Neonatal HSV: Difference between revisions

(Text replacement - "==Diagnosis==" to "==Evaluation==")
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*Prevalence similar to meningitis (0.4%) in neonates presenting for SBI workup <ref name="prevalence">Caviness AC, et al. The prevelance of neonatal herpes simplex virus compared with serious bacterial illness in hospitalized neonates. J Pediatr. 2008;153:164-169</ref>
*Prevalence similar to meningitis (0.4%) in neonates presenting for SBI workup <ref name="prevalence">Caviness AC, et al. The prevelance of neonatal herpes simplex virus compared with serious bacterial illness in hospitalized neonates. J Pediatr. 2008;153:164-169</ref>
*Risk associated with age <3 weeks, primary maternal HSV infection at delivery  
*Risk associated with age <3 weeks, primary maternal HSV infection at delivery  
===Management Considerations===
*Acyclovir if <ref>Caviness AC, et al. The prevalence of neonatal herpes simplex virus infection compared with serious bacterial illness in hospitalized neonates. J Pediatr. 2008;153(2):164</ref><ref>Long SS. In defense of empiric ayclovir therapy in certain neonates. J Pediatr. 2008;153(2):157</ref><ref>Kimberlin DW. When should you initiate acyclovir therapy in a neonate? J Pediatr. 2008;153(2):155</ref>
**Proven HSV disease
**Suspected HSV disease (see clinical features) pending studies
**At risk due to exposure (active genital lesions in mother)
*Many recommend acyclovir empirically in ill-appearing neonates with fever (including hypothermia) or aspetic meningitis until results of work-up are known


===Classification===
===Classification===
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*Not sensitive (maternal history of HSV), nor specific (maternal fever, vaginal delivery, preterm birth) <ref name="definition"></ref>
*Not sensitive (maternal history of HSV), nor specific (maternal fever, vaginal delivery, preterm birth) <ref name="definition"></ref>
**80% of mothers have no history of genital lesions <ref name="details">James SH, Kimberlin DW. Neonatal herpes simplex virus infection: epidemiology and treatment. Clin Perinatol. 2015;42(1):47-59</ref>
**80% of mothers have no history of genital lesions <ref name="details">James SH, Kimberlin DW. Neonatal herpes simplex virus infection: epidemiology and treatment. Clin Perinatol. 2015;42(1):47-59</ref>
*Vesicular lesions most specific, present in <1/2 <ref name="definition></ref>
*[[Rashes (peds)|Vesicular lesions]] most specific, present in <1/2 <ref name="definition></ref>
**Note: absence of vesicular rash does not rule out
**Note: absence of vesicular rash does not rule out
*'''May be well appearing''' - maintain high clinical suspicion  
*'''May be well appearing''' - maintain high clinical suspicion  
*Ask about:
*Ask about:
**Temperature instability (fever, '''''hypothermia''''')
**Temperature instability ([[fever (peds)|fever]], [[hypothermia]])
**Irritability  
**Irritability  
**Lethargy
**[[Altered mental status|Lethargy]]
**Seizures
**[[Seizure (peds)|Seizures]]
**Respiratory distress
**[[Shortness of breath (peds)|Respiratory distress]]


==Clinical Features==
==Clinical Features==
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**May be well appearing in SEM
**May be well appearing in SEM
*Disseminated
*Disseminated
**Neutropenia
**[[Neutropenia]]
**Thrombocytopenia
**[[Thrombocytopenia]]
**Hepatitis
**[[Hepatitis]]
**Pneumonitis
**[[Pneumonitis]]
**DIC
**[[DIC]]
**+/- CNS disease
**+/- CNS disease
*CNS
*CNS
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==Management==
==Management==
===Management Considerations===
*[[Acyclovir]] if <ref>Caviness AC, et al. The prevalence of neonatal herpes simplex virus infection compared with serious bacterial illness in hospitalized neonates. J Pediatr. 2008;153(2):164</ref><ref>Long SS. In defense of empiric ayclovir therapy in certain neonates. J Pediatr. 2008;153(2):157</ref><ref>Kimberlin DW. When should you initiate acyclovir therapy in a neonate? J Pediatr. 2008;153(2):155</ref>
**Proven HSV disease
**Suspected HSV disease (see clinical features) pending studies
**At risk due to exposure (active genital lesions in mother)
*Many recommend acyclovir empirically in ill-appearing neonates with fever (including hypothermia) or aspetic meningitis until results of work-up are known
{{Neonatal HSV antivirals}}
{{Neonatal HSV antivirals}}


Revision as of 01:28, 15 September 2019

Background

  • Causative agent: HSV-1 or HSV-2
  • Definition – “infection acquired peri-natally or postnatally without clinical manifestations at birth or in the first 24 hours of life but with subsequent clinical manifestations in the neonatal period (age less than 29 days)” [1]
  • ED prevalence:
    • 0.2% all neonates
    • 0.3% febrile neonates
    • 0.5% neonates undergoing LP
  • Prevalence similar to meningitis (0.4%) in neonates presenting for SBI workup [2]
  • Risk associated with age <3 weeks, primary maternal HSV infection at delivery

Classification

  • Whitney-Kimberlin disease categories
    • Disseminated (liver, lung, adrenal glands, skin, eye, brain) - 25%
      • 2/3 have CNS involvement
    • CNS - 30%
    • SEM (skin, eye, mouth) - 45%
      • Conjunctival disease or minor skin lesions may be only manifestation
        • May go on to CNS, disseminated disease - workup and treat the same

Historical Features

  • Not sensitive (maternal history of HSV), nor specific (maternal fever, vaginal delivery, preterm birth) [1]
    • 80% of mothers have no history of genital lesions [3]
  • Vesicular lesions most specific, present in <1/2 [1]
    • Note: absence of vesicular rash does not rule out
  • May be well appearing - maintain high clinical suspicion
  • Ask about:

Clinical Features

  • General
    • Temperature instability (febrile or hypothermic)
    • May be well appearing in SEM
  • Disseminated
  • CNS
    • Hypotonia
    • Seizures
    • Abnormal brain imaging
    • Abnormal EEG
    • CSF pleocytosis and/or proteinosis
  • SEM
    • Characteristic skin lesions of HSV – skin, eye (kerato-conjunctivitis), or mouth
    • No evidence of systemic or CNS infection

Differential Diagnosis

Pediatric fever

Evaluation

Work-up

  • Should include the following [3]
    • CBC with differential
    • Chem
    • LFT
    • Blood, urine culture
    • LP with CSF studies
    • Perform PCR/culture of:
      • Any visible lesions
      • Conjunctiva, nasopharynx, mouth, anus
        • Even in the absence of lesions
    • Consider CXR for respiratory symptoms
    • Suspected disease should get CT and EEG
    • Suspected ocular involvement should get optho consult

Evaluation

  • Always consider neonatal HSV and perform appropriate work-up and treatment if:
    • Evidence of vesicular rash (even if minor)
    • Kerato-conjunctivitis
    • Seizure
    • Poor feeding
    • Lethargy
    • Irritability
    • Respiratory distress
    • Sepsis
    • Temperature instability
    • CSF pleocytosis
    • Thrombocytopenia
    • Transaminitis
    • SBI workups

Management

Management Considerations

  • Acyclovir if [4][5][6]
    • Proven HSV disease
    • Suspected HSV disease (see clinical features) pending studies
    • At risk due to exposure (active genital lesions in mother)
  • Many recommend acyclovir empirically in ill-appearing neonates with fever (including hypothermia) or aspetic meningitis until results of work-up are known

Disposition

  • Any neonate with suspected HSV (especially if CSF pleocytosis) should be treated and admitted
    • Consider covering all febrile neonates regardless pending CSF and culture studies

Outcomes

  • SEM with treatment - all survive [1]
    • If untreated 50-60% with SEM go on to CNS or disseminated disease
  • Mortality high with CNS (4%) or disseminated (29%) disease even with treatment [3]

See Also

External Links

References

  1. ↑ 1.0 1.1 1.2 1.3 Caviness AC. Neonatal herpes simplex virus infection. Clin Ped Emerg Med. 2013;14(2):135-145
  2. ↑ Caviness AC, et al. The prevelance of neonatal herpes simplex virus compared with serious bacterial illness in hospitalized neonates. J Pediatr. 2008;153:164-169
  3. ↑ 3.0 3.1 3.2 James SH, Kimberlin DW. Neonatal herpes simplex virus infection: epidemiology and treatment. Clin Perinatol. 2015;42(1):47-59
  4. ↑ Caviness AC, et al. The prevalence of neonatal herpes simplex virus infection compared with serious bacterial illness in hospitalized neonates. J Pediatr. 2008;153(2):164
  5. ↑ Long SS. In defense of empiric ayclovir therapy in certain neonates. J Pediatr. 2008;153(2):157
  6. ↑ Kimberlin DW. When should you initiate acyclovir therapy in a neonate? J Pediatr. 2008;153(2):155
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