Herpes Simplex Virus

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Herpes Simplex Virus

• Primarily by Linda Wallen, MD
• Edited May, 2005

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Epidemiology of Herpes Simplex

• 5 patients have a history of HSV
• 20 have serologic evidence of HSV
• Primary infection Patient has NO antibodies to
  HSV
• Nonprimary prior exposure to either HSV-1 or
  HSV-2
• Recurrent infection antibodies to
  reactivating virus type
• Shedding at delivery not predicted from past
  cultures
• 2/3 of babies with HSV infection are born to
  mothers with NO previous history of HSV
• Risk neonatal infection with recurrence 2-5
• Risk neonatal infection with primary inf. 35

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Pathway of Infection for Neonatal HSV

• Primary infection may be associated with a higher
  risk of spontaneous abortion, preterm delivery,
  and neonatal infection
• Higher viral load, longer excretion (14-21 days)
• No transplacental antibody
• 85 cases are acquired at the time of delivery
• Risk increased with PROM ( 6 hour), application
  of fetal scalp electrodes and other invasive
  tests
• 10 acquired postnatally

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Presentation of Neonatal HSV Infection

• 90 present between 5-19 days of age
• 20 NEVER have skin lesions
• Initial symptoms vague in 30
• Lethargy
• Poor feeding
• Fever
• Irritability
• Intrauterine acquisition skin lesions, scars,
  chorioretinitis, evidence of CNS involvement
  (hydranencephaly or microcephaly)

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Onset of Neonatal HSV Infection
Onset of symptoms (day)

SEM
CNS
HSV type 1
HSV type 2
Disseminated
Acta Paediatr 84256, 1995
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Signs Symptoms of Neonatal HSV Before Treatment
Pediatrics 108 (2) 226, 2001
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Diagnosis of Neonatal HSV Infection

• Gold standard Positive culture of lesion,
  nasopharynx, conjunctiva, rectum, or CSF
• Rapid diagnostic methods
• Polymerase chain reaction on CSF and blood
• Fluorescent antibody stain on vesicle scraping

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Treatment of Neonatal HSV

• Acyclovir 60 mg/kg/day IV given q8h
• Suspect infection - 2 d of negative cultures
• Definite infection - 14 d for SEM, 21 d CNS
• Topical ocular ointment for eye lesions

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Mortality Morbidity after 1 Year of Age
1981-1997
Mortality
Severe Disability
Pediatrics 108 (2) 227, 2001
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Peripartum Management of Pregnant Women with
History of HSV

• If no active lesions, normal vaginal delivery
• No current recommendation to culture for mother
• or infant for HSV
• Options with active lesions at onset of labor
• If term and ROM
• If preterm and ROM, may manage expectantly with
• or without acyclovir, betamethasone treatment,
  etc.
• OR may offer C-section
• C-section does NOT eliminate risk of neonatal
  HSV

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Peripartum Management of Pregnant Women with
Possible Primary HSV

• Viral culture of active lesions
• Serological classification if accurate testing
  available
• Value of acyclovir is not known
• If 3rd trimester, consider weekly cultures
• primary infection associated with prolonged
  viral shedding
• If preterm and ROM, may manage expectantly /-
  acyclovir, betamethasone treatment, etc.
• OR may offer C-section

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Management of the Asymptomatic Neonate Exposed to
HSV at Delivery

• For recurrent maternal HSV
• Separate from other newborns, may stay with mom
  in private room
• Instruct parents re subtle signs infection, skin
  lesions
• Obtain cultures at 24-48 hours from vesicles,
  nasopharynx, conjunctiva, and rectum (do not pool
  rectal cultures with other cultures)
• If cultures are positive then treat with
  acyclovir
• Delay circumcision for 1 month

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Management of the Asymptomatic Neonate Exposed to
HSV at Delivery

• For first episode genital infection
• Manage with contact precautions (gown, glove),
  isolation
• Obtain cultures from vesicles, nasopharynx,
  conjunctiva, and rectum (do not pool rectal
  cultures with other cultures)
• Lumbar puncture for HSV PCR and culture
• Treat with acyclovir
• Delay circumcision for 1 month