History and exam
Key diagnostic factors
common
dysuria (in women)
A common symptom of genital herpes in women in primary but not recurrent disease.
lymphadenopathy
Typically presents during initial and recurrent episodes. Observed in 30% of recurrent disease. Rarely seen in oral herpes.[46]
genital ulcer
Multiple, painful ulcers start as vesicular lesions and progress to ulceration, then crusted lesions.
oral ulcer
Typically single, recurrent, painful, self-limited ulcer along the vermilion border.
uncommon
fever
Typically presents in the first episode only.
Other diagnostic factors
common
tingling sensation
Part of the prodrome, before appearance of lesions.
uncommon
headache/aseptic meningitis
Typically presents in the first episode only.
Risk factors
strong
HIV infection (risk factor for clinical disease)
Higher risk for HSV reactivation and infection. More likely to be symptomatic from disease. Chronic genital and oral ulcers as a result of HSV were first associated with AIDS early in the epidemic, and mucocutaneous ulcers lasting more than 1 month are an AIDS-defining condition.[19] Initiation of antiretroviral therapy may transiently increase the risk of genital ulcer disease.[20]
use of immunosuppressive medications (risk factor for clinical disease)
Higher risk for HSV reactivation and visceral dissemination, but not infection. Immunosuppressive therapies for organ transplantation, chemotherapy, corticosteroids, or other immunomodulatory agents increase the risk for HSV reactivation, including sites that are rarely involved in immunocompetent hosts.[21][22]
high-risk sexual behavior (risk factor for seropositivity)
Higher risk for HSV infection but not reactivation. Early age of first intercourse, increased sexual partners, history of STI(s), and contact with commercial sex workers are associated with HSV-2 seropositivity in epidemiologic studies.[25]
weak
female sex (risk factor for seropositivity)
Higher risk for HSV infection but not reactivation. Epidemiologic studies worldwide have revealed that seroprevalence with HSV-2 is higher in women.[3]
black race (risk factor for seropositivity)
Higher risk for HSV infection but not reactivation. Seroprevalence of HSV-2 is higher in black Americans compared with the overall rate in the US, and higher in sub-Saharan Africa than the overall worldwide rate. However, initial infections are more often sub-clinical and do not recur as frequently, which may be due to pre-existing antibody against HSV-1.[6][23]
increasing age (risk factor for seropositivity)
Higher risk for HSV infection. HSV-2 seroprevalence increases with age, likely reflecting an increased cumulative risk as a result of greater exposure.[24]
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