Infectious Diseases

Refining the Evaluation and Management of Neonatal Herpes Infection

By Philip R. Fischer, MD, DTM&H
Professor of Pediatrics, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN

SYNOPSIS: The typical presentation of neonatal herpes infection includes vesicular rash, seizure and/or critical illness. Those infected that did not demonstrate the aforementioned symptoms were younger than two weeks of age and/or displayed increased cell count in their cerebrospinal fluid.

SOURCE: Curfman AL, Glissmeyer EW, Ahmad FA, et al. Initial presentation of neonatal herpes simplex virus infection. J Pediatr 2016;172:121-126.

Curfman et al retrospectively reviewed detailed findings regarding children with neonatal herpes compiled over the 10 years from 2002 to 2012. The data was pulled from two children’s hospitals, to which all of the patients included in the study were admitted: St. Louis Children’s Hospital and Salt Lake City’s Primary Children’s Hospital. Children with confirmed herpes infection were included if they were born after 34 weeks of gestation and developed symptoms before 42 days of age but after their newborn hospitalization.

Forty-nine infants passed exclusion criteria to be considered in this study. Forty-three of the 49 (88%) demonstrated symptoms within their first four weeks (28 days) of life. Nearly half of the patients were normothermic, but all of these infected children had some form or combination of seizures, vesicular rash or critically ill appearance. Of the entire patient group, 45% had a disseminated disease (comorbid hepatitis/pneumonitis or disseminated intravascular coagulation), 33% had central nervous system involvement, while 20% had skin-eye-mouth involvement. Each of the 8 patients with nonspecific presentation of the disease was younger than 14 days of age and/or had CSF pleocytosis. Six of the eight went on to demonstrate one of the telltale signs of neonatal herpes: either seizures, rash or critical illness. Seven (32%) of the 22 patients with disseminated herpes disease died. None of the babies without disseminated herpes died.

Sixty-six percent of the patients were treated with acyclovir within their first day of hospitalization. The study, however, was not powered sufficiently to determine the efficacy of earlier administration of acyclovir. Of the patients with skin-eye-mouth disease, half tested positive on PCR tests for herpes, and were then treated with acyclovir for a mean duration of 21 days. Currently, the recommended acyclovir treatment duration for non-systemic illness is 14 days, a full week less.