Pediatric emergency medicine trisk 2268 2268
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TABLE 94.6
USUAL RANGES FOR CEREBROSPINAL FLUID PARAMETERS
Herpes Simplex Virus, Neonatal
CLINICAL PEARLS AND PITFALLS
Most mothers of infants with HSV infection do not provide a history of HSV, as primary infection can
be asymptomatic and vesicular lesions deep in the female genitourinary tract cannot be visualized by
the mothers. Thus, a “negative” maternal history of herpes does not rule out herpes in an infant.
HSV has substantial overlap with bacterial causes of sepsis and meningitis.
The three main forms of neonatal disease are skin, eye, and mouth (SEM) disease, CNS disease,
and disseminated disease.
HSV should be considered in the differential diagnosis of any febrile neonate with a CSF pleocytosis
and in infants with elevated hepatic transaminases or coagulopathy.
Early recognition of HSV disease and prompt initiation of acyclovir can decrease the substantial
morbidity and mortality in infants.
Current Evidence
HSV has three major manifestations in the neonatal period. HSV genital lesions will be described in the section on
sexually transmitted infections (STIs). It is estimated that 45% of adults in the United States are seropositive for
HSV-1 and 16% for HSV-2. Both viruses can cause oral or genitourinary infection, but approximately 75% of
neonatal HSV disease is caused by HSV-2. In one study, 0.4% of 0- to 60-day-old infants in whom lumbar
punctures were performed had HSV infection, with a peak in the 2nd and 3rd weeks of life. Neonatal HSV is
thought to complicate 1 in 3,200 deliveries, resulting in approximately 1,500 cases/yr in the United States. Risk
factors for transmission to neonates include primary maternal infection; vaginal delivery; prolonged rupture of
membranes; HSV-2; and use of fetal scalp electrodes. The risk of neonatal HSV is highest during the primary
infection in the mother, as viremia is often higher than with recurrent infections, and an effective immune response
has yet to be mounted. However, 75% of mothers of HSV-infected neonates did not report a history of herpes, as
primary infection can be asymptomatic. As such, the lack of maternal history of HSV should not provide false
reassurance to the PEM clinician.
