Neonatal HSV: Difference between revisions
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*See also [[Herpes simplex virus]] |
*See also [[Herpes simplex virus]] |
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− | === |
+ | ===Epidemiology=== |
*Risk of transmission is determined by maternal serostatus at time of maternal genital infection |
*Risk of transmission is determined by maternal serostatus at time of maternal genital infection |
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*Localized CNS infection is thought to occur by retrograde axonal transmission |
*Localized CNS infection is thought to occur by retrograde axonal transmission |
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− | ==Clinical |
+ | ==Clinical Manifestations== |
− | *Incubation period 7 to 21 days post-partum, with range from birth to 6 weeks |
+ | *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 |
*Spectrum of disease from cutaneous to disseminated |
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*Localized to skin, eyes, and/or mouth |
*Localized to skin, eyes, and/or mouth |
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*Usually presents in the first or second week of life |
*Usually presents in the first or second week of life |
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+ | |||
+ | ==Diagnosis== |
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+ | |||
+ | *Most commonly diagnosed with PCR of lesions, CSF, or mucosal membranes (conjunctivae, mouth, nasopharynx) |
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+ | **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 |
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+ | **Early CSF PCR may be falsely negative; consider continuing acyclovir and repeating at 72 hours if high clinical suspicion |
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==Management== |
==Management== |
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+ | === Diagnosed neonates === |
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+ | |||
+ | *Obtain CSF (± blood PCR), and transaminases to determine if the disease involves CSF and is disseminated |
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*'''Disseminated disease:''' high-dose [[Is treated with::acyclovir]] 60 mg/kg/day IV divided q8h for at least 21 days |
*'''Disseminated disease:''' high-dose [[Is treated with::acyclovir]] 60 mg/kg/day IV divided q8h for at least 21 days |
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**If CNS disease, repeat lumbar puncture at the end of therapy to document resolution of CSF parameters and ensure that PCR is negative |
**If CNS disease, repeat lumbar puncture at the end of therapy to document resolution of CSF parameters and ensure that PCR is negative |
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*'''Localized skin, eye, and mouth disease:''' high-dose [[Is treated with::acyclovir]] 60 mg/kg/day IV divided q8h for at least 14 days |
*'''Localized skin, eye, and mouth disease:''' high-dose [[Is treated with::acyclovir]] 60 mg/kg/day IV divided q8h for at least 14 days |
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**For eye involvement, consult and ophthalmologist to add topical trifluridine, idoxuridine, or vidarabine |
**For eye involvement, consult and ophthalmologist to add topical trifluridine, idoxuridine, or vidarabine |
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+ | |||
+ | === Exposed neonates === |
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+ | |||
+ | * First-episode genital HSV at delivery |
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+ | ** Rupture of membranes before vaginal or cesarean delivery |
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+ | *** Swab mucous membranes for PCR either at birth or at 24 hours |
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+ | *** Start empiric [[acyclovir]] IV for 10 days |
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+ | *** 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 |
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+ | ** 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== |
==Prognosis== |
Latest revision as of 08:58, 5 August 2020
Background
- See also Herpes simplex virus
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%
- Newly acquired
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
- Rupture of membranes before vaginal or cesarean delivery
- 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