Neonatal HSV: Difference between revisions

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== Background ==
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==Background==
* See also [[Herpes simplex virus]]
 
   
 
*See also [[Herpes simplex virus]]
−
=== Pathophysiology ===
 
* Generally acquired at time of delivery, though 5-8% may be [[Congenital HSV|congenital]]
 
   
  +
===Epidemiology===
== Clinical Presentation ==
 
* Incubation period 7 to 21 days post-partum, with range from birth to 6 weeks
 
* Spectrum of disease from cutaneous to disseminated
 
   
  +
*Risk of transmission is determined by maternal serostatus at time of maternal genital infection
=== Disseminated disease ===
 
  +
**Newly acquired
* 25% of cases
 
  +
***First-episode primary infection (mother has no serum antibodies to HSV-1 or -2 at onset): risk of transmission is about 60%
* Sepsis syndrome that predominantly affects the liver, lungs, and CNS
 
  +
***First-episode nonprimary infection (mother has a new infection with one HSV type in the presence of antibodies to the other type): risk of transmission is less than 30%
* May not have skin findings (25%)
 
  +
**Recurrent (mother has pre-existing antibodies to the HSV type that is isolated from the genital tract): risk of transmission is less than 2%
* Usually presents in the first or second week of life
 
* Should be considered in sepsis without bacterial cause and with liver dysfunction or coagulopathy
 
   
−
=== Localized CNS disease ===
+
===Pathophysiology===
* 30% of cases
 
* Usually presents in the second or third week of life
 
* May not have cutaneous manifestations
 
* Can cause seizures
 
   
 
*Generally acquired at time of delivery, though 5-8% may be [[Congenital HSV|congenital]]
=== Skin, eye, and mouth disease ===
 
  +
*Localized CNS infection is thought to occur by retrograde axonal transmission
* 45% of cases
 
  +
* Localized to skin, eyes, and/or mouth
 
 
==Clinical Manifestations==
* Usually presents in the first or second week of life
 
  +
 
*Incubation period [[Usual incubation period::7 to 21 days]] post-partum, with range from [[Incubation period range::birth to 6 weeks]]
 
*Spectrum of disease from cutaneous to disseminated
  +
 
===Disseminated disease===
  +
 
*25% of cases
 
*Sepsis syndrome that predominantly affects the liver, lungs, and CNS
 
**May not have skin findings (25%)
  +
**CNS involved in 60-75%, causing meningoencephalitis
  +
**Can also affect larynx, trachea, esophagus, stomach, lower gastrointestinal tract, spleen, kidneys, pancreas, and heart
  +
*Later in the course of the disease, may develop elevated ALT/AST and direct bilirubin, as well as coagulopathy and thrombocytopenia
 
*Usually presents in the first or second week of life
 
*Should be considered in sepsis without bacterial cause and with liver dysfunction or coagulopathy
  +
  +
===Localized CNS disease===
  +
 
*30% of cases
 
*Usually presents in the second or third week of life
 
*May not have cutaneous manifestations
 
*Can cause seizures
  +
 
===Skin, eye, and mouth disease===
  +
 
*45% of cases
 
*Localized to skin, eyes, and/or mouth
 
*Usually presents in the first or second week of life
  +
  +
==Diagnosis==
  +
  +
*Most commonly diagnosed with PCR of lesions, CSF, or mucosal membranes (conjunctivae, mouth, nasopharynx)
  +
**Do not send superficial swabs for PCR during the first 24 hours of life, since this can generate false positive from superficial contamination from the birthing process
  +
**Early CSF PCR may be falsely negative; consider continuing acyclovir and repeating at 72 hours if high clinical suspicion
  +
  +
==Management==
  +
  +
=== Diagnosed neonates ===
  +
  +
*Obtain CSF (± blood PCR), and transaminases to determine if the disease involves CSF and is disseminated
  +
*'''Disseminated disease:''' high-dose [[Is treated with::acyclovir]] 60 mg/kg/day IV divided q8h for at least 21 days
  +
**If CNS disease, repeat lumbar puncture at the end of therapy to document resolution of CSF parameters and ensure that PCR is negative
  +
*'''Localized CNS disease:''' same as for disseminated
  +
*'''Localized skin, eye, and mouth disease:''' high-dose [[Is treated with::acyclovir]] 60 mg/kg/day IV divided q8h for at least 14 days
  +
**For eye involvement, consult and ophthalmologist to add topical trifluridine, idoxuridine, or vidarabine
  +
  +
=== Exposed neonates ===
  +
  +
* First-episode genital HSV at delivery
  +
** Rupture of membranes before vaginal or cesarean delivery
  +
*** Swab mucous membranes for PCR either at birth or at 24 hours
  +
*** Start empiric [[acyclovir]] IV for 10 days
  +
*** If swabs confirm HSV infection, follow management above for diagnosed neonates
  +
*** If swabs are negative, complete the 10-day course regardless
  +
** Cesarean delivery prior to rupture of membranes
  +
*** Swab mucous membranes or blood PCR at 24 hours
  +
*** Counsel caregiver on signs and symptoms, and discharge
  +
*** If swabs confirm HSV infection, readmit to complete investigations and manage as above for diagnosed neonates
  +
* Recurrent genital HSV at delivery
  +
** Swab mucous membranes for PCR at 24 hours
  +
** Counsel caregiver on signs and symptoms, and discharge
  +
** If swabs confirm HSV infection, readmit to complete investigations and manage as above for diagnosed neonates
  +
  +
==Prognosis==
  +
  +
*Disseminated disease has 65% mortality if untreated, improves to 30% with treatment
  +
*With CNS disease, 80% have developmental problems
  +
*Prognosis much better with isolated cutaneous disease
   
 
[[Category:Pediatrics]]
 
[[Category:Pediatrics]]
  +
[[Category:Viruses]]

Latest revision as of 08:58, 5 August 2020

Background

Epidemiology

  • Risk of transmission is determined by maternal serostatus at time of maternal genital infection
    • Newly acquired
      • First-episode primary infection (mother has no serum antibodies to HSV-1 or -2 at onset): risk of transmission is about 60%
      • First-episode nonprimary infection (mother has a new infection with one HSV type in the presence of antibodies to the other type): risk of transmission is less than 30%
    • Recurrent (mother has pre-existing antibodies to the HSV type that is isolated from the genital tract): risk of transmission is less than 2%

Pathophysiology

  • Generally acquired at time of delivery, though 5-8% may be congenital
  • Localized CNS infection is thought to occur by retrograde axonal transmission

Clinical Manifestations

  • Incubation period 7 to 21 days post-partum, with range from birth to 6 weeks
  • Spectrum of disease from cutaneous to disseminated

Disseminated disease

  • 25% of cases
  • Sepsis syndrome that predominantly affects the liver, lungs, and CNS
    • May not have skin findings (25%)
    • CNS involved in 60-75%, causing meningoencephalitis
    • Can also affect larynx, trachea, esophagus, stomach, lower gastrointestinal tract, spleen, kidneys, pancreas, and heart
  • Later in the course of the disease, may develop elevated ALT/AST and direct bilirubin, as well as coagulopathy and thrombocytopenia
  • Usually presents in the first or second week of life
  • Should be considered in sepsis without bacterial cause and with liver dysfunction or coagulopathy

Localized CNS disease

  • 30% of cases
  • Usually presents in the second or third week of life
  • May not have cutaneous manifestations
  • Can cause seizures

Skin, eye, and mouth disease

  • 45% of cases
  • Localized to skin, eyes, and/or mouth
  • Usually presents in the first or second week of life

Diagnosis

  • Most commonly diagnosed with PCR of lesions, CSF, or mucosal membranes (conjunctivae, mouth, nasopharynx)
    • Do not send superficial swabs for PCR during the first 24 hours of life, since this can generate false positive from superficial contamination from the birthing process
    • Early CSF PCR may be falsely negative; consider continuing acyclovir and repeating at 72 hours if high clinical suspicion

Management

Diagnosed neonates

  • Obtain CSF (± blood PCR), and transaminases to determine if the disease involves CSF and is disseminated
  • Disseminated disease: high-dose acyclovir 60 mg/kg/day IV divided q8h for at least 21 days
    • If CNS disease, repeat lumbar puncture at the end of therapy to document resolution of CSF parameters and ensure that PCR is negative
  • Localized CNS disease: same as for disseminated
  • Localized skin, eye, and mouth disease: high-dose acyclovir 60 mg/kg/day IV divided q8h for at least 14 days
    • For eye involvement, consult and ophthalmologist to add topical trifluridine, idoxuridine, or vidarabine

Exposed neonates

  • First-episode genital HSV at delivery
    • Rupture of membranes before vaginal or cesarean delivery
      • Swab mucous membranes for PCR either at birth or at 24 hours
      • Start empiric acyclovir IV for 10 days
      • If swabs confirm HSV infection, follow management above for diagnosed neonates
      • If swabs are negative, complete the 10-day course regardless
    • Cesarean delivery prior to rupture of membranes
      • Swab mucous membranes or blood PCR at 24 hours
      • Counsel caregiver on signs and symptoms, and discharge
      • If swabs confirm HSV infection, readmit to complete investigations and manage as above for diagnosed neonates
  • Recurrent genital HSV at delivery
    • Swab mucous membranes for PCR at 24 hours
    • Counsel caregiver on signs and symptoms, and discharge
    • If swabs confirm HSV infection, readmit to complete investigations and manage as above for diagnosed neonates

Prognosis

  • Disseminated disease has 65% mortality if untreated, improves to 30% with treatment
  • With CNS disease, 80% have developmental problems
  • Prognosis much better with isolated cutaneous disease