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American Academy of Pediatrics National Conference and Exhibition
October 28, 2013
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Neonates with HSV may present with non-specific findings

ORLANDO, Fla. — Some neonates with herpes simplex virus present with non-specific symptoms and clinicians may need to consider this etiology even in neonates without the classic findings of vesicular lesions or seizures, according to recent study findings presented here.

“Pediatric hospitalists frequently care for febrile infants that undergo a ‘rule out sepsis’ workup,” researchers wrote. “Neonatal HSV is often in the differential diagnosis. It is unclear which clinical characteristics should prompt clinicians to test for HSV and start empiric acyclovir. Vesicular rash, seizures and focal neurologic signs are common presentations in neonatal HSV. It has been suggested in the literature that neonates with HSV can occasionally present with ‘non-specific’ symptoms, defined as fever, hypothermia, poor feeding or apnea without mucocutaneous or neurologic symptoms.”

The study included all cases of neonatal HSV that occurred over a 10-year period at St. Louis Children’s Hospital. All patients were aged 0 to 60 days at time of presentation. Clinical findings, cerebrospinal fluid profile and HSV laboratory data were all analyzed. Patients were then categorized as having skin/eye/mouth disease, central nervous system disease or disseminated disease based on their disease course.

Neonatal HSV is a rare disease, and this study captured the presenting signs and symptoms of 27 patients over the 10-year period (excluding neonatal ICU patients). Forty-eight percent of patients had mucocutaneous lesions and 11% had seizure or focal neurologic symptoms.However, 21% of the patients had non-specific symptoms. Out of these six patients, three had a cerebrospinal fluid pleocytosis and one had elevated alanine aminotransferase, which may have prompted clinicians to test for HSV. The three patients in this subgroup who did not have cerebrospinal fluid pleocytosis were all younger than 10 days, raising the question of whether very young neonates presenting to the hospital setting should be considered for acyclovir therapy even with nonspecific findings.

Overall, 41% had skin/eye/mouth disease, 22% had disseminated disease and 27% had central nervous system disease. Fifty-nine percent of patients had positive cerebrospinal fluid PCR. Forty-four percent of patients had positive PCR obtained from skin lesions.

"Not all patients with neonatal HSV present with the classic findings of seizures, mucocutaneous findings, or critical illness,” Alison L. Curfman, MD, of St. Louis Children's Hospital told Infectious Diseases in Children. "Lack of cerebrospinal fluid pleocytosis does not rule out the possibility of HSV disease, and further research is needed to determine if special consideration for HSV disease is warranted in very young infants presenting with non-specific findings."

For more information:

Curfman AL. Abstract #21666. Presented at: AAP National Conference and Exhibition; Oct. 26-29, 2013; Orlando, Fla.

Disclosure: The researchers report no relevant financial disclosures.