Neonatal Herpes

Background

• Neonatal herpes is an infection with herpes simplex virus (HSV) type 1 or type 2 which usually presents within 28 days of birth, although may present at up to 6 weeks of age.
• It is most commonly acquired from exposure to HSV during a vaginal delivery (85%), although rarely (5%) may be acquired as an intrauterine infection or as a postnatal infection (10%) from contact with hospital staff or family members shedding HSV-1.
• 60%-80% of infants infected with HSV disease are born to mothers with no known history of HSV.
• Infection may manifest as localized infection confined to skin, eyes, and mucosa, central nervous system (CNS) disease (HSV encephalitis), or disseminated infection.
• Onset of illness varies by type of manifestation.
  • Localized infection of skin, eyes, and mucosa typically presents at ages 10-12 days.
  • CNS disease typically presents at ages 16-19 days.
  • Disseminated disease typically presents at ages 10-12 days.
  • Symptoms of intrauterine infection are typically seen at birth.

Evaluation

• Clinical findings vary by type of disease.
  • Localized disease will have vesicular lesions on skin, eyes or mouth.
  • Central nervous system (CNS) or disseminated disease may present with temperature instability, bulging fontanelle, or seizures.
  • Disseminated disease may also cause jaundice.
• Diagnosis is confirmed by identification of herpes simplex virus (HSV) from neonate by culture.
  • Skin, eye, or conjunctival ("surface") specimens are associated with greatest yield of positive cultures.
  • Vesicular lesions, blood, and cerebrospinal fluid (CSF) specimens should also be sent for culture.
  • Positive HSV polymerase chain reaction of CSF can also confirm CNS-associated disease.

Management

• Acyclovir 20 mg/kg IV every 8 hours should be first-line treatment (Strong recommendation).
  • If cerebrospinal fluid (CSF) polymerase chain reaction (PCR) is positive, continue acyclovir for at least 21 days and then repeat CSF PCR (Strong recommendation).
    • If repeat CSF PCR is negative, stop acyclovir IV (Strong recommendation).
    • If repeat CSF PCR is positive, resume acyclovir IV for 7 days, then repeat CSF PCR and consider continued treatment if CSF remains positive (Strong recommendation).
  • If herpes simplex virus (HSV) is limited to skin, eyes, and mucosa (SEM) disease, continue acyclovir for at least 14 days (Strong recommendation).
  • Consider monitoring for neutropenia in patients on acyclovir 60 mg/kg/day IV (Weak recommendation).
  • Start acyclovir 300 mg/m² orally 3 times daily for 6 months for suppression treatment after acyclovir IV stopped (Strong recommendation).
• Other supportive treatments should be given as needed to address issues of fluid and electrolyte imbalances, hypoglycemia, seizures, respiratory distress, or disseminated intravascular coagulation.
• For asymptomatic infants born to mothers with active genital lesions:
  • For women with recurrent disease:
    • Obtain specimen during labor from maternal genital lesions and send for HSV culture and PCR (Strong recommendation).
    • At 24 hours post delivery, obtain specimens from conjunctivae, mouth, nasopharynx, rectum, skin and (if present) scalp electrode site for culture and PCR.
    • Perform full evaluation and treat with acyclovir if neonate becomes symptomatic or cultures are positive.
  • For women with suspected primary disease:
    • Obtain maternal blood for type-specific serological testing for HSV antibodies (Strong recommendation).
    • At 24 hours post delivery (or earlier if neonate is preterm [≤ 37 weeks] or history of prolonged rupture of membranes [> 4-6 hours] before delivery) (Strong recommendation):
      • Obtain specimens from conjunctivae, mouth, nasopharynx, rectum, skin and (if present) scalp electrode site for culture and (if available) PCR testing.
      • Send blood for HSV DNA PCR, obtain CSF for routine analysis and HSV DNA PCR, and send serum for alanine aminotransferase.
      • Start acyclovir 60 mg/kg/day IV in 3 divided doses.
• Monitor any asymptomatic neonates with possible exposure to HSV for at least 6 weeks (Strong recommendation).