Neonatal HSV: Difference between revisions

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==Background==
==Background==
*Causative agent: [[HSV-1]] or [[HSV-2]]
*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)” <ref name=definition></ref>
*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)” <ref name="definition">Caviness AC. Neonatal herpes simplex virus infection. Clin Ped Emerg Med. 2013;14(2):135-145</ref>
*ED prevalence:
*ED prevalence:
**0.2% all neonates
**0.2% all neonates
**0.3% febrile neonates
**0.3% febrile neonates
**0.5% neonates undergoing LP
**0.5% neonates undergoing LP
*Prevalence similar to meningitis (0.4%) in neonates presenting for SBI <ref name=prevalence></ref>
*Prevalence similar to meningitis (0.4%) in neonates presenting for SBI <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  


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===Historical Features===
===Historical Features===
*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></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>
*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  

Revision as of 22:04, 2 July 2016

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 [2]
  • Risk associated with age <3 weeks, primary maternal HSV infection at delivery

Risk Factors in Neonatal Fever

^Acyclovir if:

  • HSV infection in baby or mother
  • CSF pleocytoisis
  • Concerning skin lesions
  • Seizures
  • Abnormal LFTs

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:
    • Temperature instability (fever, hypothermia)
    • Irritability
    • Lethargy
    • Seizures
    • Respiratory distress

Clinical Features

  • General
    • Temperature instability (febrile or hypothermic)
    • May be well appearing in SEM
  • Disseminated
    • Neutropenia
    • Thrombocytopenia
    • Hepatitis
    • Pneumonitis
    • DIC
    • +/- CNS disease
  • 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

Diagnosis

  • 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

Management

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
  • Mortality high with CNS (4%) or disseminated (29%) even with treatment (3)

Bottom Line

  • Always consider neonatal HSV and perform appropriate workup 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

See Also

External Links

References

  1. ↑ 1.0 1.1 1.2 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. ↑ James SH, Kimberlin DW. Neonatal herpes simplex virus infection: epidemiology and treatment. Clin Perinatol. 2015;42(1):47-59
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