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Neonatal herpes diagnostic evaluation updated in 2012 Red Book

NEW YORK — Neonatal herpes simplex virus infection is rare, but it must be considered regularly in diagnostic evaluations, according to data presented here during the 25th Annual Infectious Diseases in Children Symposium.

Course Director David W. Kimberlin, MD, said standard diagnostic evaluation of neonatal HSV has been updated slightly as per the 2012 edition of the AAP Red Book. In addition to the traditional workup of surface cultures and cerebrospinal PCR, the evaluation should now include whole blood for PCR for HSV DNA and blood alanine aminotransferase (ALT).

 

David W. Kimberlin

“The ALT levels indicate if the baby is sicker than you think because a baby may have neonatal HSV without looking extremely ill,” said Kimberlin, who was recently appointed editor of the AAP Red Book for the 30th edition to be published in 2015.

Sites from which surface cultures should be performed include swabs of the mouth, nasopharynx, conjunctivae and rectum; the 2012 Red Book also allows for PCR from these specimens, as long as it is in addition to the gold standard culture. Direct fluorescent antibody staining of vesicle scrapings also may aid in the diagnosis.

“It’s important to unroof the vesicle for the culture,” said Kimberlin, professor of pediatrics, Sergio Stagno Endowed Chair in Pediatric Infectious Diseases, co-director of the division of pediatric infectious diseases at the University of Alabama at Birmingham.

In addition, Kimberlin said, neonatal HSV infection should be considered even when the mother is receiving antiviral suppressive acyclovir or valacyclovir therapy.

Treatment of neonatal HSV should be initiated only after full diagnostic evaluation, including surface cultures and cerebrospinal fluid PCR. A 60-mg/kg per day dose of acyclovir should be administered in three divided doses for 21 days for central nervous system disease or disseminated disease and 14 days for skin, eyes and/or mouth disease, according to Kimberlin.

If the baby has central nervous sytem involvement, Kimberlin also said the lumbar puncture should be repeated for HSV PCR before cessation of parenteral antiviral therapy. Once parenteral therapy has ceased, oral acyclovir suppressive therapy should be initiated at a 300 mg/m2 dose given orally three times daily for 6 months.

“[Absolute neutrophil counts] should be monitored at 2 and 4 weeks and then monthly,” Kimberlin said.

For more information:

Kimberlin DW. Neonatal viral infections. Presented at: 25th Annual Infectious Diseases in Children Symposium; Nov. 17-18; New York.

Disclosure: Kimberlin reports his institution receives research funding from Cellex, Cubist Pharmaceuticals and GlaxoSmithKline.