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Seizures, skin lesions common indicators of HSV in infants
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Physicians should consider herpes simplex virus meningoencephalitis among infants aged younger than 3 months, especially if infants experience seizures, skin lesions or mononuclear central nervous system plecoytosis, according to study findings in The Pediatric Infectious Disease Journal.
David Kotzbauer, MD, of Children’s Healthcare of Atlanta, and colleagues reviewed medical records of children aged younger than 3 months who had herpes simplex virus (HSV) infection documented by polymerase chain reaction from spinal fluid. Records were collected between 2005 and 2013 from two locations of Children’s Healthcare of Atlanta.
Twenty-six neonates had central nervous system HSV and a median age of 16 days. One infant presented with HSV in the first week of life, while 80% of infants presented between 10 to 28 days of age. Seven infants were delivered prematurely.
Mothers of four infants had genital HSV, and one infant’s mother had oral HSV. Among those whose mothers had genital HSV, lesions were present at some point during pregnancy but not at the time of delivery. Nineteen infants were delivered vaginally and six were delivered by cesarean section. Premature rupture of membranes occurred in two of the six cesarean deliveries.
The most common findings were fever above 38°C, seizures and skin lesions. Seizures occurred in 54% of infants. Nine infants had fever and seizures; 12 had skin lesions. Of those with only skin lesions, four had no other symptoms. Two infants only had fever.
Study participants received 60 mg/kg/day of acyclovir sodium (Acyclovir; APP Pharmaceuticals) intravenously for 21 days. Six infants were re-hospitalized for cutaneous recurrence of HSV after 21 days of treatment. Ten infants were administered acyclovir orally until aged 6 months. None were re-hospitalized for disease recurrence.
“Though central nervous system HSV infection most commonly occurs in the first month of life, this case series includes infants who presented at 32, 33, 45, and 73 days old. From our chart review, it cannot be determined with certainty if these infants acquired the disease perinatally or postnatally,” the researchers concluded. “Nonetheless, this study emphasizes that clinicians must consider HSV meningoencephalitis in infants in this age range, especially when seizures, skin vesicles, or mononuclear central nervous system pleocytosis are present.”
Disclosure: The researchers report no relevant financial disclosures.
Perspective
Back to TopPablo J. Sánchez, MD
This retrospective review of 26 infants, aged younger than 3 months, who were diagnosed with herpes simplex virus (HSV) infection of the central nervous system (CNS) as documented by a positive cerebrospinal fluid (CSF) HSV polymerase chain reaction (PCR) test highlights the continuing conundrum that is neonatal HSV infection. Although the most frequent presenting signs were fever, seizures, and skin lesions, 46% of infants did not have seizures, two infants presented with only fever, four infants only had skin lesions, and seven had no CSF pleocytosis. The alanine aminotransferase (ALT) was below 80 U/L in all infants who were tested, consistent with the exclusion of infants with disseminated HSV infection from the study. However, 10 (91%) of 11 infants had a positive blood HSV PCR test, suggesting that the CNS infection was secondary to HSV viremia rather than axonal spread, which is more common in older children and adults. The emergence of blood HSV PCR testing as a diagnostic tool brings into question the historical classifications of neonatal HSV infection, as infants who are identified as having HSV DNAemia would otherwise fit into “localized” skin/eye and/or mouth or CNS disease.
Importantly, none of the mothers had active HSV genital lesions at delivery. Unfortunately in this study, the type of HSV infection was not known, and the authors could not distinguish vertical transmission from postnatal acquisition of HSV. In addition, diagnosis of HSV CNS disease is not based solely on a positive HSV PCR test result, so the authors may have underestimated their number of cases.
Joseph B. Cantey, MD, and Natalie O. White, DO, of Nationwide Children's Hospital, contributed to this commentary.
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