Pediatric emergency medicine trisk 2479 2479
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pustular in 1 to 2 days. However, early manifestations can be subtle and
nonspecific. HSV should be suspected in infants with or without vesicles who
present with sepsis, respiratory distress, focal neurologic signs, or signs of
hepatitis or liver failure.
FIGURE 96.7 Herpes simplex infection. (Reprinted with permission from Goodheart HP.
Goodheart’s Photoguide of Common Skin Disorders . 2nd ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2003.)
Triage Consideration. Neonates presenting with new vesicles should be seen
promptly.
Clinical Assessment. Neonatal HSV is categorized into three main categories:
localized skin, eye, and mouth (SEM) disease; central nervous system (CNS) with
or without SEM; and disseminated disease, which may involve CNS, SEM, and
other organs. Comprehensive laboratory evaluation should occur in infants with
suspected HSV, even if only limited SEM involvement is suspected. Obtain CBC,
blood chemistry, liver function tests, urinalysis, blood and urine culture, lumbar
puncture, HSV polymerase chain reaction (PCR) of the blood, cerebrospinal fluid
(CSF) cell count, glucose, protein, HSV PCR, viral culture, surface culture from
conjunctiva, mouth, nasopharynx, and rectum—placed in single viral transport
media tube—and evaluation for bacterial or metabolic disease as indicated.
Management. If a neonate is suspected of having HSV, perform a complete sepsis
workup, start acyclovir, and admit the patient to the hospital. Infants may require
supportive care with intubation, mechanical ventilation, and cardiac support for
disseminated disease. In addition, infants with significant liver dysfunction may
require transfusions in the setting of significant coagulopathy and bleeding.
