Chapter 17

Herpesviruses
Virtually every vertebrate species supports at least one host PROPERTIES OF THE VIRUSES
species-specific herpesvirus, and even a herpesvirus of a
non-vertebrate species (oysters) is known. Most are well- Classification
adapted to each natural host and usually cause asymptomatic The order Herpesvirales contains three families
infections except in the very young, in immunosuppressed (Herpesviridae, Alloherpesviridae, and Malaco-
individuals or when infecting a species other than the natural herpesviridae), the first of which contains viruses of
host. This implies that herpesviruses have co-evolved with humans. Division of the family Herpesviridae into three
vertebrate species over millennia. All herpesviruses persist subfamilies was at first based on biological properties, and
indefinitely, nearly always in an episomal form within the the subfamilies were then divided into genera based mainly
nucleus of the infected cell. on antigenic cross-reactivity, genome size, and structure.
Herpesviruses of different subfamilies occupy different The subfamily Alphaherpesvirinae includes the human
anatomical niches within the human body in a non-competitive pathogens herpes simplex virus types 1 and 2 (varicella-
state. Varicella-zoster virus (chickenpox) and herpes zoster virus). The alphaherpesviruses all grow rapidly, lyse
simplex virus both establish latent infections in neurons. On infected cells, and establish latent infections in sensory
reactivation, varicella-zoster virus precipitates an attack of nerve ganglia. The subfamily Betaherpesvirinae includes
herpes zoster (shingles), whereas herpes simplex virus type human cytomegalovirus, HHV-6 and HHV-7. In contrast,
1 typically causes recurrent attacks of labial herpes, (and the replication cycle of betaherpesviruses is slow and
herpes simplex virus type 2 is mainly responsible for genital accompanied by the production of large, often multinucleate
herpes. Epstein-Barr (EB) virus and human herpesvirus 6 cells (cytomegalia). The viral genome remains latent in
(HHV-6) persist in lymphocytes, and cytomegalovirus is lymphoreticular tissue, secretory glands, kidneys, and other
latent in granulocyte/macrophage precursors in the bone tissues. The subfamily Gammaherpesvirinae contains EB
marrow. Cytomegalovirus is now the major infectious cause virus and HHV-8. Both viruses replicate in B lymphoid and
of mental retardation and other congenital defects following endothelial cells and may also be cytocidal for epithelial
the control of rubella by immunization and the consequent cells. Latency is frequently demonstrable in lymphoid
near elimination of congenital rubella syndrome. EB virus tissue. Since herpesvirus genomes have been sequenced,
is the etiological agent of infectious mononucleosis and these assignments have generally been confirmed by
is associated with a number of human cancers including extensive phylogenetic analyses (Fig. 17.1).
carcinomas and lymphomas. In contrast, HHV-6 and HHV-7 All herpesvirus species have now been assigned
cause a common exanthem in children and HHV-8 is systematic names incorporating (1) a term derived from the
associated with several late-onset tumors including Kaposi’s natural host, (2) the word “herpesvirus,” and (3) a number
sarcoma in immunocompromised patients. reflecting the historical order in which it was recognized,
The patterns of disease caused by some of these human for example, “human herpesvirus 3” (HHV-3), “equine
pathogens have changed somewhat as a result of developments herpesvirus 4” (EHV-4). However, common names in long-
in modern medicine and changing sexual practices. standing use, for example, herpes simplex virus type 2
Herpesviruses are frequently reactivated in AIDS (see (HSV-2), EB virus, etc., are still most widely used and will
Chapter 23: Retroviruses) and following immunosuppressive be used here (Table 17.1).
therapy for organ and hematopoietic stem cell transplantation,
and in cancer. Under these circumstances, together with
Virion Properties
infections of the fetus or newborn infant, lethal disseminated
disease may occur. Although most herpesviruses pose The herpesvirus virion comprises four concentric layers:
unsolved problems for vaccine development, some respond an inner core, surrounded by an icosahedral capsid, an
well to antiviral chemotherapy. amorphous tegument, and an envelope (Fig. 17.2). The

Fenner and White’s Medical Virology. DOI: http://dx.doi.org/10.1016/B978-0-12-375156-0.00017-5

© 2017
2012 Elsevier Inc. All rights reserved. 237
238 PART | II Specific Virus Diseases of Humans

DNA genome is wound like a ball of wool and is associated

with a protein core in the shape of a doughnut suspended
by fibrils anchored to the inner side of the surrounding
capsid. The capsid is an icosahedron, 100 nm in diameter,
composed of 162 hollow capsomeres: 150 hexamers, and 12
pentamers (Fig. 17.2). Surrounding the capsid is a layer of
globular material, the tegument, and this is enclosed by the
lipoprotein envelope containing numerous small embedded
glycoprotein peplomers. The envelope is fragile and the
enveloped virion is somewhat pleomorphic, with a diameter
ranging from 120 to 200 nm.
The component polypeptides within the virion vary
between different herpesviruses. For example, the herpes
simplex type 1 virion contains over 30 proteins, of which
about 6 are present in the nucleocapsid, 10 to 20 in the
tegument, and 10 in the envelope; a smaller number is
associated with the DNA in the core. The envelope proteins
are mainly glycoproteins, most but not all of which contribute
to the peplomers. Antigenic relationships are complex. There
FIGURE 17.1 Phylogenetic relationships of the human herpesviruses
(and a few closely related animal viruses) within the very large family are some shared antigens within the family, but different
Herpesviridae, order Herpesvirales. The tree is based on the amino acid species have distinct envelope glycoproteins (Table 17.2).
sequences of the major capsid protein of each virus. Classification and The herpesvirus genome consists of a linear dsDNA
abbreviations: subfamily Alphaherpesvirinae, genus Simplexvirus, herpes molecule that is infectious under appropriate experimental
simplex viruses 1 and 2 (human herpesviruses 1 and 2) (HSV-1, -2), B
conditions. There is a remarkable degree of variation in
virus (Macacine herpesvirus 1, Cercopithecine herpesvirus 1, herpesvirus
simiae); genus Varicellovirus, varicella-zoster virus (human herpesvirus 3) the composition, size, and structure of herpesvirus DNA
(VZV), pseudorabies virus (PRV), equine herpesvirus 1 (EHV-1); subfamily genomes. The genomes of the herpesviruses, together
Betaherpesvirinae, genus Cytomegalovirus, human cytomegalovirus with those of the poxviruses, are among the larger human
(human herpesvirus 5) (HCMV); genus Roseolovirus, human viral genomes, ranging from 125 to 295 kb and coding
herpesviruses 6 and 7 (HHV-6, -7); subfamily Gammaherpesvirinae, genus
for about 70 to around 200 proteins. The genomes of the
Lymphocryptovirus, Epstein-Barr virus (human herpesvirus 4) (EBV);
genus Rhadinovirus, Kaposi sarcoma herpesvirus (human herpesvirus 8) alphaherpesviruses appear to be mainly colinear, that is,
(KSHV), equine herpesvirus 2 (EHV-2), herpesvirus saimiri (HVS). the presence and order of the individual genes are similar.

TABLE 17.1 Herpesviruses of Humans

Subfamily Genus Common Name Biological Properties
Alphaherpesvirinae Simplexvirus HHV-1 Herpes simplex virus 1 Fast-growing, cytolytic, latent in neurons
Simplexvirus HHV-2 Herpes simplex virus 2 Fast-growing, cytolytic, latent in neurons
Varicellovirus HHV-3 Varicella-zoster virus Fast-growing, cytolytic, latent in neurons
Simplexvirus CeHV-1 B virus (previously Fast-growing, cytolytic, latent in neurons
Macacine herpesvirus
1 or Cercopithecine
herpesvirus 1)
Betaherpesvirinae Cytomegalovirus HHV-5 Cytomegalovirus Grows in many cell types. Latent in myeloid
lineage cells, shed from kidney and salivary gland
Roseolovirus HHV-6 Grows in T lymphocytes, salivary gland; latent in
macrophages, lymphocytes
Roseolovirus HHV-7 Grows in T lymphocytes, salivary gland; latent in
macrophages, lymphocytes
Gammaherpesvirinae Lymphocryptovirus HHV-4 Epstein-Barr virus Grows in epithelial cells. Latent in B lymphocytes
Rhadinovirus HHV-8 Kaposi’s sarcoma Infects B lymphocytes, epithelial cells
herpes virus
 Herpesviruses Chapter | 17 239

FIGURE 17.2 Herpesvirus morphology and structure. (A) Reconstruction of a herpes simplex type 1 virus icosahedral capsid generated from cryo-
electron microscopy images, viewed along three-fold axis of symmetry. The hexons are shown in blue, the pentons in red and the triplexes in green. (B)
Schematic representation of a herpes simplex virion with diameters shown in nm: G, genome; C, capsid; T, tegument; E, envelope. (C) Cryo-electron
microscopy of herpes simplex virus capsids, showing the nucleocapsid, tegument, envelope, and surface projections (peplomers). (D) Thin-section
electron microscopy of herpes simplex virus showing enveloped virions in various stages of maturation in a cytoplasmic invagination into the nucleus
of an infected cell in culture. Several capsids are about to bud through the outer lamella of the nuclear envelope. (A–C): Reproduced from King, A.M.Q.,
et al., 2012. Virus Taxonomy. In: Ninth Report of the International Committee on Taxonomy of Viruses, Academic Press, p. 100, with permission.

TABLE 17.2 Properties of Herpesviruses

Virions are enveloped and roughly spherical, 120 to 250 nm in diameter. An internal icosahedral nucleocapsid with 162 capsomers is
surrounded by amorphous tegument and then a lipid envelope containing numerous different glycoproteins, some forming peplomers
Linear dsDNA genome 125 to 229 kbp; terminal reiterated sequences are characteristic

Virus DNA replicates in the nucleus by a rolling circle mechanism; sequential transcription and translation of immediate early (α),
early (β), and late (γ) genes, producing α, β, and γ proteins respectively; the earlier genes and their gene products successively regulate
the transcription of the later ones
Encapsidation of viral DNA occurs in the nucleus; nucleocapsids acquire an envelope by budding through the nuclear membrane;
enveloped virions accumulate in the ER and are released by exocytosis
Productive infection in permissive cells is cytocidal; intranuclear inclusions are seen, and sometimes cytomegalic cells or syncytia
Latent infection is established following initial acute infection; genome persists in the nucleus in neurons or lymphocytes. Reactivation
triggers virus replication and recurrent or intermittent shedding of virus, sometimes accompanied by recrudescence of clinical disease
240 PART | II Specific Virus Diseases of Humans

FIGURE 17.3 Simplified genome structure of human herpesviruses. Herpesvirus genomes consist of linear, double-stranded DNA molecules that range
in size from about 125 to 240 kbp. The genomes characteristically contain direct or inverted repeats; the reasons for this are not known but are presumed to
contribute to the complex replication cycle. In this highly simplified graphic, the various arrangement of reiterated sequences [direct or inverted (arrows),
at the termini (TRL and TRS) or internally (IR)] results in a number of different genome structures that have been divided into several classes. Class A:
Genomes consist of a unique coding sequence flanked by direct terminal repeats. Examples: human herpesviruses 6 and 7 (HHV-6, HHV-7). Class B:
Genomes have directly repeated sequences at the termini, but these consist of variable copy numbers of a tandemly repeated sequence. Example: Human
herpesvirus 8/Kaposi sarcoma herpesvirus (HHV-8; KSHV). Class C: Genomes have an internal set of direct repeats that are unrelated to the terminal set.
Example: Epstein-Barr virus (EBV). Class D: Genomes contain two unique regions, each flanked by inverted repeats. Example: Varicella-zoster virus
(VZV). Class E: Genomes are the most complex of all, with terminal and internal repeats that are much larger and inverted giving rise to four equimolar
genome isomers. Examples: Herpes simplex viruses 1 and 2 (HSV-1, HSV-2) and human cytomegalovirus (HCMV). There is a Class F, but it does not
contain any human virus. From Bernard Roizman and Phillip Pellett, with permission.

Herpesvirus genomes display some unusual features and many of these additional genes encode regulatory proteins
generally follow one of four distinct organizational patterns and virokines important for the optimization of growth,
(Fig. 17.3). Reiterated DNA sequences generally occur at dissemination, and pathogenicity in vivo, and by such
each end of the genome and, in some viruses, internally means extend viral tissue tropism, establish and maintain
also, dividing the genome into two unique components, latency, and suppress the host immune response.
designated large (UL) and small (US). When these reiterated The HSV virion attaches via its envelope glycoproteins gC
sequences are inverted in orientation, the unique L and S and gB to the heparan sulfate moiety of cellular proteoglycans,
components can become inverted relative to each other and then forms a firmer association between the envelope gD
during replication, giving rise to two or four different isomers glycoprotein and one of further cellular receptors—herpesvirus
of the genome, each present in equimolar proportions. entry mediator (HEM) or nectin-1. Entry into the cytoplasm
Further, intragenomic and intergenomic recombinational requires viral glycoproteins gB, gD, and gH and occurs by
events can alter the number of any particular reiterated pH-independent fusion of the virion envelope with the plasma
sequence, creating polymorphism. membrane in some cells (e.g., neurons) and via endocytosis in
others (keratinocytes): the gB protein is responsible for fusion
to the cell. Tegument proteins are released, one of which (the
Viral Replication UL41 gene product, an endonuclease) shuts down cellular
Herpesvirus replication has been mostly studied using protein synthesis. The capsid is transported by retrograde
herpes simplex viruses types 1 and 2 (HSV-1 and -2); microtubule transport to a nuclear pore, where viral DNA is
betaherpesviruses and gammaherpesviruses replicate released, enters the nucleus, and is circularized.
more slowly and exhibit certain significant differences but Viral gene expression is tightly regulated, with three
generally follow a similar pattern of genome expression and classes of mRNA, α, β, and γ, transcribed by the host
replication. Unlike other DNA viruses such as papovaviruses RNA polymerase II in a strictly ordered progression
and parvoviruses that use the cellular DNA synthetic (Fig. 17.4). Immediate early (α) genes can be transcribed
machinery, herpesviruses encode most of the enzymes in the absence of de novo protein synthesis, while early
required to increase the pool of deoxynucleotides necessary (β) gene transcription is dependent upon the expression
for the replication of viral DNA. This facility is vital for of immediate early proteins and late (γ) gene expression
viral replication in resting cells such as neurons, which is dependent on viral DNA synthesis. One of the released
throughout most of the life of the host never divide and tegument proteins (the UL48 gene product) transactivates
thus never synthesize DNA. Interestingly, about half of the transcription of the five “immediate early” (α) genes.
73 genes of herpes simplex virus are not essential for viral This viral protein associates with two cellular proteins to
replication in cultured cells, and it is likely that a similar form a multi-protein complex that specifically recognizes
ratio applies in the case of other herpesviruses; presumably a nucleotide sequence in the promoter region of the viral
 Herpesviruses Chapter | 17 241

Viral
activators Primary herpes simplex virus
infection

Cellular activators
Tegument Cellular repressors
proteins

Modulate IFN
Immediate-early Immediate-early
and cytokine
genes expressed gene ecpression blocked
response
Genome silencing
LAT expression
?
Inhibition
Early genes expressed of apoptosis
DNA replication Latent infection
Inhibition ?
Commitment to established
pf apoptosis
productive
growth Viral gene
? products?

Late genes expressed Maintenance

Cell–cell Reactivation
Particle assembly
spread
DNA packaging Stimuli
Stress response

Particle egress Viral and cellular activator

expression (ICP0)

Infectious virus Latent

produced infection

Productive
infection

FIGURE 17.4 General strategies for the establishment of productive or latent infection with herpes simplex virus. The productive infection is shown by
the pathway on the left, and the latent infection by the pathway on the right. Infectious particles produced by the productive pathway may infect other cells
and enter either the productive or latent pathways. Infection can also spread from cell to cell without release of particles. Apoptosis induced by infection
is inhibited by viral gene products. Reactivation is indicated by the diagonal arrow from the latent state to the start of the productive infection. There is
debate whether reactivation requires “return to go” (immediate early gene expression) or “start in the middle” (expression of early genes required for DNA
replication). Reproduced from Flint, S.J., et al., Principles of Virology, Vol. II, p. 154. ASM Press, Washington DC, with permission.

DNA, triggering transcription by a cellular polymerase. The helicase–primase complex composed of three gene products.
α mRNAs are transported to the cytoplasm and translated Following DNA replication, certain β proteins induce the
to the several α proteins: these are regulatory proteins program of transcription to switch templates once more, and
controlling the expression of all late viral genes. One is a the resulting “late” (γ) mRNAs are synthesized and translated
protein that initiates transcription of the “early” (β) genes. into the γ proteins, most of which are structural proteins
The β proteins include enzymes required to increase the required for morphogenesis of the virion. Capsid proteins
pool of nucleotides (e.g., thymidine kinase, ribonucleotide assemble to form empty “immature” capsids in the nucleus.
reductase) and others needed for viral DNA replication Unit-length viral DNA cleaved from newly synthesized
(e.g., a DNA polymerase, primase–helicase, topoisomerase, DNA concatemers is packaged to produce mature
single-strand and double-strand DNA-binding proteins). nucleocapsids: these then associate with patches of nuclear
The viral genome replicates by a rolling circle membrane to which specific tegument proteins are bound.
mechanism from one or more origins of replication. In This triggers envelopment by budding through the inner
the case of HSV-1, this involves at least seven virus-coded nuclear membrane, but the precise details of nucleocapsid
proteins—an origin-binding protein, an ssDNA-binding exit from the nucleus are a matter of controversy. Removal
protein, a DNA polymerase composed of two subunits, and a of the envelope occurs at the outer nuclear membrane and
242 PART | II Specific Virus Diseases of Humans

the tegument proteins are added in at least two steps in the infections, while genital herpes still continues to cause a
cytoplasm. These nucleocapsids are then enveloped through disabling problem for some sufferers.
interactions with glycoproteins embedded in the Trans-Golgi
network. The mature virions are transported in vesicles to Clinical Features
the plasma membrane and released there by exocytosis.
Virus-specific proteins in the plasma membrane may serve In considering the various clinical presentations it is
as Fc receptors and may be targets for immune cytolysis. important to distinguish between primary and recurrent
Such productive infections (as distinct from latent infections (Table 17.3). Primary infections with HSV-1 and
infections) are lytic, as a result of virus-induced shutdown -2 are generally inapparent, but when clinically manifest,
of host protein and nucleic acid synthesis. Major changes primary infections tend to be more severe than recurrences
are obvious microscopically, notably the margination and in the same dermatome. Since immunity to exogenous
pulverization of chromatin and the formation of large reinfection is long-lasting, nearly all second clinical episodes
eosinophilic intranuclear inclusion bodies. These inclusion with the same HSV type are reactivations of an endogenous
bodies can usually be found both in herpesvirus-infected latent infection. However, because cross-immunity is only
tissues and in appropriately stained cell cultures. partial, de novo infection with the heterologous type can
An alternative outcome to the above is latent infection, a occur (e.g., genital herpes caused by HSV-2 in an HSV-1
process important for virus persistence in the infected host immune person); these cases are referred to as “initial
but more difficult to study. This is generally considered to disease, non-primary infection” and are usually mild.
involve a failure of immediate early (α) gene expression
leading to persistence of the input genome(s) as circular Oropharyngeal Herpes Simplex
episomal elements. However, some evidence also suggests
that productively infected cells may on occasions then Primary infection with HSV-1 most commonly involves the
progress to latency. At a later time, reactivation of immediate mouth and/or throat. In young children the classic clinical
early gene expression and entry into the productive replication presentation is gingivostomatitis. The mouth and gums
cycle may be triggered by external stimuli affecting the exhibit varying numbers of vesicles which soon rupture to
transcription factor milieu within the latently infected cell. form ulcers. Though febrile, irritable, and suffering from
the pain of bleeding gums, the child recovers uneventfully.
In adults, primary infection more commonly presents as a
HERPES SIMPLEX VIRUS INFECTION pharyngitis or tonsillitis.
Herpes simplex virus infections of the lips, mouth, and Following recovery from primary oropharyngeal infection
genital tract were described in early Sumerian and Greek the individual retains HSV DNA in neurons of the trigeminal
literature: the first successful, relatively non-toxic antiviral ganglion for life and has at least a 30 to 40% chance of
drug, acyclovir, was developed to treat herpes simplex suffering recurrent attacks of herpes labialis (otherwise known

TABLE 17.3 Diseases Caused by Herpes Simplex Viruses

Disease Primary (P) or Age Frequency Severity Type
Recurrent (R)
Gingivostomatitis P Young children Common Mild 1
Pharyngotonsillitis P Adults Common Mild 1>2
Herpes labialis R Any Common Mild 1>2
Genital herpes P, R >15 years Common Mild/moderate 2>1
Keratoconjunctivitis P, R Any Common Mild/moderate 1
a
Skin infection P, R Any Rare Mild/moderate 1, 2b
Encephalitis P, R Any Rare Severec 1 > 2d
Neonatal herpes P Newborn Rare Severec 2>1
c
Disseminated herpes P, R Any Rare Severe 1>2
a
Including herpes simplex virus infection of burns, eczema herpeticum, etc.
b
Skin above waist, 1 > 2; below waist, 2 > 1; arms, either 1 or 2.
c
Often fatal.
d
HSV-2 in neonates.
 Herpesviruses Chapter | 17 243

FIGURE 17.5 (A) Lesions of recurrent labial herpes simplex, in the healing and crusting phase. (B) Herpetic whitlow on the right thumb, occurring in a
nurse who attended the laryngeal airway of a patient with a tracheostomy. Wearing gloves is now essential for such procedures. Reproduced from Cooke,
R.A., Infectious Diseases, McGraw Hill, with permission.

as herpes facialis, herpes simplex, fever blisters, or cold sores)

from time to time throughout the remainder of life. However,
almost all infected people shed virus asymptomatically in
saliva periodically throughout life which allows transmission.
A brief prodromal period of hyperesthesia heralds the
development of a cluster of vesicles, generally around the
mucocutaneous junction on the lips (Fig. 17.5).

Genital Herpes
Most primary genital herpes is still caused by HSV-2,
despite an increasing proportion of cases attributable
to HSV-1, especially in adolescent and young women
probably as a result of orogenital sexual practices. As
a sexually transmitted disease it is seen mainly in young FIGURE 17.6 Female with genital herpes showing vesicular lesions on
adults, but it is occasionally encountered following the labia. Reproduced from Cooke, R.A., Infectious Diseases, McGraw
Hill, with permission.
accidental inoculation at any age, or in young girls who
have been victims of sexual abuse. Though the majority
of primary infections are subclinical, disease may
occasionally be severe, particularly in females. Ulcerating Even though the vast majority of recurrent genital
vesicular lesions develop on the vulva, vagina, cervix, herpes cases are less severe than was the primary attack,
urethra, and/or perineum in the female (Fig. 17.6), and the the resultant pain, sexual frustration, and sense of guilt
penis, including foreskin, in the male, or the rectum and can have psychological effects as well as consequences to
perianal region in male homosexuals. Local manifestations sexual behavior.
are pain, itching, redness, swelling, discharge, dysuria, and
inguinal lymphadenopathy; systemic symptoms, notably
Keratoconjunctivitis
fever and malaise, are often marked, especially in females.
Spread may occur to the central nervous system, causing Primary infection of the eye with HSV-1 may occur with
mild meningitis in about 10% of cases. Initial disease is exogenous virus or may result from autoinoculation.
less severe in those with immunity resulting from previous Involvement of the cornea (keratitis) often leads to a
infection with HSV-1 or previous subclinical infection with characteristic “dendritic ulcer” which may progress to
HSV-2. Asymptomatic shedding from the anogenital involve the underlying stroma. Immunopathological
mucosa is very frequent (at least daily in some) and the mechanisms including autoimmunity are thought to be
commonest cause of sexual transmission. involved. The corneal scarring that results from repeated
244 PART | II Specific Virus Diseases of Humans

HSV infections is a common cause of blindness; such Neonatal herpes may present as (1) disseminated disease,
recurrences are usually unilateral. with a case–fatality rate of 80%, most of the survivors
being left with permanent neurological or ocular sequelae,
(2) encephalitis, which also carries a high risk of death or
Skin Infections sequelae, or (3) disease localized to mucocutaneous surfaces
Primary and recurrent HSV infections may also involve such as skin, eye, and mouth (SEM disease—which may,
the skin on any region of the body. Rarely this occurs by however, progress to disseminated disease if not treated
direct traumatic contact, for example, in wrestlers or rugby promptly). Once again, intravenous acyclovir (20 mg/kg
players—called “herpes gladiatorum.” An occupational every 8 hours) has been shown to reduce morbidity and
hazard for dentists and nurses is herpetic paronychia mortality compared to lower dosages. Because this dosage
(“herpetic whitlow”—painful cutaneous infection of the can be associated with neutropenia, the patient’s white cell
distal aspect of the finger caused by HSV) (Fig. 17.5). Much count should be monitored.
more dangerous are disseminated skin infections with HSV
that complicate burns or eczema. HSV-1 can also cause and Disseminated Herpes in
complicate erythema multiforme. Immunocompromised Hosts
Patients particularly at risk of potentially lethal disseminated
Encephalitis HSV infections are those who are already compromised by
congenital or acquired immunodeficiency, for example,
Although encephalitis is a rare manifestation of HSV
following immunosuppression for organ transplantation,
infection, it is nevertheless the most common sporadic cause
HIV/AIDS, or malignancy. Other risk groups include
of this disease. The virus may spread to the brain during
those suffering from severe malnutrition with or without
primary or recurrent HSV infection, with the temporal lobes
concomitant measles, or those with severe burns, eczema,
most commonly involved. Vesicles are generally not present
and certain other skin conditions.
on the body surface. HSV-1 is usually responsible except
in the case of neonates. The presentation can include fever,
headache, behavioral changes, seizures, vomiting, and focal Pathogenesis, Pathology, and Immunity
neurological signs, with no reliable pathognomonic signs.
Untreated, the case–fatality rate is 70%, and the majority The initial site of replication for primary herpes simplex
of survivors suffer permanent neurological sequelae. The virus is usually epithelial cells of mucosal surfaces, typically
prognosis has improved significantly with the current oropharyngeal or genital mucosa. Focal areas of epithelial
policy of immediate pre-emptive treatment with intravenous cell necrosis are seen, involving the ballooning of cells and
acyclovir (the drug of choice), once herpes simplex sometimes typical intranuclear herpesvirus inclusions. An
encephalitis is suspected. Because of the risk of relapse intense inflammatory cell response and accumulation of
often within the first three months, a follow-up prolonged fluid rapidly lead to vesicle formation with progression to
course of an oral antiviral agent, for example, valacyclovir, ulcers (see Chapter 7: Pathogenesis of Virus Infections).
is generally recommended. HSV is also a significant cause Virions are released from the basal surface of infected cells,
of meningitis and more rarely, associated with a range of and fusion between viral envelopes and adjacent sensory or
other neurological conditions. autonomic nerve endings releases nucleocapsids into the
axoplasm of nerve endings. Internalized nucleocapsids can
then be transported on microtubules by dynein motors over
Neonatal Herpes
long distances to reach the body of the nerve cell in the
Herpes neonatorum is a serious disease acquired by babies, corresponding ganglion (a process known as “retrograde
usually from their mothers at delivery. The majority are axonal transport”).
HSV-2 infections acquired during passage through an When the viral DNA enters the nucleus of the neuron,
infected birth canal, but some may be acquired postnatally, productive or latent infection may ensue. Despite intensive
and a very few prenatally by viremic transmission across the study, many details of the maintenance of the latent state
placenta or by ascending infection from the cervix. If virus are not clear. The viral genomes within neurons (and some
is present in the maternal genital tract at the time of delivery other non-neuronal cells within ganglia) become coated
the risk of neonatal herpes ranges from three to four percent with nucleosomes and exhibit very limited transcription. In
with recurrent maternal infection, to 30% to 40% in primary the case of neurons latently infected with either HSV-1 or
infection. This difference is thought due to the protective HSV-2, latently infected neurons synthesize a limited
effect of pre-existing antibodies acquired transplacentally number of specific RNA molecules termed the “latency-
from a mother undergoing reactivation. Neonatal herpes associated transcripts” (LATs). Possible functions for LATs
simplex infection occurs in 1 in 5000 to 10,000 live births. include serving as mRNAs for critical proteins, as antisense
 Herpesviruses Chapter | 17 245

inhibitors of translation or as regulatory micro-RNA vulnerable, (2) site, systemic and CNS infections being
precursors, but evidence supporting any of these roles is scant. much more serious than infections confined to epithelial
While the regulatory viral and cellular factors that maintain surfaces, and (3) immunocompetence, T cell-mediated
latency are not well understood, it is clear that reactivation immunity being crucial in the control of infection.
of productive replication is a very frequent event, probably Two of the HSV glycoproteins, gE and gI, form a receptor
in a tiny fraction of infected cells, leading to transmission for the Fc domain of IgG. This Fc receptor is found on the
of virions to the periphery via the axonal transport system. surface of both virions and infected cells and can protect
On some but not all such occasions, productive infection both against immunological attack, by steric hindrance
in epithelial cells of the area of epithelium innervated by resulting from binding of normal IgG, or from “bipolar
the neuron undergoing reactivation occurs and lesions are bridging” of HSV antibodies that can attach to gE/gI by its
seen. A distinction is made between “reactivation,” that Fc end and simultaneously to another HSV glycoprotein
is, renewed virus replication, and “recrudescence,” that is, via one Fab arm. Moreover, gC is a receptor for the C3b
reappearance of clinical lesions (Fig. 17.4). component of complement and may protect infected cells
Although pre-existing neutralizing antibody directed from antibody–complement-mediated cytolysis. Also HSV
against envelope glycoproteins, notably gB and gD, may ISP47 downregulates MHCI expression on infected target
successfully prevent primary infection and limit spread of cells making these invisible to (cytotoxic) CD8 T cells, until
herpes simplex virus from epithelial cells to nerve endings, MHCI is restored by interferon gamma secreted by CD4+ T
cell-mediated immunity is the key to recovery from primary cells.
infection and maintenance of latency. Following lytic
infection of epidermal cells, viral antigens on dendritic cells
Laboratory Diagnosis
and macrophages are presented to CD4+ Th1 lymphocytes,
and these initiate viral clearance by secreting cytokines such Some of the clinical presentations of HSV, such as recurrent
as interferon γ (IFN-γ) that recruit and activate macrophages herpes labialis, are so characteristic that laboratory
and natural killer (NK) cells. CD4+ and CD8+ T cells and confirmation is not required. Others are not so evident, for
antibody-dependent cell-mediated cytotoxicity (ADCC), example, if the lesions are atypical or if vesicles are not
lyse infected cells. The overt epithelial infection is cleared, visible at all, as in encephalitis, keratoconjunctivitis, or
but some virus ascends the local sensory neurons by herpes genitalis infections confined to the cervix. Specimens
retrograde axonal transport and establishes lifelong latency in include vesicle fluid, cerebrospinal fluid (CSF), or swabs
the corresponding spinal or cerebral ganglion (see Fig. 8.5). or scrapings from the genital tract, throat, eye, or skin, as
The mechanism of establishment, maintenance, and appropriate. Speed is important in situations where the
reactivation of latency is discussed in Chapter 8: Patterns patient would benefit from early commencement of antiviral
of Infection. Experimental studies in animal models, as therapy. Rapid diagnostic methods include detection of HSV
well as the clinical observation that immunocompromised DNA in detergent-solubilized cells or mucus from the site
humans are much more prone to severe HSV infections and of lesions by real-time polymerase chain reaction (PCR).
to reactivation, make it clear that CD8+ T cell-mediated Alternative approaches include demonstration of HSV
immunity is the key to recovery from primary infection. antigen in cells scraped from lesions, genital tract, throat,
HSV-specific CD8+ T cells may also suppress the full or cornea, by immunofluorescence or immunoperoxidase
expression of HSV DNA during the establishment of staining (using type-specific monoclonal antibodies if
latency in sensory ganglia. It is not yet understood as to the desired), or by enzyme immunoassays (EIAs) on CSF
link among the apparently disparate events known to trigger or detergent-solubilized cells and mucus. Diagnosis of
reactivation, for example, immunosuppression, “stress,” encephalitis is particularly difficult, and chemotherapy
trauma, ultraviolet irradiation, fever. is now commenced pre-emptively before laboratory
Recurrences of disease are typically less severe than confirmation of the diagnosis. Brain biopsy has been used
primary disease, and the frequency and severity of such in the past but is unnecessarily invasive. PCR is now the
recurrences diminish with time. HSV-1 and -2 display a method of choice for detection of HSV DNA in CSF.
degree of selectivity in tissue tropism. HSV-2 replicates to a Virus isolation in cell culture is the traditional method for
higher titer than does HSV-1 in genital mucosa, and is more diagnosing HSV infection, today perhaps only used when
likely to lead to encephalitis and severe mental impairment an isolate is needed for research purposes, for determining
in neonates. HSV-2 is twice as likely as HSV-1 to establish drug resistance where lesions are refractory to treatment
reactivatable latent infection, and recurs almost 10 times as in immune-compromised patients; the specimen should
frequently in the anogenital region. The converse applies be taken early, placed in an appropriate transport medium,
to orolabial infections, where HSV-1 predominates. The kept on ice, and transferred to a laboratory without delay.
severity of primary HSV infection is influenced by three Human fibroblasts or Vero cells are both equally sensitive,
major factors: (1) age, premature infants being particularly but HSV replicates rapidly in many mammalian cell lines.
246 PART | II Specific Virus Diseases of Humans

Distinctive foci of swollen, rounded cells appear within one affluent communities escape infection until adolescence,
to five days (Fig. 20.4A). The diagnosis can be confirmed when there is a peak of infection as a result of exchange
within 24 hours by immunofluorescent staining of the via kissing. The prevalence of infection in adolescence
infected cell culture. Differentiation of HSV-1 from HSV-2 rarely exceeds 50% but there is considerable variation in
is not usually relevant to the acute management of the case adult seroprevalence in countries ranging from 50% to
but is required for counseling of patients as to the likelihood 80% (e.g., the United States 50%, Australia 80%). The
of recurrence of genital disease (much greater with HSV- worldwide seroprevalence of HSV-2 is even more variable
2); it simply involves selection of appropriate monoclonal ranging from 10% to 80% (Australia 12%, parts of sub-
antibodies that distinguish the two viruses. Saharan Africa 80%). In the United States the overall
When HSV encephalitis is suspected EIA can be used seropositivity rate is 15%, although it is four times higher
to demonstrate anti-HSV IgM in CSF; an abnormally high in African-Americans than in whites. Because almost all
ratio of total HSV antibody in CSF compared to the titer the transmission of HSV-2 is sexual, most initial HSV-2
in blood may also aid in diagnosis. In most other HSV infections in African-Americans are subclinical, as they
infections, however, serology is not widely used, except occur in adolescents and young adults with pre-existing
again for epidemiological and research purposes. Most antibody against HSV-1, whereas those in Caucasians tend
HSV antibodies react with both serotypes, but type-specific to be more severe and to recur more frequently.
antigens (e.g., baculovirus-cloned external domain of Asymptomatic shedding in genital secretions (typically
the gG glycoproteins of HSV-1 and HSV-2) are available HSV-2) or saliva (typically HSV-1) occurs frequently and
for EIA or “immunodot” screening assays. Type-specific is not limited to recrudescences with overt symptoms; for
serology for HSV-2 antibodies can be used to identify latent example, studies indicate that HSV-1 can be isolated from
genital herpes infections in between recrudescences, but its the saliva of up to 20% of children and 1% to 5% of adults
clinical value is limited by inability to distinguish recent at any given time whereas HSV-2 shedding can occur as
and remote infection and also to distinguish HSV-1 oral frequently as 12-hourly in short bursts or for less frequent,
from genital disease. longer durations. At least 25% of people suffer from
recurrent herpes labialis and perhaps 5% from recurrent
Epidemiology, Prevention, Control, and genital herpes. Importantly prior HSV-2 infection also
enhances HIV acquisition 3- to 7-fold through an ulcerated
Therapeutics and inflamed anogenital mucosa.
Herpes simplex viruses spread principally by close
person-to-person contact with lesions or mucosal
Prevention and Control
secretions. HSV-1 is shed principally in saliva, and virus
may be transmitted to others directly, for example, by The very substantial risk of contracting genital herpes from a
kissing, or indirectly, via contaminated hands, eating partner who is a known carrier can be reduced by the diligent
utensils, etc. Contaminated fingers may occasionally use of condoms irrespective of whether or not lesions are
spread HSV-1 to the eye or genital tract but viral survival on present. The risk of herpetic paronychia for dentists and
the surface of skin is short. HSV-2, on the other hand, is nurses handling oral catheters can be eliminated by the
transmitted mainly, but not exclusively, by sexual wearing of gloves. Patients with active herpes simplex virus
intercourse. Neonates can be infected with HSV-2 during infections, particularly heavy shedders such as babies with
passage through an infected birth canal, or with HSV-1 by neonatal herpes or eczema herpeticum, should be isolated
postnatal contact with an infected parent or hospital staff from patients with immunosuppressive disorders.
member. Transplacental transmission during pregnancy The prevention and management of neonatal herpes is
has been reported rarely, and may be associated with skin an important challenge, because timely antiviral treatment
lesions, chorioretinitis, microcephaly, hydranencephaly, significantly improves prognosis. Cesarean section has
and microphthalmia. been shown to reduce transmission of infection to the
The probability and age of acquisition of HSV are infant if carried out within 4 hours of membrane rupture,
closely linked to socioeconomic circumstances. In the but is of unproven value if delayed beyond four hours. The
developing world and in the poorer communities within identification of pregnancies at risk has been attempted by
developed nations, most children first become infected establishing a series of cultures from genital specimens
with HSV-1 within a few years after losing the protection taken at least weekly through the final four to six weeks of
of maternal antibody, and over 80% are seropositive by gestation from “high-risk” women, usually defined as those
adolescence. Doubtless this reflects the influence of such with a clinical history of genital herpes. However, this costly
factors as overcrowding, poor hygiene, and patterns of procedure is a poor predictor of viral shedding at the time of
human contact including contact associated with social labor and therefore of fetal risk, and therefore is no longer
mores. In contrast, the majority of children in more advocated except when primary genital herpes is diagnosed
 Herpesviruses Chapter | 17 247

or suspected. Currently, the preferred policy is to await the history of more than 10 attacks of genital herpes per annum.
onset of labor, then carefully examine the cervix and vulva, It also markedly reduces transmission to uninfected partners.
and collect swabs for testing. Culture or PCR should be Chemoprophylaxis is also justified in patients receiving an
done, as a reliable indicator of infection. However, if genital organ transplant, or in immunocompromised patients with
lesions are present at labor, the baby should be delivered any clinically apparent mucocutaneous HSV infection. It is
by Cesarean section as soon as possible, usually before a also indicated for the prevention of neonatal herpes in babies
laboratory result is at hand and not more than four hours delivered vaginally from mothers with proven primary
after the membranes have ruptured. If no lesions are present, herpes genitalis at the time of delivery. Renal function
vaginal delivery is appropriate; however, should the vaginal monitoring is not usually required in patients receiving
swabs subsequently prove to be HSV positive, evidence of prophylaxis except for immunocompromised patients on
neonatal infection should be sought by taking samples from high doses of valacyclovir. In none of these situations is
the baby’s eyes, nose, throat, umbilicus, and anus. Prompt valaciclovir or acyclovir a panacea, and it does not prevent
treatment with high-dose (60 mg/kg/day) intravenous the establishment of latency; at best it can be claimed that
acyclovir has led to major improvements in infant survival. early administration of the drug will restrict the progression
Neonatal transmission occurs in approximately 33% of of the disease and ameliorate symptoms. However, prolonged
cases of initial genital herpes during pregnancy, but in <5% chemoprophylaxis actually reduces the risk of drug resistance
of cases of recurrent herpes. by keeping replicating virus populations low.

Therapeutics Vaccines
The drug of choice for the treatment of alphaherpesvirus The development of herpes simplex virus vaccines has
infections is acycloguanosine (acyclovir), the mechanism proved difficult. Evidence from human studies and murine
of action of which is discussed in Chapter 12: Antiviral models has demonstrated roles for innate, humoral, and cell-
Chemotherapy. Acyclovir as an ointment formulation mediated immunity in controlling both primary and latent
is used topically for the treatment of ophthalmic herpes infection. The ultimate goal of total prevention of primary
simplex. Intravenous acyclovir (20 mg/kg 3 times daily) infection and latency may be difficult because virus gains
should be commenced promptly and continued for two access to nerve ganglia by retrograde axonal transport and
to three weeks in the case of the life-threatening HSV not by viremic spread. Nevertheless, a therapeutic vaccine
diseases, encephalitis, neonatal herpes, and disseminated that reduces recrudescence of disease in latently infected
infection in immunocompromised patients. Oral acyclovir subjects may in itself be valuable, particularly with a view to
(200 mg 5 times daily for 10 days) is appropriate treatment preventing genital and neonatal herpes and is preferable to
for primary herpes genitalis and may be of value for constant chemoprophylaxis. The delivery of such a vaccine
unusually severe primary orofacial herpes, for example, could be delayed until puberty, when a significant proportion
with atopic dermatitis. Acyclovir-containing creams applied of recipients would already have been primed by natural
early in recurrences of herpes labialis have been shown in infection with HSV-1. Various HSV glycoproteins elicit
large clinical trials to shorten by around 12 hours the mean neutralizing antibodies, but the most important appears to
duration of clinical episodes. Acyclovir is used cautiously be gD. HSV-1 and HSV-2 vaccines consisting of either gD
during pregnancy for appropriate indications, for example, or gD plus gB produced by recombinant DNA technologies
severe primary herpes infection, and has not been associated combined with an adjuvant, have been shown in some
to date with maternal complications or fetal damage. trials as significantly reducing the risk of primary genital
A number of derivatives of acyclovir have found herpes in women, but not in men, but the recurrent disease in
particular uses. Valaciclovir is more effectively absorbed seropositive women has not been reduced. A DNA plasmid
orally than acyclovir and is rapidly converted to acyclovir vaccine expressing gD, and a recombinant human HSP-70/gB
in vivo, leading to plasma levels that are 8 to 10 times HLA-restricted epitope, have also been tested in phase I
higher than can be achieved with acyclovir. Other acyclovir trials.
derivatives include penciclovir and famciclovir. Older
antiviral agents such as adenine arabinoside (vidarabine)
and phosphonoformate (foscarnet) are too toxic to be
VARICELLA-ZOSTER VIRUS INFECTION
recommended for general use, but the latter can be used to The single herpesvirus known as varicella-zoster virus
treat acyclovir-resistant life-threatening HSV infections, for (VZV) is responsible for two almost universal human
example, in AIDS patients. diseases: varicella (chickenpox), one of the exanthems
Prolonged oral prophylaxis with valaciclovir 500 mg of childhood, and herpes zoster (shingles), a disabling
twice daily (or less frequently used, aciclovir 200 mg 4 times disease, most common among aging persons and
daily) is used to suppress recurrences in patients with a immunocompromised patients.
248 PART | II Specific Virus Diseases of Humans

Clinical Features
Varicella
The rash of chickenpox appears suddenly, with or without
a prodromal fever and malaise. Erupting first on the trunk,
then spreading centrifugally to the head and limbs, crops
of vesicles progress successively to pustules then scabs.
Though painless, the lesions are very itchy, tempting the
child to scratch, and this may lead to secondary bacterial
infection and permanent scarring. Painful ulcerating vesicles
also occur on mucous membranes such as in the mouth
and vulva. The disease tends to be more severe in adults,
in whom potentially life-threatening varicella pneumonia
occurs more frequently.
Primary varicella pneumonia can be a significant
complication, accounting for many of the deaths associated
with the infection. In one study of military recruits with
varicella, 16% of cases had x-ray evidence of pneumonia
although only one quarter of these had symptoms.
Neurological complications are uncommon but potentially
serious. In about 1 case in 1000, encephalitis develops a
few days after the appearance of the rash; this can be lethal,
particularly in adults. Rarer neurological complications
include Guillain-Barré syndrome and Reye’s syndrome (see
Chapter 39: Viral Syndromes).
Varicella is a particularly dangerous disease in
immunocompromised persons and in non-immune
neonates. Children with deficient cell-mediated immunity
are especially vulnerable, whether congenital or induced by
malignancy (e.g., leukemia), anticancer therapy, or steroid
therapy. Not only may the skin manifestations be necrotizing
and hemorrhagic, but the disease becomes disseminated,
involving many organs including the lungs, liver, and brain.
If women have not been infected as children, varicella
tends to be more serious in pregnancy and may affect the
fetus. Infections occurring in the few days immediately
before or after parturition in a non-immune woman can be
particularly dangerous, since the baby does not have maternal
antibodies and may die from disseminated varicella. Very
rarely, maternal infection in the first half of pregnancy
has been associated with congenital malformations in
the fetus (cutaneous scarring, limb hypoplasia, and eye
abnormalities).

Herpes Zoster
Herpes zoster results from reactivation of virus that has
remained latent in one or more sensory ganglia following
an attack of chickenpox many years earlier. Vesicles are FIGURE 17.7 (A) Varicella in a child. Vesicles appear in recurring crops
every 24 to 48 hours, mainly on the trunk. Note lesions at various stages of
usually distributed unilaterally and confined to the area of development, some of which have become secondarily infected as a result
skin innervated by a particular sensory ganglion (zoster, of scratching. (B) Typical rash of herpes zoster, distributed along the right
Gk=girdle), usually on the trunk or on the face involving first lumbar nerve dermatome, and (C) herpes zoster lesion distributed along
the eye (Fig. 17.7); scattered lesions outside the primarily the second branch of the right fifth cranial nerve dermatome. Reproduced
affected dermatome may also occur. The accompanying from Cooke, R.A., Infectious Diseases, McGraw Hill, with permission.
 Herpesviruses Chapter | 17 249

pain is often very severe for up to a few weeks, and Laboratory Diagnosis
postherpetic neuralgia, which occurs in half of all patients
over 60 years of age, may persist for many months. Motor The clinical picture of both varicella and herpes zoster
paralysis and encephalomyelitis are rare complications. is so distinctive that the laboratory is rarely called on for
Ophthalmic zoster can result in uveitis and occasionally assistance. Rapid diagnostic methods include fluorescent
blindness. Disseminated (visceral) zoster is sometimes seen monoclonal antibody staining of fixed smears from the
in cancer patients or those otherwise immunocompromised. base of early skin lesions or sections from organs taken
at autopsy. Alternatively, EIA can be used to demonstrate
VZV antigens in vesicle fluid. Finally, PCR can be used to
Pathogenesis, Pathology, and Immunity amplify DNA extracted from virions in vesicle fluid.
Varicella-zoster virus enters by inhalation and replicates The virus can be isolated from early vesicle fluid in
initially in the mucosae of the respiratory tract and cultures of human embryonic lung fibroblasts; however,
oropharynx. Its progression during the 10- to 20-day virus tends to remain cell-associated, very little being
incubation period (typically 14 days) is presumed to be released, and hence the cytopathic effect (CPE) develops
comparable to that seen in other generalized exanthems. slowly and only in distinct foci over a period of 2 or more
Dissemination occurs via lymphatics and the bloodstream, weeks. VZV antigen can be demonstrated in nuclear
and the virus multiplies in mononuclear leukocytes and inclusions by immunofluorescence before the end of the
capillary endothelial cells. Eventually the rash results first week.
from multiplication of virus in epithelial cells of the skin; Recent infection can also be confirmed by detecting a
keratinocytes show ballooning and intranuclear inclusions, rising titer of antibodies, or by IgM serology preferably
and virus is plentiful within the characteristic vesicles. At using EIA. The immune status, for example, of potentially
this time, virus ascends the axons of various sensory nerves vulnerable leukemic children following contact with a
to localize in sensory ganglia, where it becomes latent for person with chickenpox, can be determined rapidly using
life until reactivated by immunosuppression, as discussed EIA. Specific tests for cell-mediated immunity are also
in Chapter 7: Pathogenesis of Virus Infections. Unlike HSV, used both for research purposes and vaccine assessment.
where the distribution of latently infected ganglia is usually
tightly confined to the site of primary infection, ganglia Epidemiology, Prevention, Control, and
latently infected with VZV may be widely distributed. The
Therapeutics
primary infection is generally rapidly controlled by T cell-
mediated immunity. Varicella infection usually induces Prior to the widespread use of vaccine, varicella occurred
prolonged immunity, but subclinical reinfections may throughout the year but was most prevalent during late
occur more frequently than once thought, and mild disease winter and spring. Epidemics occurred among groups of
is sometimes seen, particularly in immunocompromised susceptible children, for example, in schools or children’s
individuals. hospitals. The annual number of cases was similar to the
Herpes zoster occurs when varicella virus in a sensory birth cohort size, and most children became infected
ganglion is reactivated and is transported anterogradely during their first years at school. Spread probably occurs
in the axon of a sensory nerve. In contrast to herpes via airborne respiratory droplets generated from vesicles
simplex, VZV latency is rather tightly suppressed by host on oropharyngeal mucosa, as well as by contact with skin
immunity; herpes zoster occurs in only 10 to 20% of those lesions or fomites. Children are highly contagious and should
previously infected with VZV, it is mainly confined to be excluded from school for as long as moist vesicles are
the elderly, and more than a single attack is exceptional. present on the skin; a week is normally sufficient.
Zoster annually affects about one percent of persons Passive immunization with zoster immune globulin
aged 50 to 60 years, with the incidence climbing rapidly obtained originally from convalescent zoster patients has
thereafter to the point where most 80-year-olds have an important place in the prevention of varicella. Zoster
suffered an attack. The condition is particularly common immune globulin should be administered to non-immune
in patients suffering from Hodgkin’s disease, lymphatic pregnant women who have come into close contact with
leukemia, or other malignancies, following treatment a case of varicella within the preceding three days but is
with immunosuppressive drugs, particularly for organ or ineffectual if delayed further. Should a pregnant woman
hematopoietic stem cell transplantation or irradiation, in contract varicella within the few days before or soon after
AIDS, or following injury to the spine. A decline in the level delivery, the probability of disseminated disease in the baby
of cell-mediated immunity is thought to precipitate attacks may be reduced by treating the mother with valacyclovir
of herpes zoster, and the protracted course of the disease in and the baby (at birth) with zoster immune globulin.
older or immunocompromised patients is presumably due Administration of zoster immune globulin is also indicated
to a weakened cell-mediated immune response. for immunocompromised patients who become exposed to
250 PART | II Specific Virus Diseases of Humans

the risk of infection; a typical crisis situation would be the the incidence of zoster in older persons has been slowly
occurrence of a case of varicella in the leukemia ward of a increasing, but this increase began prior to the introduction
children’s hospital. of the vaccine. Vaccine wild-type recombinant strains of
virus have been occasionally isolated from cases of herpes
zoster in vaccinated children, a finding that complicates the
Chemotherapy
ongoing surveillance of vaccine-related adverse effects.
Varicella in the normal child can generally be managed by
prevention of itching, scratching, and secondary bacterial
CYTOMEGALOVIRUS INFECTION
infection. However, varicella pneumonitis requires vigorous
treatment with intravenous acyclovir (10 mg/kg 3 times In much of the world, cytomegalovirus (CMV) infection
daily for 7 to 10 days). For herpes zoster, valacyclovir (1 g is acquired sub-clinically by the majority of people during
3 times daily) or famciclovir (750 mg tds) can be used to childhood, but in some more affluent communities infection
accelerate healing in severe cases of zoster provided it is tends to be delayed until an age when it can result in clinical
commenced promptly, and this is particularly important disease. Significant clinical impact occurs most often in the
when the eye is involved. very young, during pregnancy or in immunosuppressed
individuals, in whom both primary infection and
reactivation can bring serious, sometimes life-threatening
Vaccine
consequences. For example, primary infections during
The Oka strain of VZV was isolated in Japan from a healthy pregnancy can lead to severe congenital abnormalities in the
child with natural varicella, and was attenuated through fetus. Iatrogenic infections may follow blood transfusion or
sequential passages in cultures of human embryonic lung organ transplantation, and CMV can be a major cause of
cells, embryonic guinea-pig cells, and human diploid cell blindness or death in AIDS patients.
line WI-38. Routine vaccination with the Oka vaccine was
introduced in the late 1990s in Japan, the United States, and Clinical Features
a number of other developed countries. It is normally given
by subcutaneous injection, the first dose at 12 to 15 months Prenatal Infection and Disease
of age, the second dose at 4 to 6 years of age. For catch-up Cytomegalovirus infection during pregnancy is a major
vaccination, the second dose is given at least 3 months viral cause of congenital abnormalities in the newborn, and
after the first dose for children under the age of 13 years. has been recognized as the leading priority in the control
The vaccine has led to a reduction by 80% to 90% in the of congenital infections in the developed world. Less than
incidence of reported varicella cases, hospitalizations, and two percent of babies are born with asymptomatic CMV
deaths. The vaccine can induce fever and a few skin papules, infection, and only about 1 in 2000 has signs of cytomegalic
occasionally in normal children but more frequently in inclusion disease (CID). The classic syndrome is not
children who are immunocompromised. This attenuated always seen in its entirety. The infant is usually small, with
vaccine often establishes a latent infection in dorsal ganglia petechial hemorrhages, jaundice, hepatosplenomegaly,
and may lead to zoster in later years, but such reactivations microcephaly, encephalitis, and sometimes chorioretinitis
are mild and less frequent than those associated with a or inguinal hernia, or both. The abnormalities of the brain
natural varicella infection. and eyes are associated with mental retardation, cerebral
In the United States shingles (zoster) vaccine is palsy, impairment of hearing, and rarely impairment of
recommended for people aged 60 years and older (it sight. Many of these infants require special care for life.
is indicated for people older than 50, but not formally More subtle syndromes result in socially and educationally
recommended so as to become standard practice). In large important intellectual or perceptual deficits such as hearing
clinical trials the vaccine has been shown to be effective loss, subnormal IQ, epilepsy, and behavioral problems which
in preventing (51%) or markedly ameliorating (66%) the may not become apparent until as late as two to four years
symptoms of shingles and postherpetic neuralgia (60%). after birth.
In people who have had shingles the vaccine helps prevent
future recurrences of the disease. The vaccine employs the
Infectious Mononucleosis
same Oka strain attenuated virus, but at 14× the dose used
in varicella vaccine for children. New vaccines employing Most infections acquired after birth, by whatever route, are
a single varicella recombinant glycoprotein (E) and the subclinical. On occasion, however, a syndrome resembling
complex adjuvant ASO1B appear promising in trials. EB virus mononucleosis is seen, particularly among
Since adults with latent VZV are now being re-exposed young adults and in recipients of blood transfusions. This
less often to naturally circulating virus, there have been syndrome is usually less severe than that caused by EB virus
fears that protective levels of immunity might wane. Indeed and occurs on average a decade later, that is in early-mid
 Herpesviruses Chapter | 17 251

adulthood. Typically, the patient presents with a prolonged reactivation of a latent, dormant infection in cells of either
fever and on examination is found to have splenomegaly, the donor or the graft recipient.
abnormal liver function, and lymphocytosis, often with Relatively little is known about the pathogenesis of
“atypical lymphocytes” but usually at lower levels than CMV infection and the mechanism of latency. It is likely
those observed in EB virus infections (see below). In that virus commonly enters via the epithelium of the
contrast to EB virus mononucleosis, however, pharyngitis upper alimentary, respiratory or genitourinary tracts, but
and lymphadenopathy are uncommon, and heterophile infection can also bypass epithelial surfaces, as shown by
antibodies are absent. transmission by blood transfusion or organ transplantation.
During acute infection, whether primary or reactivated,
CMV Infection in the cell-free virus is not found in the blood, but virus DNA
can be recovered from monocytes, neutrophils, and less
Immunocompromised Host
commonly from T lymphocytes. That these and other cells
Cytomegalovirus infection has been one of the commonest are potentially permissive has been confirmed by in vitro
and most difficult to manage of opportunistic infections cultivation of CMV in monocytes, endothelial cells, vascular
among either immunocompromised patients or in premature smooth muscle cells, and some CD8+ T cells, but not B
infants receiving a blood transfusion. However this problem cells. However, it is almost impossible to reactivate CMV
has been considerably reduced in developed countries over by co-cultivation of leukocytes from healthy carriers with
the past few years following routine use of pre-emptive susceptible fibroblasts in vitro. PCR or in situ hybridization
therapy or prophylaxis with either ganciclovir or its prodrug studies reveal that only about one percent of peripheral blood
equivalent, valganciclovir. If untreated, infection may be mononuclear cells from carriers contain the viral genome
widely disseminated and almost any organ may be seriously but in such instances only the major immediate early gene
affected. The spectrum and severity of disease and the timing (IE1) is transcribed and translated. There is evidence to
of its development vary, depending on the underlying basis suggest that the viral genome persists principally in lineage-
for the immunosuppression, the nature of the transplant, committed myeloid cells, including progenitors giving
and whether infection is due to reactivation of endogenous rise to granulocytes, macrophages, and dendritic cells,
virus or de novo introduction of virus into a seropositive and also in endothelial cells, stromal cells, and/or ductal
or seronegative recipient. The most important presentations epithelial cells in salivary glands and renal tubules, from
are interstitial pneumonia, hepatitis, chorioretinitis, arthritis, which virus is shed into the saliva and urine respectively.
carditis, chronic gastrointestinal ulcerative lesions, such as It is now believed that the state of cell differentiation is a
gastritis or colitis, and various CNS diseases, especially factor controlling permissiveness; as primary peripheral
encephalitis, Guillain-Barré syndrome, and transverse blood monocytes differentiate to monocyte-derived
myelitis. Untreated CMV infection can also trigger graft macrophages, reactivation of latent CMV can be detected.
rejection; there is also an association with the accelerated There has been a debate whether persistence is maintained
atherosclerosis that is seen in transplant patients, although by a continuous low-level chronic productive infection, or
there may not be a direct causative link. by true latency in which episomal viral DNA is maintained,
but expression of most genes is restricted until reactivation
occurs. However, recent evidence suggests there is a distinct
Pathogenesis, Pathology, and Immunity subset of genes that are expressed in latency but not in
Once infected with CMV, an individual carries the virus for productive infection.
life and may shed it intermittently in saliva, urine, semen, Cell-mediated immunity appears to be principally
cervical secretions, and/or breast milk. Up to 10% of people responsible for controlling CMV. Studies of murine CMV
may be shedding virus at any one time, especially young in mice and of human CMV in humans have shown that NK
children. The intermittent nature of CMV shedding and cells are important to host defense early in infection, and
the fluctuations observed in antibody levels suggest that that CD8+ T lymphocytes directed at the major immediate
asymptomatic reactivation occurs regularly throughout life. early protein, IE1 and the tegument protein pp65, confer
Reactivation occurs more commonly during pregnancy, protection, although many other viral proteins are recognized
rising markedly as term approaches. Hormonal factors may by these cells in different subjects. Neutralizing antibodies
be responsible for this, but immunosuppression is generally directed mainly against the envelope glycoprotein gB, and
the most powerful trigger. CMV is a common cause of to a lesser extent gH, may contribute to protection, but
death in untreated AIDS patients as well as in transplant exogenous reinfection can occur. It is uncertain whether this
recipients, especially hemopoietic stem cell transplantation is generally with a different strain; more than one strain has
patients. The virus can be isolated from over 90% of been isolated concurrently from a single individual.
patients profoundly immunosuppressed for organ and tissue Although CMV infection elicits a virus-specific cell-
transplantation. Such infections generally are the result of mediated immune response, a number of characteristics
252 PART | II Specific Virus Diseases of Humans

of infection may contribute to its persistence in the body. they may be found in salivary glands or renal tubules of
First, the virus multiplies extremely slowly and can spread many normal children. Progressive damage may occur not
contiguously from cell to cell by fusion, thereby escaping only throughout pregnancy, but also after birth. The affected
neutralization by antibody. Second, a number of CMV- infant synthesizes specific IgM antibodies, and immune
coded proteins modulate and interfere with the immune complexes are plentiful, but CMV-specific and non-specific
response. For example, several viral proteins inhibit MHC cell-mediated immune responses are markedly depressed.
class I presentation of viral antigens by multiple mechanisms Postnatal or natal (intrapartum) infection is more common
during acute infection, thus perhaps protecting infected than prenatal infection and may occur via at least two different
cells to some degree from recognition and lysis by cytotoxic routes. Approximately 10% or more of women shed CMV
lymphocytes. A CMV protein, UL18, which displays from the cervix at the time of delivery; some of the babies
homology with the heavy chain of MHC class I proteins, who become infected sub-clinically may acquire the infection
can interact with β2-microglobulin, thereby not only during delivery. More severe disease including pneumonitis
interfering with T cell recognition but also coating the free and hepatosplenomegaly is common in premature infants,
virion and protecting it from antibody. Further, in common particularly in infants of seronegative mothers who acquire
with other herpesviruses, CMV codes for a protein with the infection as the result of blood transfusion. Second, 10%
functional characteristics of an Fc receptor, and this protects to 20% of nursing mothers shed CMV in their milk, and
the plasma membrane of the infected cell against immune their infants have a 50% chance of becoming infected via
attack in a manner similar to that described above for HSV. breastfeeding; such infections are subclinical and perhaps the
It is possible that delaying immune clearance of infection most common mode of transmission of CMV in the neonatal
helps to allow infection of myeloid progenitor cells and the period.
establishment of latency. Finally, CMV infection can also
be generally immunosuppressive, thereby also predisposing
CMV Infection in Later Life
to secondary infection with bacterial or fungal agents.
Oropharyngeal secretions are believed to constitute the
principal vehicle of transmission, not only in childhood
Congenital CMV Infection and Infection
but again in adolescence, either via direct contact or
in Infancy
contamination of hands, eating utensils, etc. Kissing and
Transplacental infection with CMV is now the commonest sexual contact no doubt account for the sudden increase
viral cause of prenatal damage to the fetus and newborn. in CMV seropositivity from 10% to 15% to 30% to 50%
Approximately one percent of all babies become infected between the ages of 15 and 30 in countries such as the United
in utero. A majority of these infections are derived from States, though it is difficult to determine unequivocally the
endogenous recurrences (reactivation) in the mother and relative importance of each of the two routes. CMV is also
are generally uneventful. In contrast, most cases of overt shed intermittently in cervical secretions and in semen,
congenital disease result from primary infections occurring hence sexual transmission may be significant, for example,
in the mother during the first 6 months of pregnancy. Hence CMV infection is almost universal among promiscuous
this syndrome tends to be a disease of affluence, as over 50% male homosexuals.
of women in developed countries, compared with less than The two remaining mechanisms of acquiring CMV,
10% in developing countries, are still seronegative as they blood transfusion and organ transplantation, constitute
enter child-bearing years. Primary infection during the first special cases of iatrogenic infection. Almost all those
six months of pregnancy carries a 30% to 40% risk of prenatal who receive multiple transfusions of large volumes of
infection and 10% to 15% risk of clinical abnormalities in blood develop CMV infection at some stage. Most such
the neonate. The risk of fetal infection following recurrent episodes are subclinical, but the mononucleosis syndrome
CMV infection during pregnancy is about one percent, with is not uncommon. More serious manifestations of primary
a low risk of fetal abnormality. Higher amounts of virus infection may occur following transfusion of seropositive
are transmitted to babies from mothers with primary than (infected) blood into seronegative premature infants,
with recurrent infection. The pre-existing immunity present pregnant women, or immunocompromised patients. CMV
in the latter also confers considerable protection against infection of recipients of kidney, heart, liver, or bone marrow
disease in the fetus, and major deficits other than unilateral transplants may also be of exogenous origin, introduced via
deafness are rare in babies infected prenatally as a result of the donated organ or via accompanying blood transfusions.
reactivation of maternal CMV. Such an exogenous infection may be primary or may be a
A minority of babies with clinical abnormalities at reinfection with a different CMV strain. On the other hand,
delivery are stillborn or die shortly after birth. Autopsy may the profound immunosuppression demanded for organ
reveal fibrosis and calcification in the brain and liver. Typical transplantation, or indeed for other purposes such as for
cytomegalic cells may be found in numerous organs; indeed, cancer therapy, is sufficient for the reactivation of a previous
 Herpesviruses Chapter | 17 253

management of the child and facilitates parental counseling.

TABLE 17.4 Syndromes Caused by Cytomegalovirus
In order to confirm a congenital infection, samples must
Infections
be taken within a few days of birth in order to distinguish
Age or Route of Disease Caused it from the more common, clinically benign, perinatal
Immunocompetence Acquisition by Primary infection. Classically, virus can be isolated in cultured
Infection human fibroblasts from urine or saliva samples. The virus
Prenatal Transplacental Encephalitis,
replicates slowly, but because these infants often have high
hepatitis, titers of virus, cultures may become positive within a few
thrombocytopenia days instead of the one to three weeks required to isolate
Long-term
smaller amounts of virus. The sensitivity and speed of the
sequelae brain method can be enhanced by use of culture-enhancement
damage, nerve centrifugation systems such as the shell vial assay, with
deafness, staining for early antigen. Detection of CMV DNA by PCR
retinopathy is now more widely used, and can be done on those dried
Perinatal Cervical Nil blood spots collected for genetic screening. Serology is
secretions, breast of less value, as a positive result for IgG antibodies will
milk, saliva reflect passive transfer of maternal antibodies to the infant;
Any age Blood transfusion Pneumonitis, the presence of CMV IgM antibodies indicates a congenital
disseminated infection, as IgM antibodies do not cross the placenta, but
disease
this may be present in only 70% of infected babies.
Saliva or sexual Mononucleosis,
intercourse mild hepatitis
Prenatal Diagnosis
Blood transfusion Mononucleosis
Pre-existing maternal infection is readily identified during
Immunocompromiseda Saliva, sex, organ Pneumonia,
graft, blood hepatitis, retinitis,
pregnancy by detection of CMV IgG antibodies. It is more
transfusion encephalitis, difficult to reliably identify a maternal primary infection
myelitis, with its more serious prognostic implications, since paired
gastrointestinal sera with appropriate timing to demonstrate a rising titer
disease are usually not available. CMV IgM antibody tests are
a
Diseases shown occur less commonly after reactivation of a latent not always reliable or consistent, and IgM antibodies
infection. can sometimes be detected during virus reactivations or
persisting for more than a year after the acute episode. An
alternative approach is the demonstration of low avidity IgG
antibodies, because antibody avidity progressively increases
infection. Primary CMV infections, in particular, are
after the initial infection as the immune response matures.
serious and often lethal in immunocompromised patients.
Prenatal diagnosis of fetal infection can be undertaken in
Primary infections are also often associated with rejection
women with primary or undefined CMV infection contracted
of the transplanted organ, for example, glomerulopathy in a
during the first half of pregnancy. This includes ultrasound
transplanted kidney. Reactivation of latent CMV is also one
examination for fetal abnormalities, culture of amniotic fluid
of the commonest opportunistic infections leading to death
for virus, and the quantitation of CMV DNA in amniotic
among untreated AIDS patients.
fluid by PCR; low viral DNA levels suggest an asymptomatic
The relationship between the circumstances of
fetal infection, whereas viral loads >103 copies/mL
transmission of CMV and the more common clinical
are suggestive of disease.
outcomes is summarized in Table 17.4.

Laboratory Diagnosis Immunocompromised Hosts

The strategies and techniques used for laboratory diagnosis CMV infections can be a life-threatening risk in
of cytomegalovirus infection vary according to the clinical immunocompromised persons, and early diagnosis is
setting. needed to ensure appropriate antiviral therapy is instigated.
It is important not only to detect CMV but to discern
whether the patient is undergoing an active acute infection
Congenital CMV Infection in the Newborn rather than an asymptomatic chronic infection accompanied
Laboratory confirmation of CMV in a newborn infant by virus shedding, and if so, whether that acute episode is
is important as it affects the medical and educational a primary infection of exogenous origin or an endogenous
254 PART | II Specific Virus Diseases of Humans

reactivation of a previous persistent infection. Serological Therapeutics

tests for IgG and IgM antibody and antibody avidity can
be used to distinguish primary from pre-existing infection Ganciclovir and valganciclovir (see Chapter 12: Antiviral
as described above. The most useful tests are the detection Chemotherapy) have dramatically reduced the impact
of the viral pp65 antigen by immunofluorescence in of CMV disease in immunosuppressed patients, and new
circulating polymorphs, and the detection of viral DNA therapeutic and prophylactic regimens continue to be
in plasma and urine by qualitative and quantitative PCR. explored. Ganciclovir is active against herpes simplex, but
The detection of pp65 antigen is less sensitive than PCR is also 100 times more active than acyclovir against CMV.
and may not be easy to do in neutropenic patients, but CMV does not possess a homolog of the HSV thymidine
both a positive antigen test and high DNA levels are valuable kinase gene, and the activity of ganciclovir in CMV-
indicators of invasive disease, and serve as an indication infected cells is via direct phosphorylation by a CMV-coded
to initiate antiviral therapy. Other specimens appropriate protein kinase, the product of the UL97 gene. Intravenous
to particular clinical presentations include bronchoalveolar ganciclovir is the drug of choice for the treatment of severe
lavage and samples from various organs taken at biopsy or CMV infections such as pneumonia, chorioretinitis, or
autopsy. colitis in AIDS patients and recipients of organ grafts. When
There is only a single serotype of human CMV, administered intravenously for up to 3 months ganciclovir
but different strains can be distinguished by kinetic often leads to fever, rashes, diarrhea, and hematological
neutralization, restriction endonuclease mapping, or toxicity: resistant viral mutants can also emerge.
sequencing. These techniques can also be employed in As ganciclovir must be administered intravenously, it
identifying the source of virus. has been replaced in many indications by its valine ester
valganciclovir which is delivered orally: valganciclovir is
cleaved to ganciclovir in the gut and the liver. It is the drug
Epidemiology, Prevention, Control, and of choice for routine CMV prophylaxis for bone marrow
and solid organ transplant patients. It can be used to treat
Therapeutics CMV chorioretinitis in AIDS patients, and has also been
Iatrogenic infection via blood transfusion or organ considered for prophylaxis against CMV in HIV-infected
transplantation can be reduced by screening both donor people who have severe immunosuppression.
and recipient for evidence of CMV infection through the Useful second-line drugs when CMV develops
detection of IgG antibodies. The presence of antibodies in the resistance to ganciclovir include foscarnet, cidofovir,
intended recipient indicates a significant degree of immunity, maribavir, and high-dose valaciclovir or related compounds
whereas antibodies in the donor provide a warning that (see Chapter 12: Antiviral Chemotherapy).
virus, or reactivatable viral episomes, may be transmitted
to the recipient with adverse consequences. This potentially
Vaccines
dangerous combination is averted if seronegative recipients
are given organs or blood taken only from seronegative The development of a vaccine against CMV has been
donors. The amount of testing involved is not cost-effective recognized as a high priority and is likely to be cost-
for routine blood transfusions but CMV-negative blood effective. The major aim would be a reduction in congenital
should be used when the recipients are premature infants, CMV disease, the leading viral cause of sensorineural
pregnant women, or immunocompromised individuals. hearing loss and neurodevelopmental delay. CMV
Removal of the leukocytes by filtration of donor blood presents particular scientific challenges; natural immunity
effectively prevents transmission of CMV. following infection is only partial, latent infection
Some authorities have proposed routine screening in invariably persists despite an immune response, primary
pregnancy to identify non-immune women. This would infection is usually asymptomatic and not recognized, and
allow adoption of simple hygiene measures to reduce the good animal models are not available. Nevertheless the
risk of infection, including care with the handling of body successful introduction of the vaccine against VZV, a virus
fluids, particularly in nurseries and daycare centers where with some biological similarities to CMV, has provided
CMV excretion is common. For women who do seroconvert, some encouragement.
CMV hyperimmune globulin may be of value in preventing Live attenuated CMV vaccine strains, for example, the
perinatal transmission, and CMV hyperimmune globulin Towne strain, have been developed by serial passage in
and/or antivirals may reduce the risk of sequelae in infants human fetal fibroblasts. Although these vaccines confer
who do become infected, although objective evidence of some protection against disease they do not protect these
benefit is still limited. Universal screening is not generally against infection, and therefore presumably latent infection
accepted at present, but screening may be clinically justified can still develop. The question of the safety of live CMV
in particular risk situations. vaccines must also be addressed, particularly in relation
 Herpesviruses Chapter | 17 255

to adequacy of attenuation, establishment of persistence, Clinical Features

subsequent reactivation, and possible oncogenicity. Many
alternative approaches are at various stages of development; Although the majority of infections are asymptomatic,
these include a recombinant gB envelope subunit vaccine, HHV-6B causes the childhood illness roseola infantum, also
DNA vaccines, peptide vaccines, and vaccines based on known as exanthema subitum or sixth disease. The illness
either poxvirus or adenovirus vectors. Several of these have begins with the abrupt onset of a febrile phase lasting three
recently shown encouraging results in phase II trials. to five days, sometimes accompanied by bilateral periorbital
edema and/or febrile convulsions. This may be followed by
an erythematous maculopapular rash starting on the trunk
HUMAN HERPESVIRUSES 6 AND 7 and then spreading centrifugally to the face and limbs,
(HHV-6 AND HHV-7) INFECTION coinciding with the return of body temperature to normal.
HHV-6 was discovered in human lymphocytes in 1986. Commonly, not all of these aspects may be seen, and
Since then it has been shown to be ubiquitous, infecting HHV-6 is a frequent cause of an acute non-specific febrile
most children worldwide in the first year or two of life. illness or febrile convulsions in children under two years
The closely related HHV-7 was first isolated in 1990 from of age. Meningoencephalitis may occasionally occur, and
CD4+ T cells. Both viruses cause a generally harmless there have been isolated reports of other possible clinical
febrile illness sometimes associated with a rash which associations, such as hepatitis. Adults have been reported
has been known since the early 20th century as exanthem with fever, lymphadenopathy, and a mononucleosis-like
subitum, roseola infantum, or sixth disease. syndrome with negative test results for CMV and EBV.
Symptomatic infection with HHV-6A is largely seen
in immunocompromised hosts after solid organ or bone
Properties of HHV-6 and HHV-7 marrow transplantation, where it can cause multiorgan
The biological properties of HHV-6 resemble those of involvement, accelerate graft rejection, and contribute to
CMV, and sequencing of the genome has confirmed a morbidity and mortality. HHV-7 is less well studied but
taxonomic relationship. The genome occurs as a single appears similar in manifestations to HHV-6B although
isomer consisting of a unique 142-kb segment flanked by clinical roseola is less common.
a direct repeat sequence of 10 to 13 kb as a single copy at HHV-6 has been investigated for a possible etiological
each end. HHV-6 is classified as a species within the genus or triggering role in multiple sclerosis, chronic fatigue
Roseolovirus, within the subfamily Betaherpesvirinae. syndrome, Hashimoto’s thyroiditis, and other conditions.
There are two strains, HHV-6A and HHV-6B, with 95% Needless to say, the widespread natural distribution of the
sequence homology, but these are now viewed as separate virus, both within populations and within the body, makes
species as the two viruses can be distinguished by restriction confirming or disproving such proposals a demanding
endonuclease mapping and reactivity with subsets of virus- exercise.
specific monoclonal antibodies. HHV-6A strains have
been isolated mainly from adults, whereas most exanthem Pathogenesis, Pathology, and Immunity
subitum isolates have been characterized as due to HHV-6B.
Interestingly, HHV-6 is the only human herpesvirus in HHV-6 replicates most efficiently in dividing CD4+ T
which latency involves integration of the viral genome into lymphocytes and continuous T cell lines, Infected T cells show
chromosomal DNA rather than persistence as episomal ballooning, often with more than one nucleus and nuclear
DNA. The direct repeat termini of the HHV-6 genome or cytoplasmic inclusions, or both, before eventually dying.
contain the hexanucleotide TTAGGG identical to a sequence Macrophages are persistently infected and may represent an
present in the telomeres of mammalian chromosomes, and important reservoir. Transformed B lymphocytes, NK cells,
HHV-6 integrates into sub-telomeric regions of preferred megakaryocytes, glial cells, fibroblasts, and epithelial cells
chromosomes. A limited number of genes are transcribed have also been reported to support the productive replication
during latency, and reactivation of replicating virus occurs of certain HHV-6 strains in culture. HHV-6A is readily
intermittently. Up to one percent of the population has been demonstrable by in situ hybridization and immunofluorescence
found to have chromosomally integrated HHV-6 (“CIHHV- in salivary glands, and is regularly isolated from saliva,
6”), in which every cell including the germ line contains suggesting that salivary glands may represent a major reservoir,
integrated and complete HHV-6 genomes, with high viral with saliva the main route of transmission. Reactivation is
loads (e.g., >5.5 log10 copies/mL) may be found in whole precipitated by immunosuppression, as in transplantation and
blood, but usually low levels in plasma. The infection is in AIDS patients.
vertically transmitted in a Mendelian manner. Such infections HHV-6 infection leads to multiple dysregulation of the
are usually asymptomatic but may be misdiagnosed as an immune system. There is impairment of immune function
acute primary infection. and a variety of mechanisms have been identified, including
256 PART | II Specific Virus Diseases of Humans

suppression or depletion of CD4+ T cells, cytotoxic effector encephalitis, severe infections in immunosuppressed) have
cells, macrophages, dendritic cells, cytokine production, been treated with ganciclovir, foscarnet, or cidofovir, based
and innate antiviral responses. The virus codes for proteins on in vitro sensitivity data and limited experience in patients.
analogous to chemokines and chemokine receptors, and
this molecular mimicry may facilitate latency in a way yet EPSTEIN-BARR VIRUS INFECTION
to be defined. HHV-6 also codes for gene products that
transactivate HIV-1 long terminal repeat (LTR)-directed Clinical Features
gene expression. Co-infection with HHV-6A has been shown
to accelerate disease progression in pigtailed macaques Infectious Mononucleosis (Glandular Fever)
infected with simian immunodeficiency virus, and there In young children EBV infections are asymptomatic
is evidence of its presence accelerating the progression of or very mild. However, when infection is delayed until
HIV infection in humans. adolescence, as happens in developed countries, the
result is often infectious mononucleosis. Following a long
incubation period (four to seven weeks), the disease begins
Laboratory Diagnosis
insidiously with headache, malaise, and fatigue. The clinical
Exanthem subitum may be mistaken clinically for measles or presentation can vary, but three regular features are fever,
rubella. Laboratory diagnosis of primary infection can be made pharyngitis, and generalized lymphadenopathy, although
by demonstrating a four-fold rise in antibody titer measured by some patients may present without pharyngitis. The fever is
ELISA or immunofluorescence (IFA), but IgM antibody tests high and fluctuating, and the pharyngitis is characterized by
have not proved as reliable or specific. Detection of significant a white or gray malodorous exudate covering the tonsils that
viral DNA levels by PCR in plasma can give presumptive may occasionally be so severe as to obstruct respiration. The
evidence of primary infection, since viral loads are much spleen is often enlarged and liver function tests abnormal.
lower or not detected in chronic infection. Reactivation can In around 10% of patients a faint, widespread non-itchy
be suspected if a qualitative PCR detects viral DNA in serum, maculopapular rash may last for about a week. This is
or if a quantitative PCR demonstrates a high titer of virus in different from the more intense, itchy, maculopapular rash
a whole blood sample. Distinguishing between HHV-6A, on extensor surfaces and pressure points that commonly
-6B, and -7, and diagnosing primary HHV-7 infection in an appears following misguided treatment with amoxicillin or
individual persistently infected with HHV-6, requires more ampicillin (but not penicillin), and is thought to represent
specific tests. Virus can be isolated from peripheral blood some kind of unexplained hypersensitivity reaction. The
mononuclear cells of roseola patients in the early febrile clinical disease usually lasts for two to three weeks, but
stage of the illness, or from saliva of adults intermittently convalescence may be very protracted.
throughout life, by centrifugation-enhanced infection of An extraordinary range of further complications can
phytohemagglutinin-activated peripheral blood leukocytes. occasionally occur. Neurological complications include
Alternatively, virus can be detected using T cell lines: HHV-6 Guillain-Barré syndrome, Bell’s palsy, meningoencephalitis,
antigen is identified in infected cells by immunofluorescence and transverse myelitis. Other complications include
using an appropriate monoclonal antibody. hemolytic anemia, thrombocytopenia, carditis, nephritis,
and pneumonia. Splenic rupture, either spontaneous or
Epidemiology, Prevention, Control, and following trauma, is a potentially serious complication seen
in 0.1% to 0.5% of patients. As may occur after a number of
Therapeutics acute systemic infections, a very small minority of patients
Serological surveys indicate that almost all children have can progress to develop chronic fatigue syndrome (see
been infected with HHV-6 by two to three years of age, Chapter 39: Viral Syndromes). This sometimes disabling
strongly suggesting intrafamilial spread, probably from the entity is diagnosed using a specific panel of distinct clinical
mother shortly after maternal antibodies have declined in criteria and is associated with a range of disturbances in
the infant. The high incidence of shedding of virus in saliva cellular immunity that may represent a final common
points to this as the likely, but not necessarily the only, pathway following a number of different infections.
natural route of transmission. HHV-7 tends to be acquired
later, in the first five or six years of life; the reasons for this Infection in Immunocompromised Hosts
difference are not known.
A variety of syndromes associated with uncontrolled
progression of infection occur in individuals with congenital
Therapeutics
or an acquired inability to mount an adequate immune
Although no international guidelines have yet been response to EBV. For example, a rare fatal polyclonal B cell
developed, life-threatening infections with HHV-6 (e.g., proliferative syndrome caused by EBV infection occurs
 Herpesviruses Chapter | 17 257

in families with an X-linked recessive immunodeficiency infected B cells can exist in three different phenotypes
associated with a reduced ability to synthesize interferon γ (known as latency I, latency II, and latency III, depending
(X-linked lymphoproliferative syndrome). There is on the respective restricted but distinctive pattern of viral
an inexorable expansion of virus-infected B cells and gene expression). The genome persists as a circular, self-
concomitant suppression of normal bone marrow cells, replicating episome in the B cell nucleus. At least one of
and about half of boys die within a month from sepsis or the viral gene products, EBNA-2, immortalizes the B cell.
hemorrhage; the remainder develop dysgammaglobulinemia Each resulting B cell clone secretes its own characteristic
or die from malignant B cell lymphomas. monoclonal antibody. The “heterophile” antibodies that
Much more common is progressive lymphoproliferative result from this polyclonal B cell activation represent
disease, seen in immunodeficient children, AIDS just one manifestation of the immunological chaos that
patients, or transplant recipients (post-transplantation characterizes the acute phase of infectious mononucleosis.
lymphoproliferative disorders, PTLDs). In these By the end of the incubation period (30 to 50 days), up to
immunocompromised individuals, the absence of cell- 25% to 50% of circulating memory B cells are latently
mediated immunity permits unrestrained replication of infected. There is also a general depression of cell-
EBV, acquired exogenously or reactivated from the latent mediated immunity with an increase in regulatory T cells.
state. Some of the infections present as mononucleosis, but Meanwhile, clones of CD8+ cytotoxic T lymphocytes that
others are atypical, presenting, for example, as pneumonitis recognize class I MHC-bound peptides derived from EBV
or hepatitis. Infants with AIDS develop a lymphocytic proteins EBNA-2 to EBNA-6 and latent membrane protein
interstitial pneumonitis; adults with AIDS may develop (LMP) become activated to proliferate and lyse B cells and
EBV-associated lymphoproliferative conditions of various oropharyngeal epithelial cells expressing LMP protein on
kinds. the cell surface. It is these cytotoxic T lymphoblasts, not the
infected B cells, that comprise the pathognomonic “atypical
lymphocytes” so characteristic of infectious mononucleosis
Burkitt’s Lymphoma, Nasopharyngeal
(Fig. 17.8B). They also are the major contributors to the
Carcinoma, and Other Malignancies
lymphadenopathy. In individuals with congenital or
The reader is referred to Chapter 9: Mechanisms of Viral acquired T cell immunodeficiencies, unrestrained virus
Oncogenesis for a discussion of the highly malignant replication continues, and B cell lymphomas or other lethal
neoplasms Burkitt’s lymphoma and nasopharyngeal conditions may overwhelm the patient.
carcinoma, and their relationship to EBV. The virus is also Most infected B cells are killed by the host immune
associated with a proportion of Hodgkin and non-Hodgkin defense, but approximately 1 in 100,000 persist as small,
lymphomas, other NK/T cell lymphomas, lymphoepithelial- non-proliferating memory B cells, with either no EBV
like carcinomas, and gastric carcinomas. A cerebral protein expression or latency I or II. These cells are
lymphoma is characteristic. important as a potential long-term reservoir of virus: these
The oncogenesis of many EBV-related tumors is not cells begin to produce infectious virus when cultivated in
fully understood. However, it is clear that a breakdown in vitro. After trafficking to adjacent epithelial cells in the
the immune surveillance of EBV-infected cells contributes oropharynx, the memory B cells can become stimulated
to the survival of the virus-bearing tumor cells. Tumor cells to produce virus once more and deliver virus to permissive
carrying EBV genomes usually show a “latency profile” of epithelial cells, from whence virus is shed in saliva to
partial genome expression. reach a new host. In the long term, a remarkable state of
Treatments of EBV-related malignancies include equilibrium is set up between active immune elimination
conventional approaches (surgery, chemo-, and of infected B cells recognized as bearing viral targets, and
radiotherapy) as well as a reduction in immunosuppression the selection of persistently infected B cells representing a
and the transfer of EBV-specific T cells from genetically more benign latent state.
related donors. Strains of EBV fall into two classes, based mainly
on differences in sequence of the nuclear antigen genes
EBNA-2 and EBNA-3. EBV-1 is 10 times more common
Pathogenesis, Pathology, and Immunity than EBV-2 in Europe and the United States, whereas
In primary infection, EBV replicates in both locally EBV-2 is more common in Africa, New Guinea, and among
infiltrating B cells and epithelial cells of the nasopharynx immunocompromised, particularly HIV-infected patients.
and salivary glands, especially the parotid, and infectious
virions are released into the saliva (Fig. 17.8A). Proliferating
Laboratory Diagnosis
B cells resembling lymphoblastoid cell line (LCL)-like cells,
with latency III form of expression (see below), arise in the The clinical picture of infectious mononucleosis can be so
tonsillar tissue and are found in the circulation. Latently variable that laboratory confirmation is normally required.
258 PART | II Specific Virus Diseases of Humans

FIGURE 17.8 (A) Epstein-Barr virus (EBV) primary and persistent infection. (Left) Primary infection. Epstein-Barr virus infects epithelial cells in
the oropharynx (e.g., the tonsils), and then infects resting B cells in the lymphoid tissue. Virus-infected B cells produce the full complement of latent
viral proteins and RNAs (e.g., LMP-1 and LMP-2), and are stimulated to enter mitosis and proliferate. These cells may enter the circulation and produce
antibody and function as B cells. During the acute phase, these latently infected B cells are attacked by natural killer cells and CTLs, and the clinical
syndrome of infectious mononucleosis is seen. (Right) Persistent infection. Most infected B cells are killed as a result of innate and immune defenses, but
a few (approximately 1 in 100,000) persist in the blood as small, non-proliferating memory B cells that synthesize only LMP-2A mRNA. These memory
B cells are presumably the long-term reservoir of Epstein-Barr virus in vivo and the source of infectious virus when peripheral blood cells are removed
and cultured. (B) Blood film of patient with infectious mononucleosis, showing an atypical lymphocyte (reactive T cells) with large pleomorphic lobulated
nuclei. A normal lymphocyte is shown above for comparison. (A): Reproduced from Flint, S.J., et al., Principles of Virology, Vol. II, 3rd edition, p. 157.
ASM Press, with permission. (B): Reproduced from Cooke, R.A., Infectious Diseases, McGraw Hill, with permission.
 Herpesviruses Chapter | 17 259

This rests on (1) differential white blood cell counts, (2) disease is that a high proportion of asymptomatic
heterophile antibodies, and (3) EBV-specific antibodies. individuals carry the latent genome and/or shed virus
By the second week of the illness, the white blood for life.
cell count is raised 10,000 to 20,000 per cubic millimeter
or even higher. Lymphocytes plus monocytes account for
60% to 80% of this number. Of these, at least 10%, and Epidemiology, Prevention, Control, and
generally more than 25%, are atypical lymphocytes, that Therapeutics
is lymphocytes that are larger than normal with large Following an attack of mononucleosis, virus is found in saliva
pleomorphic lobulated nuclei and deeply basophilic for several months, and more sensitive assays reveal that
vacuolated cytoplasm (Fig. 17.8B), that persist for two most EBV-seropositive people secrete the virus at a lower
weeks to several months. titer thereafter, continuously or intermittently, probably
In 1932 John Paul and William Bunnell made the for life. Chronic shedding is highest in young children, in
empirical observation that sera from glandular fever patients early pregnancy, and in immunocompromised patients. In
agglutinate sheep erythrocytes. These agglutinins are just most developing countries EBV infection is ubiquitous.
one of the “non-Forssmann” heterophile antibodies elicited Almost all infants become infected in the first year or two
by EBV infection: heterophile antibodies are a group of of life, probably by salivary exchange, contamination of
IgM antibodies that react with red blood cell antigens from eating utensils, and other oropharyngeal contact. At this
other species. Heterophile antibodies are often detected by age almost all infections are subclinical; glandular fever
the time of onset of symptoms, reach a peak between two is virtually unknown in developing countries. By way of
and five weeks later, and can be measured for up to 1 contrast, in countries with higher standards of living many
year. The Paul–Bunnell test is still useful. Commercially persons reach adolescence before first encountering the
available kits use red blood cells or sensitized latex virus. When primary infection occurs in adolescence, there
particles as an indicator of agglutination, although test is a much higher likelihood of clinical disease developing.
sera may require prior absorption to remove non-specific The intimate salivary contact involved in kissing is the
“Forssmann” antibody activity. In some patients, the test principal means of transmission. Mononucleosis is a
may remain negative for one to two weeks following the disease of 15- to 25-year-olds. More than 90% of people
onset of symptoms, and in some cases it remains negative, eventually acquire infection and are permanently immune
therefore virus-specific antibody tests also play a key (see Fig. 13.5).
confirmatory role. As with CMV, conventional respiratory transmission
IgM antibodies against the EBV capsid antigen VCA of EBV by droplets does not appear to be significant. For
develop to high titer early in the illness and then decline example, casual roommates of mononucleosis patients
rapidly over the next three months or later; this therefore are not at increased risk and much closer contact seems to
represents a good index of primary infection. VCA or be required. By analogy with CMV it may be reasonable
other cloned EBV antigens can also be used to screen for to speculate that EBV can also be transmitted by sexual
IgG antibodies. Because antibodies to EBNA first appear intercourse. In this context male homosexuals have a very
a month or more after onset of disease and then persist, a high rate of seropositivity. Blood transfusions can also
rising titer is diagnostic. It should be noted, however, that rarely transmit the virus.
antibody to EBNA-1 is specifically missing from many
immunocompromised patients with severe chronic active
infection. On the other hand, antibodies against the early Therapeutics
antigen EA-D are diagnostic of acute, reactivated, or Although acyclovir inhibits EBV replication by inhibiting
chronic active infection, as they decline rapidly and are not the DNA polymerase, oral or intravenous administration of
detected in asymptomatic carriers. IgG (or total) antibodies acyclovir has not shown clinical benefit in acute infections,
against VCA represent the most convenient measure of past presumably because the symptomatic phase results from
infection and the immune status of the individual. the immunopathology in response to the EBV-transformed
Isolation of virus is rarely used as a diagnostic procedure B lymphocytes. Available antiviral drugs have not shown
because no known cell line is fully permissive for EBV. The any benefit against chronic infection or EBV-related
only method for isolating EBV in vitro is to inoculate infected malignancies.
oropharyngeal secretions or peripheral blood leukocytes
onto umbilical cord lymphocytes and to demonstrate the
Vaccines
immortalization of the latter into a lymphoblastoid cell
line that can be stained successfully with fluoresceinated It is now clear that cytotoxic T cells play a major role in
monoclonal antibody against EBNA. The other problem controlling both lytic and latent EBV infection, with
with virus isolation for routine diagnosis of EBV-induced immunodominant T cell responses demonstrable against
260 PART | II Specific Virus Diseases of Humans

both lytic and latent stage viral antigens. Possible vaccine

strategies include a prophylactic vaccine to prevent
primary infection, thereby reducing both glandular fever
in developed countries and EBV-related malignancies, or
a therapeutic vaccine to treat malignancies associated with
latent infection. Approaches under current development
include subunit and recombinant vaccines based on the
major membrane glycoprotein complex gp350/gp220 to
generate neutralizing antibodies; peptide epitope vaccines,
either in adjuvant or loaded onto dendritic cells; and a
poxvirus vector coding for antigenic viral fusion proteins. In
a phase II human trial, a gp350 subunit vaccine reduced the
incidence of clinical infectious mononucleosis but did not
affect the rate of EBV infection. For therapeutic vaccines,
the antigens selected include viral proteins LMP-1 and
-2 and EBNA-1 as these antigens are displayed on EBV-
associated nasopharyngeal and Hodgkin’s lymphoma cells
and thus offer targets for immune attack.
FIGURE 17.9 H&E stained section of Kaposi sarcoma, showing
malignant spindle cells arranged in whorls forming vascular channels.
HUMAN HERPESVIRUS 8 (HHV-8: KAPOSI’S
SARCOMA-ASSOCIATED HERPESVIRUS)
tumors, the majority of Kaposi’s sarcoma-associated spindle
INFECTION
cells (a tumor cell that expresses markers of both endothelial
Classical Kaposi’s sarcoma is an uncommon multicentric cells and macrophages) contain HHV-8 DNA, as a latent or
tumor of endothelium occurring typically in older non-productive infection in most cells (Fig. 17.9).
Mediterranean men. A more aggressive form of Kaposi’s Serological surveys of blood donors have demonstrated
sarcoma in younger men emerged in nearly 40% of that the prevalence of HHV-8 varies widely, ranging from
persons infected with HIV in the mid-1980s and became >70% in parts of Africa and Mediterranean countries to
recognized as a marker for AIDS. There was speculation 3% or less in North America and many other regions of
that, in addition to the HIV-related loss of tumor immune the world. HHV-8 is frequently detected in the saliva
surveillance, pathogenesis of Kaposi’s sarcoma might of seropositive individuals, and transmission is thought
include a role for the enhanced acquisition of an exogenous to be by saliva within families and by sexual intercourse.
oncogenic pathogen. The eventual discovery of a new Clinically, primary infection with HHV-8 has been linked
herpesvirus HHV-8 resolved this debate. An endemic type to a febrile illness with a maculopapular rash in children,
of Kaposi’s sarcoma in sub-Saharan African populations, or with lymphadenopathy in homosexual men and in organ
and an iatrogenic type in immunosuppressed individuals, transplant recipients. A lifelong latent infection may be
are also recognized. All four syndromes require HHV-8 complicated by the late development of HHV-8-associated
infection. angioproliferative and lymphoproliferative disorders.
HHV-8 is classified within the subfamily Kaposi’s sarcoma presents as a group of scattered flat
Gammaherpesvirinae, and while having some similarities violaceous plaques or nodules of characteristic appearance.
to EBV it is considered as a separate species within the These are rarely painful or life-threatening except when
genus Rhadinovirus. A number of different subtypes and there is extensive involvement of the lungs or gastrointestinal
clades have been described, all of which tend to cluster tract. Treatments used include surgery, local irradiation,
by geographical region, and virus isolated from a single liposomal anthracyclines, cytotoxic agents, and interferon.
individual does not vary over time. HHV-8 can produce a Ganciclovir treatment prior to the onset of Kaposi’s
latent infection with limited expression of genes from the sarcoma may reduce its incidence, and adequate anti-HIV
viral episome, or a lytic infection with the ordered cascade chemotherapy can reduce the subsequent development of
of gene expression typical of herpesviruses. In infected disease by up to 90%. HHV-8 is also associated with the late
patients, HHV-8 DNA has been found in circulating B onset of two lymphoproliferative disorders. Multicentric
lymphocytes as well as in prostatic epithelial cells and Castleman’s disease (MCD) involves lymphadenopathy,
salivary epithelial cells, the latter possibly contributing to splenomegaly, recurrent fevers, and autoimmune
the shedding of virus in saliva and semen. It expresses many phenomena, with different forms of histology in biopsies
immune-evasion genes unlike EBV which gains the same taken from infected lymph nodes. It frequently progresses
effect by manipulating cellular genes. In Kaposi’s sarcoma to Kaposi’s sarcoma or to lymphoma. Primary effusion
 Herpesviruses Chapter | 17 261

lymphoma and related lymphomas arise usually in HIV- FURTHER READING

positive patients. Abnormal tumor cells of B cell origin are
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