Herpes Simplex Virus

Primarily by Linda Wallen, MDEdited May, 2005

Epidemiology of Herpes Simplex

• 5 % patients have a history of HSV • > 20% have serologic evidence of HSV

Primary infection = Patient has NO antibodies to HSV Nonprimary= prior exposure to either HSV-1 or HSV-2 Recurrent infection = + antibodies to reactivating

virus type Shedding at delivery not predicted from past cultures

• > 2/3 of babies with HSV infection are born to mothers with NO previous history of HSV

• Risk neonatal infection with recurrence= 2-5%• Risk neonatal infection with primary inf.= 35%

Pathway of Infection for Neonatal HSV

Pathway of Infection for Neonatal HSV

• < 5% with intrauterine acquired infection• Primary infection may be associated with a

higher risk of spontaneous abortion, preterm delivery, and neonatal infection Higher viral load, longer excretion (14-21 days) No transplacental antibody

• 85% cases are acquired at the time of delivery Risk increased with PROM (> 6 hour), application of

fetal scalp electrodes and other invasive tests

• 10% acquired postnatally

Presentation of Neonatal HSV Infection

Presentation of Neonatal HSV Infection

• > 90% present between 5-19 days of age• > 20% NEVER have skin lesions• Initial symptoms vague in 30%

LethargyPoor feedingFever Irritability

• Intrauterine acquisition: skin lesions, scars, chorioretinitis, evidence of CNS involvement (hydranencephaly or microcephaly)

Onset of Neonatal HSV InfectionOnset of Neonatal HSV Infection

0

5

10

15

20

25O

nset

of

sym

pto

ms (

day)

*

Disse

min

ated

SEMCNS

HSV

type 1

HSV

type 2

Acta Paediatr 84:256, 1995

Signs & Symptoms of Neonatal HSV Before Treatment

Signs & Symptoms of Neonatal HSV Before Treatment

Disseminated Encephalitis Skin/eye/mouth Skin vesicles (%) (# d+SEM)

58 4 +1

63 6 +1

83 4 +1

Lethargy (%) (# d+SEM)

47 3 +1

49 5 +1

19

Fever (%) (# d+SEM)

56 5 +1

44 3 +1

17 5 +1

Conjunctiv (%) (# d+SEM)

17 6 +2

16 4 +1

25 6 +2

Seizures (%) (# d+SEM)

22 2 +1

57 3 +1

2 7

Pneumonia (%) (# d+SEM)

37 4 +1

3 9+6

0

Pediatrics 108 (2): 226, 2001

Diagnosis of Neonatal HSV Infection

Diagnosis of Neonatal HSV Infection

Gold standard = Positive culture of: lesion, nasopharynx, conjunctiva, rectum, or CSF

• Rapid diagnostic methods Polymerase chain reaction on CSF and

blood Fluorescent antibody stain on vesicle

scraping

Treatment of Neonatal HSVTreatment of Neonatal HSV

• Acyclovir 60 mg/kg/day IV given q8h Suspect infection - 2 d of negative

cultures Definite infection - 14 d for SEM, 21

d CNS

• Topical ocular ointment for eye lesions

Mortality & Morbidity after 1 Year of Age: 1981-1997Mortality & Morbidity after 1 Year of Age: 1981-1997

0

20

40

60

80

100

CNS Dissemin CNS Dissemin

HSV-1

HSV-2

Mortality Severe DisabilityPediatrics 108 (2): 227, 2001

Peripartum Management of Pregnant Women with History of

HSV

Peripartum Management of Pregnant Women with History of

HSV• If no active lesions, normal vaginal delivery• No current recommendation to culture for mother

or infant for HSV•Options with active lesions at onset of labor:

If term and ROM <4-6 (?24) hours, C-section If preterm and ROM, may manage expectantly with or without acyclovir, betamethasone treatment, etc. OR may offer C-section

• C-section does NOT eliminate risk of neonatal HSV

Peripartum Management of Pregnant Women with Possible Primary HSV

• Viral culture of active lesions• Serological classification if accurate testing

available• Value of acyclovir is not known• If 3rd trimester, consider weekly cultures

• primary infection associated with prolonged viral shedding

• If preterm and ROM, may manage expectantly +/- acyclovir, betamethasone treatment, etc.• OR may offer C-section

• Viral culture of active lesions• Serological classification if accurate testing

available• Value of acyclovir is not known• If 3rd trimester, consider weekly cultures

• primary infection associated with prolonged viral shedding

• If preterm and ROM, may manage expectantly +/- acyclovir, betamethasone treatment, etc.• OR may offer C-section

Management of the Asymptomatic Neonate Exposed

to HSV at Delivery

Management of the Asymptomatic Neonate Exposed

to HSV at Delivery• For recurrent maternal HSV:

Separate from other newborns, may stay with mom in private room

Instruct parents re: subtle signs infection, skin lesions

Obtain cultures at 24-48 hours from vesicles, nasopharynx, conjunctiva, and rectum (do not pool rectal cultures with other cultures)

If cultures are positive then treat with acyclovir Delay circumcision for > 1 month

Management of the Asymptomatic Neonate Exposed

to HSV at Delivery

Management of the Asymptomatic Neonate Exposed

to HSV at Delivery• For first episode genital infection:

Manage with contact precautions (gown, glove), isolation

Obtain cultures from vesicles, nasopharynx, conjunctiva, and rectum (do not pool rectal cultures with other cultures)

Lumbar puncture for HSV PCR and culture Treat with acyclovir Delay circumcision for > 1 month