Ab and cell mediated immune responses (CMIR) demonstrated by ELISA and in vitro lymphoproliferation respectively. Thirteen control subjects were negative in both tests. Thirty-three patients were repeatedly investigated for 6-38 months during which time they suffered 1-8 recrudescences. HSV-induced lymphoproliferation was depressed during recrudescences, rose to a peak several weeks later, and declined slowly to a background level. However, ELISA titres and lymphoproliferative responses to Concanavalin A (Con A) were high throughout and circulating peripheral blood mononuclear cell (PBMC) subsets did not change. Depressed lymphoproliferative responses to HSV antigen (Ag) during recrudescences were enhanced by removal of CD8+ cells from PBMC using either a panning technique or cell sorting; re-constitution of CD8+ cells suppressed the HSV-specific lymphoproliferative response. CD8+ cell depletion affected neither HSV-induced lymphoproliferation recrudescence, nor lymphoproliferative responses to another Ag (PPD) during recrudescence. Depressed HSV-induced lymphoproliferation during recrudescences might thus be due to CD8+ suppressor T cell (Ts) function rather than low numbers of circulating lymphocytes. Suppression or delay of normal CMIR to asymptomatic recurrent epidermal HSV infection by Ts might allow development of recrudescent HSV lesions.

Clinical and serological outcome of genital herpes simplex virus (HSV) type 2 inoculation following oral HSV type 1 infection in guinea-pigs

The clinical and serological outcome of genital herpes simplex virus type 2 (HSV-2) inoculation in animals previously orally infected with HSV type 1 was evaluated. A prior HSV-1 oral infection modified the genital HSV-2 infection so that only four of 18 (22%) animals were initially symptomatic although all but one animal shed HSV-2 from the cervicovaginal area for at least 5 days following inoculation. Three of four animals with symptomatic initial disease also developed recurrences, as did an additional six animals that did not manifest acute genital disease. Anti-glycoprotein gG-1 antibody was found in 17 of 18 animals with only an HSV-1 infection and anti-gG-2 antibody in all of nine animals with only an HSV-2 infection. Anti-gG-2 antibody was detected in eight of 17 animals with a prior HSV-1 infection following HSV-2 inoculation and one had an indeterminate response. Eight of these nine animals developed recurrent genital disease compared to one of eight that did not respond to gG-2 (P less than 0.006). Thus a prior oral HSV-1 infection modified both the initial presentation of HSV-2 infection and the HSV type-specific serological response.

Lack of correlation between HLA-B35 resistance against herpes labialis and antibody titers to HSV-1

To investigate whether genetic factors linked to the human leukocyte antigens (HLA) might influence individual resistance to recurrent herpes labialis (RHL), we studied the frequencies of HLA-A, -B, and -C antigens in a sample of Sicilian population. The frequency of HLA-B35 was significantly decreased in the patient group (p corrected = 0.018). Consequently, the relative risk of development of RHL in a subject positive for HLA-B35 was 20 times smaller than in a subject who does not bear B35. Furthermore, a study was made of the possible relationship between the presence of HLA-B35 antigen and antibody titers to herpes simplex virus type 1 (HSV-1) in 62 persons affected or not by RHL. Significantly elevated titers to HSV-1 were found in the diseased group (p less than 0.001), but the geometric mean of antibody titers in HLA-B35 positive subjects was not different from that of B35 negative subjects either of RHL-affected or in healthy persons. These data are in a good agreement with the hypothesis that humoral immune responses play a marginal role in the protection from HSV-1 recurrences.

[Recurrent herpes labialis infections: cellular immunity and immunomodulation]

The therapy with thymus extracts, oral and parenteral, reduced the frequency and the intensity of recurrences of herpes labialis infections. The duration of the effect was at least 6 month after interruption of the therapy. Indomethacin was effective and developed and intensive effect only during the therapy. The skin test with recall-antigens and the neopterin-elimination were altered at the first day of the menstruation during the recurrence. The normalisation succeeded during therapy. In patients with recurrences in the perimenstrual time we observed a reduced T-helper/T-suppressor index during the first day of menstruation. Normal data were registered out of the recurrence time and/or under therapy. Inhibitors of the lymphokine: leucocyte/migration inhibitory factor (LIF) with a molecular weight of 6-12 KD were obtained with the specific stimulation of mononuclear cells of patients with recurrent infections with herpes labialis using the herpes-virus-1 antigen. The inhibition of fibrinolysis/proteolysis with aprotinin, tranexamic acid, phenyl-methyl-sulphonyl-fluoride and di-isopropyl-fluorophosphate could prevent the appearance of inhibitors. Inhibitors could be produced by splitting the LIF-molecule with urokinase and plasminogen but not with trypsin. The production, but not the activity, of present LIF-inhibitors are blocked in vivo and in vitro by indomethacin and thymus peptides.

Immune inhibition of virus release from herpes simplex virus-infected cells by human sera

Human sera contain antibody (IVR antibody) which will inhibit the release of herpes simplex virus type 1 from virus-infected cells. This antibody activity was removed by adsorption of sera with virus-infected cell extract. There was a positive correlation between IVR and neutralizing antibody activity, particularly when measured by augmented neutralization test; measurement of IVR antibody was equally as sensitive as measurement of neutralizing antibody by augmented neutralization test. IVR antibody levels provided indication of a history of recurrent herpes labialis, the pattern of antibody response following primary herpetic infection, and indication of response to Skinner herpes vaccine in human subjects. It is suggested that consideration should be given to measurement of IVR antibody in both clinical and epidemiological studies of herpes and other virus infections.

Beta interferon produced by keratinocytes in human cutaneous infection with herpes simplex virus

beta Interferon (IFN) was demonstrated by specific, sequential antibody-neutralization assays of vesicle fluids from patients with recurrent skin lesions due to herpes simplex virus. To determine the origin of this antiviral activity, we cultured keratinocytes from normal facial skin and infected them with three strains of herpes simplex virus. Keratinocyte cultures then developed characteristic cytopathic changes, and antiviral activity was found in culture supernatant media. All such activity from these supernatants was neutralized with specific antiserum to IFN-beta but not with antiserum to IFN-alpha. No IFN-gamma was detectable by radioimmunoassay. Immunoperoxidase staining with antiserum to IFN-beta in five biopsy specimens from culture-proven, recurrent herpes simplex lesions showed positive staining of epidermal keratinocytes but not of dermal or infiltrating cells. Thus, the primary sources of IFN-beta in recurrent herpes lesion vesicles are the virus-infected keratinocytes.

Immune responses to herpes simplex virus in patients with recurrent herpes labialis: I. Development of cell-mediated cytotoxic responses

Groups of subjects during acute (0-3 days) and convalescent (2-3 weeks) phase of recurrent herpes labialis (RHL), and other subjects seropositive or seronegative for herpes simplex virus type 1 (HSV-1) antibody without any history of RHL, were tested for the appearance of cell-mediated cytotoxic responses by stimulating peripheral blood leukocytes (PBL) in vitro with ultraviolet-inactivated HSV-1 antigen, using the release of radiolabelled chromium (51Cr) from HSV-1-infected autologous, or allogeneic lymphocytes and K562 erythroleukemia cell line as nonspecific targets. Development of HSV specific cytotoxic response using autologous targets was essentially limited to subjects with RHL and in HSV antibody seropositive control subjects. Peak activity was observed during the acute phase of the disease, compared to the activity in the convalescent phase in seropositive subjects with RHL, and was preceded by high lymphoproliferative response to HSV. Higher cytotoxic responses against K562 cells were also observed in RHL subjects compared to the controls. Depletion of Leu-2+, Leu-3+ or Leu-11 effector lymphocytes from HSV-1-stimulated PBL cultures by treatment with complement and appropriate monoclonal antibodies resulted in significant reduction of cytotoxicity to HSV-1-infected autologous cells. However, cytotoxicity to K562 cells was reduced only after depletion of Leu-11+ cells. Low levels of allogeneic restriction were observed for cytotoxicity to HSV-1-infected targets. These observations suggest selective activation of virus specific Leu-2+ and Leu-3+ T cell subsets as well as natural killer cell mediated cytotoxic mechanisms during the active phase of recurrences of herpes simplex virus infection.

Immune response to herpes simplex virus in patients with recurrent herpes labialis. II. Relationship between interferon production and cytotoxic responses

The relationship between the development of cytotoxic cellular immune response to herpes simplex virus type I (HSV-1)-infected autologous cells and the production of interferon (IFN) was studied using in vitro secondary sensitization of peripheral blood leukocytes in subjects with recurrent herpes labialis (RHL) and in normal controls without any history of recurrent herpes labialis. There was a significant discordance between optimal HSV-1 antigen dose required for induction of peak cytotoxic responses and for maximal activity of IFN. Moderate IFN activity (6-100 U/ml) was demonstrated in all HSV-1 antigen-stimulated peripheral blood leukocytes collected from subjects during both acute and convalescent phase of RHL. However, only 50% of seropositive controls and no seronegative controls exhibited detectable IFN activity, when stimulated with HSV-1 antigen, although such in vitro stimulation resulted in maximal virus-specific cell-mediated cytotoxicity. A correlation of virus specific cytotoxic activity to HSV-1 and IFN production (r = 0.38, p less than 0.05) was less marked than that of cytotoxic activity to K562 (natural killer-sensitive target cells) and IFN titer (r = 0.48, p less than 0.01). Furthermore significant reverse correlations between cytotoxicity against HSV-1-infected autologous cells and a titer of gamma-IFN was observed in samples with high cytotoxic activity. These observations suggest that gamma-IFN produced by HSV immune T cell may also act as an autoregulatory factor against the production of cytotoxic cellular activity against HSV-1-infected autologous cells.

Hypothesis: the gingival tissue as a reservoir for herpes simplex virus

The reservoir site of Herpes simplex virus (HSV), from the primary infection until reactivation and in between recurrences was found to be in the dorsal roots of the trigeminal ganglion or in the sensory root ganglion. However, the triggering of viral genome in the ganglion does not exclusively explain the recurrences and appearance of skin lesions. Other sites cannot, therefore, be excluded, and virus may well be occult also in extraneural tissues. Herpes virus antigens were found by us in the sulcular epithelium of approximately 60% of patients with clinically healthy gingivae; we therefore hypothesised that the epithelial cells might act as the preferential site for latent HSV. In order to prove this assumption, viral genome should be traced in cells of oral tissues, and efforts should be made to rescue virus.

[Comparison of complement fixation and Tzanck smear tests for the diagnosis of herpes labialis]

In this study, the serum antibody titer of Herpes simplex virus type 1 (HSV-1) in 82 patients with herpes labialis and 100 controls was determined using the complement fixation test. In own experience, the Tzanck smear test (reported to be an aid in the diagnosis of HSV infection) was of no value. In comparison to patients in an early stage of infection, convalescent patients had an antibody titer that was 4 or more times higher (1/64-1/256). Fifty-eight percent of the control group was negative. In own opinion, the variation in titer between the acute and convalescent stages in Herpes simplex cases would be of particular value in diagnosing cases of urethritis, cystitis encephalitis, meningitis, conjunctivitis, primary and recurrent eczema herpeticum and erythema multiforme when HSV is suspected to play a role in the etiology.

Viral inhibition of lymphocyte proliferative responsiveness in patients suffering from recurrent lesions caused by herpes simplex virus

Herpes simplex viruses (HSV) are able to prevent the lectin-driven mitogenesis of coincubated human peripheral blood lymphocytes. This abrogation of responsiveness is independent of infection and can be obtained by using ultraviolet-inactivated as well as live virus particles. Lymphocytes from patients prone to frequent recurrences of HSV-induced lesions were more susceptible to inhibition of proliferative responsiveness than were cells from either individuals seronegative for HSV type 1 and HSV type 2 or individuals subject only to infrequent recurrences of HSV-induced disease. Lymphocytes from all patients tested were more susceptible to viral abrogation of mitogen responsiveness during preepisodic and acute as opposed to convalescent and postepisodic periods. When exogenous T cell growth factor was added to lymphoid cell cultures that had been coincubated with HSV, the cells were generally able to overcome the inhibition of responsiveness that would otherwise occur. However, this restoration of responsiveness occurred less efficiently in cells from patients with acute HSV-induced lesions and in cells from patients with frequent recurrences of lesions.

Immunostimulatory function of herpes simplex virus isolates from patients with frequent herpes labialis and a deficiency in immune-specific interferon production

Approximately 30% of persons with frequent episodes of herpes labialis are deficient in the production of HSV-induced immune-specific interferon (IFN) (Green, 1985). Herpes simplex virus (HSV) strains isolated from persons who make immune-specific IFN and from persons who do not make it were examined for their immunostimulatory capabilities. HSV isolated from the primary oral lesions of two patients deficient in immune-specific IFN production, one person with an intact immune-specific IFN response, HSV types 1 and 2 laboratory strains, and Newcastle disease virus (NDV) were added to cultures of peripheral blood mononuclear cells (PBML) from HSV seropositive donors. All HSV-isolates induced comparable titers of immune-specific IFN. These studies suggest that failure of some patients to develop an immune-specific IFN response is determined by the host, not the virus.

Immune-specific interferon production by peripheral blood mononuclear leukocytes from patients with primary and recurrent oro-labial herpes simplex virus infections

Immune-specific IFN (IFN) is produced by the peripheral blood mononuclear leukocytes (PBML) of greater than 95% of HSV-seropositive humans with infrequent recurrences of herpes labialis [Green, Yeh, and Overall, 1981]. However, herpes virus-induced immune-specific IFN was produced by PBML from only 33 of 48 (68.8%) persons with frequent recurrences (2-12 episodes a year). Two of eight subjects with primary herpes gingivostomatitis also failed to produce immune-specific IFN during either the acute or convalescent phases of their initial HSV infection. These data suggest that some persons have a defective immune-specific IFN response that exists from the time of their primary oro-labial HSV type 1 infection. This defect may predispose to a higher frequency of disease in some individuals.

Prevention of recurrences in frequently relapsing herpes labialis with thymopentin. A randomized double-blind placebo-controlled multicenter study

The present randomized, placebo-controlled double-blind multicenter study included a population of 36 subjects with frequent recurrences (at least once a month) of herpes labialis. Most of the patients had failed to respond adequately to previous treatment with other therapeutic tools, including acyclovir. Either 50 mg of thymopentin or of placebo was administered 3 times a week, by the subcutaneous route, for 6 weeks. Subsequently, the patients were observed for nearly 6 months on the average. The results achieved with thymopentin for the individual parameters were significantly superior to those obtained with placebo; thus significant improvement was seen in patients on thymopentin in the duration of the longest symptomfree period (prolonged from 2.1 weeks to 20.9 weeks, p = 0.000), in the number of relapses (reduced from 1.6 to 0.4 episodes/month, p = 0.001), and in the total duration of herpes symptoms per month (shortened from 2.0 to 0.3 weeks, p = 0.000). Placebo treatment also resulted in considerable improvement (p less than 0.05 or 0.01), but was significantly inferior to the improvement obtained with thymopentin. The longest symptomfree period in the placebo group was prolonged from 2.4 to 11.2 weeks. The number of relapses per month was reduced from 1.4 to 0.8, and the total duration of herpes symptoms per month from 2 to 0.9 weeks. The results of intergroup analyses, in which the observed parameters and the improvement achieved in either group were compared, significantly favored thymopentin treatment. The effect of thymopentin was in all but one parameters superior to that of placebo and highly significant (p less than 0.01).