Transcript Neonatal HSV Acquisition - LSU School of Medicine

November 5, 2010
 Intrauterine
Fetal demise
 Perinatal
85%
HSV from maternal genital tract


Often asymptomatic
Higher risk with primary infection
 Postnatal
Rare
10%
Caretaker with active HSV
 Maternal



outbreak at delivery
Primary infection: transmission 25%-60%
Reactivated infection: transmission 2%
Nearly impossible to discern clinically
 >75%
of infants with HSV are born to women
with negative history and physical
 Three



Skin, eye, mouth (SEM)
Central nervous system (CNS)
Disseminated
 May

categories (may overlap)
be caused by HSV-1 or HSV-2
HSV-2 worse prognosis
 Most

common first 2wks
Seen up to 6wks
 Perform
thorough evaluation for CNS and
disseminated dz
 Favorable outcome if treated early
 Most

Seen up to 6wks
 May

common first 2wks
occur with or without SEM
Up to 70% have skin findings
 Clinical




manifestations
Seizures
Lethargy
Full fontanel
Systemic signs: Irritability, tremors, poor feeding,
temp instability, apnea
 Most


survive, but with substantial sequelae
Consider imaging
Early Intervention
 Liver,

lungs, adrenals, CNS, skin, eye, mouth
Neutropenia, DIC
 CNS
in 70%
 Maternal fever is risk factor
 Usually presents 1st week of life
 Advanced cases may present with
hypothermia, respiratory failure and shock
 Skin

vesicles may appear late
Absent in 20%
 Complications



Respiratory failure: intubation
Liver failure:
transplantation
If untreated, mortality 80%

Often diagnoses at autopsy
 Sepsis
syndrome, negative bacterial cultures,
liver dysfunction
 Sepsis syndrome, abnormal CSF

especially in setting of neonatal seizure
 Cell






culture
Mouth
Nasopharynx
Conjunctivae
Rectum
CSF
(skin vescicles and blood)
 Direct

Fluorescent Antibody staining
Vesicular scrapings
 PCR
useful for CSF
 Tzanck
test has low sensitivity and is
outdated
 Parenteral



 If
acyclovir
60mg/kg/day in 3 divided doses
14 days for SEM
21 days for CNS or disseminated
ocular involvement, add topical drops
 Cesarean

delivery if active lesions present
Decreases risk of neonatal HSV
 Maternal
history is not an indication for C/S
 Avoid fetal scalp monitors during labor
 Infants


infected or exposed during delivery
Contact precautions
Continuous rooming in with mom in private room
 Postpartum

women with HSV infection
Breastfeeding is allowed


No lesions on breasts
Any other lesions are covered
 Maternal

Obtain cultures at 12-24hrs of life

Mouth, nasopharynx, conjunctivae, rectum
 Maternal

active genital HSV at birth
first-episode genital lesions
?Start empiric acyclovir
 Careful
exam and observation
 Educate caretakers of warning signs