Microbiology 3

Dr. Benedicto
CASE F- Herpes Simplex Virus Sept. 11, 2013

CASE - Gram stain: Gram negative rods appearing as “school of

fish”
A 21 year old college student from Pasay City consulted a
gynecologist because of painful multiple vesicles and ulcers on her - Tend to coalesce and are excavated or deeper
genitalia. She confided to have been working as a commercial sex
worker. Sexual history revealed she had about 15 different sexual
partners. Dark field microscopy is negative for spirochetes. Tzanck
smear revealed presence of multinucleated giant cells.

Important Data:

• 21 year old female

• Chief complaint: Painful multiple vesicles and ulcers on
genitalia
• Commercial sex worker (15 different partners)
• Dark field microscopy negative OTHERS:
• Tzanck smear revealed presence of multinucleated giant
cells D. Lymphogranuloma Venereum
- Caused by Chlamydia trachomatis serotype L1, L2 and L3
GUIDE QUESTIONS - Painless
- May be positive for Groove’s sign
1. Enumerate and differentiate the common STIs that could cause genital
ulcers.

THREE MOST COMMON:

A. Primary Syphilis
- Caused by Treponema pallidum
- Painless, solitary and firm
- Presents as a hard chancre
- Dark microscopy will be positive with presence of E. Granuloma Inguinale (Donovanosis)
spirochetes - Caused by Klebsiella granulomatis
- Painless
- Gram stain: Gram negative rods with presence of
Donovan bodies

B. Herpes Simplex
- Caused by Herpes Simplex Virus 1 and 2
- Starts as multiple vesicles and eventually ulcerates
- Painful, superficial and shallow
- Presence of Cowdry Type A cells upon microscopy
2. What could be the most likely etiologic agent? Why?
- Herpes Simplex Virus
- Presence of multinucleated giant cells is characteristic
- Is a DNA virus and is icosahedral in shape

C. Chancroid
- Caused by Haemophilus ducreyi
- May also start as multiple vesicles and eventually
ulcerates
- Presents as painful soft chancre
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 MICROBIOLOGY 3

LABORATORY TESTS: 3. What is your management?

A. Tzanck Smear - Acyclovir 200mg 5x daily or 400mg TID for 7-10days
- Done as a presumptive test for to identify presence or
absence of a viral infection 4. What is the mechanism of action of the antiviral you opt
- Only helps in the identification of the presence of a viral to give?
infection - Inhibition of viral DNA synthesis by inhibiting polymerases
- Rapid, can be completed in minutes and is not diagnostic that are required for viral replication
- A sample is taken by scraping the base of the ulcer and is
then fixed with alcohol and Giemsa stain 5. Give recommendations for counseling of persons with HSV
- Upon microscopy, multinucleated giant cells are seen infection.
- Education regarding natural history of disease
B. Diagnostic Tests  HSV is a lifelong infection
 Virologic Tests  There is no cure but antiviral therapy may be
- Viral Culture given when there is eruption of signs and
 Takes 10 weeks to complete the test symptoms
- Polymerase Chain Reaction  Infected persons are encouraged to inform their
 May also be done but is not approved for genital partners regarding presence of HSV infection
ulcers  Transmission is possible even when the patient
is asymptomatic due to viral shedding
 Serologic Tests - Abstain from sexual activity when symptomatic
 Faster compared to viral cultures - Use of condoms
 For identification of presence of antibodies - Treat seropositive sexual partners
 Available in the Philippines: - Screen for other STIs
- Herpeselect – ELISA or Immunoblot test  Clustering of STIs is possible
- Biokit HSV
- Western Blot Test

APPENDIX: CLINICAL FEATURES OF GENITAL ULCERS

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