Herpes Simplex Virus

Primarily by Linda Wallen, MD

Edited May, 2005
 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%
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
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)
 Onset of Neonatal HSV Infection
25
Onset of symptoms (day)
20

15

10
*
5

Acta Paediatr 84:256, 1995

 Signs & Symptoms of Neonatal HSV Before
Treatment
Disseminated Encephalitis Skin/eye/mouth
Skin vesicles (% ) 58 63 83
(# d+ SEM) 4 + 1 6 + 1 4 + 1
Lethargy (% ) 47 49 19
(# d+ SEM) 3 + 1 5 + 1
Fever (% ) 56 44 17
(# d+ SEM) 5 + 1 3 + 1 5 + 1
Conjunctiv (% ) 17 16 25
(# d+ SEM) 6 + 2 4 + 1 6 + 2
Seizures (% ) 22 57 2
(# d+ SEM) 2 + 1 3 + 1 7
Pneumonia (% ) 37 3 0
(# d+ SEM) 4 + 1 9+ 6
Pediatrics 108 (2): 226, 2001
 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
 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

Mortality & Morbidity after 1 Year of Age: 1981-1997
100

80

60
HSV-1
40 HSV-2

20

0
CNS Dissemin CNS Dissemin
Mortality Severe Disability
Pediatrics 108 (2): 227, 2001
 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
 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
 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 24-48 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

 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