Neonatal HSV

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 (2)
• Risk associated with age <3 weeks, primary maternal HSV infection at delivery

Risk Factors in Neonatal Fever

^Acyclovir if:

• HSV infection in baby or mother
• CSF pleocytoisis
• Concerning skin lesions
• Seizures
• Abnormal LFTs

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) (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

Diagnosis

• 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

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

See Also

• Neonatal conjunctivitis
• Pediatric fever of uncertain source
• Herpes viruses