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Screening recommendations for HSV changing in 2012 Red Book
AAP 2011 National Conference
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BOSTON — Although neonatal herpes simplex virus can be a devastating disease, the good news is that it remains rare, according to a speaker here at the 2011 AAP National Conference and Exhibition.
David W. Kimberlin, MD, who is an Infectious Diseases in Children Editorial Board member, said that incidence rates range from one in 1,300 cases in certain parts of the United States to one in 3,200 in Seattle. However, even these low rates are still somewhat higher in the United States than in other parts of the world. He said the data are not clear on why this is, and speculated they could be attributed to reporting differences.
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The route of infection is most commonly intrapartum, with 85% of all infections acquired in this manner. Ten percent of infections occur in the postnatal period, which typically occurs when other family members with fever blisters kiss the baby. The remaining 5% of infections are acquired in utero, according to Kimberlin.
He also noted that about 45% of intrapartum and postpartum infections are skin, eye and mouth (SEM) related, about 30% are encephalitis-related, characterized by seizures, lethargy, and other complications, and 25% of HSV infections are disseminated, and those can be characterized by pneumonia, hepatitis and central nervous system complications.
When making the diagnosis of HSV, Kimberlin suggested that skin vesicles are the most common symptoms — however he highlighted data from a study in the 1990s that showed 83% of patients with SEM disease had skin vesicles, but a significant amount (17%) did not. He interpreted these data:
“Just because you don’t see skin lesions does not rule out herpes,” Kimberlin said. “It will be around 2 to 3 weeks of age you have to be most concerned about baby coming in and having neonatal HSV.”
Kimberlin advised surface cultures, including skin vesicle cultures, whole blood for PCR, blood for alanine aminotransferase, as well as DFA staining of vesicle scrapings. These recommendations are in line with what will likely be recommended in the 2012 American Academy of Pediatrics’ Red Book.
“You need to look at the CNS,” Kimberlin said. “Send surface cultures of the conjunctivae, rectum, mouth nasopharynx, and if you have skin vesicles, swab the base of the vesicle and send that for culture as well.”
In those situations where a neonate is delivered to a woman with active genital HSV lesions, the 2012 Red Book recommendations will likely not deviate from the 2009 Red Book, which recommends obtaining HSV cultures at the first 12 to 24 hours of life.
“If you find no evidence of disease, empiric treatment should be started for 10 days,” Kimberlin said. Although he warned that there are limited data, he said that if there is evidence of disease than treatment should be for 14 to 21 days.
Discussing recurrent herpes labialis treatment, Kimberlin said that antivirals are only modestly effective in immunocompetent people, and that treatment should be individualized. He said that clinicians may consider suppressive therapy if recurrences occur. — by Colleen Zacharyczuk
Disclosures: Dr. Kimberlin reported no relevant financial disclosures.
For more information:
- Kimberlin D. #F2118. HSV. The Neonate and Beyond. Presented at: AAP National Conference and Exhibition. Oct. 15-18, 2011. Boston.
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