A 24-year-old man comes to the physician with painful blisters on the shaft of his penis. The lesions erupted 2 days ago. The patient has had 5 lifetime sexual partners and is currently sexually active with one female partner; he uses condoms inconsistently. Examination shows multiple vesicular lesions on the penis, and Tzanck smear is positive for multinucleated giant cells. HIV testing is negative. The patient has had several similar episodes every year for the past 2 years but had been too embarrassed to seek treatment until now. Which of the following would most likely have prevented recurrence of this patient's condition?

Question

A 24-year-old man comes to the physician with painful blisters on the shaft of his penis.  The lesions erupted 2 days ago.  The patient has had 5 lifetime sexual partners and is currently sexually active with one female partner; he uses condoms inconsistently.  Examination shows multiple vesicular lesions on the penis, and Tzanck smear is positive for multinucleated giant cells.  HIV testing is negative.  The patient has had several similar episodes every year for the past 2 years but had been too embarrassed to seek treatment until now.  Which of the following would most likely have prevented recurrence of this patient's condition?

Quizplus · Accepted Answer

This patient's recurrent vesicular lesions and positive Tzanck smear are consistent with recurrent genital herpes simplex virus (HSV), generally due to reactivation of latent HSV-2 infection within the S2, S3, and S4 dorsal root (sensory) ganglia. Recurrence of genital HSV can be suppressed or minimized with daily oral valacyclovir (preferred as it is dosed once daily and has good bioavailability), acyclovir, or famciclovir. Although the antiviral agents may not be active against latent virus forms, they can suppress further multiplication as soon as reactivation occurs. Suppressive therapy would likely have been offered to this patient with multiple yearly episodes of recurrence; it is generally continued for years with periodic re-evaluation. (Choice B) Immunoglobulin therapy can be used for varicella postexposure prophylaxis (eg, in neonates or pregnant women) but is not commonly used for genital HSV infections. (Choice C) Lamivudine is a nucleoside analog reverse transcriptase inhibitor with activity against HIV and hepatitis B virus. It is not known to be effective against HSV-2. (Choice D) Although condom use may prevent sexual transmission of HSV-2 (and therefore might have prevented this patient from acquiring his primary genital HSV-2 infection), it does not reduce the frequency of recurrence of genital herpes. (Choice E) A short (7-10 days) course of treatment with oral acyclovir during primary genital HSV infection usually reduces the duration of viral shedding, time for lesional healing, and local pain; however, it does not appear to alter recurrence rates. Educational objective: A new-onset genital vesicular rash with a positive Tzanck smear in a previously asymptomatic patient is suggestive of primary genital herpes simplex virus (HSV) infection due to HSV-2. Recurrences of genital herpes can be reduced through daily treatment with oral valacyclovir, acyclovir, or famciclovir. Condom use can help prevent a primary genital HSV infection but does not prevent reactivation of latent infection. __________ References: Genital herpes. (http://www.ncbi.nlm.nih.gov/pubmed/25153069)

A 24-Year-Old Man Comes to the Physician with Painful Blisters