Neonatal herpes is a rare disorder affecting newborn infants infected with the herpes simplex virus (HSV), also called herpesvirus hominis. In most instances, a parent with oral or genital herpes transfers the disorder to an offspring before, during, or shortly after birth. Symptoms vary from mild to severe depending on which of two types of herpes simplex virus is involved. Type 1 HSV is responsible for the more severe cases of the disorder while patients with Type 2 HSV usually present with milder symptoms.
Another way of classifying this disorder depends on probable outcomes (prognosis). Using prognosis as the classifying principal yields three forms:
1. disseminated neonatal herpes infection 2. central nervous sytem herpes in the neonate 3. mucocutaneous and ocular herpes .
Disseminated Neonatal Herpes Infection (about 25% of cases) In this form, the disorder spreads to involve organs throughout the body. Viral infections may spread to the lungs (pneumonitis), the liver (hepatitis), or the circulatory system (disseminated intravascular coagulation) that may lead to infections of the brain covering (encephalitis), rashes on the skin (exanthem), and inflammation of the cornea and the tissue surrounding it (keratoconjunctivitis).
The disorder usually becomes obvious between 9 and 11 days after birth. However, presentation may be delayed for as long as 30 days.
Central Nervous Sytem Herpes in the Neonate (about 35% of cases) This form is usually indicated by irritability, seizures, spiking temperatures (thermal instability), poor feeding and a bulging soft spot (fontanel) on top of the head. Such signs will suggest that tests of the infant's central spinal fluid (CSF) be made. Some 25%-40% of the cases will be positive for HSV cultures. Other signs indicated by CSF tests include an abnormally high number of cells in the CSF (pleocytosis) as well as high concentrations of protein (proteinosis).
The disorder is usually evident between five and nine days after birth.
Mucocutaneous and Ocular Herpes (about 40% of cases) Patients with this form of the disorder present with the disease localized to the skin, mouth, and/or eyes. Laboratory tests, including liver and chest X-rays, are normal with no evidence of internal organ (visceral) involvement or neurological deficits. Cultures for the presence of the HSV will be positive, as will tests for the HSV antigen.
The disorder usually becomes obvious between 15 and 17 days after birth. However, presentation may be delayed for as long as 30 days. .
Neonatal herpes is caused by an infection of the newborn by the herpes simplex virus (HSV).
In 80% to 90% of cases, the disease is acquired during the period beginning with the fifth month of pregnancy and extending to the twenty-fifth day after birth (the perinatal period) via an infected maternal delivery tract or, if the fetus is in the uterus, by an ascending infection. Infection may occur even if the membranes associated with birth are intact, i.e. before the sac is broken. An asymptomatic mother who shows no signs of herpes infection may breast-feed an infant with milk that contains the herpes virus, thus infecting the infant. Rarely, an attendant at the birthing process may also transfer his or her infection to the newborn child if sterile precautions are not adequate. .
Neonatal Herpes is a very rare disorder. It affects about 1 in 5,000 to 7,500 live births. During their first year of life, these infants usually develop antibodies against the Herpes virus. Only malnourished infants, those with an impaired immune system, or otherwise weakened infants tend to carry the infection after one year.
Infants born to a mother with a first time Herpes infection late in her pregnancy are at higher risk to develop Neonatal Herpes than infants of mothers with recurrent Herpes infection. In the first case the mother has not yet developed antibodies against the virus which would ordinarily protect her baby.
Symptoms of the following disorders can be similar to those of neonatal herpes. Comparisons may be useful for a differential diagnosis.
Varicella zoster is an infectious disease also caused by the herpes virus. During childhood, the virus causes chickenpox (varicella). During adulthood, it causes shingles (herpes zoster). Chickenpox is a highly contagious disease characterized by an itchy skin rash and fever. Chickenpox usually begins with mild constitutional symptoms such as a mild headache, moderate fever and discomfort followed by an eruption appearing in itchy groups of flat or elevated spots and blisters, which form crusts. Shingles is a painful localized recurrence of the skin rash during adulthood. (For more information on this disorder, choose Varicella Zoster as your search term in the Rare Disease Database.)
Cytomegalovirus infection (CMV) is a viral infection occurring at birth (congenitally), after birth (postnatally), or at any age. CMV ranges in severity from a silent infection without consequences to a disease manifested by fever, hepatitis, and (in newborns) severe brain damage, with possible life-threatening complications. (For more information on this disorder, choose Cytomegalovirus Infection as your search term in the Rare Disease Database.)
Congenital rubella is a syndrome that occurs when a fetus has been infected with the rubella virus while in the uterus. It is primarily characterized by abnormalities of the cardiovascular system, the eyes and the ears. Women who contract rubella during pregnancy have a high risk of having a baby with congenital rubella. (For more information on this disorder, choose Rubella, Congenita" as your search term in the Rare Disease Database.) .
Diagnosis The diagnosis of neonatal herpes is difficult and requires the physician to maintain a high level of skepticism and wariness. Frequently, neither parent is aware that he or she is carrying the virus. HSV infection must be considered for any neonate presenting with non-specific symptoms such as fever, poor feeding, lethargy and/or seizure. Any rash accompanyied by fluid-filled blisters (vesicles) should be cultured for HSV, and because such tests take days before the results are known, anti-viral treatment should be started.
Treatment If a pregnant woman or her sexual partner is carrying herpes virus, their physician should be notified as soon as possible in anticipation of the baby becoming infected during the birth process. Baby and mother may be cultured at birth. If tests are positive, treatment of the virus can be started immediately after birth.
When a mother shows signs of a genital herpes infection, delivery by cesarian section is advised.
Acyclovir (Zovirax) and vidarabine (Ara-A, Vira-A), are the drugs most commonly used to treat herpes virus infections. If treatment is started early enough, the disorder usually remains restricted to the skin, eyes, and mucous membranes, and does not progress to the more serious forms. .
Information on current clinical trials is posted on the Internet at www.clinicaltrials.gov. All studies receiving U.S. government funding, and some supported by private industry, are posted on this government web site.
For information about clinical trials being conducted at the NIH Clinical Center in Bethesda, MD, contact the NIH Patient Recruitment Office:
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Corey L. Herpes Simplex Viruses. In: Fauci AS, Braunwald E, Isselbacher KJ, et al. Eds. Harrison's Principles of Internal Medicine. 14th ed.McGraw-Hill Companies. New York, NY; 1998:1084-85.
Grose C. Viral Infections of the Fetus and Newborn. In: Behrman RE, Kliegman RM, Arvin AM. Eds. Nelson Textbook of Pediatrics. 15th ed. W.B. Saunder Company. Philadelphia, PA; 1996:523-25.
JOURNAL ARTICLES Watts DH, Brown ZA, Money D, et al. A double-blind, randomized, placebo-controlled trial of acyclovir in late pregnancy for the reduction of herpes simplex virus shedding and cesarean delivery. Am J Obstet Gynecol. 2003;188:836-43.
Brown ZA, Wald A, Morrow RA, et al. Effect of serological status and cesarean delivery on transmission rates of herpes simplex virus from mother to infant. JAMA. 2002;289:203-09.
Toth C, Harder S, Yager J. Neonatal herpes encephalitis: a case series and review of clinical presentation. Can J Neurol Sci. 2003;30:36-40.
Lipsitch M, Davis G, Corey L. Potential benefits of a seriodiagnostic test for herpes simplex virus type 1 (HSV-1) to prevent neonatal HSV-1 infection. Sex Transm Dis 2002;29:399-405.
Rudnick CM, Hoekzema GS. Neonatal herpes simplex virus infections. Am Fam Physician. 2002;15:1138-42.
Levin MJ, Weinberg A, Leary JJ, et al. Development of acyclovir-resistant herpes simplex virus early during the treatment of herpes neonatorum. Pediatr Infect Dis J. 2001;20:1094-97.
Kimberlin DW, Lin CY, Jacobs RF, et al. Natural history of herpes simplex virus infections in the acyclovir era. Pediatrics. 2001;108:223-29.
FROM THE INTERNET Strandjord TP. Neonatal Herpes. NICU-WEB. University of Washington Academic Medical Center. Last Revised: 9/18/01. 8pp. www.neonatal.peds.washington.edu/NICU-WEB/HSV/hsv.stm
The Prognosis for Many Infants With Neonatal Herpes Simplex Virus Infection Remains Poor. Medscape. 2001:4pp. www.medscape.com/viewarticle/418193
Wong T, Burton S, Steben M. Neonatal Herpes Simplex Virus Infection. Canadian Paediatric Society. 2001:6pp. www.cps.ca/english/CPSP/Resources/Rneonatalherpes.htm
CDC. STD Prevention. 3. Preventing Neonatal Herpes. Last reviewed; December 14, 2002. 2pp. www.cdc.gov/nchstp/dstd/Reports_Piblications/part3.htm
FOR NON-CLINICIANS Ebel C, Wald A. Managing Herpes: How to Live and Love with a Chronic STD. 3rd Ed. American Social Health Association. Research Triangle Park: NC. 272pp.
Understanding Herpes. American Social Health Association. Research Triangle Park: NC. 16pp.
Centers for Disease Control and Prevention 1600 Clifton Road NE Atlanta, GA 30333 Tel: (404)639-3534 Tel: (800)311-3435 Email: http://www.cdc.gov/netinfo.htm Internet: http://www.cdc.gov/
NIH/National Institute of Allergy and Infectious Diseases 6610 Rockledge Drive MSC 6612 Bethesda, MD 20892-6612 Tel: (301)496-5717 Fax: (301)402-3573 TDD: (800)877-8339 Internet: http://www.niaid.nih.gov/
Genetic and Rare Diseases (GARD) Information Center PO Box 8126 Gaithersburg, MD 20898-8126 Tel: (301)519-3194 Fax: (240)632-9164 Tel: (888)205-2311 TDD: (888)205-3223 Email: gardinfo@nih.gov Internet: http://www.genome.gov/10000409
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