Herpes in a Newborn

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Morning Report

Leah Farley, PGY-2

10/25/2013



Case

•7 day old female transferred from an OSH for

respiratory distress

•Birth History Uncomplicated pregnancy with normal prenatal

ultrasound

Born at 38 weeks via NSVD

Mom was GBS positive, other prenatal labs

reassuring

Infant observed for 48 hours in nursery and then

discharged home with parents



•About 12 hours of being home she had anepisode of apnea associated with emesis that

resolved with stimulation

•An hour later parents went to feed her but she

seemed limp and she had another period of

apnea

•She was stimulated and started breathing,

however shortly afterward had another episodeof apnea

•911 called and she was admitted to OSH



Hospital Course

•Developed oxygen need on hospital day 2

•Blood cultures drawn and started on amp/gent

•Worsening hypoxia, respiratory distress and

continued apneic episodes so she was started

on HFNC

•LifeFlight was called for transport

Noted significant respiratory distress requiringintubation

Hypotensive requiring fluid bolus and Dopamine



History

•FH:Paternal relatives with history of heart murmur.

Dad and older half-brother with OSA 2/2

hypertrophied tonsils and adenoids.Mom and older half-sister healthy

Dad with schizophrenia

•SH: Lives in UT with both parents. 2 dogs at

home. Mom and Dad smoke outside.



Physical Exam

Temp 35.5-36.2, P 150s-130s RR 32 on vent, BP 60s/30s, sats 92% on 70%

FiO2, Weight 2.7 kg (2%ile)

GENERAL: Sedated, intubated, non-irritable.

EYES: PERRL, conjunctivae clear, sclerae nonicteric,

HENT/MOUTH: NC/AT, AFSF, orally intubated MMM,

LYMPH: Neck supple, no LAD.

LUNGS: coarse bilaterally, no increased WOB, good aeration, no adventitious

sounds, not breathing over the vent.

CV: RRR, no M/R/G, nl perfusion and pulses.

ABD: Soft, ND, liver edge palpable, nl BS, no masses

GU: Nl external genitalia, nl Tanner stage for age, Foley catheter in place.BACK: Unable to examine

MSK/EXTREMITIES: No C/C/E. No e/o joint swelling or erythema.

SKIN: Pale. No rashes, jaundice, cyanosis.

NEURO: Somewhat hypotonic. Does awaken slightly and move head.



Differential Diagnosis?

7 day old female with respiratory

failure and hypotension.



Differential Diagnosis

ID Pertussis

RSV

Enterovirus

Sepsis GBS

E. coli

Listeria

Enterococcus

HSV

TORCH

Pneumonia Chlamydia

GBS

Aspiration

CV HLHS

Aortic coarctation

Truncus arteriosis

TAPVR

Transposition of the

great arteries

Pulmonic

atresia/stenosis

Tricuspid atresia Aortic stenosis

Tetralogy of Fallot

DILV

FEN/GI TE fistula

GER

Viral hepatitis

Neuro Seizures

Pulm RDS

Pulmonary

hemorrhage

Other NAT

DIC



Labs/Work-up

•CMP - BUN 3, Cr 0.29, Albumin 1.4, Bilirubin

4.3, Alk. Phos. 56, ALT 100, AST 260

•UA – 1+ glucose, neg LE, nitrite, ketone,

protein, Hgb •PTT - 36 PT/INR: 17.2/1.4 Fibrinogen: 165

•Serum HSV PCR – pos

•CSF HSV PCR –

pos •Tracheal aspirate – HSV pos

•Conjunctival swab – HSV pos

•



Neonatal HSV - Epidemiology

•Incidence 1 in 3,000 to 1 in 20,000 live births

•Risk greater with primary infection

Esp when acquired close to delivery

•Transmission most commonly direct contact with infected

vaginal secretionsIncreased risk with longer ROM

•Transmission can also occur in utero or post-natally

•3 types

Skin, Eyes, Mouth ~45% CNS disease ~33%

Disseminated ~25%



Skin, Eye, Mouth HSV

•Present ~10-12 days of life

•High rates of progression to CNS or

disseminated if not treated

•Clustering vesicular lesions with erythematous

base

•Eye infection usually asymptomatic but may

have watering, crying from eye pain,conjunctival erythema



aapredbook.aappublications.org



CNS HSV

•2nd-3rd week of life

•Presentation: Seizures, lethargy, irritability,

tremors, poor feeding, temp instability, full

anterior fontanelle, DIC, apnea, shock •Diagnosis: CNS normal or with mononuclear

cell pleiocytosis and elevated protein

60-70% will have skin lesions



Disseminated HSV

•Usually present in 1st week of life

•Can involve: Adrenals, CNS, eye, liver, lung,

mouth and skin

60-75% have CNS involvement Skin vesicles are usually late finding and 20% do not

have any skin manifestations

Serious complications – severe coagulopathy, liver

dysfunction, pulmonary involvement

•Mortality >80% if untreated



Diagnosis

HSV PCR on blood, CSF and specimen

from skin vesicle

Viral Culture

Swab specimens from mouth, nasopharynx,conjunctiva, anus

Specimens from skin vesicles and CSF

Most cultures will grow within 5 days

Whole blood measurement of ALT



Treatment

PreventionC-section for women with lesions resembling HSV

Avoid scalp monitors in women with HSV lesions

High dose Acyclovir (60 mg/kg/day div q8hrs)

for at least 21 days (14 days for SEM)

Ocular involvement – topical 1% trifluridine,

0.1% iododeoxyuridine or 3% vidarabine

Suppressive therapy: 6 months of oralacyclovir 3,000 mg/m2

Improves neurologic outcomes in CNS disease

Prevents skin recurrences in all classifications



Outcomes

Mortality29% for Disseminated HSV

4% for CNS HSV

Percent of survivors with normal neurologicdevelopment

98% for SEM

83% for disseminated

31% for CNS



References

Thompson, C and R Whitley. “Neonatal Herpes

Simplex Virus: Where are We Now?” Advances

in Experimental Medicine and Biology. 2011; 697: 221-230.

Robinson, JL, Vaudry, WL, Forgie, SE, et al. “Prevention,

recognition and management of neonatal HSV infections.”Expert review of anti-infective therapy. 2012; 10(6): 675-685.

Uptodate. “Neonatal Herpes Simplex Virus Infection.”

AAP RedBook

Herpes in a Newborn

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