Rosen & Barkin's 5-Minute Emergency Medicine Consult (344 page)

• Systemic or severe infection requiring hospitalization:
  
  • Acyclovir: 5–10 mg/kg IV over at least 1 hr q8h for 5–10 days
    
    • Neonate/peds: 10–20 mg/kg IV over at least 1 hr q8h for 7–10 days
      
• 1st episode (7–10 day therapy; extend if not healed in 10 days):
  
  • Acyclovir: 400 mg PO TID or 200 mg PO 5 times per day:
    
    • Peds: 20 mg/kg PO TID or 5 mg/kg IV q8h.
      
  • Famciclovir: 250 mg PO TID for 7–10 days
    
  • Valacyclovir: 1,000 mg PO BID for 7–10 days
    
• Recurrent infection (5 day therapy):
  
  • Must start within 1 day of appearance of lesion or during prodrome
    
  • Acyclovir: 800 mg PO TID for 2 days or 800 mg PO BID for 5 days.
    
  • Famciclovir: 1,000 mg PO BID for 1 day or 125 mg PO BID for 5 days.
    
  • Valacyclovir: 500 mg PO BID for 3 days or 1,000 mg PO daily for 5 days.
    
• Suppressive therapy (daily):
  
  • Acyclovir: 400 mg PO BID
    
  • Famciclovir: 250 mg PO BID
    
  • Valacyclovir: 500 mg PO daily or if > 10 recurrences yearly, 1,000 mg PO daily
    
• Treatment of patients with HIV coinfection:
  
  • Recurrent infection (5–10 days therapy):
    
    • Acyclovir: 400 mg PO TID
      
    • Famciclovir: 500 mg PO BID for 5–10 days
      
    • Valacyclovir: 1,000 mg PO BID
      
  • Suppressive therapy:
    
    • Acyclovir: 400–800 mg PO BID–TID
      
    • Famciclovir: 500 mg PO BID
      
    • Valacyclovir: 500 mg PO BID
      

FOLLOW-UP

• Systemic involvement (encephalitis, meningitis), significant dissemination
  
• Severe local symptoms (pain, urinary retention)
  
• Severely immunocompromised patient
  

• Immunocompetent patient without systemic involvement
  
• Discharge counseling:
  
  • Avoid sexual contact during prodrome until healed
    
  • Practice safe sex techniques even if there are no lesions
    
  • Expect future recurrences; consider suppressive therapy if frequent
    
  • Analgesics and antipruritics as needed
    
  • Dysuria and urinary retention may be relieved with sitz baths or pouring warm water over lesions during urination
    

• Neonatal herpes infection
  
• Sexual abuse in children
  
• Herpes infection during pregnancy
  

• Treat primary infections
  
• Consider sexual abuse in children with genital herpes
  
• Herpes is a lifelong infection
  

• ACOG Committee on Practice Bulletins. ACOG Practice Bulletin No. 82: Management of herpes in pregnancy.
  Obstet Gynecol.
  2007;109:1489–1498.
  
• Borhart J, Birnbaumer DM. Emergency department management of sexually transmitted infections.
  Emerg Med Clin North Am
  . 2011;29:587–603.
  
• Cernik C, Gallina K, Brodell RT. The treatment of herpes simplex infections: An evidence based review.
  Arch Intern Med
  . 2008;168:1137–1144.
  
• Corey L, Wald A. Maternal and neonatal herpes simplex virus infections.
  N Engl J Med.
  2009;361:1376–1385.
  
• Roett MA, Mayor MT, Uduhiri KA. Diagnosis and management of genital ulcers.
  Am Fam Physician
  . 2012;85:254–262.
  
• Sexually transmitted diseases treatment guidelines 2010. Centers for Disease Control and Prevention. Available at
  http://www.cdc.gov/std/treatment/2010/genital-ulcers.htm
  

See Also (Topic, Algorithm, Electronic Media Element)

Herpes Simplex

CODES

• 054.10 Genital herpes, unspecified
  
• 054.11 Herpetic vulvovaginitis
  
• 054.13 Herpetic infection of penis
  

BASICS

• Sudden, involuntary contraction of the diaphragm (usually unilateral) and other inspiratory muscles terminated by abrupt closure of the glottis
  
• Medical terminology: Singultus
  
• Usually occur with a frequency of 4–60/min
  
• Occurs as a result of stimulation of the hiccup reflex arc:
  
  • Irritation of the vagus and phrenic nerves
    
  • The “hiccup center” is located in the upper spinal cord or brainstem
    
• Classification:
  
  • Hiccup bout: <48 hr
    
  • Persistent hiccups: 48 hr–1 mo
    
  • Intractable hiccups: >1 mo
    
• Male > female (4:1)
  

• GI:
  
  • Gastric distention, overeating, eating too fast
    
  • Esophageal: Gastroesophageal reflux, achalasia, candida esophagitis, cancer
    
  • Gastric: Ulcers, cancer
    
  • Hepatic: Hepatitis, hepatoma
    
  • Pancreatic: Pancreatitis, pseudocyst, cancer
    
  • Bowel obstruction
    
  • Inflammatory bowel disease
    
  • Cholelithiasis, cholecystitis
    
  • Appendicitis
    
  • Abdominal aortic aneurysm
    
  • Postoperative, abdominal procedure
    
• Diaphragmatic irritation:
  
  • Hiatal hernia
    
  • Intra-abdominal mass
    
  • Pericarditis
    
  • Eventration
    
  • Splenomegaly, hepatomegaly
    
  • Peritonitis
    
• CNS:
  
  • Vascular lesions: Ischemic/hemorrhagic stroke, head trauma, arteriovenous malformations
    
  • Infectious: Encephalitis, meningitis, abscess
    
  • Structural: Cancer, Parkinson disease, multiple sclerosis, hydrocephalus
    
  • Ventriculoperitoneal shunt
    
• Thoracic:
  
  • Infectious: Pneumonia, TB
    
  • Cardiac: MI, pericarditis
    
  • Aortic aneurysm
    
  • Cancer
    
  • Mediastinal lymphadenopathy
    
• Head and neck:
  
  • Otic foreign body irritating the tympanic membrane
    
  • Pharyngitis
    
  • Laryngitis
    
  • Goiter
    
  • Retropharyngeal/peritonsillar abscess
    
  • Neck mass
    
• Metabolic:
  
  • Uremia
    
  • Hyponatremia
    
  • Hypocalcemia
    
  • Gout
    
  • DM
    
• Toxic/drug induced:
  
  • Alcohol
    
  • Tobacco
    
  • α-methyldopa
    
  • Benzodiazepines
    
  • Steroids
    
  • Barbiturates
    
  • Narcotics
    
  • Chemotherapeutic agents
    
  • Antibiotics
    
  • General anesthesia
    
• Psychogenic causes:
  
  • Stress/excitement
    
  • Grief
    
  • Malingering
    
  • Conversion disorder
    
• Idiopathic
  

DIAGNOSIS

• Characteristic sound abruptly ending an inspiratory effort
  
• Attacks usually occur at brief intervals and last only a few seconds or minutes.
  
• Attacks lasting >48 hr or persisting during sleep suggest an organic etiology.
  

• Targeted history and review of systems to determine likelihood of potential underlying etiology:
  
  • Severity and duration of current episode
    
  • History of previous episodes and treatment attempts
    

• Careful physical exam in search of an underlying cause, with exam focused on:
  
  • Head and neck
    
  • Chest
    
  • Abdomen
    
  • Neurologic