Neonatal HSV Encephalitis

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Source: https://www.picuki.com/tag/Optimised

The image above shows a transilluminating newborn’s head, affected by Herpes Simplex virus (HSV), leading to encephalitis and causing extensive damage to the cerebral tissue which then gets replaced by the saclike accumulation of fluid, thus the transillumination. Neonatal bedside transillumination a diagnostic test, rather a screening tool

Neonatal herpes simplex virus infection

It has high morbidity and mortality with an incidence of one in 3,000 to one in 20,000 live births. Incidence is higher when the mother has an active primary genital HSV infection at the time of delivery or late in the third trimester. Reactivation of HSV in mothers is associated with lower transmission risk. Most of the cases of neonatal HSV infection are transmitted during birth, while transplacental and hospital-acquired being responsible for a handful. HSV type 2 being a more common culprit than type 1. It is noteworthy that only 30% of the affected neonates have mothers with symptomatic HSV.

Signs And Symptoms

Affected neonates may show signs and symptoms between 1 to 3 weeks of life and less commonly up to the 4th week, varying from skin vesicles to localised CNS disease to widespread infection (causing hepatitis, adrenalitis, encephalitis, DIC, etc.).
If former is the case, then a more serious form of the disease may take its course over a period of  7 to 10 days, if left untreated.

4% of the neonatal HSV infections are congenital HSV infection, in that case, the infant may present with microcephaly, vesicular skin lesions, hydrocephalus and chorioretinitis.
The case in discussion here is of HSV causing localised CNS infection: encephalitis.
This can present with fever, neurologic findings such as convulsions, hypotonia, apnea, lethargy, etc, CSF pleocytosis, and increased protein concentration. Skin, eyes, and mouth may or may not be involved
Unfortunately, the infection of this newborn remained undiagnosed during his hospital stay, due to which 90% of his brain tissue was damaged. 

Source: https://www.msdmanuals.com/professional/pediatrics/infections-in-neonates/neonatal-herpes-simplex-virus-hsv-infection
SOurce: DR P. MARAZZI/SCIENCE PHOTO LIBRARY https://www.msdmanuals.com/professional/pediatrics/infections-in-neonates/neonatal-herpes-simplex-virus-hsv-infection

Diagnosis

Although a rapid diagnosis is a key to successful treatment, it is initially difficult to promptly diagnose due to vague and non-specific symptoms like lethargy, irritability, hypotonia, etc.
Viral culture or HSV PCR is essential, for which fluid from skin vesicles is tested. In neonates especially, skin findings are usually absent and the virus inhabits the CNS only.
Therefore, infants require a high index of suspicion. Suspect HSV infection in all neonates presenting with nonspecific symptoms such as fever, poor feeding, hypotonia or seizure within the first month of life. Culture any vesicular rash if present till eight weeks of life and immediately start parenteral antiviral, not awaiting the culture results. CSF PCR should be performed.
However, if HSV encephalitis remains undiagnosed, it has devastating effects that cannot be reversed even with antiviral therapy.

Treatment

Parenteral antiviral therapy is the treatment of choice for all suspected and diagnosed neonatal HSV infections, for 14 days if the disease is localised and 21 days if disseminated or if the central nervous system is involved.

How to prevent neonatal transmission?

  • Obtain history of HSV infection during the first prenatal visit.
  • Prophylactic acyclovir if active lesion at the time of labour, in the third trimester or in cases of frequent outbreaks.
  • In mothers with active genital lesions, avoid vaginal delivery and fetal scalp monitoring.

References

– CAROLINE M. RUDNICK, M.D., PhD, St. Anthony’s Medical Center, St. Louis, Missouri GRANT S. HOEKZEMA, M.D., St. John’s Mercy Medical Center, St. Louis, Missouri Am Fam Physician. 2002 Mar 15;65(6):1138-1142.
https://www.aafp.org/afp/2002/0315/p1138.html

– https://www.msdmanuals.com/professional/pediatrics/infections-in-neonates/neonatal-herpes-simplex-virus-hsv-infection


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Dr. Arsia Hanif has been a meritorious Healthcare professional with a proven track record throughout her academic life securing first position in her MCAT examination and then, in 2017, she successfully completed her Bachelors of Medicine and Surgery from Dow University of Health Sciences. She has had the opportunity to apply her theoretical knowledge to the real-life scenarios, as a House Officer (HO) serving at Civil Hospital. Whilst working at the Civil Hospital, she discovered that nothing satisfies her more than helping other humans in need and since then has made a commitment to implement her expertise in the field of medicine to cure the sick and regain the state of health and well-being. Being a Doctor is exactly what you’d think it’s like. She is the colleague at work that everyone wants to know but nobody wants to be. If you want to get something done, you approach her – everyone knows that! She is currently studying with Medical Council of Canada and aspires to be a leading Neurologist someday. Alongside, she has taken up medical writing to exercise her skills of delivering comprehensible version of the otherwise difficult medical literature. Her breaks comprise either of swimming, volunteering services at a Medical Camp or spending time with family.

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