Congenital/Neonatal Herpes Simplex Infections

Infectious and Tropical Pediatric Division

Department of Child Health

Medical Faculty

University of Sumatera Utara

Herpes Infections“Herpes” – from the Greek “to creep, crawl”

“Herpetic eruptions”

HHV1 – HSV1

HHV2 – HSV2

HHV3 – VZV“Herpetic eruptions” described as early as 100 AD

1960’s – HSV1 and HSV2 differentiated

HHV3 – VZV

HHV4 – EBV

HHV5 – CMV

HHV6 – Causes?

HHV7 –

HHV8 -

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 TypesSkin, Eye, Mouth (SEM)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 Transmission85% via infected maternal genital tract

Ascending infection?Ascending infection?

En route

10% postpartum

5% (or less) –intrauterine/congenital infection

Congenital HSVRare, most devastating

Only 50 cases described

Archival Photo:HSV “In Utero”

Healed by Time

Of Birth – WithMicrocephally

described

Skin vesicles

Chorioretinitis

Microcephaly

Micro-ophthalmia

IUGR

Skin, Eye, Mouth (SEM)Approximately ½ of all HSV infections

1st-2nd week presentation

Groin Vesicles 16 Days of Lifepresentation

Limited to skin, eye, mouth/mucous membranes

60-70% of untreated patients progress to CNS/disseminated disease

16 Days of Life

HSV-1, This InfantHad a Cardiac Cath

(Groin Line) At 3 Days of Life

SEM (cont)Long term neurologic sequelae seen in 30% of cases – even if cases – even if treated

Ophthalmology involvement

“Presenting Part” (SEM)

HSV 2 Arm Lesions9 Days of LifePresenting Limb in a 34 Week Premature Infant

Scalp Monitors

Scalp Lesions

11 Days of LifeHSV-2, Monitored

With Scalp Lead

HSV - CNS DiseaseEncephalitis without visceral involvement, mainly involving the temporal lobestemporal lobes

Early to 3rd week of life presentation

Skin lesions may appear late, if at all

35% of all cases, only 2-5% untreated survive normally

HSV – 2, Necrotic Brain

Radiographic Findings

Disseminated DiseaseApproximately 20% of all infections

Hepatitis

PneumonitisPneumonitis

DIC

Infant may be ill on first day of life

Skin lesions appear late, or not at all

Signs

Postnatal acquisitionMost 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 have direct patient care of neonates”.

Family transmission has been described

Morbidity and Mortality

Stretch Break

Take Home MessageInfection is most common when a mother develops a genital infection late in pregnancy ( her primary HSV1 or 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-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 negativeIf 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 mom’s 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 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%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 Management70’s-80’s – weekly HSV cultures

1988 – patient examined at delivery, Cesarean delivery if: (no data)

Identifiable genital lesions

Patient describes prodromal symptomsPatient 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)effect)

DFA –sensitivity/specificity in the 75%-85% range

PCR TestingDetects minute amounts of DNA, RNA

DISSEM – 93%

CNS – 76%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

SkinSkin

CulturesStool

Urine

CSF >100 WBC/Inc. Pro

Tzanck – neither sensitive nor specific

Treatment - AcyclovirSEM infections

60mg/kg/day divided q8h for 14 days

May be lengthened to 21 days in the near futurefuture

Oral Acyclovir needed later in life?

DISSEM and CNS HSV infections60mg/kg/day divided q8h for 21 days

Re-tap if CNS disease exists prior to d/c

Watch for neutropenia – 2x week ANCs

Take Home MessagesMost neonates with HSV infection are born to mothers with asymptomatic genital shedding at delivery, 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?