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Year : 2016  |  Volume : 61  |  Issue : 1  |  Page : 122
Diagnostic pitfalls of neonatal herpes infection

Department of Dermatology, Venereology and Leprosy, Gandhi Medical College, Hyderabad, Andhra Pradesh, India

Date of Web Publication15-Jan-2016

Correspondence Address:
K Bhumesh Kumar
Department of Dermatology, Venereology and Leprosy, Gandhi Medical College, Hyderabad, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-5154.174140

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How to cite this article:
Kumar K B, Kiran A G, Kumar B U. Diagnostic pitfalls of neonatal herpes infection. Indian J Dermatol 2016;61:122

How to cite this URL:
Kumar K B, Kiran A G, Kumar B U. Diagnostic pitfalls of neonatal herpes infection. Indian J Dermatol [serial online] 2016 [cited 2018 May 22];61:122. Available from:


Neonatal herpes simplex virus (HSV) infections are often life-threatening and difficult to diagnose. Most infections are treatable when they are detected early. Antiviral treatment should be strongly considered in infants with vesicular lesions at the earliest, even before a definitive culture or polymerase chain reaction results are available. Mortality following multi-organ disease in the absence of therapy is very high (80%), and most infants surviving central nervous system (CNS) or disseminated disease are neurologically impaired.

Here, we report a case of 10-day-old (3 kg) male baby who developed multiple grouped vesicles on erythematous base on anterior chest wall [Figure 1]a on the 10 th day of life which was diagnosed as insect bite reaction by a general practitioner. On the 15 th day baby developed fever, lethargy, seizures and became unconscious and was brought to our institution. There was no history of genital lesions in mother. Baby was admitted in Neonatal Intensive Care Unit.
Figure 1: (a) Case 1 -Multiple grouped vesicles on an erythematous base on the anterior chest wall. (b) Case 2 -Multiple, grouped and discrete vesicles on the chest and abdomen. (c) Case 2 -Tzanck test-multinucleated giant cells

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Another newborn baby (3.5 kg) was brought to us with the history of multiple, grouped and discrete vesicles in the axilla, chest, abdomen, [Figure 1]b, [Figure 2] and [Figure 3] and back of 2 days duration. There was a history of genital HSV lesions in the mother.
Figure 2: Case 2 -Multiple, grouped and discrete vesicles in the axilla

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Figure 3: Case 2 -Multiple, grouped and discrete vesicles on the abdomen

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In both cases, routine investigations such as complete blood picture, erythrocyte sedimentation rate, complete urine examination, chest X-ray and ultrasound abdomen were within normal limits. Specific investigations such as Tzanck smear [Figure 1]c and Serology for HSV-2 antibodies (immunoglobulin M) were positive.

Based on clinical and laboratory evidence, first baby was diagnosed as neonatal HSV meningoencephalitis and the second baby was diagnosed as neonatal HSV infection (Skin, Eyes and Mouth [SEM] type).

In both the babies, we started intravenous (IV) acyclovir 20 mg/kg/dose thrice daily along with supportive therapy. We could not revive the first baby because of delayed diagnosis and treatment.

The second baby was given IV acyclovir for 14 days. All the lesions resolved and there was complete recovery without any sequelae.

   Discussion Top

Neonatal herpes can result from infection with either HSV-1 or -2, with the latter being associated with a poor prognosis. [1] The most common cause of genital herpes in adults is HSV-2 in 85% of cases and in neonatal herpes it is seen in 70% of cases. [2] Neonatal infection with HSV most often occurs during delivery. Infection can also occur in utero (congenital 5%) or following delivery (intrapartum 85%) or during the postpartum period (10%). [3]

Neonatal HSV infection manifest as grouped vesicular lesions on an erythematous base localized to the SEM type, which is the earliest manifestation due to maternal transmission. The other findings are CNS involvement with or without SEM. The disseminated infection involving multiple organs such as the liver, lung, adrenal glands and/or brain can occur at a late stage. [3]

A study conducted by Whitley RJ, Corey et al. and Kimberlin et al. found that the mortality rate in babies with SEM type of herpes is zero, and the neurological impairment is 38%. In neonatal herpes presenting with encephalitis, the mortality rate is 50%, and the neurological impairment is 67% whereas herpes presenting with disseminated type, the mortality rate is 85% and the neurological impairment is 50%. [4] This gives further evidence that neonatal herpes if not diagnosed and treated early will lead to further complications as we have reported in our first case. SEM disease presents at approximately at 10-11 days after birth. [5] Disease limited to the SEM is manifested by discrete vesicles and keratoconjunctivitis. Unless there is an index of suspicion, it is difficult to diagnose herpetic infection in spite of cutaneous vesicular lesions. Though there is no mortality associated with SEM type, 30-40% develops neurological impairment if they do not receive antiviral therapy. The significant neurological findings include spastic quadriplegia, microcephaly and blindness that become apparent in the following 6-12 months. Infants may appear healthy, and some many have a subclinical infection of the CNS. Moreover, 75% of babies with SEM infection progress to either CNS involvement or disseminated disease in the absence of antiviral therapy. [4] This is probably due to widespread viremia leading to the involvement of the brain, liver, or lungs. Hence, all infants with SEM disease should be treated aggressively and followed-up carefully up to 6-12 months.

Depending on disease classification and duration of treatment with acyclovir ranging from 10 to 21 days improves morbidity and mortality. Acyclovir is used because of its safety and convenient dosing regimen. [5]

   Conclusions Top

HSV infections in the neonate have the potential to cause significant morbidity and mortality. Recognition of herpes simplex in neonates is difficult unless there is a high index of suspicion evaluating vesicular lesions. Early diagnosis and treatment decrease the morbidity and mortality.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Prober CG, Corey L, Brown ZA, Hensleigh PA, Frenkel LM, Bryson YJ, et al. The management of pregnancies complicated by genital infections with herpes simplex virus. Clin Infect Dis 1992;15:1031-8.  Back to cited text no. 1
Fleming DT, McQuillan GM, Johnson RE, Nahmias AJ, Aral SO, Lee FK, et al. Herpes simplex virus type 2 in the United States, 1976 to 1994. N Engl J Med 1997;337:1105-11.  Back to cited text no. 2
Whitley RJ. Herpes simplex virus infections of women and their offspring: Implications for a developed society. Proc Natl Acad Sci U S A 1994;91:2441-7.  Back to cited text no. 3
Whitley RJ, Corey L, Arvin A, Lakeman FD, Sumaya CV, Wright PF, et al. Changing presentation of herpes simplex virus infection in neonates. J Infect Dis 1988;158:109-16.  Back to cited text no. 4
Kimberlin DW, Lin CY, Jacobs RF, Powell DA, Corey L, Gruber WC, et al. Safety and efficacy of high-dose intravenous acyclovir in the management of neonatal herpes simplex virus infections. Pediatrics 2001;108:230-8.  Back to cited text no. 5


  [Figure 1], [Figure 2], [Figure 3]


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