Neonatal HSV: Difference between revisions
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==Background== | ==Background== | ||
*Causative agent: [[HSV-1]] or [[HSV-2]] | *Causative agent: [[HSV-1]] or [[HSV-2]] | ||
*Risk | *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)” <ref name="definition">Caviness AC. Neonatal herpes simplex virus infection. Clin Ped Emerg Med. 2013;14(2):135-145</ref> | ||
*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 <ref name="prevalence">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</ref> | |||
*Risk associated with age <3 weeks, primary maternal HSV infection at delivery | |||
Conjunctival disease may be manifestation | ===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 | |||
=== | ===Historical Features=== | ||
*Not sensitive (maternal history of HSV), nor specific (maternal fever, vaginal delivery, preterm birth) <ref name="definition"></ref> | |||
**80% of mothers have no history of genital lesions <ref name="details">James SH, Kimberlin DW. Neonatal herpes simplex virus infection: epidemiology and treatment. Clin Perinatol. 2015;42(1):47-59</ref> | |||
*[[vesiculobullous rashes|Vesicular lesions]] most specific, present in <1/2 <ref name="definition></ref> | |||
**Note: absence of vesicular rash does not rule out | |||
*'''May be well appearing''' - maintain high clinical suspicion | |||
*Ask about: | |||
**Temperature instability ([[fever (Peds)|fever]], [[hypothermia]]) | |||
**Irritability | |||
**[[Altered mental status|Lethargy]] | |||
**[[Seizure (peds)|Seizures]] | |||
**[[Shortness of breath (peds)|Respiratory distress]] | |||
==Clinical Features== | ==Clinical Features== | ||
*General | |||
**Temperature instability ([[fever (Peds)|febrile]] or [[hypothermia|hypothermic]]) | |||
**May be well appearing in SEM | |||
*Disseminated | |||
**[[Neutropenia]] | |||
**[[Thrombocytopenia]] | |||
**[[Hepatitis]] | |||
**[[Pneumonitis]] | |||
**[[DIC]] | |||
**+/- CNS disease | |||
*CNS | |||
**Hypotonia | |||
**[[seizure (peds)|Seizures]] | |||
**Abnormal brain imaging | |||
**Abnormal EEG | |||
**CSF pleocytosis and/or proteinosis | |||
*SEM | |||
**Characteristic [[neonatal rashes|skin lesions]] of HSV – skin, eye (kerato-conjunctivitis), or mouth | |||
**No evidence of systemic or CNS infection | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Pediatric fever DDX}} | |||
== | ==Evaluation== | ||
===Work-up=== | |||
*Should include the following <ref name="details"></ref> | |||
**CBC with differential | |||
**Chem | |||
**[[LFTs]] | |||
**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 CNS 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) | |||
**[[Keratoconjunctivitis]] | |||
**[[Seizure]] | |||
**Poor feeding | |||
**[[altered mental status (peds)|Lethargy]] | |||
**Irritability | |||
**[[shortness of breath (peds)|Respiratory distress]] | |||
**[[sepsis (peds)|Sepsis]] | |||
**Temperature instability | |||
**CSF pleocytosis | |||
**[[Thrombocytopenia]] | |||
**Transaminitis | |||
**Working up for serious bacterial illness | |||
==Management== | ==Management== | ||
===Management Considerations=== | |||
*[[Acyclovir]] if <ref>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</ref><ref>Long SS. In defense of empiric ayclovir therapy in certain neonates. J Pediatr. 2008;153(2):157</ref><ref>Kimberlin DW. When should you initiate acyclovir therapy in a neonate? J Pediatr. 2008;153(2):155</ref> | |||
**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 | |||
{{Neonatal HSV antivirals}} | {{Neonatal HSV antivirals}} | ||
==Disposition== | ==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 <ref name="definition"></ref> | |||
**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 <ref name="details"></ref> | |||
==See Also== | ==See Also== |
Revision as of 18:36, 6 October 2019
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
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 [3]
- 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
- Specific virus
Evaluation
Work-up
- Should include the following [3]
- CBC with differential
- Chem
- LFTs
- 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 CNS 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)
- Keratoconjunctivitis
- Seizure
- Poor feeding
- Lethargy
- Irritability
- Respiratory distress
- Sepsis
- Temperature instability
- CSF pleocytosis
- Thrombocytopenia
- Transaminitis
- Working up for serious bacterial illness
Management
Management Considerations
- Acyclovir if [4][5][6]
- 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
- 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 [3]
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
- ↑ 3.0 3.1 3.2 James SH, Kimberlin DW. Neonatal herpes simplex virus infection: epidemiology and treatment. Clin Perinatol. 2015;42(1):47-59
- ↑ 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