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Primary Herpes Simplex Virus (HSV) Infection

by Minh Nguyen

Primary Herpes Simplex (HSV-I) type 1 produces the most common viral infection in the oral cavity. It most often occurs in children under 6 years of age but can involve older patients. In most children primary infection is sub-clinical (without clinical signs or symptoms); about 13% of children have had symptomatic herpes by age 9.

The herpes simplex viruses are virtually ubiquitous in the general population; over 90% of adults have antibodies to herpes simplex virus by the fourth decade of life. Once an individual is infected, the virus spreads to regional mass of nerve tissue, ganglia (e.g., the trigeminal ganglion), where it remains latent but can be reactivated whenever conditions are appropriate.

The causes and the course of the disease:

Both herpes simplex types 1 and 2 may cause both orofacial and genital infections, but HSV-I is more frequently responsible for lesions in and about the mouth ranging from the relatively trivial cold sore to a vesiculoinflammatory (having small blisterlike elevations on the skin with fluid in them) eruption. These lesions typically involves large areas of the oral mucosa, the moist surface tissues that line the mouth, throat and lips. This condition is called gingivostomatitis.

In addition, herpes simplex virus infection may involve the membranes of the eye, causing the keratoconjunctivitis. In newborn infants or immuno-compromised (with depressed immune system) adults, the infection may involve visceral organs (e.g., lungs, liver) or produce encephalitis (inflammation of the brain) or fatal disseminated disease.

Recurrent herpetic infections develop in about one third of those patients who have had a primary infection. Herpes labialis is the most frequent type of recurrent infection. It usually is seen as a cluster of vesicles appearing around the lips after a systemic illness or other stress-fill situation. Ultraviolet light and mechanical stimuli may also produce recurrences.

The clinical features

(1) Herpes Labialis:

The "cold sore" or "fever blister" as is well known to all, constitutes a vesicular lesion usually located around mucosal orifices such as the lips and noses. Often several lesions appear simultaneously or in quick succession. There is frequently a history of previous respiratory infection or fever, exposure to sunlight or cold, or trauma to the area, but whether these influences in fact activate the virus remains unclear.

The vesicular lesion begins with a focus of intracellular and intercellular edema followed by ballooning degeneration of epidermal cells and acantholysis (separation of cells) with the formation of an intraepithelial vesicle (blister). Individual epidermal cells in the margins of the vesicle or lying free within the fluid develop intranuclear inclusions composed of live and dead virions. Sometimes several cells fuse to produce polykaryons or giant cells that can be identified in smears of blister fluid (Tzanck preparations). The vesicles are prone to burst to produce superficial ulcerations, and in most cases, in the course of a few days are covered with a fibrinous coagulum and progressively heal.

(2) Herpetic Gingivostomatitis:

Primary herpetic gingivostomatitis is a more florid form of herpetic infection of the oral cavity that occurs in the compromised host (debilitation, impaired immunity, immunosuppressive therapy, and in the very young who lack antibodies). The lips and gingival and buccal mucosa are involved but sometimes also the tongue and retropharynx. The individual lesions may begin as vesicles but may extend into the mucosa and deep cutaneous layers, favoring systemic dissemination. Coalescence of the lesions leads to denudation of large areas of the mucosa. There is a commensurate greater inflammatory reaction and consequent edema and erythema.
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