2/9/2015

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Tom Rand MD PhD

St. Luke’s Children’s Infections and Immune Deficiency Clinic

February 20, 2015

Herpes simplex virus

Cytomegalovirus

Hepatitis B virus

West Nile virus

Ebolavirus

Lyme disease (Borrelia burgdorferi)

Syphilis (Treponema pallidum)

“some minor pathogens”

Molecular diagnosis

Acyclovir dose for all neonatal management of HSV

60 mg/kg/day divided q 8 hr IV

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*10 days acyclovir therapy reserved for newborns diagnosed by surveillance cultures after exposure and before disease (“preemptive therapy”)*Kimberlin et al. “Guidance on management of

asymptomatic neonates born to women with active genital herpes lesions” Pediatrics 131:e635-646, 2013

*14 days IV acyclovir therapy for HSV

disease confined to skin, eye, mucus

membranes (SEM)

*21 days of IV acyclovir therapy for CNS

or disseminated HSV disease

*For positive CSF PCR, repeat LP

before end of therapy and treat

additional week until negative CSF PCR

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After completion of IV acyclovir therapy for

neonatal HSV disease, continue suppressive

oral acyclovir 300 mg/m2/dose TID for 6

months

Kimberlin et al. “Oral acyclovir suppression and

neurodevelopmental outcome after neonatal herpes” New

England Journal of Medicine 365:1284-1292, 2011

*Lesion HSV culture

*Pooled conjunctivae and pharynx

swabs for HSV culture

*Genital or rectal swab for HSV

culture

*CSF PCR, and routine CSF studies

*Blood PCR

*Hepatic chemistries and CBC

*Primary maternal infection

*Reactivated maternal infection

*New infection with different

strain than primary infection

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Failed newborn hearing screen with

confirmation of sensorineural hearing

loss of any degree prompts testing urine

CMV culture.

This is the responsibility of primary care

provider to order testing and should not

be deferred for specialty evaluation.

*We screen for hearing loss present in

newborns

*An unknown proportion of congenital

CMV infections develop hearing loss

beyond newborn period

*No screening for congenital CMV per se

*Antiviral therapy for congenital CMV can prevent progressive hearing loss, but standard 6 weeks IV ganciclovir is too short to have an impact.

*Hearing loss may progress in an infant that is not otherwise symptomatic from congenital CMV. “Asymptomatic” congenital CMV does not have recommendation to treat with IV ganciclovir.

*Duration of oral valganciclovir therapy and selection of candidates for therapy are currently subjected to clinical trials.

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Must test greater than month after final

hep B vaccine (approximately 9 months):

•HBsAg

•Anti-HBs

*Tenofovir, lamivudine, and telbivudine current options

• If taking adefovir or entecavir, then change

*Each drug has specific safety concerns, but actual

experience in pregnancy is encouraging

*Flare of hepatitis at end of pregnancy is common and

can be controlled by antivirals

*Demonstrated reduction of 1) mother to infant

transmission 2) HBV DNA 3) hepatic issues

*Be sure women with chronic viral hepatitis B and

C infection have a provider identified to continue to

counsel and monitor liver disease.

*Changes in therapies for hepatitis B and C have

expanded options. Individuals that were

previously discouraged from therapy have become

promising candidates for newer therapies.

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Please include hep B vaccine in

standing orders for newborn.

No one has a “low-risk

population”!

Important failsafe for all human

and med record failures in

prenatal HBsAg testing

*West Nile virus

*Ebolavirus

*Lyme disease (Borrelia

burgdorferi)

Only a couple publications but consistent

features of fetal infection with

chorioretinitis and cerebral white matter

disease

Transmission by breastfeeding reported

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Viral hemorrhagic fevers have exceedingly poor

outcome during pregnancy.

Most fetuses spontaneously aborted

Obstetrical emergencies responsible for substantial

transmission of ebolavirus to healthcare workers

Death rate of ebolavirus-infected mothers 95%

Mupapa et al. Journal of Infectious Diseases 179:S11012, 1999

For example, publications such as:

Kuhn, Grave, Bransfield, and Harris. “Long term antibiotic therapy may be an effective treatment for children co-morbid with Lyme disease and Autism Spectrum Disorder” Medical Hypotheses 78:505-615, 2012.

*

*Ixodes pacificus

Lyme disease is geographically

restricted by tick vector

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Occasional reports of infection of fetus

No consistent consequences of congenital

infection

No inflammation associated with spirochetes in

tissues in the fetuses or babies reported

Shapiro and Gerber, In Reminton & Klein Infectious Diseases

of the Fetus and Newborn Infant, 7th ed, 2011, pp 564-576

Mylonas, Vector-borne and zoonotic diseases, 11:891-898,

2011

*Syphilis

*Leptospirosis

*Relapsing fever borreliosis

*90% are diagnosed during erythema migrans

*Disseminated manifestations are reversible with treatment, including carditis, cranial nerve palsies, meningitis

*Arthritis may take months to resolve clinically after treatment

*Existence of chronic Lyme disease has been refuted (for example Feder et al. New England Journal of Medicine 357:1422-1430, 2007)

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Most Lyme disease is treated during

symptoms of erythema migrans

*No relationship of the clinical problems

leading to fatal outcome to the tissues

where spirochetes were found

*Appeared to be incidentally found in

variety of adverse outcomes due to

other causes

*Pregnancies treated for acute symptomatic Lyme disease (erythema migrans or other) no consequences

*Seroconversions during pregnancy or seropositives at end of pregnancy no consequences

*Birth defects no pattern or increased incidence

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There is no reason to think

that a burden of

neurodevelopmental

problems in children has

resulted from undiagnosed

congenital Lyme disease.