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Herpes Simplex Virus

HSV is a rare but significant cause of disease among neonates occurring in an estimated 1 in 3200 births. Neonatal HSV infection manifests in three ways, 1) disseminated, 2) central nervous system (CNS) or 3) Skin, Eye, and/or Mouth (SEM) disease.  These manifestations are not mutually exclusive, and disease can occur in more than one category.

Children’s Mercy Virology and Molecular Infections Disease Laboratory have validated and approved for HSV 1 and HSV 2 PCR from the following sources:

CSF, Blood (plasma), Neonatal Multiple Sites (Anus, Mouth, Conjunctivae, Nasopharynx), conjunctival swabs, cutaneous and mucocutaneous lesions (includes specimens such as genital, skin, lesions for patient outside neonatal period). Previous studies on neonates suspected of HSV conjunctivitis have shown that PCR is equal or superior to culture from ocular specimens. Based on current literature the Care Process Model team recommends the use of HSV PCR assay in the neonate with suspected conjunctivitis.

Per the 2018 Red Book Recommendations : For diagnosis of neonatal HSV infection, all of the following specimens should be obtained for each patient: (1) Swab specimen from the mouth, nasopharynx, conjunctivae, and anus ( “ surface specimens”) for HSV culture or PCR assay; (2) specimens of skin vesicles for HSV culture or PCR assay; (3) CSF sample for HSV PCR assay; (4) whole blood sample for HSV PCR assay; and (5) whole blood sample for measuring alanine transaminase ( ALT).

Rationale, current evidence, and consensus statement:

While isolated conjunctivitis due to HSV is rare (less than 1%), those neonates who are at high risk for HSV should be evaluated for SEM, systemic, and CNS disease.

  • HSV PCR assays should be obtained from the palpebral conjunctiva, mouth, nose, rectum, and any vesicular lesions. 

  • Serum AST and ALT should be obtained as part of the evaluation for suspected systemic disease. 

  • HSV CSF PCR should be obtained for suspected CNS involvement.

Infants with suspected SEM, systemic or CNS HSV disease should be managed and treated in conjunction with pediatric infectious disease and ophthalmology.

References:

Hammerschlag, M. R., Roblin, P. M., Gelling, M., Tsumura, N., Jule, J. E., & Kutlin, A. (1997). Use of polymerase chain reaction for the detection of Chlamydia trachomatis in ocular and nasopharyngeal specimens from infants with conjunctivitis. Pediatr Infect Dis J, 16(3), 293-297.

Workowski, K. A., Bolan, G. A., Centers for Disease Control & Prevention. (2015). Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep, 64(RR-03)

Johnson, R. E., Newhall, W. J., Papp, J. R., Knapp, J. S., Black, C. M., Gift, T. L., . . . Berman, S. M. (2002). Screening tests to detect Chlamydia trachomatis and Neisseria gonorrhoeae infections--2002. MMWR Recomm Rep, 51(RR-15), 1-38; quiz CE31-34.

These guidelines do not establish a standard of care to be followed in every case. It is recognized that each case is different and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare guidelines for each. Accordingly these guidelines should guide care with the understanding that departures from them may be required at times.