Neonatal HSV: Difference between revisions
(edited for more specifics with citations) |
ClaireLewis (talk | contribs) No edit summary |
||
(8 intermediate revisions by 4 users not shown) | |||
Line 8: | Line 8: | ||
*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> | *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 | *Risk associated with age <3 weeks, primary maternal HSV infection at delivery | ||
===Classification=== | ===Classification=== | ||
Line 29: | Line 21: | ||
*Not sensitive (maternal history of HSV), nor specific (maternal fever, vaginal delivery, preterm birth) <ref name="definition"></ref> | *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> | **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> | ||
*Vesicular lesions most specific, present in <1/2 <ref name="definition></ref> | *[[vesiculobullous rashes|Vesicular lesions]] most specific, present in <1/2 <ref name="definition></ref> | ||
**Note: absence of vesicular rash does not rule out | **Note: absence of vesicular rash does not rule out | ||
*'''May be well appearing''' - maintain high clinical suspicion | *'''May be well appearing''' - maintain high clinical suspicion | ||
*Ask about: | *Ask about: | ||
**Temperature instability (fever, hypothermia) | **Temperature instability ([[fever (Peds)|fever]], [[hypothermia]]) | ||
**Irritability | **Irritability | ||
**Lethargy | **[[Altered mental status|Lethargy]] | ||
**Seizures | **[[Seizure (peds)|Seizures]] | ||
**Respiratory distress | **[[Shortness of breath (peds)|Respiratory distress]] | ||
==Clinical Features== | ==Clinical Features== | ||
*General | *General | ||
**Temperature instability (febrile or hypothermic) | **Temperature instability ([[fever (Peds)|febrile]] or [[hypothermia|hypothermic]]) | ||
**May be well appearing in SEM | **May be well appearing in SEM | ||
*Disseminated | *Disseminated | ||
**Neutropenia | **[[Neutropenia]] | ||
**Thrombocytopenia | **[[Thrombocytopenia]] | ||
**Hepatitis | **[[Hepatitis]] | ||
**Pneumonitis | **[[Pneumonitis]] | ||
**DIC | **[[DIC]] | ||
**+/- CNS disease | **+/- CNS disease | ||
*CNS | *CNS | ||
**Hypotonia | **Hypotonia | ||
**Seizures | **[[seizure (peds)|Seizures]] | ||
**Abnormal brain imaging | **Abnormal brain imaging | ||
**Abnormal EEG | **Abnormal EEG | ||
**CSF pleocytosis and/or proteinosis | **CSF pleocytosis and/or proteinosis | ||
*SEM | *SEM | ||
**Characteristic skin lesions of HSV – skin, eye (kerato-conjunctivitis), or mouth | **Characteristic [[neonatal rashes|skin lesions]] of HSV – skin, eye (kerato-conjunctivitis), or mouth | ||
**No evidence of systemic or CNS infection | **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 | **CBC with differential | ||
**Chem | **Chem | ||
** | **[[LFTs]] | ||
**Blood, urine culture | **Blood, urine culture | ||
**LP with CSF studies | **[[LP]] with CSF studies | ||
**Perform PCR/culture of: | **Perform PCR/culture of: | ||
***Any visible lesions | ***Any visible lesions | ||
***Conjunctiva, nasopharynx, mouth, anus | ***Conjunctiva, nasopharynx, mouth, anus | ||
****Even in the absence of lesions | ****Even in the absence of lesions | ||
**Consider CXR for respiratory symptoms | **Consider [[CXR]] for respiratory symptoms | ||
**Suspected disease should get CT and EEG | **Suspected CNS disease should get CT and EEG | ||
**''Suspected ocular involvement should get optho consult'' | **''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}} | ||
Line 85: | Line 103: | ||
===Outcomes=== | ===Outcomes=== | ||
*SEM with treatment - all survive | *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> | *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