1. Congenital/Neonatal Herpes Simplex Infections
Infectious and Tropical Pediatric Division
Department of Child Health
Medical Faculty
University of Sumatera Utara

2. Herpes Infections “Herpes” – from the Greek “to creep, crawl”
“Herpetic eruptions” described as early as 100 AD
1960’s – HSV1 and HSV2 differentiated
HHV1 – HSV1
HHV2 – HSV2
HHV3 – VZV
HHV4 – EBV
HHV5 – CMV
HHV6 – Causes?
HHV7 –
HHV8 -

3. Neonatal HSV 1 in 2,500-5,000 deliveries / 500-1500 per yr.
Birth to 7 weeks of life
HSV2 = 70-75%, HSV1 = 25-30%
3 Main Types
Skin, Eye, Mouth (SEM)
CNS
Disseminated Disease (DISSEM)
At Risk: Premature, ROM >6hr, Fetal scalp monitoring
Can be acquired congenitally, during the birth process, and in the post-partum period

4. Routes of Transmission
85% via infected maternal genital tract
Ascending infection?
En route
10% postpartum
5% (or less) – intrauterine/congenital infection

5. Congenital HSV Rare, most devastating Only 50 cases described
Skin vesicles
Chorioretinitis
Microcephaly
Micro-ophthalmia
IUGR

6. Skin, Eye, Mouth (SEM) Approximately ½ of all HSV infections
1st-2nd week presentation
Limited to skin, eye, mouth/mucous membranes
60-70% of untreated patients progress to CNS/disseminated disease

7. SEM (cont)
Long term neurologic sequelae seen in 30% of cases – even if treated
Ophthalmology involvement

8. “Presenting Part” (SEM)

9. Scalp Monitors

10. HSV - CNS Disease
Encephalitis without visceral involvement, mainly involving the temporal lobes
Early to 3rd week of life presentation
Skin lesions may appear late, if at all
35% of all cases, only 2-5% untreated survive normally

11. Radiographic Findings

12. Disseminated Disease Approximately 20% of all infections
Hepatitis
Pneumonitis
DIC
Infant may be ill on first day of life
Skin lesions appear late, or not at all

13. Signs

14. Postnatal acquisition
Most commonly HSV1
Moms with HSV
Mask
Breastfeeding – O.K. if without lesions
The Mohel and the Mezizah

15. Contacts
“Personnel with an active herpetic whitlow should not have direct patient care of neonates”.
Family transmission has been described

16. Morbidity and Mortality

17. Stretch Break

18. Take Home Message
Infection 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 Simplex
Approximately 5% of the general population has been diagnosed with genital herpes – but approximately 20-30% of women may be infected with HSV-2
Viral shedding occurs without identifiable lesions on 1-3% of days

20. Maternal Testing?
Identify discordant couples to avoid transmission in the third trimester
If mom is HSV1/HSV2 negative
If mom is HSV2 negative
If 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 pregnancy
25% of women with a history of genital herpes have an outbreak at some time during their pregnancy, 11-14% at time of delivery
36% 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 lesions
Patient describes prodromal symptoms
Vaginal delivery for those with hx only
Primary infection diagnosed - treat
Estimated $2-4 million to prevent each case
20-30% 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%)
Rectum
Skin
Cultures
Stool
Urine
CSF >100 WBC/Inc. Pro
Tzanck – neither sensitive nor specific

27. Treatment - Acyclovir SEM infections DISSEM and CNS HSV infections
60mg/kg/day divided q8h for 14 days
May be lengthened to 21 days in the near future
Oral Acyclovir needed later in life?
DISSEM and CNS HSV infections
60mg/kg/day divided q8h for 21 days
Re-tap if CNS disease exists prior to d/c
Watch for neutropenia – 2x week ANCs

28. Take Home Messages
Most neonates with HSV infection are born to mothers with asymptomatic genital shedding at delivery, with no history of genital herpetic lesions
No one test is 100% sensitive / specific
Keep HSV in mind
How would you manage our case?