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1ïžâ£ Empirical Acyclovir in Encephalitis
- Donât wait for PCR (24-48 hr turnaround)
- Start within hours of presentation
- Empirical: acyclovir + ceftriaxone + ampicillin + vancomycin + ± dex (cover bacterial meningitis + HSV)
- Continue ⥠14d if HSV PCR confirmed
2ïžâ£ Repeat CSF PCR at End of Treatment
- Controversial
- Some advocate: persistent + â extend acyclovir
- Most: clinical response guides duration; donât routinely repeat unless concern
3ïžâ£ Bellâs Palsy Workup
- HSV-1 reactivation theorized in many idiopathic cases
- Treatment: steroid (clearly beneficial, House-Brackmann recovery)
- Antiviral (acyclovir / valacyclovir): mixed evidence; some advocate addition; minimal harm
4ïžâ£ Genital HSV + Pregnancy Algorithm
- Routine cervical PCR not necessary
- Acyclovir 400 mg tid from 36 wk gestation in recurrent genital HSV
- Cesarean if active genital lesions at delivery (visible vesicles/ulcers)
- Counsel re neonatal HSV risk
5ïžâ£ HSV-2 Suppression for Transmission
- Daily valacyclovir 500 mg in HSV-2+ partner with HSV- partner
- 50% transmission reduction
- Combined with condom + abstinence during prodromal/active
6ïžâ£ HSV + HIV Co-infection
- Increased ulcer severity + frequency in HIV
- HSV-2 ulcers â HIV transmission
- Suppression valacyclovir 1 g qd in HSV-2+ HIV-
- ART improves HSV control
7ïžâ£ HSV Encephalitis Sequelae
- Long-term cognitive + behavioral changes
- Memory deficit (temporal lobe)
- Personality / mood changes
- Hippocampal sclerosis
- Rehabilitation, neuropsychology follow
8ïžâ£ Pritelivir for Refractory Mucocutaneous
- Helicase-primase inhibitor
- Phase 3 trials for acyclovir-R immunocompromised
- May replace foscarnet in this niche
- Better tolerated
9ïžâ£ HSV Vaccine Pipeline
- gB2/gD2 subunit
- mRNA candidates (Moderna, BioNTech)
- Therapeutic (reduce recurrences) + prophylactic (prevent acquisition)
- Phase 1-2 trials 2024+
- Optimistic mid-2020s