Congenital Herpes Simplex Virus (HSV)

00:01 Let’s switch now to congenital herpes simplex virus or HSV.

00:07 So HSV is when an intrauterine infection presents in the first week of life with severe disseminated disease.

00:16 This is congenital HSV.

00:18 This is different from exposure during birth.

00:22 We don’t see this very often.

00:24 Usually, infants who get HSV don’t get it transplacentally.

00:28 Mostly, they get it during the birthing process and then they have a delay in those symptoms.

00:33 But congenital HSV can be very bad when it’s from an intrauterine infection.

00:38 These infants have bad, severe, disseminated disease in general.

00:43 However, they can also get it during birth.

00:46 In the first week of life, they may typically present with skin/eye/mouth disease.

00:51 This carries an excellent prognosis and if treated, will usually not progress to other disease.

00:57 Between two and four weeks of life, they may present with a simple meningitis, which is not simple because it’s very devastating if not treated and even if it is, can result in deafness and cognitive delay.

01:11 Or they may have disseminated disease a little bit later, that’s usually two to four weeks.

01:16 And again, these infants are generally very sick and have involvement of the liver, the CNS, and multiple systems.

01:25 So the presentation of congenital disease of congenital HSV depends on which organs are involved.

01:33 For skin/eye/mouth disease, they simply present with a focal or a disseminated skin rash, which is typically described as a group of vesicles on an erythematous base.

01:44 Any small vesicle in an infant must be considered to be HSV until proven otherwise.

01:50 Or they can present with disseminated diseases such as meningitis, a mild or severe hepatitis, other things like that.

02:00 The meningitis is the one we really worry about.

02:04 For disseminated disease, these patients may have a severe encephalitis.

02:09 This encephalitis often involves the temporal lobes like you can see in this patient.

02:13 So if you see temporal lobe involvement in an infant, with seizing or brain damage or fever, that’s going to be HSV until proven otherwise.

02:23 They may also have chorioretinitis, those skin lesions, they may have a mild or severe hepatitis.

02:29 We will often get LFTs simply to confirm the concern of disseminated disease.

02:34 They may go frankly coagulopathic or have disseminated intravascular coagulation.

02:40 And they may have a pneumonitis, a sort of pneumonia caused by a virus that can be reasonably severe.

02:49 For HSV testing in infants, we generally test very broadly to maximize our chance of figuring out what it is.

02:56 What’s controversial is whether we should test a simple, well-appearing, febrile infant.

03:01 Most centers do not do this, some centers do.

03:04 But anyway, what are the tests? We have the blood PCR, which is the best test for disseminated disease.

03:11 We have an HSV-CSF-PCR, which is your best test for meningitis.

03:18 And we also will culture the eyes, the mouth, the rectum, and we’ll send those for culture.

03:25 The culture is very affective and it grows reasonably quickly.

03:28 You should know the results in a day or two.

03:31 Also, we usually call ophthalmology to come see these infants to check and do a comprehensive eye exam to make sure there isn’t any eye involvement.

03:41 So that’s my summary of the TORCH infections in kids.

03:45 Thanks for your time.