Genital Herpes Caused by Herpes Simplex Virus

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Introduction

Access to medical care often determines people’s health-related decisions and dictates their choices in seeking help. In the United States, large populations of people in underserved neighborhoods cannot afford a doctor visit or a diagnostic test, often relying on home-prepared remedies and simple over-the-counter medication (Velasco-Mondragon, Jimenez, Palladino-Davis, Davis, & Escamilla-Cejudo, 2016). Moreover, the lack of awareness about specific issues and practices leaves these individuals at risk of contracting infectious conditions or developing severe chronic problems (Tharpe, Farley, & Jordan, 2017). In the considered case, the patient comes into the office with an issue that has been bothering her for several years. However, without sufficient funds or insurance, she could not attend to her health in time. The patient’s examination points to the primary diagnosis of genital herpes with differential diagnoses, including syphilis, human papillomavirus (HPV), and chancroid.

General Patient Information

The patient is 23 years old; she identified herself as Hispanic. The patient is currently single; she does not have a stable romantic relationship or a long-term sexual partner.

Current Health Status

The patient comes to the clinic with a complaint of lesions in the vaginal and perianal regions. The lesions resemble blisters and are painful. They first started appearing about two years ago and have been disappearing and reoccurring periodically. The latest outbreak began four days ago, and the patient felt discomfort and pain and decided to get medical advice since she was now able to do that. The patient reports that the blisters usually recur for about a week. She did not consider using any pharmacological or nonpharmacologic solutions to alleviate the discomfort. There are also no apparent factors that exacerbate the condition. The patient rates her discomfort as a 3/10 on a pain scale.

The patient’s last menstrual period (LMP) was on 9/20/19. She is sexually active, and she uses condoms occasionally when engaging in sexual activity with men. She does not use any other types of barrier prevention. The patient is bisexual – she states that she has had sexual relationships with several male and female partners in the past years. She seems to be somewhat dissatisfied with her sexual relations, especially in the past year, since the blisters started appearing. According to the patient, she always mentions blisters to her partners before sexual activity.

Contraception Method

The patient reports that she does not use any long-term contraception method as she was unable to access proper medical care for years, and she states that, without support, all options are expensive. She also says that she has used condoms in the past, but only with some of the male partners. She did not attempt to use any protective methods with female sex partners. The patient admits to having minimal knowledge about different ways of birth control and sexual hygiene.

Patient History

There are no significant pertinent events in the patient’s medical history. The patient does not report having any problems with mental health. Currently, the patient does not take any medications or home remedies since she only recently got access to Medicaid. She has no known food, drug, animal, or environmental allergies. The patient had her first and only Pap test at 21 at a free clinic. Her vaccinations are incomplete – the patient did not receive an HPV vaccine in time to be eligible for financial support, but she had an MMR, hepatitis B, and DTaP in 2015.

The patient’s family does not have any conditions that are relevant to her issue. Her mother is 45 years old and alive; she has type 2 diabetes. Her father is 47 years old and alive; he does not have any diagnoses. The patient has two siblings, brothers (20 and 25 years old), both healthy. She also has three young children – two daughters (2 and 3 years old) and a son (5 years old). She is single, so the fathers’ health data is unavailable.

The gynecologic history shows a multipara, as the woman has three children. She does not have an account of sexually transmitted infections (STIs), although this lack of evidence may be to her restricted access to healthcare. The patient reports her menstrual patterns to be healthy, 4-5 days of menarche between 28 days. She is a G3 P2-1-0-3. The patient’s first child was born preterm (36 weeks) and underweight.

The patient lives in an underserved neighborhood with limited access to proper medical care. She currently works as a cashier at Dollar Tree. The patient does not have higher education and is in a difficult economic position, being a single mother of three young children and working a low-wage job. She does not report any incidences of forced sex, although stating that she had some negative experiences with her past partners involving physical and financial abuse. The job of a cashier is stressful and demanding; the patient does not have much time to rest or sit down.

Her home environment is taxing as well – she has to look after her three children, work, and maintain the household, although she received some help from her family with babysitting. The patient denies the use of illicit drugs and tobacco, but she admits to occasionally drinking alcohol – the results of CAGE screening are negative (0 points). She does not exercise due to the lack of time, but she often walks to her job instead of using public transport. Her diet appears to be limited due to available funds, and there is a lack of fresh produce and a surplus of processed foods; the patient often skips meals. She does not report any problems sleeping, but she sometimes gets less than 6 hours of sleep. She drinks coffee almost every morning and, rarely, during the day on weekdays instead of lunch.

Review of Systems (ROS)

The patient appears in good health; she denies fatigue or fever. Her vision is acute, and she does not wear glasses or contact lenses. The patient has no difficulty hearing and no pain in the ears. Her sinus is not congested, there is no discharge or nasal pain, and the patient denies having a sore throat. The patient has no complaints about her cardiovascular system – no palpitations, chest pain or discomfort, or edema. She has no difficulty breathing and denies wheezing or cough. The patient has no history of reflux; she denies abdominal pain, nausea, vomiting, diarrhea, or constipation.

The patient states that she did not notice any abnormal vaginal discharge. She does not have dysuria, and her bowel and bladder function as usual. The patient denies back, joint, or muscle pain or stiffness or any difficulties in movements. She does not have headaches, syncope, memory problems, or weakness; her mood is stable, and she does not have depression or anxiety. The patient does not have thyroid problems, polyuria, polyphagia, or polydipsia. She denies any unusual bruises, bleeding, anemia, also stating that she never noticed any allergic reactions.

Physical Exam

The patient is alert and oriented; she seems calm and nourished. Her temperature is 98 F, blood pressure 123/70, and pulse 86 bpm. The patient’s height is 5’5”, while her weight is 149lbs, making her BMI equal to 24.8. The pupillary test shows centered equal round pupils reacting to light, darkness, and accommodation. The sclera is white, and the conjunctiva is pink; the vision is 20/20. The patient’s oral and nasal mucosa are pink and moist; there is no nasal discharge, erythema, or inflammation in the throat. Her heart beats at a regular rate with S1 and S2 and no murmurs or gallops. The respiratory system is clear to auscultation without wheezes or rales. The abdomen is soft, non-tender, not distended, without masses; normal bowel sounds are present. The bladder is not tender on palpation; there is no distention noted.

The external genitalia has several blister-like lesions filled with fluid; some are ruptured and ulcerated. The sores are tender and painful to touch; some are located on the vulva, while others appear on the perineum. There is some edema present with the vulva inflamed and reddish, but the inflammation is not intense. The inguinal lymph nodes are not tender, and there is no visible vaginal discharge. The rest of the patient’s skin is soft, warm, and dry to touch, with no irritation or rash. The patient has a normal gait and good reflexes; her cranial nerves II-XII are intact, and she answers questions clearly and appropriately without any problems.

Labs, Tests, and Other Diagnostics

Several tests should be performed since the symptoms can be connected to a variety of conditions. Syphilis serology, a polymerase chain reaction (PCR) test for HSV and HSV antibody serology, is among the first diagnostics to complete (Jin, 2016). Moreover, a biopsy of the blisters’ fluid can give a more reliable result about their origin (Tharpe et al., 2017). Tests for other STIs, such as gonorrhea, are advised since some infections can coexist. Finally, an HIV (human immunodeficiency virus) test is required to confirm that the patient does not have it (Schuiling & Likis, 2017). Additionally, if these tests do not show any conclusive results, a check for Haemophilus ducreyi is necessary to eliminate the possibility of chancroid (Lautenschlager, Kemp, Christensen, Mayans, & Moi, 2017). This number of diagnostics is the basis of removing possible differential diagnoses, but the patient may need other tests if the results are negative.

Differential Diagnoses

The first differential diagnosis is genital herpes caused by HSV. This type of herpes is known as HSV-2, which is transmitted during sexual contact (Gnann & Whitley, 2016). The condition is mostly asymptomatic, similar to other STIs, but its main sign is the appearance of sores that look like blisters, which occur on one’s genitalia, buttocks, thighs, anus, and sometimes mouth. This infection is widespread in the US, and its recurrences may happen for years since herpes never leaves the body completely (Ramchandani et al., 2018). In some cases, lesions reappear multiple times per year, being less painful than the original outbreak. The central risk factor for genital herpes is unprotected sexual activity with multiple partners (Gnann & Whitley, 2016). This diagnosis is strongly considered due to the patient’s physical examination and medical history.

The second possible condition is syphilis, an STI caused by the bacteria Treponema pallidum. It develops in stages, starting with small painless sores called chancres (Park et al., 2018). Later, a rash may appear on other parts of the body, and such signs as fever and muscle pain are common (Park et al., 2018). Then, syphilis can be completely asymptomatic while also severely damaging one’s body systems. The patient’s blisters do not have a strong resemblance to the lesions developing during syphilis. Nonetheless, a test is necessary to make sure that the patient does not have it to avoid serious consequences.

Genital warts caused by the human papillomavirus (HPV) are the third differential diagnosis. HPV presents with warts on different parts of the boy, including one’s genitalia. These warts can put one at risk of cancer and should be checked out to lower this possibility (Park, Introcaso, & Dunne, 2015). The patient’s blisters may be an atypical presentation of HPV and, since the patient is not vaccinated, present a real danger to her health.

The final differential diagnosis is chancroid, an infection that, similar to other STIs, increases the risk of HIV. Its prevalence has dramatically decreased in the US, but some cases are still possible. Chancroid is caused by Haemophilus ducreyi and is characterized by painful genital ulcers and lymphadenopathy (Lautenschlager et al., 2017). The patient’s symptoms are close to the presentation of this infection. If she does not have signs of syphilis, herpes, or other described conditions, this diagnosis has to be considered.

Management Plan

The primary diagnosis is genital herpes due to the recurring nature of the condition, the patient’s examination, and the PCR test. Herpes cannot be cured completely, and the blisters will likely continue to appear. The treatment, thus, focuses on the alleviation of symptoms, protection from transmission, and reduction of lesions’ frequency and severity. First of all, the patient can take Acyclovir 400 mg orally three times a day for five days during outbreaks and Acyclovir 400 mg orally twice a day to suppress the infection during other periods (Schuiling & Likis, 2017, p. 505). Topical solutions are inadvisable since the membranes of the genitalia are extremely sensitive. Some alternative and nonpharmacologic therapies include warm baths with baking soda, well-fitting underwear made from cotton and comfortable clothing, and keeping the area dry with soft towels.

Essential parts of patient education are genital hygiene and sexual activity awareness. It is vital to explain to the patient that genital cleaning should be gentle and non-invasive as not to disturb the natural balance of the internal genitalia. The patient should communicate with partners about her conditions and aim to minimize the risk of infection. For example, she should be aware that periods when lesions form and shed are the most infectious, but the lack of symptoms does not lower the risk substantially (Groves, 2016). Thus, during outbreaks, all sexual activity is highly discouraged, and at other times, protection is essential. Latex condoms and dental dams are to be used during sex, and water-based lubrication will protect the genitals from irritation. Follow-up care involves missed vaccination, Pap test in the following year, nutrition advice, and subsequent STI tests to maintain the patient’s health.

Summary

In the discussed case, a young Hispanic female is concerned about recurring blisters on her genitalia. The physical examination and previous medical history point to the primary diagnosis of genital herpes caused by HSV. The patient’s difficult financial situation and lack of access to care explain her inability to treat the condition sooner. The management plan includes symptom alleviation since herpes is an incurable infection. Acyclovir is the primary medication that can decrease the rate and severity of recurrence. Patient education should focus on protection and awareness during sexual activity.

References

Gnann Jr, J. W., & Whitley, R. J. (2016). Genital herpes. New England Journal of Medicine, 375(7), 666-674.

Groves, M. J. (2016). Genital herpes: A review. American Family Physician, 93(11), 928-934.

Jin, J. (2016). Screening for genital herpes. JAMA, 316(23), 2560-2560.

Lautenschlager, S., Kemp, M., Christensen, J. J., Mayans, M. V., & Moi, H. (2017). 2017 European guideline for the management of chancroid. International Journal of STD & AIDS, 28(4), 324-329.

Park, I. U., Fakile, Y. F., Chow, J. M., Gustafson, K. J., Jost, H., Schapiro, J. M.,… Bolan, G. (2018). Performance of treponemal tests for the diagnosis of syphilis. Clinical Infectious Diseases, 68(6), 913-918.

Park, I. U., Introcaso, C., & Dunne, E. F. (2015). Human papillomavirus and genital warts: A review of the evidence for the 2015 centers for disease control and prevention sexually transmitted diseases treatment guidelines. Clinical Infectious Diseases, 61(suppl_8), S849-S855.

Ramchandani, M., Selke, S., Magaret, A., Barnum, G., Huang, M. L. W., Corey, L., & Wald, A. (2018). Prospective cohort study showing persistent HSV-2 shedding in women with genital herpes 2 years after acquisition. Sexually Transmitted Infections, 94(8), 568-570.

Schuiling, K. D., & Likis, F. E. (2017). Women’s gynecologic health (3rd ed.). Burlington, MA: Jones and Bartlett Publishers.

Tharpe, N. L., Farley, C., & Jordan, R. G. (2017). Clinical practice guidelines for midwifery & women’s health (5th ed.). Burlington, MA: Jones & Bartlett Publishers.

Velasco-Mondragon, E., Jimenez, A., Palladino-Davis, A. G., Davis, D., & Escamilla-Cejudo, J. A. (2016). Hispanic health in the USA: A scoping review of the literature. Public Health Reviews, 37(31), 1-27.

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