Management of a Newborn with Pustules and Maternal History of HSV
A newborn presenting with pustules who has a mother with history of HSV requires immediate evaluation for neonatal HSV infection with prompt initiation of intravenous acyclovir therapy while awaiting diagnostic results.
Immediate Assessment and Management
Initial Diagnostic Workup
- Obtain specimens for HSV testing:
- Swabs from skin vesicles/pustules for HSV PCR and culture
- Blood for HSV PCR and culture
- Mouth/nasopharynx swabs for HSV PCR and culture
- Eye swabs for HSV PCR and culture
- Urine and stool/rectal specimens for HSV culture
- Cerebrospinal fluid (CSF) for HSV DNA PCR and routine studies 1
Laboratory Studies
- Complete blood count with differential
- Blood culture
- Liver function tests
- CSF analysis (cell count, protein, glucose)
- Consider testing for other congenital infections if clinically indicated
Treatment
Antiviral Therapy
- Initiate high-dose intravenous acyclovir at 20 mg/kg/dose every 8 hours (60 mg/kg/day) immediately while awaiting test results 1
- Duration of therapy depends on disease classification:
- Skin, eye, and mouth (SEM) disease: 14 days
- CNS disease or disseminated disease: 21 days
- For CNS disease, repeat CSF HSV PCR at day 19-21; continue therapy if still positive 1
Monitoring During Treatment
- Monitor complete blood count for neutropenia (common side effect)
- Monitor renal function (acyclovir is primarily excreted by kidneys)
- Assess for clinical improvement
Disease Classification and Considerations
Categories of Neonatal HSV Infection
Skin, Eye, and Mouth (SEM) Disease
- Limited to skin lesions, eye involvement, or mouth ulcers
- Better prognosis than other forms
- Still requires full course of IV acyclovir to prevent progression
CNS Disease
- Involves the central nervous system
- Higher risk of neurologic sequelae
- Requires 21 days of therapy and CSF PCR monitoring
Disseminated Disease
- Multi-organ involvement (liver, lungs, adrenals, etc.)
- Highest mortality rate
- Requires 21 days of therapy
Important Clinical Considerations
Risk Assessment
- The presence of pustules in a newborn with maternal HSV history warrants immediate action
- Even with maternal history of recurrent HSV (lower transmission risk of ≤3%), the presence of skin lesions indicates active infection requiring treatment 1
- Most infants with neonatal HSV are born to mothers without clinically evident genital herpes during pregnancy 1
Pitfalls to Avoid
Delayed diagnosis and treatment
- Waiting for confirmatory test results before starting acyclovir can lead to disease progression and worse outcomes
- Early treatment is critical for reducing mortality and morbidity 2
Inadequate evaluation
- Failure to obtain complete diagnostic testing may miss CNS or disseminated disease
- All systems must be evaluated even if lesions appear limited to skin
Insufficient treatment duration
- Premature discontinuation of acyclovir therapy can lead to relapse
- Complete the full recommended course based on disease classification
Lack of follow-up
- Even after successful treatment, infants with neonatal HSV remain at risk for neurologic sequelae
- 2-6% of infants with SEM disease may develop later neurologic complications 1
Combination Therapy Considerations
- While standard of care is acyclovir monotherapy, research suggests that combination therapy with anti-HSV antibodies may improve outcomes in severe cases, particularly when treatment is delayed 3
- Consider consultation with infectious disease specialists for complex cases
Long-term Follow-up
- Neurodevelopmental assessment
- Ophthalmologic evaluation
- Consider suppressive acyclovir therapy after acute treatment course for recurrent HSV infections
Early diagnosis and prompt initiation of high-dose intravenous acyclovir are essential for improving outcomes in neonates with suspected HSV infection, particularly when skin lesions are present.