LAS VEGAS — Most cases of disseminated and CNS neonatal herpes don't present with skin lesions, Dr. M. Jeffrey Maisels said at a meeting sponsored by the American Academy of Pediatrics and its California Chapters 1, 2, 3, and 4.
“You can't rely on seeing a herpetic-looking vesicle on a baby's skin to tip you off that the baby might have systemic herpes or CNS neonatal herpes,” said Dr. Maisels, who chairs the department of pediatrics at William Beaumont Hospital, Royal Oak, Mich. The chief complaint in cases of disseminated neonatal herpes is often decreased activity—the so-called “quiet baby”—in the first 2 weeks of life, as well as decreased oral intake and some respiratory distress.
Physical exam may reveal hypothermia, lethargy, and/or hypoperfusion. Tachypnea and seizures also may occur.
“When you do the lab tests, these babies commonly have metabolic acidosis,” said Dr. Maisels, also of Wayne State University, Detroit. They commonly come in with severe thrombocytopenia and severe coagulopathy. They have liver involvement, renal involvement, and hypoglycemia.
Treatment involves acyclovir 60 mg/kg per day as well as intensive care and management of the coagulopathy, which usually consists of multiple transfusions with fresh frozen plasma, cryoprecipitate, packed red blood cells, and platelets.
“This condition has a high mortality: 56%–90%, and it is close to 100% if they come in with severe shock or coma,” Dr. Maisels said.
In cases of CNS neonatal herpes, which typically occurs between birth and 6 weeks of life, the chief complaints are decreased feeding and slowly progressive lethargy. Physical exam usually reveals hypothermia, depressed neurologic exam, and apnea. Seizures also may occur.
CBC and other lab tests will usually be normal or nonspecific. Cerebrospinal fluid (CSF) findings vary depending on the presence of meningoencephalitis, encephalitis, or meningitis.
In a case of herpetic meningoencephalitis, “the most striking finding is significantly elevated CSF protein,” Dr. Maisels said. “So if you have a baby who shows up and looks a little sick and has what looks like aseptic meningitis but has a CSF protein of 250 [ng/L], then you have to think about CNS neonatal herpes,” he said. “The [blood] glucose can be normal. It can be low as well.”
In the case of herpes meningitis or pure encephalitis, the CSF protein may not be elevated.
Mortality of CNS neonatal herpes is about 15%.