November 5, 2010

NEONATAL HSV ACQUISITION Intrauterine- Rare

Fetal demise Perinatal- 85%

HSV from maternal genital tract Often asymptomatic Higher risk with primary infection

Postnatal- 10%Caretaker with active HSV

NEONATAL HSV ACQUISITION 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

NEONATAL HSV Three categories (may overlap)

Skin, eye, mouth (SEM)Central nervous system (CNS)Disseminated

May be caused by HSV-1 or HSV-2HSV-2 worse prognosis

SKIN, EYE, MOUTH

Most common first 2wksSeen up to 6wks

Perform thorough evaluation for CNS and disseminated dz

Favorable outcome if treated early

CNS DISEASE Most common first 2wks

Seen up to 6wks May occur with or without SEM

Up to 70% have skin findings Clinical manifestations

SeizuresLethargyFull fontanelSystemic signs: Irritability, tremors, poor

feeding, temp instability, apnea

CNS DISEASE Most survive, but with substantial

sequelaeConsider imagingEarly Intervention

DISSEMINATED HSV Liver, lungs, adrenals, CNS, skin, eye,

mouthNeutropenia, 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

DISSEMINATED HSV Skin vesicles may appear late

Absent in 20% Complications

Respiratory failure: intubationLiver failure: transplantation If untreated, mortality 80%

Often diagnoses at autopsy

INDEX OF SUSPICION Sepsis syndrome, negative bacterial

cultures, liver dysfunction Sepsis syndrome, abnormal CSF

especially in setting of neonatal seizure

DIAGNOSTIC TESTING Cell culture

MouthNasopharynxConjunctivaeRectumCSF (skin vescicles and blood)

Direct Fluorescent Antibody stainingVesicular scrapings

PCR useful for CSF

DIAGNOSTIC TESTING Tzanck test has low sensitivity and is

outdated

TREATMENT Parenteral acyclovir

60mg/kg/day in 3 divided doses14 days for SEM21 days for CNS or disseminated

If ocular involvement, add topical drops

PRECAUTIONS Cesarean delivery if active lesions

presentDecreases risk of neonatal HSV

Maternal history is not an indication for C/S

Avoid fetal scalp monitors during labor

PRECAUTIONS Infants infected or exposed during

deliveryContact precautionsContinuous rooming in with mom in private

room Postpartum women with HSV infection

Breastfeeding is allowed No lesions on breasts Any other lesions are covered

CARE OF EXPOSED NEWBORN Maternal active genital HSV at birth

Obtain cultures at 12-24hrs of life Mouth, nasopharynx, conjunctivae, rectum

Maternal first-episode genital lesions?Start empiric acyclovir

CARE OF INFANT WITH POSITIVE MATERNAL HISTORY ONLY Careful exam and observation Educate caretakers of warning signs