HSV1 infections usually affect the oral cavity, lips or face, and HSV2 infections the genital region, but there is considerable cross-over, especially of HSV1 to the genital region.
In Herpes 1, labial herpes ('cold sore') is the most common manifestation. The primary infection is symptomless in most cases, but may present as fever, enlarged submandibular lymph nodes, sore throat, gingivostomatitis with ulcers or vesicles, oedema, with associated anorexia, pain and malaise. This condition usually lasts for 10-21 days, and may be accompanied by inability to eat or drink. Dehydration may be a problem, especially in small children. Symptomatic primary infection is most common in children of 1-5 years of age, with an incubation time of 2-12 days, mean about 4 days. There may be a prodrome of burning, itching or tingling pain for some hours followed by groups of vesicles usually on the external borders of the lips. Lesions may also be found in skin surrounding the lips; chin, cheeks or nose. Within a few days the vesicles progress to pustules or ulcers with brownish-yellow crusts. Pain is most severe in the beginning and resolves during the next 4-5 days.
The Herpes 2 infection usually affects the genital regions. The primary genital infection may be severe, with illness usually lasting up to about 3 weeks (sometimes longer) with a shedding period of virus usually terminating shortly before or at the time of healing. The lesions are vesicles or ulcers localized to the cervix, vagina, vulva or perineum of the female, or the penis in the male. The lesions are painful, and may be associated with inguinal lymphadenopathy and dysuria. Systemic complaints, including fever and malaise, usually occur. Complicating extragenital affections, including aseptic meningitis, have been observed in about 10-20% of cases. Paraesthesia or dysesthesia may occur after the genital affection. Especially in women the severity of the primary infection may be associated with a high number of complications and frequent recurrences. Previous HSV1 infection reduces the severity and duration of primary HSV2 infection. The recurrent genital affection is usually milder, with fewer vesicles or ulcers and with a duration of 7-10 days. The recurrent lesions seldom last more than 10 days, and the shedding of virus may terminate sooner. Sometimes, virus excretion can occur between active periods. Differential diagnosis. The gingivostomatitis can be mistaken for Vincent's angina. In herpangina (coxsackie A virus) the lesions are fewer and smaller, localized to the pharynx and back of the mouth, and there is no gingivitis. Recurrent aphthous stomatitis is not caused by HSV. Skin lesions should be distinguished from impetigo and syphilis. Zoster may occasionally be a diagnostic problem. Eczema herpeticum (see Complications) may resemble varicella-zoster clinically. The encephalitis has to be distinguished from a brain abscess, and this can be done with computer-assisted tomography. Encephalitis caused by VZV is clinically very similar to herpes encephalitis. Similarly, a postinfectious encephalitis (measles, rubella, varicella) should be considered. Generalized disease in the newborn can also be caused by coxsackie B virus, and it is essential to exclude a bacterial sepsis.
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