Herpes simplex virus is a common virus that causes a variety of clinical presentations ranging from mild to life-threatening. Orolabial and genital herpes are common disorders that can often be managed in an outpatient setting; however, some patients do present to the emergency department with those conditions, and emergency clinicians should be aware of possible complications in the pediatric population. Neonatal herpes is a rare disorder, but prompt recognition and initiation of antiviral therapy is imperative, as the morbidity and mortality of the disease is high. Herpes encephalitis is an emergency that also requires a high index of suspicion to diagnose. Herpes simplex virus is also responsible for a variety of other clinical presentations, including herpes gladiatorum, herpetic whitlow, eczema herpeticum, and ocular herpes. This issue reviews the common clinical presentations of the herpes simplex virus, the life-threatening infections that require expedient identification and management, and recommended treatment regimens.
Key words: herpes simplex virus, HSV1, HSV2, neonatal herpes, herpes labialis, genital herpes, herpes encephalitis, eczema herpeticum, herpes gladiatorum, herpetic whitlow, ocular herpes, polymerase chain reaction testing, Tzanck smear, lumbar puncture, liver function tests, antiviral medications, acyclovir, famciclovir, valacyclovir
A 10-day-old full-term girl is brought to the ED with a rectal temperature of 38.6°C. She has no cough, congestion, runny nose, vomiting, or diarrhea. She is formulafed and is tolerating her regular feeds. The mother received prenatal care, and the prenatal labs, including Group B Streptococcus, were negative for any pathology. The mother has no reported history of HSV, but she has had a fever and throat pain for the past few days. The infant is sleeping comfortably in her mother’s arms. On examination, the anterior fontanel is soft and flat, and the skin is negative for rash or lesions. Cardiac, respiratory, and abdominal examinations are within normal limits. The infant’s temperature is now 38.7°C rectally. You explain to the medical student working with you on the case that because the baby is < 28 days old and there are no symptoms other than fever, she will require a full sepsis workup, including a lumbar puncture. You inform the medical student that this is standard of care for neonates who present with a fever, and the diagnostics will aid in determining the cause of the fever. Even though the mother has no history of HSV, you have a high index of suspicion for this. The medical student asks you if the baby should be started on acyclovir.
Herpes simplex virus (HSV) is a common virus that affects up to 90% of the population by adulthood.1 Approximately one-third of children contract a primary HSV1 infection by the age of 5 years.2 In the United States, neonatal HSV disease occurs in approximately 1 in 3200 deliveries, or 1500 new cases annually.3 Because HSV has many clinical presentations, the emergency clinician must maintain a high index of suspicion for HSV infections and be prepared to offer the appropriate management. The emergency clinician must also be aware of possible complications in the pediatric population as well as the recommended treatments.
A search was performed in PubMed for articles published since 1960 pertaining to children aged < 18 years using multiple combinations of the search terms herpes simplex virus, neonatal herpes, acyclovir, treatment, herpes encephalitis, and genital herpes. The Cochrane Database of Systematic Reviews was also consulted. Articles relevant to pediatric HSV infections were selected and reviewed. Over 300 articles were reviewed, 122 of which were chosen for inclusion in this review, including a number of randomized controlled trials, meta-analyses, and clinical practice guidelines.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study will be included in bold type following the references, where available. The most informative references cited in this paper, as determined by the author, will be noted by an asterisk (*) next to the number of the reference.
Jennifer E. Sanders, MD; Sylvia E. Garcia, MD
January 1, 2014