Neonatal Herpes Simplex Quiz

Herpes Simplex

• Neonatal Manifestations:
  • Disseminated disease (60-75% of cases) affecting multiple organs, primarily the liver and lungs, often with CNS involvement.
  • Localized CNS disease, with or without skin, eye, or mouth involvement.
  • Localized disease limited to skin, eyes, or mouth (SEM disease).
  • Disseminated disease accounts for 25%, CNS disease for 30%, and SEM disease for 45% of neonatal HSV cases.
  • More than 80% of neonates with SEM disease have skin vesicles; those without vesicles are affected in eyes and mouth.
  • A significant proportion of neonates with disseminated or CNS disease will have skin lesions, but these may not be visible at the onset.
  • Symptoms like sepsis syndrome (negative bacterial culture), severe liver dysfunction, consumptive coagulopathy, or suspected viral pneumonia can indicate disseminated disease.
  • Fever (especially in the first three weeks of life), vesicular rash, or abnormal cerebrospinal fluid (CSF) findings (especially during seizures or when enteroviruses are not circulating) can suggest HSV infection.
  • Asymptomatic HSV infection is unusual in neonates.
• Mortality and Morbidity:
  • Neonatal herpetic infections are severe, with high mortality and morbidity rates, even with antiviral treatment.
  • Mortality rates from neonatal herpes increased between 2004 and 2013 compared to earlier years.
  • Recurrent skin lesions are common in survivors, often occurring within 1-2 weeks after completing initial treatment.
  • Nearly all infants develop clinical signs within the first month of life, with those having disseminated or SEM disease showing signs earlier in the first or second weeks.
• Beyond Neonatal Period and Adolescents:
  • Most primary HSV infections beyond the neonatal period are asymptomatic.
  • Gingivostomatitis (most common childhood manifestation) involves fever, irritability, tender submandibular adenopathy, and mouth lesions with perioral vesicles.
  • Genital herpes: Vesicular or ulcerative lesions in the male or female genitalia, perineum; HSV-1 is now the most frequent cause of genital herpes in the US.
  • Asymptomatic genital herpes is common.
  • Eczema herpeticum can develop in patients with atopic dermatitis.
  • Immunocompromised patients may develop severe local lesions or disseminated infection with generalized vesicular skin lesions affecting internal organs.
• Recurrent Infections:
  • HSV persists latently after primary infection.
  • Reactivation is usually asymptomatic.
  • Recurrent HSV-1 infection, such as cold sores (oral herpes), usually affects the perioral region.
  • Recurrent genital herpes affects the penis, scrotum, vulva, cervix, buttocks, perianal areas, thighs, or back.
  • Recurrences in immunocompromised patients are more frequent and longer lasting.
  • A painful prodrome, such as burning or itching, may precede recurrent infection.
• Other manifestations:
  • Conjunctivitis and keratitis from primary or recurrent HSV infection.
  • Herpetic whitlow: Vesicles on the fingers (common in wrestlers).
  • HSV encephalitis (HSE) occurs in children, adolescents, and adults. It affects the temporal lobe and symptoms include fever, altered consciousness, personality changes, seizures, and focal neurological signs.
  • Aseptic meningitis is a self-limiting infection frequently associated with genital HSV-2.

Diagnosis

• Diagnostic Tests:
  • HSV grows readily in traditional cell culture.
  • PCR assays are commonly used to detect HSV DNA in CSF.
  • CSF PCR assay is the method of choice for CNS HSV infection.
  • Other diagnostic tests include fluorescent antibody staining, enzyme immunoassays, and monolayer culture.
• Detection:
  • Testing of various bodily fluids, such as surface specimens from the mouth, nasopharynx, conjunctiva, and anus, or skin vesicles.
  • CSF (cerebrospinal fluid) sampling.
  • Blood samples for HSV PCR assay.
  • ALT (alanine transaminase) blood tests.

Treatment

• General Considerations:
  • Specific antiviral treatment with acyclovir, valacyclovir, or famciclovir is recommended.
  • Dosages and durations of treatment vary depending on the infection type and severity.
  • Intravenous acyclovir is the common treatment for neonatal HSV infections.
• Neonatal Treatment: Intravenous acyclovir is the standard treatment for neonatal herpes infections at 60 mg/kg in 3 divided doses. The treatment duration is commonly 14 days for SEM disease, and 21 days for CNS or disseminated disease.
• Infants: should be assessed at 2 and 4 weeks, and monthly thereafter, for recurrent HSV cases.

Control Measures

• Prevention of Neonatal Infection:
  • Women with active genital herpes should be offered suppressive antiviral therapy during pregnancy, particularly at or beyond 36 weeks.
  • Infants born to mothers with active genital HSV lesions should be managed with contact precautions.
  • Evaluation considers maternal HSV classification, the duration of membrane rupture, and whether delivery was vaginal or via Cesarean.
• Care of Infants: Infants should get prompt clinical evaluation, including neuroimaging, if symptoms develop.
• Health Care Professionals: Health care personnel with cold sores should not touch or interact with infants or patients with immunocompromised conditions.

Test your knowledge on the neonatal manifestations of herpes simplex virus. This quiz covers the various types of diseases, their symptoms, and effects on the neonate. Explore the critical details about dissemination, CNS involvement, and localized conditions.