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Herpes Simplex Virus in the Newborn

Herpes Simplex Virus in the Newborn . Sonya Mary Palathumpat, MD. I ntroduction. Discovery of neonatal Herpes Simplex virus (HSV) in the 1930s Neonatal infection with HSV occurs in 1/3200 to 1/10,000 live births

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Herpes Simplex Virus in the Newborn

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  1. Herpes Simplex Virus in the Newborn Sonya Mary Palathumpat, MD

  2. Introduction • Discovery of neonatal Herpes Simplex virus (HSV) in the 1930s • Neonatal infection with HSV occurs in 1/3200 to 1/10,000 live births • HSV infection accounts for 0.6 percent of in-hospital neonatal deaths in the United States • Estimated 1500 cases of neonatal HSV infection annually in the United States

  3. Virology • HSV enters human host through inoculation of oral, genital, or conjunctival mucosa or break in skin • HSV infects the sensory nerve endings  transports via retrograde axonal flow to the dorsal root ganglia (where it remains for the life of the host)

  4. Transmission • Intrauterine (Congenital HSV) • Maternal viremia • Ascending infection • Usually after prolonged rupture of membranes • Perinatal • HSV infection is present in the genital tract of pregnant woman at time of delivery • Most common mode (85%) of neonatal HSV infection transmission • Postnatal • When active HSV infection has close contact with the newborn

  5. Clinical Manifestations • Intrauterine HSV • Placental Infarcts • Necrotizing, calcifying funisitis (inflammation of the umbilical cord) • Hydrops fetalis • Fetal in utero demise • Surviving babies: • Skin vesicles, ulcerations, or scarring • Eye damage • Severe CNS manifestations • Microcephaly • Hydranencephaly

  6. Clinical manifestations Hypopigmented, scaling, and crusted erosions of the trunk and extremities in a neonate with intrauterine herpes simplex virus infection.

  7. Clinical Manifestations • Neonatal HSV • Seen in infection with both HSV-1 and HSV-2 • HSV-2 associated with poorer outcome • Skin, Eye, Mouth • Central Nervous System • Disseminated Disease

  8. Clinical manifestations • Skin, Eyes, & Mouth • Usually presents in the first two weeks of life • Associated with high risk of progression to CNS or disseminated disease • Skin • Coalescing or clustering vesicular lesions with an erythematous base • Eyes • Excessive watering of the eye • Crying from apparent eye pain • Conjunctival erythema • Periorbital skin vesicles • Can progress to cataracts and chorioretinitis permanent vision loss • Mouth • Localized ulcerative lesions of the mouth, palate, and tongue

  9. Clinical Manifestations

  10. Clinical manifestation • CNS Disease • 1/3 of neonatal HSV disease involves the CNS • Occurs because • Localized retrograde spread from nasopharynx and olfactory nerves to brain • Hematogenous spread in neonates with disseminates disease • Presents in second-third week of life • Seizures (focal or generalized) • Lethargy • Irritability • Tremors • Poor feeding • Temperature instability • Full anterior fontanelle

  11. Clinical manifestation • Disseminated Disease: • ¼ of HSV disease is in the disseminated form • Present in the first week of life • Affects: liver, lungs, adrenals, CNS, skin, eyes, and mouth • Presenting with nonspecific signs and symptoms: • Temperature dysregulation • Apnea • Irritability • Lethargy • Reparatory distress • Abdominal distention • Ascites

  12. Clinical manifestations • Disseminated Disease: • Hepatitis with elevated liver transaminases • Ascites • Direct hyperbilirubinemia • Neutropenia • Thrombocytopenia • DIC (disseminated intravascular coagulation) • Hemorrhagic pneumonitis • Necrotizing Enterocolitis • Meningoencephalitis with seizures • Repiratory failure and shock • Advanced disseminated neonatal HSV disease

  13. Evaluation & Diagnosis • If neonate presents with mucocutaneous lesions, CNS abnormalities, or sepsis-like picture and Pt born to an HSV +, or HSV unknown mother, consider a work-up • CBC with manual differential • Liver Transaminases, total and direct bilirubin, ammonia • To assess liver function • BUN, Creatinine, UA • To assess renal function • HSV DNA PCR of blood • CSF count, glucose, protein, and HSV DNA PCR • Mononuclear pleocytosis, elevated protein, normal or elevated glucose • Swabs/ scrapings of skin or mucous membrane lesions for HSV direct immunofluorescence assay and viral culture

  14. Evaluation & Diagnosis • EEG • Should be considered in all neonates suspected to have CNS involvement • Brain Imaging • MRI or CT to determine the location and extent of brain involvement • Chest Radiograph • May demonstrate bilateral, diffuse pneumonitis • Abdominal US • May demonstrate ascites and/or enlarged liver in neonates with HSV hepatitis and acute liver failure

  15. Treatment • Acyclovir • Dose: • 60 mg/kg per day IV every 8 hours • Duration: • Localized skin, & eye, mouth (If localized CNS infection as been excluded: • 14-day course • Disseminated and/or CNS infection • 21-day course • Adverse effects: • Renal Failure • Due to crystallization in the renal tubules • More likely in the dehydrated patient • Ensure Pt has adequate PO, otherwise place Pt on IVF!

  16. Sources • Neonatal Herpes Simplex Virus Infection: Clinical Features and Diagnosis. UptoDate. Demmier-Harrison, Gail MD • Neonatal Herpes Simplex Virus Infection: Management and Prevention. UptoDate. Demmier-Harrison, Gail MD • Neonatal Herpes Simplex Virus Infections. American Family Physician. Rudnick, Caroline MD, Hoekzema, Grant MD. 03/15/2002, 1138-1142

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