Laboratory Studies

Scrapings from suspected lesions of herpes simplex (Tzanck smear). This is not a reliable screening test, with a reported sensitivity of 65%. It also does not identify the type of herpes simplex virus (HSV) present.

Multinucleated giant cells, as shown in the image below

Tzanck smear showing a multinucleated giant cell.
View Media Gallery
Intranuclear inclusions

Viral culture from skin vesicles (more sensitive that Tzanck smear but dependent on duration of viral shedding); consider the following:

Preferably from vesicular lesions within 3 days of appearance
The earlier the sample is taken, the more accurate the results

Monoclonal antibody testing; consider the following:

Primarily used when other methods cannot be used (ie, no active lesions to swab)
Also used when other methods yielded negative results but there still is significant concern for infection ^[14]

Serology

HSV IgG detection via ELISA or Western blot

Cerebrospinal fluid (CSF) analysis for lymphocytic pleocytosis

Bloody CSF
Polymerase chain reaction (PCR) detects HSV DNA

Imaging Studies

CT scan and MRI for differentiation of encephalitis from other entities

Procedures

Slit-lamp examination for dendritic keratitis with ocular involvement

Lumbar puncture, if concerned about encephalitis

Brain biopsy, if encephalitis is considered

Treatment & Management

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Media Gallery

Cutaneous vesicles characteristic of herpes simplex virus infection.
Herpes labialis.
Penile infection with herpes simplex virus type 2.
Tzanck smear showing a multinucleated giant cell.
Herpes simplex virus dendritic ulcer with fluorescein staining.
Genital herpes infection.

of 6

Author

Melissa Kohn, MD, MS, FACEP, EMT-PHP Clinical Instructor of Emergency Medicine, Sidney Kimmel Medical College of Thomas Jefferson University; Emergency Medicine/EMS Physician, Director of EMS Resident Education, Medical Command Facility Director, Einstein Medical Center

Melissa Kohn, MD, MS, FACEP, EMT-PHP is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Eric L Weiss, MD, DTM&H Medical Director, Office of Service Continuity and Disaster Planning, Fellowship Director, Stanford University Medical Center Disaster Medicine Fellowship, Chairman, SUMC and LPCH Bioterrorism and Emergency Preparedness Task Force, Clinical Associate Professor, Department of Surgery (Emergency Medicine), Stanford University Medical Center

Eric L Weiss, MD, DTM&H is a member of the following medical societies: American College of Emergency Physicians, American College of Occupational and Environmental Medicine, American Medical Association, American Society of Tropical Medicine and Hygiene, Physicians for Social Responsibility, Southeastern Surgical Congress, Southern Oncology Association of Practices, Southern Clinical Neurological Society, Wilderness Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM Chair, Department of Emergency Medicine, LeConte Medical Center

Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Lawrence C Brilliant, MD Clinical Assistant Professor, Department of Primary Care and Community Services, MCP Hahnemann University; Attending Physician, Department of Emergency Medicine, Doylestown Hospital

Lawrence C Brilliant, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Robin R Hemphill, MD, MPH Associate Professor, Director, Quality and Safety, Department of Emergency Medicine, Emory University School of Medicine

Robin R Hemphill, MD, MPH is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Rahul Sharma, MD, MBA, FACEP Medical Director and Associate Chief of Service, NYU Langone Medical Center, Tisch Hospital Emergency Department; Assistant Professor of Emergency Medicine, New York University School of Medicine

Rahul Sharma, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Association for Physician Leadership, Phi Beta Kappa, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.