– Christian Hoffmann – Herpes simplex infections are a common problem in HIV patients, and especially with significant immunodeficiency (below 100 CD4 cells / mm) chronic courses are possible. There are two different viruses: HSV-1 is transmitted through mucosal contact (kissing) and causes itchy perioral blisters on the lips, tongue, palate or buccal mucosa. HSV-2 is sexually transmitted and causes herpetiform lesions on the penis, vagina, vulva and anus. The lesions increase the risk of transmission of HIV significantly (Freeman 2006 Ouedraogo 2006 see chapter on prevention). In severe cases, other organs can be markedly affected. These include esophagus (ulcers), CNS (encephalitis), eye (keratoconjunctivitis, uveitis) and respiratory tract (pneumonitis, bronchitis). In these cases, and the persistence for more than four weeks, the herpes simplex virus infection, is regarded as AIDS-defining. clinic The itching and burning blisters. In oral infestation food intake is difficult. In genital or anal infection (proctitis!
) Micturition and defecation can be very painful. Patients with severe immunodeficiency extensive lesions are possible. Often regional lymph nodes are swollen. The clinic disseminated herpes infections depends on the affected organs. diagnostic For oral, genital or perianal infection often extends the visual diagnosis. If in doubt, a swab be taken, which must be brought into a virus culture medium rapidly to the lab. Also resistance testing in refractory lesions are possible. Organ manifestations are usually diagnosed histologically. In the HSV encephalitis, diagnosis is difficult as the cerebrospinal fluid often does not help. Serologies only Assagekraft if they are negative, thus making (rare) HSV infection improbable. therapy Each therapy is more effective the sooner it is started.
In good immune status and only discrete lesions topical administration of acyclovir can range. Penciclovir cream (Vectavir®) is likely to be just as effective (Chen 2000) and supposedly a little less irritating, however, considerably more expensive. Systemic remains nucleoside analogue acyclovir drug of choice. It inhibits the DNA polymerase of herpes viruses. Resistances are also 40 years after launch rare (Levin 2004). Aciclovir is well tolerated and is effective against HSV-1 and HSV-2. In severe cases and in organ manifestations should be treated intravenously. Since the CNS levels are lower than in the plasma, the dose should be increased at an encephalitis. In the intravenous administration of acyclovir, the kidney values should be monitored. Equivalent alternatives are valacyclovir and famciclovir (Ormrod 2000 Conant 2002) that must be taken in better oral availability less frequently, they also cost more and not allowed with immunosuppression. They should be used only if acyclovir does not act. We made with Famciclovir, a prodrug of penciclovir (Vinh 2006), good experience. In uncomplicated genital lesions may be sufficient for only two days of 500 mg famciclovir, unless there is immunodeficiency (Bodsworth 2008).
For HSV-1 and VZV brivudine is an alternative, however, the increase of the mitochondrial toxicity and jeopardize the effect of ART can (Ulrich Walker, pers. Comm). Treatment / prevention of HSV infection (daily dose) acute treatment Duration: 7-14 days 1st Choice acyclovir Aciclovir ratiopharmÒ 5 x 1 Tbl. 400 mg Severe cases Aciclovir p. i. Ò 3 x ½-1 Amp.
500 mg (3 x 5-10 mg / kg) i. v. alternatives valaciclovir ValtrexÒ 3 x 2 tablets. 500 mg alternatives famciclovir FamvirÒ 3 x 1 Tbl. Of 250 mg alternatives brivudine ZostexÒ 1 x 1 Tbl.
Of 125 mg prophylaxis Not recommended In exceptions, especially when lesions remain refractory to treatment, several weeks of therapy with foscarnet can be useful. New drugs that inhibit another enzyme of the herpes viruses with the helicase, were in animals more effective than acyclovir – their clinical value must be shown (Kleymann 2003). For painful mucocutaneous lesions, a local anesthetic is also useful. Unfortunately, the best tetracaine solution (Herviros®) was taken off the market, some pharmacies may but touch anything comparable. prophylaxis A primary prophylaxis with HSV drugs is generally not recommended. An early meta-analysis, according to which under acyclovir, the risk of both HSV and Cardiac disease by more than 70% and even mortality decline (Ioannidis 1998), is now believed to relativize. However: For stubborn recurrences can low continuous dose acyclovir or valacyclovir (DeJesus 2003 Warren 2004) may be useful. Interactions between HIV and herpes simplex increase genital HSV infections, the risk almost tripled, becoming infected with HIV (Freeman 2006) – see also the section on prevention in STYLE section.
Large randomized studies have shown in recent years that under an HSV therapy interestingly also decreases the viral load, rising by 0. 26 to 0. 53 logs below valaciclovir (Nagot 2007, Baeten 2008) and 0. 25 to 0 , 34 logs below acyclovir (Delany 2008 Celum 2010). This reduction was indeed at first glance not very impressive, but it is still significant. If a acyclovir therapy HIV transmission obviously could not prevent (Celum 2008 + 2010 Watson-Jones 2008), these observations of HSV and especially the acyclovir therapy in recent months new life breathed into (Vanpouille 2009) , All of a sudden a “very old drug” such as acyclovir has become interesting once again possibly new derivatives on this basis can be developed, their antiviral potency is better with good tolerance to HIV. literature Baeten JM, knitting LB, Lucchetti A, et al. Herpes simplex virus (HSV) -suppressive therapy Decreases plasma and genital HIV-1 levels in HSV-2 / HIV-1 coinfected women: a randomized, placebo-controlled, cross-over trial. J Infect Dis 2008 198: 1804-8. Bodsworth N, Bloch M, McNulty A, et al. 2-day versus 5-day famciclovir as treatment of Recurrences of genital herpes: results of the FaST study. Short-Course Herpes Therapy Study Group.
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