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Neonatal HSV
From WikEM
Contents
Background
- Causative agent: HSV-1 or HSV-2
- Definition – “infection acquired peri-natally or postnatally without clinical manifestations at birth or in the first 24 hours of life but with subsequent clinical manifestations in the neonatal period (age less than 29 days)” [1]
- ED prevalence:
- 0.2% all neonates
- 0.3% febrile neonates
- 0.5% neonates undergoing LP
- Prevalence similar to meningitis (0.4%) in neonates presenting for SBI workup [2]
- Risk associated with age <3 weeks, primary maternal HSV infection at delivery
Management Considerations
- Acyclovir if [3][4][5]
- Proven HSV disease
- Suspected HSV disease (see clinical features) pending studies
- At risk due to exposure (active genital lesions in mother)
- Many recommend acyclovir empirically in ill-appearing neonates with fever (including hypothermia) or aspetic meningitis until results of work-up are known
Classification
- Whitney-Kimberlin disease categories
- Disseminated (liver, lung, adrenal glands, skin, eye, brain) - 25%
- 2/3 have CNS involvement
- CNS - 30%
- SEM (skin, eye, mouth) - 45%
- Conjunctival disease or minor skin lesions may be only manifestation
- May go on to CNS, disseminated disease - workup and treat the same
- Conjunctival disease or minor skin lesions may be only manifestation
- Disseminated (liver, lung, adrenal glands, skin, eye, brain) - 25%
Historical Features
- Not sensitive (maternal history of HSV), nor specific (maternal fever, vaginal delivery, preterm birth) [1]
- 80% of mothers have no history of genital lesions [6]
- Vesicular lesions most specific, present in <1/2 [1]
- Note: absence of vesicular rash does not rule out
- May be well appearing - maintain high clinical suspicion
- Ask about:
- Temperature instability (fever, hypothermia)
- Irritability
- Lethargy
- Seizures
- Respiratory distress
Clinical Features
- General
- Temperature instability (febrile or hypothermic)
- May be well appearing in SEM
- Disseminated
- Neutropenia
- Thrombocytopenia
- Hepatitis
- Pneumonitis
- DIC
- +/- CNS disease
- CNS
- Hypotonia
- Seizures
- Abnormal brain imaging
- Abnormal EEG
- CSF pleocytosis and/or proteinosis
- SEM
- Characteristic skin lesions of HSV – skin, eye (kerato-conjunctivitis), or mouth
- No evidence of systemic or CNS infection
Differential Diagnosis
Pediatric fever
- Upper respiratory infection (URI)
- UTI
- Sepsis
- Meningitis
- Febrile seizure
- Pneumonia
- Acute otitis media
- Whooping cough
- Unclear source
- Kawasaki disease
- Neonatal HSV
Evaluation
Work-up
- Should include the following [6]
- CBC with differential
- Chem
- LFT
- Blood, urine culture
- LP with CSF studies
- Perform PCR/culture of:
- Any visible lesions
- Conjunctiva, nasopharynx, mouth, anus
- Even in the absence of lesions
- Consider CXR for respiratory symptoms
- Suspected disease should get CT and EEG
- Suspected ocular involvement should get optho consult
Evaluation
- Always consider neonatal HSV and perform appropriate work-up and treatment if:
- Evidence of vesicular rash (even if minor)
- Kerato-conjunctivitis
- Seizure
- Poor feeding
- Lethargy
- Irritability
- Respiratory distress
- Sepsis
- Temperature instability
- CSF pleocytosis
- Thrombocytopenia
- Transaminitis
- SBI workups
Management
- Acyclovir 20 mg/kg IV every 8 hours (duration depends on classification)
- If ocular involvement:
- 1% trifluridine, 0.1% iododeoxyuridine, or 3% vidarabine
- Optho consult
- As for any febrile neonate SBI evaluation:
- Ampicillin + gentamycin
- May substitute gentamycin with cefotaxime/ceftazidime
- Ampicillin + gentamycin
Disposition
- Any neonate with suspected HSV (especially if CSF pleocytosis) should be treated and admitted
- Consider covering all febrile neonates regardless pending CSF and culture studies
Outcomes
- SEM with treatment - all survive [1]
- If untreated 50-60% with SEM go on to CNS or disseminated disease
- Mortality high with CNS (4%) or disseminated (29%) disease even with treatment [6]
See Also
External Links
References
- ↑ 1.0 1.1 1.2 1.3 Caviness AC. Neonatal herpes simplex virus infection. Clin Ped Emerg Med. 2013;14(2):135-145
- ↑ Caviness AC, et al. The prevelance of neonatal herpes simplex virus compared with serious bacterial illness in hospitalized neonates. J Pediatr. 2008;153:164-169
- ↑ Caviness AC, et al. The prevalence of neonatal herpes simplex virus infection compared with serious bacterial illness in hospitalized neonates. J Pediatr. 2008;153(2):164
- ↑ Long SS. In defense of empiric ayclovir therapy in certain neonates. J Pediatr. 2008;153(2):157
- ↑ Kimberlin DW. When should you initiate acyclovir therapy in a neonate? J Pediatr. 2008;153(2):155
- ↑ 6.0 6.1 6.2 James SH, Kimberlin DW. Neonatal herpes simplex virus infection: epidemiology and treatment. Clin Perinatol. 2015;42(1):47-59
