Zakhireh Khaˆrazmshaˆhi is the greatest Persian medical book in Islamic traditional
medicine. One of the interesting aspects of this book is it's precise description
of various diseases and their treatments. While the viral nature of many diseases,
including herpes simplex, has recently been referenced in modern medicine, Jorjaˆni
described the labial and genital form of the disease in Zakhireh in the 13th century
AD.
The definition of herpes simplex in modern medicine
Herpes simplex, caused by the herpes simplex virus (HSV) or herpes virus hominies,
is one of the most common infections of humans throughout the world. There are two
major antigenic types: type I, which is classically associated with facial infections;
and type 2, which is typically genital, although there is considerable overlap in
disease manifestations. Both type 1 and type 2 HSV are acquired by direct contact
with, or droplets from, infected secretions entering via skin or mucous membrane,
where primary infection may become evident.
Primary infections may rarely produce a painful, vesicular stomatitis. In crowded
areas of the developing world, over 90% of children have antibody by the age of 5
years, but in more temperate areas and higher socioeconomic groups, the incidence
is lower in children but rises steadily with age. Type 2 infections occur mainly after
puberty, and are often transmitted sexually. Seropositivity is low in children, but
about a third of young adults are seropositive for type 2 and this rises to half the
population during later life. The primary HSV-2 infection is more commonly symptomatic
(1).
Worldwide, 60%–95% of the population is infected by one or more viruses of the herpes
viridae family. In an immunocompetent host, herpesvirus infections can often cause
debilitating diseases, which may have psychological and physical sequelae in persons
with frequent recurrences. Herpesviruses have two unique biologic properties: the
ability to invade and replicate in the host nervous system and the ability to establish
a site of latent infection. The neurovirulent properties of herpes simplex virus (HSV)
enable the virus to cause a disease primarily of the sensory nervous system rather
than of the skin.
During primary infection, virus is transported via sensory ganglia to establish a
chronic latent infection, most commonly in the trigeminal, cervical, or lumbosacral
ganglia. Retrograde transport of HSV along nerves and the establishment of latency
are not dependent on viral replication in the skin or neurons and therefore neurons
can be infected in the absence of symptoms.
Periodically, HSV may reactivate from its latent state and virus particles then travel
along sensory neurons to the skin and other mucosal sites to cause recurrent disease
episodes. Recurrent mucocutaneous shedding of HSV can be asymptomatic or associated
with lesions, and in either scenario is allied with a period when virus can be transmitted
to a new host (2).
Herpes simplex virus (HSV) is a common cause of both genital and oral disease. HSV
type 2 (HSV-2), sexually transmitted pathogen, infects >500 million people worldwide
and causes an estimated 23 million new infections each year. HSV type 1 (HSV-1) is
even more common, with an estimated seroprevalence of >90% in many nations. HSV-1
is frequently acquired during early childhood, primarily through oral secretions.
However, the epidemiology of HSV-1 is changing, such that the frequency of sexual
transmission of HSV-1 has increased in many countries, including the United States
(3).
Clinical features of HSV
HSV infections have a wide range of clinical presentations, and asymptomatic infection
is very common. In primary infections, symptoms typically occur within 3 to 7 days
after exposure. A prodrome of tender lymphadenopathy, malaise, anorexia and fever
often occurs before the onset of mucocutaneous lesions, which may be preceded by localized
pain, tenderness, burning or tingling. Painful, grouped vesicles appear on an erythematous
base and may become umbilicated, followed by progression to pustules, erosions and/or
ulcerations with a characteristic scalloped border. Crusting of lesions and resolution
of symptoms typically occurs within 2 to 6 weeks. A similar prodrome can precede recurrent
lesions, but these are often fewer in number, with decreased severity and duration
compared to those of a primary infection.
The majority of primary orolabial infections are asymptomatic. Symptomatic infections
often present as gingivostomatitis in children, and as pharyngitis and a mononucleosis-like
syndrome in young adults. The mouth and lips are the most common sites of involvement,
with lesions typically appearing on the buccal mucosa and gingivae. Edema and painful
oropharyngeal ulcerations can lead to dysphagia and drooling. Recurrent lesions appear
most often on the vermilion border of the lip. Less common sites are the perioral
skin, nasal mucosa, oral mucosa overlying bone (e.g. hard palate) and the cheek. Primary
and non-primary initial genital herpes infections are frequently asymptomatic but
(especially with the former) can also present as an excruciatingly painful, erosive
balanitis, vulvitis or vaginitis. In women, lesions often also involve the cervix,
buttocks and perineum and are associated with inguinal adenopathy and dysuria. Lesions
in men typically occur on the glans or shaft of the penis, and the buttocks are occasionally
affected. Systemic complaints and complications are more common in women. Extragenital
lesions, urinary retention and aseptic meningitis occur in 20%, 10-1 S’X. and 10%
of affected women.
A short note about the importance of Zakhireh Khaˆrazmshaˆhi
Seyyed Esma’il Jorjaˆni (433_531 AH/1041_1136 AD) was the most important famous physician
after Avicenna who wrote several worthy books on medicine during his lifetime. Zakhireh
Khaˆrazmshaˆhi “The Treasure of Khaˆrazmshaˆh” is considered the most detailed medical
book in Persian with nine big chapters which explains diseases from cap a pie, manifestations,
diagnostic methods and the ways to treat them, also about cosmetics and beautification,
poisons; and two appendices on simple and compound drugs (5). The book has been translated
into Hebrew and Turkish due to the importance of its content.
In this writing we wish to discuss Jorjaˆni's point of view about HSV and his precise
definition of the disease.
In Arabic, herpes is called “Namleh” and erysipelas is called “Homreh”. In the page
753 of Zakhire Kharazmshahi it is written that erysipelas affects the lips and the
penis (6). Although apparently Jorjaˆni confused between erysipelas and herpes but
an important point is that he had differentiated between the genital and labial types
of herpes centuries ago.
In chapter 7 page 639 of Zakhire Kharazmshahi, Jorjani said the following about erysipelas:
“Homra” is a hot, severely itchy and corrosive rash which irritates the skin and tends
to cause corrosion, and merges to the skin somewhat deeply and remains as a black
scar. It looks similar to a scar caused by heat (burning), yet is less moist. Its
inducing agent is almost like black bile. Rashes are few and dispersed and pea size
or larger. There are also some types without rash but they are itchy and irritating
and appear in red and then turn to lead color or gray. Sometimes it is accompanied
by a severe fever which is fatal (6).
In page 644 from the mentioned chapter of the book, Jorjaˆni said the following about
herpes:
“Namle” is small spots which are close to each other and interconnected. It is spread
widely, with itching and burning, and is warm to the touch.
The stinging of the rashes is like an ant biting. It is mostly spread spots that look
like warts. The base of the spots is wide and the top is narrow. It seems like a pensile,
yellow in color. Some spots become wounds and some disappear. The main cause of the
“Namle” is a stingy (irritant) substance that is mixed with the blood under the skin
and passes over narrow vessels of the skin (6).
Bad Sorkh (erysipelas)
Erysipelas is an acute and inflammatory type of cellulitis which differs from other
types of cellulitis in the significant lymph node involvement of erysipelas.
In contrast to classical cellulitis, erysipelas is a more superficial infection; which
affects the dermis and upper part of subcutaneous tissue and has a clear and distinct
surrounding.
Group A Streptococci are the most common cause of Bad Sorkh (Red Wind). The onset
of the disease is abrupt.
The most common site of involvement is the leg. Face, arm and loin are other common
sites. In infants, the skin around the navel is a common area of infection.
One or more of the red, firm and tender spots raise fast and produce a firm and extremely
stiff, erythematous, hot and shiny stain with irregular borders.
The erythematous lesion is extremely dark in color and may progress on the sidelines
and on the ongoing level (surface) of the lesion, vesicles are formed.
Itching, burning, tenderness, and pain may be moderate to severe.
Herpes simplex (cold sores)
Herpes simplex virus is a double-stranded DNA virus with two different viruses (type
one and two) that can be differentiated by lab methods.
Type one is generally associated with mouth ulcers and vesicular infections, while
type two is commonly associated with genital infections. The herpes simplex virus
infection has two stages: primary infection, after which the virus becomes established
in a nerve ganglion, and the secondary stage in which the disease recurs in the same
location.
Symptoms appear 3 to 7 days after exposure. Tenderness, pain, mild paresthesia, or
tingling are displayed before the appearance of lesions at the site of inoculation.
Inflammation of the gums and mouth (gingivostomatitis) and pharyngitis are the most
common manifestations of the infection in the first exposure to type one herpes simplex.
Local pain, lymphadenopathy, tenderness, headache, pervasive pain and fever are the
typical and prognostic symptoms.
Women with primary and symptomatic genital infection may be attacked by vulvovaginitis,
erosion with pain and edema in the vagina and cervices, and also urinary irritation.
A group of vesicles appear on the erythematous body and then reform to erosions. The
lesions last for 2 to 4 weeks and then heal without any scars. After 2 to 4 days the
vesicles are ruptured and form aphthous ulcers in the vaginal area, or erosions covered
with a rough layer on the lips and skin.
Conclusion
The precise definition of diseases in earlier centuries by Jorjaˆni shows the precise
and close view of the scientist. The interesting point in his definition about HSV
is the differential diagnosis of the labial and genital types of HSV. Due to the intricacies
of Islamic medicine and the scrutinized view of the scientists of this period, more
attention to subjects that have been neglected in this period is necessary.