1. Primarily by Linda Wallen, MD Edited May, 2005
Herpes Simplex Virus
Primarily by Linda Wallen, MD
Edited May, 2005

2. Epidemiology of Herpes Simplex
5 % patients have a history of HSV
> 20% have serologic evidence of HSV
Primary infection = Patient has NO antibodies to HSV
Nonprimary= prior exposure to either HSV-1 or HSV-2
Recurrent infection = + antibodies to reactivating virus type
Shedding at delivery not predicted from past cultures
> 2/3 of babies with HSV infection are born to mothers with NO previous history of HSV
Risk neonatal infection with recurrence= 2-5%
Risk neonatal infection with primary inf.= 35%

3. Pathway of Infection for Neonatal HSV
< 5% with intrauterine acquired infection
Primary infection may be associated with a higher risk of spontaneous abortion, preterm delivery, and neonatal infection
Higher viral load, longer excretion (14-21 days)
No transplacental antibody
85% cases are acquired at the time of delivery
Risk increased with PROM (> 6 hour), application of fetal scalp electrodes and other invasive tests
10% acquired postnatally

4. Presentation of Neonatal HSV Infection
> 90% present between 5-19 days of age
> 20% NEVER have skin lesions
Initial symptoms vague in 30%
Lethargy
Poor feeding
Fever
Irritability
Intrauterine acquisition: skin lesions, scars, chorioretinitis, evidence of CNS involvement (hydranencephaly or microcephaly)

5. Onset of Neonatal HSV Infection5 10 15 20 25
Onset of symptoms (day) *
SEM
CNS
HSV
type 1
HSV
type 2
Disseminated
Acta Paediatr 84:256, 1995

6. Signs & Symptoms of Neonatal HSV Before Treatment
Pediatrics 108 (2): 226, 2001

7. Diagnosis of Neonatal HSV Infection
Gold standard = Positive culture of: lesion, nasopharynx, conjunctiva, rectum, or CSF
Rapid diagnostic methods
Polymerase chain reaction on CSF and blood
Fluorescent antibody stain on vesicle scraping

8. Treatment of Neonatal HSV
Acyclovir 60 mg/kg/day IV given q8h
Suspect infection - 2 d of negative cultures
Definite infection - 14 d for SEM, 21 d CNS
Topical ocular ointment for eye lesions

9. Mortality & Morbidity after 1 Year of Age: 1981-1997
Severe Disability
Pediatrics 108 (2): 227, 2001

10. Peripartum Management of Pregnant Women with History of HSV
If no active lesions, normal vaginal delivery
No current recommendation to culture for mother
or infant for HSV
Options with active lesions at onset of labor:
If term and ROM <4-6 (?24) hours, C-section
If preterm and ROM, may manage expectantly with
or without acyclovir, betamethasone treatment, etc.
OR may offer C-section
C-section does NOT eliminate risk of neonatal HSV

11. Peripartum Management of Pregnant Women with Possible Primary HSV
Viral culture of active lesions
Serological classification if accurate testing available
Value of acyclovir is not known
If 3rd trimester, consider weekly cultures
primary infection associated with prolonged viral shedding
If preterm and ROM, may manage expectantly +/- acyclovir, betamethasone treatment, etc.
OR may offer C-section

12. Management of the Asymptomatic Neonate Exposed to HSV at Delivery
For recurrent maternal HSV:
Separate from other newborns, may stay with mom in private room
Instruct parents re: subtle signs infection, skin lesions
Obtain cultures at hours from vesicles, nasopharynx, conjunctiva, and rectum (do not pool rectal cultures with other cultures)
If cultures are positive then treat with acyclovir
Delay circumcision for > 1 month

13. Management of the Asymptomatic Neonate Exposed to HSV at Delivery
For first episode genital infection:
Manage with contact precautions (gown, glove), isolation
Obtain cultures from vesicles, nasopharynx, conjunctiva, and rectum (do not pool rectal cultures with other cultures)
Lumbar puncture for HSV PCR and culture
Treat with acyclovir
Delay circumcision for > 1 month