Neonatal Herpes Simplex Quiz

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Questions and Answers

Which imaging modality is most sensitive for detecting herpes simplex encephalitis (HSE)?

Ultrasound

X-ray

Computed tomography (CT)

Magnetic resonance imaging (MRI) (correct)

What is a typical finding in cerebrospinal fluid (CSF) analysis for herpes simplex encephalitis?

Predominance of lymphocytes (correct)

Increased erythrocytes

Elevated protein levels

Decreased glucose levels

Which of the following is an unusual central nervous system manifestation of HSV?

Fever

Seizures

Bacterial meningitis

Ascending myelitis (correct)

Which symptom is a common manifestation of herpes simplex infection?

Alterations in the state of consciousness Signup and view all the answers

Which type of herpes simplex virus infection is more likely to recur?

Genital HSV-2 Signup and view all the answers

What characterizes infants affected by neonatal herpes simplex virus (HSV) infection?

Severe neurological impairment Signup and view all the answers

Which test is most commonly used for diagnosing an active HSV infection?

Polymerase chain reaction (PCR) assay Signup and view all the answers

What is a characteristic of herpes simplex virus types in relation to geographic distribution?

HSV-1 and HSV-2 can affect both neonates and adults Signup and view all the answers

What percentage of neonatal HSV cases manifest as disseminated disease?

25% Signup and view all the answers

Which clinical manifestation of neonatal HSV infection involves multiple organs and often the central nervous system?

Disseminated disease Signup and view all the answers

Which of the following is NOT a recognized manifestation of neonatal herpes simplex virus infection?

Skin disease only Signup and view all the answers

Which percentage of neonatal HSV cases primarily manifests as skin, eye, or mouth disease?

45% Signup and view all the answers

In which order do the clinical manifestations of neonatal HSV typically occur, from most common to least common?

Disseminated disease, localized CNS, SEM disease Signup and view all the answers

What is the most prominent organ affected in cases of disseminated disease due to neonatal herpes simplex virus?

Liver Signup and view all the answers

Which clinical manifestation has the highest percentage of occurrence among neonatal HSV cases?

SEM disease Signup and view all the answers

Which of the following describes the involvement of the central nervous system in localized CNS disease?

Can occur with or without skin involvement Signup and view all the answers

What are the preferred tests for detecting HSV in genital lesions?

HSV PCR assay and cell culture Signup and view all the answers

Which statement regarding serologic tests for HSV is true?

Type-specific serologic tests confirm genital herpes for HSV-2. Signup and view all the answers

What is a limitation of using viral culture for detecting HSV in lesions?

Its sensitivity declines rapidly as lesions heal. Signup and view all the answers

What is the median time to seroconversion for HSV-2 first episode patients?

21 days Signup and view all the answers

Why should histologic examination for multinucleated giant cells not be performed routinely?

It has a low sensitivity for confirming HSV. Signup and view all the answers

What does failure to detect HSV through culture or PCR assay indicate?

The patient may still have HSV infection. Signup and view all the answers

Why are PCR assays increasingly used for HSV detection?

They are more sensitive than viral culture. Signup and view all the answers

Which aspect of HSV-1 antibodies in serologic testing is misleading?

A significant number of initial genital infections are caused by HSV-1. Signup and view all the answers

Study Notes

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.

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Description

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.