HSV-2

Primary genital infection produces painful grouped vesicles progressing to shallow ulcers on an erythematous base, with tender inguinal lymphadenopathy, dysuria, and systemic symptoms; recurrences are milder, shorter, and often preceded by a prodrome of tingling. Latency in the sacral ganglia permits reactivation, and asymptomatic viral shedding accounts for much transmission, so a negative history does not exclude infection. Diagnosis is by PCR of a lesion swab, which has replaced Tzanck smear, though the Tzanck smear's multinucleated giant cells with intranuclear Cowdry A inclusions remain a classic exam finding shared with HSV-1 and VZV. Treatment is aciclovir, valaciclovir, or famciclovir, given episodically or as daily suppression, which also reduces transmission. Neonatal herpes is the gravest complication, presenting as skin-eye-mouth disease, central nervous system disease, or disseminated infection, and risk is highest with maternal primary infection near term, so caesarean delivery is indicated for active genital lesions. HSV-2 also causes aseptic meningitis, including recurrent Mollaret meningitis, whereas HSV-1 causes temporal lobe encephalitis.