Management of Neonatal HSV

Question 1

What are the 3 ways that neonatal HSV can be acquired and what is the most common way?

Answer 1

1. Intrauterine (5%)
2. Peripartum (85% = MOST COMMON)
3. Postpartum (10%)

Question 2

What are 5 major risk factors for transmission of HSV from mother to neonate?

Answer 2

1. Primary vs Secondary infection
2. Maternal Ab status
3. longer duration of rupture of membranes
4. integrity of mucocutaneous barriers
5. mode of delivery (C-section vs SVD)

Question 3

What are the two main reasons women with primary genital HSV infections are at higher risk of passing HSV to their newborn?

Answer 3

1. less antibodies to HSV passed to child and those antibodies that are transferred have less effective binding ability
2. HSV shedding is larger and shed for longer in primary infection

Question 4

What are the 3 categories of HSV infection?

Answer 4

1. Disseminated (multi-organ)
2. CNS (+/- mucocutaneous involvement)
3. SEM (skin, eyes, mouth)

Question 5

What percentage of CNS HSV-infected patients develop skin findings?

Answer 5

60-70%

Question 6

What are 5 major tests that should be obtained to help diagnose HSV infection?

Answer 6

1. mucocutaneous swabs (oropharynx, mouth conjunctiva, rectum)
2. skin vesicles (if present)
3. CSF
4. Whole blood samples
5. ALT (hepatic involvement?)

HSV PCR

Question 7

What test must ALL children found to have HSV infection, regardless of classification, have performed?

Answer 7

EYE EXAM

• look for uveitis, conjunctivitis, keratitis

Question 8

What region of the brain does HSV tend to infect?

Answer 8

Temporal Lobes (abscesses)

Question 9

What is the treatment for HSV infection and how long does it last?

Answer 9

Acyclovir 20 mg/kg/dose q8h

Disseminated/CNS = 21 day treatment
SEM = 14 day treatment

Question 10

What testing should be done at the end of acyclovir treatment and what happens if patient is still positive for HSV at that point?

Answer 10

• perform CSF testing at 21 day mark
• if still HSV (+) ? = continue acyclovir for additional week and recheck CSF cultures (continue cycle until CSF (-) for infection)

Question 11

What is the main toxicity of high-dose acyclovir?

Answer 11

Neutropenia

check ANC twice weekly

Question 12

What ANC level would you consider stopping acyclovir at? What ANC level would you consider restarting acyclovir?

Answer 12

• < 500 = stop acyclovir OR start GCS-F
• resume parenteral acyclovir when ANC > 750

Question 13

How long should oral acyclovir treatment last following parenteral acyclovir completion?

What is the dosage for the oral treatment and how often?

Answer 13

• continue oral acyclovir for additional 6 months

dosage: 300 mg q8h

Question 14

While taking oral acyclovir suppressive therapy, how often should ANC be monitored?

Answer 14

Check ANC after 2 weeks, 4 weeks, then monthly

Question 15

What is the preferred mode of delivery for a mother with active HSV genital lesions?

Answer 15

C-Section

• reduces (but not completely eliminates) risk of HSV transferral

Question 16

How soon following delivery should labs be drawn to further investigate possible neonatal HSV infection?

Answer 16

after 24 hours

Question 17

What is the average age of onset of neonatal HSV disease?

Answer 17

1.5-3 weeks of age