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HERPESVIRIDAE I * Fbz.oM: A C~~~~P~U-@eU~LIFE /h/~lffG~hMs 2 52 DNA VIRUSES: &DNA, Cubic or Helical Symmetry HERPESVIRIDAE i Lipomratelm- - earclove Cmpsld eoclorlmg Tegmmert, cornpored of protelms emcoded by double-ntramded : the rlrmr amd s8rrooadimg the moeleocapsid DNA pen8lralion Cytoplmrm of hott ccll Cytoplarmic membrmme or Lort cell Viral DNA replicalion Envelope Transport through cytoplarrn and rrleare from call by unknown 2-rnrchanirnr .mk- FIGURE 52 Replication of herpes simplex virus. Specific glycoproteins in the viral envelope are'.essential for adsorption on host cell receptors in the cytoplasmic membrane. Envelope and cell membrane fuse and the viral nucleocapsid is released into the cytoplasm. Viral DNA is then uncoated and transported to the nucleus. Early transcription and rnRNA are apparently catalyzed by host enzymes. The resulting early viral enzymes are used in DNA replication. Further RNA transcripts are responsible for synthesis d viral capsid and envelope proteins as well as glycoproteins in the nuclear membrane. The structural proteins enter the nucleus to participate in the assembly of novel viral nucleocapsids. The latter are enveloped by budding through the nuclear membrane and complete viruses are released by unknown mechanisms. (Modified from Pelczar, M.J.,Chan, E.C.S., and Krieg, N.R., Microbiology - Concepts and Applicatiom, McGraw-Hill, New York, Q 1993,428. Reproduced with permission of The McGraw-Hill Companies.) PER I 5 ........................................................ Herpes simple& Virus Infection David Rakel, M.D. HYSIOLOGY INTEGRATIVE THERAPY pe~sonalContact Avoiding exposure to persons =Periencing out- breaks of either HSV-1 or HSV-2 infection is war- ranted but does not ensure against contracting the disease. Use of condoms while limiting the number of sexual partners will help reduce the prew alence of infection. Oral sex should also be avoided because genital herpes can cause oral lesions, and tially affects these mucous mem- vice versa- shin is thin. Other common dermal at are overly moist or been compromised assic progression of symp mation, and erythema fol- **oino=u'ation The patient should be educated on how to prevent transmission to other Parts of the body durinl3 an outlmak For example, after bathing, patting dry with a towel instead of rubbing should be encour- aged, The transmission of vesicular fluid to other parts of the body must be avoided. \ Trauma to the Skin at higher risk for complications. It is o observe that many more people have 1 HSV is more prone to causing recurrence and primary infection if the skin is traumatized or exposed to ultraviolet radiation. The patient should be encouraged to use sun protection to help prevent recurrence of HSV-1 infection, should avoid trau- potential effects of this virus is a point matic intercourse, and should prevent chapping of dy and invites an integrative therapeu- the lips. Using zinc ointment on the lips not only to reduce the severity of the disease protects against ultraviolet light exposure but may e has occurred. also help to suppress HSV growth. 133 1 34 CHAPTERIS W Herpes Simplex VhInfection Dorsal root ganglia Latent viral genome (may be interated or extrachrornosomal) Stimulus for reactivation (stress, UV light, etc.) peripheral sensory nerves Figure 15- 1. Schematic diagram of herpes simplex virus latency and reactivation. W, ultraviolet. prom Whitley RI: Herpes simplex virus infections. In Goldman L, Bennett JC [eds]: Cecil Textbook of Medicine, 21st ed. Philadelphia, WE3 Saunders, 2001; 1810-1814.) Table 15- 1. Potential Triggering Factors for recommendation for helping patients reduce recur- Reactivation of Herpes rence of HSV infections, Evidence from in vitro stud- ................................................................ ies supports this approach. The replication of the HSV-1-Spedfic Tmn~ virus requires proteins rich in arginine, and arginine Ultraviolet light itself may be a stimulator of HSV replication. Lysine Immunodeficiency exerts antiviral effects by blocking the activity of Stress, depression, anxiety (chronic) argi~~ine.~Clinical studies show mixed results?' Poor sleep One argument is that inadequate doses of lysine Trauma to mucosa Cold, windy, or dry weather were used. In one study, 52 people with recurring Hot food or lip biting oral and genital HSV infections were assigned to Food allergy receive either L-lysine 1 g 3 times daily or placebo; Fever they also avoided nuts, chocolate, and gelatin (argi- nine-rich foods). After 6 months, 74% of persons Immunodeficiency receiving lysine reported their treatment as either Stress, depression, anxiety (chronic) effective or very effective, versus 28% of those Poor sleep receiving placebo. The mean number of outbreaks Food allergy Trauma to genital mucosa was 3.1 in the lysine group, compared with 4.2 in Menses (usually 5-12 days before onset) those taking pla~ebo.~ There is some concern that taking supplemental lysine for prolonged periods of time may increase the Sleep risk of atherosclerosis, possibly by increasing levels of lowdensity lipoprotein^.^ Accordingly, adjusting Poor sleep hygiene can result in fatigue, which may lead to an increased frequency of recurrence. The Table 15-2. Arginine-Containing and Lysine-Rich clinician should specifically inquire about sleep Foods: Dietary Recommendations for Prophylaxis of habits to help the patient make changes that will Herpes Simplex Virus Infection Recurrence result in an improved sleep cycle. .............................................................. Foods to Avoid Foods to Include (High Arginine Content) (High Lysine Contenf) Nutrition Chocolate Vegetables Peanuts B&S Lysine- and Arginine-Containing Foods Almonds ~ish Cashews Turkey A diet that promotes lysine-rich foods and reduces ~unflowerseeds Chicken arginine-containing foods has become a popular CHA~IS W Herpes Simplex Virus Infection 1 35 the amount of arginine in the diet by reducing the adrenal gland. Overactivity of the adrenals can arginine-rich foods may be the safer approach (see lead to suppression of the immune response and Table 15-2). increase susceptibility to recurrent HSV infection (see Chapter 94, Learning to Meditate). Food Allergy Supplements Although there is limited research to back the claim that food allergies trigger recurrences of HSV Vitamin C infection, a trial of an elimination diet should be offered to persons with frequent recurrences (see When used early in the prodrome of an outbreak, Chapter 82, on elimination diets). vitamin C 1000 mg with the addition of 1000 mg bioflavonoids taken 5 times a day for 3 days after recognition of symptoms was found to reduce blister Good Nutrition healing time in herpes labialis, from 10 days in the placebo group to 4.4 days in the treatment group.'* The most important nutritional factor in preven- tion of HSV infection is a balanced diet with 7 or 8 servings of fruits and vegetables a day, to help Zinc support a healthy immune system. Zinc has been found to inhibit HSV replication in vitro and enhances cell-mediated immunity to help Mind-Body Medicine reduce HSV infection recurrence. Oral compound of 25 mg of zinc with 250 mg of vitamin C was given It has been a common belief that isolated stressful twice a day for 6 weeks, which resulted in either events may lead to recurrent HSV outbreaks, although complete suppression of an outbreak or resolution of research has not supported this association. One HSV-1 eruptions within 24 hours.13 Topical applica- study of 64 people with HSV infection found no corre- tion of a zinc sulfate solution of 0.01% to 0.025% lation between acute stressful events and a later out- concentration has also been found to be helpful in break.' On the other hand, chronic or persistent healing HSV-1 lesions and in inhibiting recurrence.14 stressors have been found to correlate with an Use of zinc and vitamin C supplementation constitu- increased frequency of rec~rrence.~This correlation tes an inexpensive option for the patient with fre- is consistent with findings showing a decrease in HSV quent recurrences. immunity in caregivers of dementia sufferers1' and a Dosage. Zinc 25 mg a day with vitamin C 250 mg a decrease in herpes zoster immunity in persons with day for recurrence prophylaxis. depression." Therapeutic focus should be on helping Precautions. In prescribing zinc supplementation, the patient find a balance of lifestyle demands and on the clinician should be aware that zinc competes learning techniques to reduce day-to-day stress in with copper, calcium, and iron absorption. The persons with frequent recurrences. patient should not take more than the recommended dose and should not take calcium and iron supple- ments with zinc. Doses greater than 50 mg per day have been found to be associated with reduction in serum copper levels. Chronic rather than isolated stress has been found to result in more heequentHSV outbreaks. Lysine As discussed previously under "Nutrition," lysine Relaxation Exercises exerts antiviral effects by blocking the activity of arginine, which promotes HSV replication. Although Teaching the patient a simple relaxation exercise the results of research are mixed, a trial of 1 g of -'at can be used on a regular basis or when needed lysine daily to prevent recurrences, increased to 1 g 3 ,,r ,,r recurring stressful events can empower the times a day during an outbreak, seems reasonable. patient to learn how to reduce stress (see Chapter Dosage. L-Lysine 1 g daily for prevention, 1 g 3 91, Prescribing Relaxation Techniques). times a day for acute outbreaks. Precautions. Diarrhea and abdominal pain have I been reported in persons taking doses of more than editation 10 g a day. There has been a single case documented of tubulointerstitial nephritis progressing to renal For persons with chronic recurring stress, practice failure.'' Lysine may cause a modest rise in low- f meditation can help to reduce the stimulation of density lipoprotein levels. 136 CHAPTERIS Herpes Simplex VimInfection Vitamin E Oil been found to enhance the immune function and may be a component of its therapeutic benefit.
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