Herpes Virus 1 & Herpes Virus 2

Moderator : Dr Shaista Nazir

Presenter : Dr Raihana Ali
Date : 08 -01 -2018
 From the Greeks-------- Hippocrates
“Herpes”----- to creep or crawl.
------ Term used to describe the Spreading nature of
Skin lesions
History
• 100 AD Cold sores (herpes febrilis) were described by the Roman
physician Herodotus
• John Astrus (1736) physician to the king of France first described
genital herpes lesions
• Gruter (1912) – Cultivation of HSV on rabbit cornea & differentiated
HSV from VZV.
• 1925 : HSV was grown in vitro
• Nahmias and Dowdle (1960]-----reported two antigenic types of HSV
with different sites of viral recovery
Virus Classification
Group: Group I ds DNA
Order: Herpesvirales
Family Herpesviridae
Subfamily Alpha-herpesvirinae
Genus: Simplex virus

Species: 1. Herpes simplex virus 1 (HSV-1)

2. Herpes simplex virus 2 (HSV-2)
Herpesviridae Family
Virus Characteristics
– Large, ds DNA
– Enveloped
– Derives Envelope from nuclear membrane
– Icosahedral Symmetry
– Intranuclear Inclusions
– Establishes Latency
 Herpesviridae Family---Sub-Family
Alpha 1. Short Reproductive Cycle (12- 18 hours cycle) 1. HSV1
herpesvirinae 2. Efficient Destruction of infected Cells 2. HSV2
3. Rapid Spread In Culture 3. VZV
4. Latency in Sensory Ganglia—[but not
exclusively]

Beta 1. Long Reproductive Cycle [(over 7 days)] CMV (HHV-5)

herpesvirinae 2. Enlargement of infected Cells[(cytomegalia) HHV-6A , 6B)
3. Slow cell to cell spread in culture HHV-7
4. Multiple Non –ganglionic latency cells
Gamma 1. Replication In Lympho-blastoid Cells EBV
herpesvirinae 2. Latency in KSHV
1. Lymphoid Tissue[ EBV]
2. Monocytes & B- Lymphocytes [HHV-8]
HSV1-Prototypical Virus

• One of the most extensively studied herpes virus

• Share basic properties with all herpes virus
• Provides general model for all herpes virus in regard to
– Virion & genome structure
– Infection mechanisms
– Gene expression
– Replication
Properties of Herpes viruses-1

• Size: large (120–200 nm in diameter)

• Symmetry: icosahedral

• Enveloped Virus

• Genome: linear double-stranded DNA.

• Virus is similar to Bacteriophage

• Site of Latency: Sensory nerve ganglia.
– In orofacial herpes trigeminal ganglia are mostly involved.
• Replication occurs in the nucleus.

• The virion does not contain a polymerase.

• Herpes viruses encode DNA-dependent DNA polymerase

• The herpesviruses are ubiquitous.

• Man is the only natural host for HSV.

– Reservoir : Human Mucosa & ganglia

• Well Adapted Virus

• HSVs are sensitive to treatment with
– acid
– fat solvents (such as alcohol, chloroform, ether, and bile salts.
– Detergents
– Drying.
• They are readily inactivated
– in the conditions prevalent in the gastrointestinal tract.
 VIRION STRUCTURE

• Spherical particle
• Symmetry Icosahedral
• average diameter :186 nm-225nm
• Naked Virion Size: 100nm
•
• The variation is in part due to
variability
– in the thickness of tegument.
– variability is the state of the envelope
• HSV virion consists
– Core
– Capsid
– Tegument
– Outer lipid bilayer envelope
VIRION STRUCTURE: CORE
CORE

Diameter: 100nm
DNA: Negatively Charged
Polymines : Positively Charged

1. contains the double-strand (ds)

DNA genome wrapped as a toroid or
spool in a liquid crystalline state.
1. does not contain highly basic proteins-----
---histones
2. Do contain polyamines spermidine and
spermine

High resolution, computer-enhanced electron

microscopy of frozen viral capsids images of
the virus.
HSV1:Capsid
Diameter :100nm
Symmetry : Icosahedral

• comprised of 162 capsomers, including

• 140 hexons,
• 11 pentons, and one portal,

• Capsomere Shape: doughnut shaped

• The four conserved capsid proteins

that comprise the major structural
features of the capsid include
a. The major capsid protein (MCP)-
Vp5
Envelope
1. Lipid bilayer
2. Derived from its host cell’s nuclear
membrane.
3. Contains transmembrane viral
glycoproteins
1. Appear as “spikes”on envelope surface
2. Required for binding/entry to target Glycoprotein "spikes" on the HSV surface.
cells
•at least 13 distinct viral glycoproteins
embedded in it.
1. (gB),(gH) , (gL) (gM), (gN)
4. Glycoprotein G –
1. Type specific Immune reagent
2. present in HSV2
Tegument
• Space between the envelope and the
capsid is the tegument.
• contain more than 20 different virally
encoded proteins,
• involved in the initiation of replication
Various Proteins Within Tegument
1. VP16/aTIF / UL48----virion
transactivator protein
2. VHS protein (UL41) ---Virion host
shutoff [ Degrades host mRNA]
HSV GENOMEs
• 150 kbp linear genome

• Encodes at least 84 genes

• Divided into two segments : Long [L] & Short [S]

– Each segment possesses unique sequence regions Flanked on

ends by Inverted Repeats

– Unique Long Segment [UL]: Contains 65 ORFs

– Unique Short Segment [US]: Contains 14 ORFs

Repeat Regions
1. a(n)b-Repeat Sequence Flanks left of UL
2. b'a'(n)---- inverted internally at Right end of UL
3. a '(n) c‘ Right end of US and
4. ca flank left of US

n= no. Or more copies of sequence in tandem

a sequence =200-500bp possess signals for genome packaging
[no genes present]
 Replication
• Rolling circle mechanism
– Rolling circle DNA replication is used by bacteriophages to
generate multiple copies of circular DNA.
Sequence of events before reaching to
site of Replication (nucleus)
1. Receptor binding

2. Membrane fusion at plasma membrane or after endocytosis

3. Management of intrinsic responses by tegument proteins

4. Transport of nucleocapsid and tegument-associated IE-activators

to nucleus

5. Injection of viral genome through nuclear pores into nucleus

6. Genome chromatinization and initial interactions with

transcriptional machinery
 Receptor binding

Viral Components Host Components

interactions cell surface receptors
1. Glycoproteins gB Heparan sulfate proteoglycans
2. Glycoproteins
gC:
Coreceptors
1. Herpes virus: entry mediator
Glycoprotein gD [HVEM]----the tumor necrosis
factor receptor family of proteins
(Hve-A)
2. Nectin -1 cellular adhesion
molecule----immunoglobulin
superfamily (nectin family), or
3. both
4. the 3-O-sulfated heparin sulfates.
• Membrane fusion
– at plasma membrane or after endocytosis
– mediated by gB and the gH/gL complex

• Capsid moves along the microtubules to reach nucleus

– Capsid docks at the nuclear pores &releases DNA

• Tegument Proteins Provide Immediate function

– a-TIF protein which functions in enhancing immediate early viral
transcription via cellular transcription factors.
– The virion-associated host shutoff protein (vhs--UL41) appears to
remain in the cytoplasm where it causes the disaggregation of
polyribosomes and degradation of cellular and viral RNA
Pathogenesis & Latency
Herpes Simplex Virus (HSV) Infection
 Epidemiology of Herpes Virus 1
 Worldwide Distribution
 HSV infections occur throughout the year.
 Humans appear to be the only natural reservoir----------Trigeminal
Ganglia
 Geographic location, socioeconomic status, and age are the primary
factors that influence the acquisition of HSV-1 infection .
 HSV infections are acquired more frequently and earlier
 More than 90% of adults have antibodies to HSV-1 by the fifth decade
of life.
 Epidemiology of Herpes Virus 1 :Prevalence
Globally

1. Between the ages of 0 and 49 years :

1. 3.7 billion people globally (67% of the population/ two-thirds of the
population

2. Between the ages 15 to 49 years—

1. -estimated 140 million people –[ with genital HSV-1 ]

3. prevalence of the infection

• Africa (87%) (highest )
• Americas (40-50%). (lowest )
South-East Asia: [ Prevalence: 0-49 ]
1. 432 million women (59%),
2. 458 million men (58%)
TRANSMISSION OF HSV-1
• Transmission most frequently occurs through close contact with a
– persons with active ulcerative lesions
– persons who have no clinical manifestations but who is shedding
virus
– at a peripheral site
– at a mucosal surface,
– or in genital secretions or
– Oral secretions
Herpes Simplex Virus 1: Clinical Manifestations

• Generalities About HSV Infections

– Multiple Clinical Syndromes
– HSV1 more often above the belt
– HSV2 more often below the belt
– Often Silent (With asymptomatic Shedding)
Host –Parasite Inter-relationship of Herpes Simplex
Virus

Susceptible Host Virus

Exogenous re-infection with

new virus
Primary Infection
Recurrent Manifestations

Reactivation of latent
Infection
Inapparent Infection

Clinical Disease Carriers

Clinical Spectrum: HSV1 & HSV2
Clinical Manifestations HSV1 Clinical Manifestations HSV2

1. Primary/Recurrent Oropharyngeal 1. Genital herpes

Disease 2. Neonatal herpes
1. Gingivostomatitis • Perinatal Infections
2. Pharyngitis 3. In Utero ( Congenital Infections)
3. Recurrent Herpes Labialis
2. Skin Infections
1. Herpetic whitlow
2. Eczema herpeticum
3. Herpes Simplex Keratoconjunctivitis
4. Infections of the Central Nervous
System Encephalitis
5. Visceral Infections/Disseminated
infections
1. Emergent Cause of---Genital herpes,
Neonatal herpes
Population At Risk –HSV-1
• Children
• Athletes involved in contact sports:
– Cutaneous and ocular HSV-1 infections
– Outbreaks among wrestlers are well recognized.

• Healthcare workers
– Dentists
– Respiratory care unit personnel
– Laboratory-acquired and
– Nosocomial outbreaks in hospital or nursery personnel
– Classic HSV lesions ----
vesicular with an
erythematous base---“the
dew drop on a rose petal”.

• Appear about 3 days after

exposure and can last up
to 2 weeks (primary
herpes)
 OROPHARYNGEAL DISEASE

Mucosal infections
1. Primary Oropharyngeal Disease
1. Gingivostomatitis
2. Pharyngitis
3. Acute herpetic
pharyngotonsillitis

Pharyngotonsillitis

Gingivostomatitis
Recurrent Oropharyngeal Disease

• Recurrent herpetic eruptions

1. A.k.a Herpes Labialis,
are precipitated by :
called cold sores/fever – Overexposure to sunlight
(UV light)
blisters.
– Febrile illnesses
2. Most common – Physical or emotional
stress
manifestation of recurrent
– Immunosuppression
HSV-1 infection – Unknown stimuli
Recurrent herpes simplex labialis.
Other SKIN INFECTIONS
Population At Risk : HSV1
1. Atopic dermatitis----- Eczema
Herpeticum

2. Wrestlers---Herpes Gladiatorum

3. Rugby Players--- Scum Pox

(Herpes Rugbeiorum).

4. Health Care Workers----

Herpetic Whitlow

5. Other Groups
– Darier disease and Sezary
syndrome
– skin abrasions or
– burns
EYE INFECTIONS

1. HSV keratitis
1. Characteristic
Ulceration—Dendritic
Ulcers
2. MC cause of Corneal
Blindness in
Industrialized areas
2. Chorioretinitis
1. Manifestation of
disseminated HSV
infection
1. HIV
2. Neonates
3. Acute a necrotizing retinitis
• HSV1 & HSV2 Associations
– Erythema multiforme (75% of cases )
– severe HSV-associated erythema multiforme are candidates for chronic
suppressive oral antiviral therapy.
HSV1 Encephalitis

• Mc common sporadic Encephalitis

• acute onset,
• focal neurological symptoms
• Fever, headache, altered sensotium
• Mc involve temporal lobe--- Temporal Lobe Hemorhagic
Encephalitis
• CSF Pleocytosis, Proteins, RBCs
• 70% untreated mortality rate
HERPES VIRUS 2
Structure : HSV2

Antigenic homology HSV-1 and 2 show >80% antigenic homology

DNA homology HSV-1 and 2 show >50% homology in the
genomic sequence
Differences between HSV-1 and HSV-2

Characteristics Herpes Virus 1 Herpes Virus 2

Common modes Direct contact with Sexual mode or
of transmission mucosa or abraded vertical mode
skin
Site of latency Trigeminal ganglia Sacral ganglia
Age of primary infection Young children Young adults
Children are at risk for sexually active people are
acquiring HSV-1 at increased risk to HSV-
infection, 2 infection
Geographical distribution more common than HSV-
2 infection.
 Diseases:
Vesicular lesions in the skin Above the waist Below the waist, especially
the genitalia
Gingivostomatitis Common Rare
Pharyngotonsillitis Common Rare
Keratoconjunctivitis Common Rare
Infection of the CNS Encephalitis Meningitis
Infection in neonates Rare Skin lesions and
disseminated infections
Infection in Dissemination to visceral No dissemination
immunocompromised hosts organs
Transmission of infection Contact (often saliva) Sexual
Neurovirulence Less neurovirulent More neurovirulent

Recurrence Less chance of recurrence More recurrence irrespective

of site—8-10times more
frequently

Resistance to antiviral agents in Less resistant More resistant

culture
Growth on CAM Small pocks Large pocks
Growth in chick embryo Replicates poorly Replicates well
fibroblast
 Clinical Manifestations HSV2
1. Genital herpes
2. Neonatal herpes
• Perinatal Infections
3. In Utero ( Congenital Infections)
Epidemiology :Burden of HSV-2
• Leading cause of genital ulcer disease worldwide
• Between the Ages of 15 and 49 years :
– 417 million individuals (11.3%) worldwide
• Both HSV-1 or HSV-2 together,
– the estimates reveal that over half a billion people between the ages
of 15-49 years have genital infection
– about one out of six, people aged 14 to 49 years have genital HSV-2
infection
• Prevalence of HSV-2 infection was estimated
– Africa (31.5%)( highest ),
– followed by the Americas (14.4%).
• The highest numbers of people newly-infected were adolescents
• More women are infected with HSV-2 than men;
– 267 million women---
– 150 million men
 HSV-2 Incidence
• An estimated 19.2 million new HSV-2 infections occurred
among adults and adolescents aged 15–49.
Mode of Transmission

HSV-2 transmitted by
1. Sexual contact
2. autoinoculation
3. from an infected mother to her infant at birth
.
Special “at risk” groups:
1. Neonates
2. Immunocompromised
3. Physicians, nurses, dentists, etc. in contact with oral and
genital secretions.
Genital Herpes
• More often by HSV-2((70%-80%) --
– But HSV-1(10-20%) can also cause
• Characterized by vesico-ulcerative lesions with local discomfort.
• Lesions present on genitals, rectum, perirectal, proctitis
• Incubation period 2 - 7 days
• Person sheds the virus for 3 weeks.
• Associated with systemic symptoms
Primary infection—40-70%
Recurrent infection----5-10%
 Genital Herpes
• Primary infections

• are more severe than recurrent infections

• More severe in women than in men

• Complications of Genital Herpes include

– extragenital site ulcers
– aseptic meningitis.
Impact of Genital Herpes:

• Genital herpes is associated

– with considerable morbidity and even mortality.
– can lead to substantial psychological morbidity.
– Neonatal herpes
– HIV-1 acquisition and transmission
HSV2 & HIV

• HIV-1 acquisition and transmission

– Genital herpes is associated with an increased risk of HIV acquisition
by two- to threefold,
– HIV transmission on a per-sexual act basis by up to fivefold, and may
account for 40–60% of new HIV infections in high HSV-2 prevalence
populations.
 Neonatal Herpes
• Global Neonatal Herpes Estimates (WHO )
– Roughly 14,000 Cases Annually

– 10 out of every 100,000 births globally

• Mortality Rate :65%;

• Neonatal HSV infections are due to

– HSV-1(30% )

– HSV-2(70% )
RISK OF NEONATAL HSV INFECTION

• Intrapartum infection (perinatal infections)---- 85% of cases

• Postpartum (postnatal)---- 10% of cases

• Intrauterine (in utero)-----Congenital Infection---- 5% of cases

Five factors known to influence transmission of HSV from mother to
neonate are:

1. Type of maternal infection (primary versus recurrent)

2. Maternal HSV antibody status

3. Duration of rupture of membranes

4. Integrity of mucocutaneous barriers (eg, use of fetal scalp electrodes)

5. Mode of delivery (caesarean versus vaginal delivery).

CLINICAL MANIFESTATIONS OF NEONATAL HSV
DISEASE

• Skin, Eye, Mucous Membrane : 40%

• CNS Neonatal Herpes: 25%

• Disseminated Neonatal Herpes:25%

• Congenital Neonatal Herpes: 5%

Types of Immunocompromised Hosts
Susceptible to HSV Infections
• New Born Infants
• Congenital Immunodeficiencies
• Acquired Immunodeficiencies
• Immunosuppressive Therapy
• Transplant Recipients
• Compromised Skin Barriers ( Burns, Eczema)
General Features of HSV Infections in
Immunocompromised Hosts
• More Recurrent
• More Prolonged
• More Progressive & Destructive
• More Wide spread (disseminated)
– Liver
– Lungs
– Esophagus
– Brain
 Diagnosis of HSV Infections

Clinical
Laboratory DX
Dx

To confirm the To guide Typical Vesicular

diagnosis therapy Lessions
Herpes Laboratory Diagnosis
 Specimen
 Specimen collection and transport
 Diagnostic Tests:
a. Viral Cultures & Typing
b. Direct Detection of Viruses in Clinical Samples
i. Light Microscopy---Detection of Inclusions
ii.Electron Microscopic detection of Viral particles
iii.Immunologic Detection of Viral antigens
c. Serologic Dx of Viral Infections
d. Molecular Techniques--
i. PCR , RFLP , Next Generation Sequencing
Specimen & Specimen Collection

– collected in the acute

stage of the disease (3
days - 7 days)
– Do Not use calcium alginate
swabs.
• Specimen
– Vesicle fluid,
– swab of base of lesion
– Neonatal surface culture:
Multiple sites can be cultured
using a single swab (ending
with a rectal swab).
 Viral culture
Viral Cultures:
 Gold standard
 Highly specific (>99%)
 Sensitivity
 depends on stage of lesion;
declines rapidly as lesions
begin to heal
 Primary infection (80%–90%)
than with recurrences (30%)--
Viral culture

 Culture Interpretation
 CPE
 Virus Ag Detection
 Cultures should be typed
 Using DFA
HSV Antigen Detection :

1. Direct immunofluorescence assays (DFA)

2. ELISA
3. Immunoperoxidase assay
4. Hemagglutination assays, or
5. Avidin-biotin enzyme conjugate assays.
Direct immunofluorescence assays (DFA)
1. MC used Procedure
2. MC Used For Mucocutaneous Lessions
3. Sensitivity ----ranged from 50 to 100% when
used alone
4. Specificity--- approaches 100%---Used along
with viral Cultures
5. Not reliable for detecting asymptomatic HSV
shedding.
Uses
1. Rapid Test -----2hrs
2. Can be used on Older Lesions
3. Can be used for atypical clinical situations
Brightly fluorescing (apple green)
HSV-1 infected cells.
Cytology and Histology

Microscopy & Staining

– Characteristic Cytopathologic effects (CPEs) identified include

• syncytia, “ballooning” cytoplasm
• Multinucleated giant cells with faceted nuclei and
• homogeneously stained ‘ground glass’ chromatin (Tzanck
cells).
• Type A Cowdry intranuclear inclusions (Lipschultz body
• Tzanck smear, Papanicolaou smear,H & E : Biopsy specimen
Microscopy And Staining

•
Intranuclear type A inclusion bodies
Giemsa- Stained Smears

(Tzanck cells

Cells with
ground-glass inclusions
Polymerase Chain Reaction (PCR)

• – More sensitive than viral culture; has been

used instead of culture in some settings;
however PCR tests are not widely available

Preferred test
1. for detecting HSV in spinal fluid - test of
choice to diagnose herpes encephalitis.
2. detection of low copy numbers of HSV DNA
3. to demonstrate HSV DNA in old genital
lesions
4. can be used on various specimens; old , dry,
CSF, eye, distint geography
Serologic Tests
Type-specific Serologic Tests
1. Non-type-specific HSV
antibody Assays
2. Type-specific serologic Indications
Tests 1. Recurrent genital Herpes or atypical
Symptoms with Negative PCR or culture
Methods: 2. To Manage Sex Partners of person with genital
Herpes
• Western blot (WB)
• ELISA 3. To Prevent Neonatal Herpes

• Neutralization Tests 4. Routine Sexual Heath Screen

• Complement Fixation Tests
HSV1+2 Ig M Enzyme Immuno Assay [EIA]
Test
1. Solid Phase EIA based on Immunecapture
principle
2. Qualitative detection of IgM Abs to
HSV1/2
3. Read the tests at 450/630-700nm[for better
results]
4. Clinical Sensitivity=85.7%[ 57.2-98.2%]
5. Clinical Specificity=95.4%[ 87.3-99.1%]
6. Test Interpretations
a. Dx should not be established on single
test
b. Requires further testing
c. Test should be interpreted along with
clinical information
Management of Disease

Treatment
– Supportive Treatment
– Specific /Antiviral Treatment

– Prevention
1. Patient Counselling and Education
2. Anti-suppressive Therapy
3. Vaccination
Supportive Treatment

PAIN CONTROL MEASURES SUPPORTIVE CARE

Topical anesthetics • Fluid is given to maintain proper
2% lidocaine hydration and electrolyte balance
0.1% diclonine hydrochloride • Antipyretics can be given to
0.5% benzocaine hydrocholride control fever
 Acyclovir is the treatment of Topical Antivirals
choice • 5% acyclovir cream
 Penciclovir  Trifluridine

 Valacyclovir  3% Penciclovir Cream

 Famciclovir  Iododeoxyuridine

 Trifluridine  10% docosanol cream

Acyclovir Resistance:-----he options for treatment

include cidofovir and foscarnet,
but both are very nephrotoxic.
Prevention
1. Patient Counselling and Education

2. Anti-suppressive Therapy
a. Indications
i. Susceptible Pregnant women
ii.HSV-2-infected women in late pregnancy as a means of reducing
reactivation of HSV-2 at term.
iii.Immunocompromised patients.
iv.Patients with severe HSV-associated erythema multiforme
3. Vaccination
a. No vaccine is available till date
a. GEN -003
For Herpes Virus 1
 Hand washing, Gloving –Gowning Precautions
 Avoidance of direct contact with lesions reduces the risk of infection.
 Isolation of patients with disseminated , mucocutaneous & Genital Lesions
For Herpes Virus 2
1. Patient Education & Counselling----
2. Avoid contact ---horizontal ---Use of Condom Barriers
3. Male Circumcision
4. Knowing the sexual Partners of HSV- sero-positive status---associated with
lowering 50% incidence of acquiring HSV-2 Infection
From Mother to Fetus—Prevention of Neonatal herpes
• Serological Screening of HSV
• Anti-chemosuppressive Therapy : ( Acyclovir—400mg TID daily
beginning at 36 weeks gestation)
• Avoid contact ---vertical ----Cesarean section.
Thank You