Neonatal Herpes Simplex

Infections
MAJ Mark Burnett
Pediatric ID Fellow
MAR 2003
 Neonatal Herpes
Background
A Case Study
Types of Infections
Risks of Infection
Diagnostics
Treatment
Summary
 Herpes Infections
Herpes from the HHV1 HSV1
Greek to creep, HHV2 HSV2
crawl HHV3 VZV
Herpetic eruptions HHV4 EBV
described as early
as 100 AD HHV5 CMV
1960s HSV1 and HHV6 Causes?
HSV2 differentiated HHV7
HHV8 -
 A Case Study A.B.
Term infant born to a 22 y/o GBS+ mother
with no Pmhx of HSV-2
4 doses of IV PCN given PTD
ROM <18 hours PTD, no maternal fevers
Forceps delivery
APGARS of 9/9
Well until fever to 101.7 at 30 hrs of life
Fever work-up initiated
 A.B.
WBC 23K (50S 2B 38L)
AST 98 ALT 92
CSF 48 WBC 2650 RBC Pro 93/Glu 53
HSV PCR, Enteroviral PCR, HSV Surface cx
sent
Exam unremarkable
Amp/Gent/Acyclovir initiated
Fevers persisted over next 13 hours, again
spiking to 101.5
AST 147 / ALT 93 two days later
 A.B. additional info
No history of HSV reported in mother,
father
Mother without febrile illness
Niece with a cold sore visited prior to
delivery, and held the baby after he
was born
LP repeated two days after initial study
with normalization of cell count
A New Development
 Questions?
What diagnostic tests could we perform, and
how reliable are they really?
Would it be worthwhile to run tests on mom?
Is the nieces cold sore a red herring
what are the risks?
Bottom line how worried should we be
about HSV, and how would we treat it?
 Neonatal HSV
1 in 2,500-5,000 deliveries / 500-1500 per yr.
Birth to 7 weeks of life
HSV2 = 70-75%, HSV1 = 25-30%
3 Main Types
Skin, Eye, Mouth (SEM)
CNS
Disseminated Disease (DISSEM)
At Risk: Premature, ROM >6hr, Fetal scalp
monitoring
Can be acquired congenitally, during the birth
process, and in the post-partum period
 Routes of Transmission
85% via infected
maternal genital
tract
Ascending infection?
En route
10% postpartum
5% (or less)
intrauterine/congeni
tal infection
 Congenital HSV
Rare, most Archival Photo:
devastating HSV In Utero
Healed by Time
Only 50 cases Of Birth With
Microcephally
described
Skin vesicles
Chorioretinitis
Microcephaly
Micro-ophthalmia
IUGR
 Skin, Eye, Mouth (SEM)
Approximately of all
HSV infections
1st-2nd week Groin Vesicles
presentation 16 Days of Life
HSV-1, This Infant
Limited to skin, eye, Had a Cardiac Cath
(Groin Line)
mouth/mucous At 3 Days of Life

membranes
60-70% of untreated
patients progress to
CNS/disseminated
disease
 SEM (cont)
Long term
neurologic sequelae
seen in 30% of
cases even if
treated
Ophthalmology
involvement
Presenting Part (SEM)

HSV 2 Arm Lesions

9 Days of Life
Presenting Limb in a 34 Week
Premature Infant
Scalp Monitors

Scalp Lesions
11 Days of Life
HSV-2, Monitored
With Scalp Lead
 HSV - CNS Disease
Encephalitis without
visceral involvement,
mainly involving the
temporal lobes
Early to 3rd week of life
presentation
Skin lesions may appear
late, if at all
35% of all cases, only HSV 2, Necrotic Brain

2-5% untreated survive

normally
Radiographic Findings
 Disseminated Disease
Approximately 20%
of all infections
Hepatitis
Pneumonitis
DIC
Infant may be ill on
first day of life
Skin lesions appear
late, or not at all
Signs
 Postnatal acquisition
Most commonly
HSV1
Moms with HSV
Mask
Breastfeeding O.K.
if without lesions
The Mohel and the
Mezizah
 Contacts
Personnel with an
active herpetic
whitlow should not
have direct patient
care of neonates.
Family transmission
has been described
Morbidity and Mortality
Stretch Break
 Take Home Message
Infection is most common when a
mother develops a genital infection late
in pregnancy ( her primary HSV1 or
HSV2 infection) then delivers before
the development of protective maternal
antibodies
 Herpes Simplex
Approximately 5% of the general
population has been diagnosed with
genital herpes but approximately 20-
30% of women may be infected with
HSV-2
Viral shedding occurs without
identifiable lesions on 1-3% of days
 Maternal Testing?
Identify discordant couples to avoid
transmission in the third trimester
If mom is HSV1/HSV2 negative
If mom is HSV2 negative
If mom is HSV2 positive risk is low for a vaginal
delivery?
Is testing after delivery going to be helpful?
Will blood tests of the baby be helpful, or just
reflect moms status?
Psychosocial ramifications?
 Herpes during Pregnancy
As many as 2% of pregnant women are
infected with HSV2 during pregnancy
25% of women with a history of genital
herpes have an outbreak at some time during
their pregnancy, 11-14% at time of delivery
36% at delivery for those with first infection!
Virus is recovered from 1% of asymptomatic
women at delivery
 What is the risk?
Vaginal delivery when mom has presence of
first symptomatic lesions 50%
Vaginal delivery when mom is asymptomatic,
but is newly infected 33%
Vaginal delivery when mom has recurrent
lesions 4%
Vaginal delivery when mom has a history of
herpes lesions in past, none presently
0.04%
 OB Management
70s-80s weekly HSV cultures
1988 patient examined at delivery,
Cesarean delivery if: (no data)
Identifiable genital lesions
Patient describes prodromal symptoms
Vaginal delivery for those with hx only
Primary infection diagnosed - treat
Estimated $2-4 million to prevent each case
20-30% of infants who are diagnosed with
neonatal herpes are delivered by Cesarean
delivery
 Diagnostics

HSV Cx positive in
1-2 days (cytopathic
effect)
DFA
sensitivity/specificity
in the 75%-85%
range
 PCR Testing
Detects minute
amounts of DNA, RNA
DISSEM 93%
CNS 76%
SEM 24%
False negative may
occur if CSF is obtained
too early
Order through IVF!
 Diagnostics (cont)
Surface cultures
Mouth (40-50%)
Eyes (25%)
Rectum
Skin
Cultures
Stool
Urine
CSF >100 WBC/Inc. Pro
Tzanck neither
sensitive nor specific
 Treatment - Acyclovir
SEM infections
60mg/kg/day divided q8h for 14 days
May be lengthened to 21 days in the near
future
Oral Acyclovir needed later in life?
DISSEM and CNS HSV infections
60mg/kg/day divided q8h for 21 days
Re-tap if CNS disease exists prior to d/c
Watch for neutropenia 2x week ANCs
 Questions / Controversies
Would maternal
pre-treatment
change the time
/clinical presentation
of HSV?
Should an infant
delivered vaginally
to a mother with
active lesions be
treated?
Can HSV be
resistant to
Acyclovir?
 Take Home Messages
Most neonates with HSV
infection are born to
mothers with
asymptomatic genital
shedding at delivery,
with no history of
genital herpetic lesions
No one test is 100%
sensitive / specific
Keep HSV in mind

How would you manage

our case?