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November 5, 2010

November 5, 2010. Neonatal HSV Acquisition. Intrauterine- Rare Fetal demise Perinatal - 85% HSV from maternal genital tract Often asymptomatic Higher risk with primary infection Postnatal- 10% Caretaker with active HSV. Neonatal HSV Acquisition. Maternal outbreak at delivery

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November 5, 2010

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  1. November 5, 2010

  2. Neonatal HSV Acquisition • Intrauterine- Rare • Fetal demise • Perinatal- 85% • HSV from maternal genital tract • Often asymptomatic • Higher risk with primary infection • Postnatal- 10% • Caretaker with active HSV

  3. Neonatal HSV Acquisition • Maternal outbreak at delivery • Primary infection: transmission 25%-60% • Reactivated infection: transmission 2% • Nearly impossible to discern clinically • >75% of infants with HSV are born to women with negative history and physical

  4. Neonatal HSV • Three categories (may overlap) • Skin, eye, mouth (SEM) • Central nervous system (CNS) • Disseminated • May be caused by HSV-1 or HSV-2 • HSV-2 worse prognosis

  5. Skin, eye, mouth • Most common first 2wks • Seen up to 6wks • Perform thorough evaluation for CNS and disseminated dz • Favorable outcome if treated early

  6. CNS Disease • Most common first 2wks • Seen up to 6wks • May occur with or without SEM • Up to 70% have skin findings • Clinical manifestations • Seizures • Lethargy • Full fontanel • Systemic signs: Irritability, tremors, poor feeding, temp instability, apnea

  7. CNS Disease • Most survive, but with substantial sequelae • Consider imaging • Early Intervention

  8. Disseminated HSV • Liver, lungs, adrenals, CNS, skin, eye, mouth • Neutropenia, DIC • CNS in 70% • Maternal fever is risk factor • Usually presents 1st week of life • Advanced cases may present with hypothermia, respiratory failure and shock

  9. Disseminated HSV • Skin vesicles may appear late • Absent in 20% • Complications • Respiratory failure: intubation • Liver failure: transplantation • If untreated, mortality 80% • Often diagnoses at autopsy

  10. Index of Suspicion • Sepsis syndrome, negative bacterial cultures, liver dysfunction • Sepsis syndrome, abnormal CSF • especially in setting of neonatal seizure

  11. Diagnostic Testing • Cell culture • Mouth • Nasopharynx • Conjunctivae • Rectum • CSF • (skin vescicles and blood) • Direct Fluorescent Antibody staining • Vesicular scrapings • PCR useful for CSF

  12. Diagnostic Testing • Tzanck test has low sensitivity and is outdated

  13. Treatment • Parenteral acyclovir • 60mg/kg/day in 3 divided doses • 14 days for SEM • 21 days for CNS or disseminated • If ocular involvement, add topical drops

  14. Precautions • Cesarean delivery if active lesions present • Decreases risk of neonatal HSV • Maternal history is not an indication for C/S • Avoid fetal scalp monitors during labor

  15. Precautions • Infants infected or exposed during delivery • Contact precautions • Continuous rooming in with mom in private room • Postpartum women with HSV infection • Breastfeeding is allowed • No lesions on breasts • Any other lesions are covered

  16. Care of exposed newborn • Maternal active genital HSV at birth • Obtain cultures at 12-24hrs of life • Mouth, nasopharynx, conjunctivae, rectum • Maternal first-episode genital lesions • ?Start empiric acyclovir

  17. Care of infant with positive maternal history ONLY • Careful exam and observation • Educate caretakers of warning signs

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