Presentation on theme: "Congenital/Neonatal Herpes Simplex Infections"— Presentation transcript:
1 Congenital/Neonatal Herpes Simplex Infections Infectious and Tropical Pediatric DivisionDepartment of Child HealthMedical FacultyUniversity of Sumatera Utara
2 Herpes Infections “Herpes” – from the Greek “to creep, crawl” “Herpetic eruptions” described as early as 100 AD1960’s – HSV1 and HSV2 differentiatedHHV1 – HSV1HHV2 – HSV2HHV3 – VZVHHV4 – EBVHHV5 – CMVHHV6 – Causes?HHV7 –HHV8 -
3 Neonatal HSV 1 in 2,500-5,000 deliveries / 500-1500 per yr. Birth to 7 weeks of lifeHSV2 = 70-75%, HSV1 = 25-30%3 Main TypesSkin, Eye, Mouth (SEM)CNSDisseminated Disease (DISSEM)At Risk: Premature, ROM >6hr, Fetal scalp monitoringCan be acquired congenitally, during the birth process, and in the post-partum period
4 Routes of Transmission 85% via infected maternal genital tractAscending infection?En route10% postpartum5% (or less) – intrauterine/congenital infection
5 Congenital HSV Rare, most devastating Only 50 cases described Skin vesiclesChorioretinitisMicrocephalyMicro-ophthalmiaIUGR
6 Skin, Eye, Mouth (SEM) Approximately ½ of all HSV infections 1st-2nd week presentationLimited to skin, eye, mouth/mucous membranes60-70% of untreated patients progress to CNS/disseminated disease
7 SEM (cont)Long term neurologic sequelae seen in 30% of cases – even if treatedOphthalmology involvement
10 HSV - CNS DiseaseEncephalitis without visceral involvement, mainly involving the temporal lobesEarly to 3rd week of life presentationSkin lesions may appear late, if at all35% of all cases, only 2-5% untreated survive normally
18 Take Home MessageInfection is most common when a mother develops a genital infection late in pregnancy ( her primary HSV1 or HSV2 infection) – then delivers before the development of protective maternal antibodies
19 Herpes SimplexApproximately 5% of the general population has been diagnosed with genital herpes – but approximately 20-30% of women may be infected with HSV-2Viral shedding occurs without identifiable lesions on 1-3% of days
20 Maternal Testing?Identify discordant couples to avoid transmission in the third trimesterIf mom is HSV1/HSV2 negativeIf mom is HSV2 negativeIf mom is HSV2 positive – risk is low for a vaginal delivery?Is testing after delivery going to be helpful?Will blood tests of the baby be helpful, or just reflect mom’s status?Psychosocial ramifications?
21 Herpes during Pregnancy As many as 2% of pregnant women are infected with HSV2 during pregnancy25% of women with a history of genital herpes have an outbreak at some time during their pregnancy, 11-14% at time of delivery36% at delivery for those with first infection!Virus is recovered from 1% of asymptomatic women at delivery
22 What is the risk?Vaginal delivery when mom has presence of first symptomatic lesions – 50%Vaginal delivery when mom is asymptomatic, but is newly infected – 33%Vaginal delivery when mom has recurrent lesions – 4%Vaginal delivery when mom has a history of herpes lesions in past, none presently – 0.04%
23 OB Management 70’s-80’s – weekly HSV cultures 1988 – patient examined at delivery, Cesarean delivery if: (no data)Identifiable genital lesionsPatient describes prodromal symptomsVaginal delivery for those with hx onlyPrimary infection diagnosed - treatEstimated $2-4 million to prevent each case20-30% of infants who are diagnosed with neonatal herpes are delivered by Cesarean delivery
24 Diagnostics HSV Cx – positive in 1-2 days (cytopathic effect) DFA – sensitivity/specificity in the 75%-85% range
25 PCR Testing Detects minute amounts of DNA, RNA DISSEM – 93%CNS – 76%SEM – 24%False negative may occur if CSF is obtained “too early”Order through IVF!
26 Diagnostics (cont) Surface cultures Cultures Mouth (40-50%)Eyes (25%)RectumSkinCulturesStoolUrineCSF >100 WBC/Inc. ProTzanck – neither sensitive nor specific
27 Treatment - Acyclovir SEM infections DISSEM and CNS HSV infections 60mg/kg/day divided q8h for 14 daysMay be lengthened to 21 days in the near futureOral Acyclovir needed later in life?DISSEM and CNS HSV infections60mg/kg/day divided q8h for 21 daysRe-tap if CNS disease exists prior to d/cWatch for neutropenia – 2x week ANCs
28 Take Home MessagesMost neonates with HSV infection are born to mothers with asymptomatic genital shedding at delivery, with no history of genital herpetic lesionsNo one test is 100% sensitive / specificKeep HSV in mindHow would you manage our case?