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Background:Catastrophic antiphospholipid syndrome (CAPS) is a severe autoimmune condition, characterized by multiorgan failure due to thromboses and/or hemorrhage. Concurrent HSV/VZV infection is an exceedingly rare event, occurring mostly in immunocompromised patients. Herein, we report the first case of CAPS triggered by concurrent HSV/VZV infection, manifesting with zosteriform rash and haemorrhages at multiple sites.Objectives:To describe a case of CAPS provoked by concurrent HSV/VZV infection, manifesting with zosteriform rash and haemorrhages at multiple sites.Methods:A 36-year-old male, with a history of antiphospholipid syndrome (APS) presented with a 5-day history of epigastric pain, associated with fever, hematuria, rash and swelling in bilateral ears. Past medical history was remarkable for APS, based on 4 episodes of DVT/PE and triple positive antiphospholipid antibodies, on chronic well-maintained warfarin anticoagulation. On examination, a purpuric rash was evident on the right side of the neck as well as on both ears, consistent with a C3 dermatomal distribution (Figure 1). Laboratory studies revealed anemia, thrombocytopenia and acute kidney injury.Figure 1.Results:A full-body CT scan demonstrated the presence of multifocal lymphadenopathy, alveolar infiltrates suggestive of diffuse alveolar haemorrhage, and haemorrhage in both kidneys and the left adrenal gland; anticoagulation was held, despite the INR being within the patient’s baseline therapeutic levels. He was admitted with a working diagnosis of CAPS and possible zoster infection. Appropriate immunologic workup was requested. He was prescribed intravenous acyclovir, antibiotics, pulse dose of glucocorticoids, and IVIG. Bronchoscopy with bronchoalveolar lavage revealed the presence of haemosiderin-laden macrophages. The rash regressed, and the patients’ condition improved. He was discharged with glucocorticoid tapering regimen, hydroxychloroquine, aspirin and warfarin.Antibody titers were taken prior to IVIG administration at presentation, and at 4 weeks. High VZV IgG titers found at presentation regressed over four times on follow-up. Furthermore, at 4 weeks the patient had developed IgM antibodies against both VZV and HSV. These findings confirmed a concurrent infection.Conclusion:This is the first report of coexisting HSV/VZV infection associated with CAPS. A literature review identified a total of 28 patients with coexisting HSV/VZV infection, whereas only one case of CAPS triggered by HSV was identified1. This case illustrates that concurrent infection can occur in the absence of immunosuppressive therapy in patients with APS, serving as a trigger for hemorrhagic CAPS. Simultaneous treatment with antiviral against herpesviruses, glucocorticoids and IVIG may mitigate the inflammatory cascade associated with CAPS.References:[1]Catoggio C, Alvarez-Uría A, Fernandez PL, Cervera R, Espinosa G. Catastrophic antiphospholipid syndrome triggered by fulminant disseminated herpes simplex infection in a patient with systemic lupus erythematosus. Lupus. 2012 Oct;21(12):1359-61.Disclosure of Interests:None declared.

OBJECTIVE--To investigate whether adverse psychological consequences and impaired sexual and interpersonal functioning are present in individuals suffering from recurrent genital herpes simplex infection (HSV). DESIGN--A questionnaire-based study completed by subjects defined as having more than one episode of HSV infection. SUBJECTS--Completed questionnaires were returned from 90 subjects; 40 from the department of genitourinary medicine at our hospital and 50 from members of the Herpes Association. RESULTS--Stress and being physically run-down were identified as provoking factors by the majority of individuals (78% and 56% respectively). The frequency of sexual activity was not different when comparing rates before and after infection (p < 0.001) and the majority of subjects had told partners of their infection. Women reported significantly greater disturbances in several psychological variables and reported a greater decrement in their general health. However, overall there were no differences in the psychological sequelae following herpes infection. CONCLUSIONS--The study suggests that, given time, most people are able to adjust psychologically to having recurrent herpes infection. However, for a minority of subjects this is not the case and these individuals may require psychotherapeutic intervention.

Introduction Diagnosis of anogenital herpes is definitively established by testing anogenital lesion specimens from symptomatic patients by culture or molecular methods. The objective of this study was to evaluate the cobas ® HSV 1 and HSV 2 Test using clinician-collected swab specimens from external anogenital lesions as part of a large multicenter clinical trial conducted in the United States of America. Methods Two swabs were collected from patients with possible HSV infection at 8 geographically diverse sites. The first swab was used for culture by the ELVIS ® HSV ID and D³ Typing Test (Diagnostic Hybrids, Inc., Athens, OH) and PCR followed by Sanger sequencing for HSV-1 and HSV-2. The second swab was for the cobas ® HSV 1 and 2 Test. Sensitivity and specificity were calculated compared to the combined results of culture and Sanger sequencing using the “any positive rule”. The positive (PPA) and negative percent agreement (NPA) were calculated compared with culture. Results There were 243 HSV positive subjects, with 84 HSV-1 (51 female, 33 male) and 167 HSV-2 (85 female, 82 male) positive subjects, among 408 evaluable participants (205 female, 203 male). The sensitivity and specificity of the cobas ® HSV 1 and HSV 2 Test compared the Reference Method for HSV-1 was 92.9% (78/84) and 98.8% (320/324), respectively, and for HSV-2 was 97.0% (162/167) and 94.6% (228/241), respectively. The PPA and NPA of the cobas ® HSV 1 and HSV 2 Test compared to the culture for HSV-1 was 100% (67/67) and 93.9% (199/212), respectively, and for HSV-2 was 99.2% (128/129) and 83.2% (232/279), respectively. Conclusion The cobas ® HSV 1 and 2 Test displayed excellent performance compared to the combined results of culture and Sanger sequencing. The test is highly suitable to detect HSV in clinician-collected anogenital swab specimens from patients with suspected HSV infection. Disclosure of interest statement This clinical trial study was supported by Roche Molecular Diagnostics.

Objectives The objective of this study was to evaluate the cobas ® HSV 1 and HSV 2 Test using clinician-collected swab specimens from external anogenital lesions as part of a large multicenter clinical trial. Methods Two swabs were collected from patients with possible HSV infection at 8 geographically diverse sites. The first swab was used for the Quidel Lyra™ Direct HSV 1+2/VZV on the Cepheid SmartCycler II System and the second for the cobas ® HSV 1 and 2 Test. The Quidel Lyra™ Direct HSV 1+2/VZV test was performed at a reference laboratory and the cobas ® HSV 1 and HSV 2 Test was performed at 3 sites. Discrepant analysis included HSV culture using the ELVIS ® HSV ID and D³ Typing Test, a second FDA-cleared nucleic acid amplification test (BD ProbeTec TM Herpes Simplex viruses [HSV 1 and 2] Q x Amplified DNA Assays) and Sanger sequencing. The sensitivity and specificity were calculated by comparing cobas ® HSV 1 and HSV 2 Test results with the Quidel Lyra™ Direct HSV 1+2/VZV test following discrepant analysis using the majority result from the three comparator tests. Results There were 229 HSV positive subjects, with 73 HSV-1 (44 female, 29 male) and 157 HSV-2 (78 female, 79 male) positive subjects, among 409 evaluable participants (205 female, 204 male). The sensitivity and specificity of the cobas ® HSV 1 and HSV 2 Test compared to the Quidel Lyra™ Direct HSV 1+2/VZV following discrepant analysis for HSV-1 was 98.6% (72/73) and 97.0% (326/336), respectively, and for HSV-2 was 100% (157/157) and 92.9% (234/252), respectively. Conclusion The cobas ® HSV 1 and 2 Test, on the automated cobas ® 4800 system, displayed excellent performance compared Quidel Lyra™ Direct HSV 1+2/VZV Test combined with discrepant analysis. The test is highly suitable to detect HSV in clinician-collected anogenital swab specimens from patients with suspected HSV infection. Disclosure of interest This clinical trial study was supported by Roche Molecular Diagnostics.

Background Neonatal herpes simplex infection can result in serious morbidity and mortality. This study assessed the attitudes of paediatric doctors towards the use of empirical aciclovir in the management of febrile neonates. Methods Invitations to participate in an online survey were sent to paediatric trainees (at senior house officer (SHO) and specialist registrar (SpR) level) and consultants (n = 513) in two medical deaneries in the UK (Wessex and Oxford Deanery) between May and June 2013. Four hypothetical scenarios of a febrile neonate were described to represent disseminated HSV disease (scenario 1), low-risk for HSV (scenario 2), HSV skin, eye and mouth disease (scenario 3) and HSV central nervous system disease (scenario 4). Participants were asked to indicate which antimicrobials they would commence for each scenario. Findings A total of 64 individuals participated (response rate: 12.5%). A substantial proportion of participants indicated they would not commence aciclovir despite the presence of clinical and/or laboratory features suggestive of neonatal HSV infection in scenarios 1(34/63, 54%), 3 (24/57, 42%) and 4 (31/54, 57%). Conversely, a total of 7/60 participants (12%) indicated they would start aciclovir in the scenario with low probability of HSV disease (scenario 2). Throughout, there was a trend for a higher proportion of consultants choosing to commence aciclovir compared with trainees; however, this was not statistically significant. Conclusion The results indicate that there is lack of awareness of key features suggestive of neonatal herpes simplex infection, and highlight the need to integrate guidance on the use of empirical aciclovir in febrile neonates into national guidelines.

Commentary on: Shah SS, Aronson PL, Mohamad Z, et al. Delayed acyclovir therapy and death among neonates with herpes simplex virus infection. Pediatrics 2011;128:1153–60.[OpenUrl][1][Abstract/FREE Full Text][2] High-dose acyclovir therapy substantially reduces death and improves neurological outcome from neonatal herpes simplex virus (HSV) infection.1 The effect of time of initiation of therapy on outcomes is not known precisely. Shah and colleagues sought to determine whether delayed acyclovir therapy after hospitalisation was associated with death among neonates with HSV infection. In this retrospective, multicentre observational study, data were obtained from the Paediatric Health Information System (PHIS), a US national database containing resource-utilisation data during hospitalisation in 41 freestanding, tertiary care children's hospitals from 2003 through 2009. Infants ≤28 days of age with a discharge diagnosis of HSV infection were studied. The primary exposure of interest was early acyclovir administration (given … [1]: {openurl}?query=rft.jtitle%253DPediatrics%26rft_id%253Dinfo%253Adoi%252F10.1542%252Fpeds.2011-0177%26rft_id%253Dinfo%253Apmid%252F22123868%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/ijlink?linkType=ABST&journalCode=pediatrics&resid=128/6/1153&atom=%2Febmed%2F18%2F2%2Fe20.atom

A 5-day-old male presents to the emergency department septic and jaundiced, is resuscitated and started on broad spectrum intravenous antibiotics. However tragically in this case despite showing initial signs of stabilisation, he deteriorated with refractory metabolic acidosis and disseminated intravascular coagulation, and later passed away. At postmortem, disseminated herpes simplex virus-1 (HSV-1) was found. Paediatricians are well aware of the risk factors for bacterial neonatal sepsis and actively seek information from parents to identify those children at risk. When however should a viral aetiology be considered? Should all neonates receive empirical therapy until proven otherwise? The authors review the literature surrounding neonatal HSV infection and discuss the potential pitfalls of empirical treatment.

Background Herpes simplex virus (HSV) is one of the most prevalent sexually transmitted infections worldwide. The stigma associated with HSV infection remains problematic and may lead to negative psychological sequelae and delayed care-seeking. Media technology is an innovative tool for countering stigma. Publicly-produced media content is not well-studied in this context, but may offer key lessons on successful de-stigmatising strategies. Methods The Australian Herpes Management Forum and Novartis organised an online contest inviting the public to develop brief videos to de-stigmatise HSV. In the present study, content analysis was performed to identify de-stigmatising strategies employed in the videos. Two researchers independently coded each video and resolved discrepancies by consensus with a third coder. Results Of 113 videos, 11 were excluded from analysis because they did not mention HSV, provided inaccurate information, or had no identifiable strategy. Five de-stigmatising strategies emerged from review of the remaining videos: normalising through familiarity, providing knowledge or fostering knowledge-seeking, expressing moral indignation, promoting disclosure, and negating a negative perception. Despite employing one or more of these strategies, many videos did not successfully de-stigmatise HSV infection. Coders perceived just over half of the videos as de-stigmatising but the remainder as stigmatising, neutral, or mixed. Most de-stigmatising videos shared two important characteristics: 1) they employed familiarity“ as a strategy and 2) they acknowledged actual negative aspects of HSV infection but offered a successful positive counterpoint. Stigmatising videos did not offer sufficiently positive counterpoints. Neutral videos were primarily informational. Mixed videos had strong stigmatising and de-stigmatising messages. One barrier to success was communicating important negative information (such as symptomatology or transmissibility of HSV) without stigmatising the disease. Conclusions The results emphasise that de-stigmatising HSV infection is difficult. Simultaneously acknowledging negative aspects of HSV infection while providing a sufficiently strong positive counterpoint-especially by promoting familiarity-may represent a key element in developing effective media campaigns to counter HSV stigma. Future research should evaluate the hypotheses generated in this study in target audiences such as those infected with HSV and members of the public.