Pediatric Herpes Simplex Virus Infection Follow-up

  • Author: Swetha G Pinninti, MD; Chief Editor: Russell W Steele, MD   more...
 
Updated: Jan 24, 2012
 

Further Inpatient Care

In-patient management is often indicated for patients with herpes simplex virus (HSV) infections.

Few suggested criteria are as follows:

  • Many children with severe herpes simplex virus gingivostomatitis with dehydration for intravenous (IV) fluids and pain management.
  • Neonates with disseminated/CNS disease.
  • Older patients with encephalitis who may be very ill at presentation and need inpatient evaluation and intensive care.
  • Herpes simplex virus infection in immunocompromised patients.
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Further Outpatient Care

Adolescents with genital herpes simplex virus infection may require ongoing care for recurrences of herpes simplex virus infections (see Medication).

With effective antiviral therapy, an increasing number of newborns with herpes simplex virus infection survive and require long-term follow-up care. These children should receive ongoing evaluations from specialists in areas including neurodevelopment, ophthalmology, and audiology.

Parents of a child with neonatal herpes simplex virus infection often have considerable feelings of guilt. Parents often require interventional care. In this situation, support from the primary care physician can be of great value to the family.

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Inpatient & Outpatient Medications

Recurrent herpes simplex virus disease in adolescents may be an indication for long-term suppressive treatment with antiviral medications (see Medication).

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Transfer

Transfer should be arranged if the required care is not available locally.

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Deterrence/Prevention

Genital herpes simplex virus infections are among the most common sexually transmitted infections (STIs) in the United States. A growing number of adolescents are infected with the virus. Prevention of sexual transmission of herpes simplex virus is difficult because most transmission occurs during subclinical viral shedding. Avoiding contact with individuals excreting the virus in saliva or genital secretions is difficult because they are often asymptomatic.

Oral antiviral therapy started at the first symptom or sign of genital herpes simplex virus disease reduces (but may not eliminate) the duration of lesions, symptoms, and viral shedding in persons with recurrent genital herpes.[50, 59, 60]

Daily suppressive treatment with oral antiviral agents reduces the frequency of recurrences and viral shedding in persons with genital herpes simplex virus infection.[30, 59] It may also improve psychosocial functioning.

Promote the use of condoms.

Patients with history of genital herpes simplex virus infection may have been exposed to or are at risk of continued exposure to other STIs. Appropriate evaluation, counseling, and education are needed for all patients.

The transmission of herpes simplex virus from mother to infant cannot be eliminated because of asymptomatic primary or recurrent genital infection. The high prevalence of herpes simplex virus type 2 (HSV-2) infections in the United States means that women are at risk of acquiring new infections during pregnancy. One in 5 women is infected before pregnancy. Management to prevent transmission of the virus to newborns includes the following:

  • Reassure women with recurrent disease that risk of neonatal infection is low. The risk of asymptomatic reactivation is approximately 2%, and the attack rate in exposed infants is approximately 3%.
  • Because laboratory methods cannot be used to detect asymptomatic shedding in a timely manner, perform cesarean delivery if a mother has active lesions during delivery.[61] Because of the low risk of transmission, a vaginal delivery is appropriate in women with history of recurrent herpes simplex virus disease who have no active clinical disease at delivery.[62]
  • Observe infants delivered vaginally by mothers with active genital herpes. Within 24-48 hours, obtain surface culture samples. Positive cultures should prompt further evaluation and consideration of therapy. However, these recommendations have not been proven in prospective studies. No information is available to support the administration of acyclovir to exposed infants without signs of infection. Careful clinical follow-up care of neonates and immediate institution of antiviral therapy if symptoms occur are appropriate.[2]
  • In women with symptomatic genital herpes, antiviral suppressive treatment initiated at 36 weeks' gestation reduced both the rates of cesarean delivery due to HSV lesions and positive viral cultures or polymerase chain reaction (PCR) tests at the time of delivery.[12, 21, 63, 64] However, data are insufficient to recommend antiviral suppressive therapy to pregnant women who are HSV-2 seropositive and asymptomatic.[65, 62]
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Complications

Complications of cutaneous herpes simplex virus infections in children and adolescents include eczema herpeticum in children with underlying atopic skin disease, herpetic whitlow of the fingers, and herpes gladiatorum in wrestlers (see History, Physical). Secondary bacterial infections can also occur.

Herpes simplex virus infection of the visceral organs results from viremia with dissemination to many organs. Although this disease is most common in the immunocompromised population, it can also occur in immunologically healthy individuals. Most cases reflect disseminated skin disease, though multiple organs may be involved and hepatitis may be prominent. Disseminated infection can also result in esophagitis, pneumonitis, encephalitis, and adrenal necrosis. Leukopenia, thrombocytopenia, and disseminated intravascular coagulation are not uncommon.

Newborns with herpes simplex virus skin disease have recurrences for months to years, particularly with HSV-2 disease, even if antiviral therapy was administered. The role of suppressive oral antiviral therapy with acyclovir in prevention of these cutaneous herpes simplex virus recurrences is an area of active investigation.[66]

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Prognosis

Herpes simplex virus infections beyond the fetal and neonatal period usually increase morbidity but are not life threatening.

Herpes simplex virus encephalitis is a serious disease that can result in clinically significant neurologic impairment or death. The mortality rate is approximately 70% in untreated patients and 19% in treated patients.[2] Even after treatment, survivors have some neurologic impairment (impaired learning, dysnomia) noted through detailed clinical cognitive testing.

Even with antiviral therapy, neonatal herpes simplex virus infection is associated with morbidity and mortality. Death typically does not occur after skin, eye, and mucus membrane (SEM) disease is treated, but 12-month mortality rates approach 4% with neonatal CNS disease and 29% with disseminated disease. Among antivirally treated neonates, 98% of children with SEM disease, 31% of children with herpes simplex virus–related CNS disease, and 83% of children with disseminated herpes simplex virus disease develop normally 2 years after infection.[2]

The results of one study noted that infants who survived neonatal herpes simplex virus infection with CNS involvement who received suppressive therapy with oral acyclovir (300 mg/m2/dose PO tid for 6 mo) had significantly higher mean Bayley mental-development scores at 12 months than did infants who did not.[67] Another multicenter, retrospective, cohort study suggest that delayed initiation of acyclovir therapy was associated with significantly greater odds of death in neonates with herpes simplex virus infection.[58]

Genital herpes simplex virus infection may not be life threatening but is an important cause of physical and psychological morbidity.

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Patient Education

Because increasing rates of STIs are occurring in adolescents, offer patients regular and appropriate education in sexual health as well as in the diagnosis and treatment of their diseases. The presence of an STI should prompt assessment and potential treatment for other infections (eg, chlamydia, HIV infection, syphilis, hepatitis B, hepatitis C).

Antiviral therapy may decrease the duration of clinical manifestations of herpes simplex virus disease but does not cure the infection.

Initiate antiviral therapy as soon as possible after signs and symptoms of disease are noted.

Daily maintenance treatment with oral antiviral agents reduces the frequency of herpes simplex virus recurrences and viral shedding. Consider antiviral suppressive therapy in adolescents with frequent genital recurrences (6 or more per year).

Condom use decreases the risk of the sexual transmission of HSV-2[68] .

For patient education resources, see the Sexually Transmitted Diseases Center, as well as Genital Herpes, Birth Control Overview, and Birth Control FAQs.

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Contributor Information and Disclosures
Author

Swetha G Pinninti, MD  Fellow in Pediatric Infectious Diseases, Department of Pediatrics, University of Alabama at Birmingham School of Medicine

Swetha G Pinninti, MD is a member of the following medical societies: American Academy of Pediatrics, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Coauthor(s)

Robert W Tolan Jr, MD  Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine

Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility

Disclosure: Novartis Honoraria Speaking and teaching

Specialty Editor Board

Leonard R Krilov, MD  Chief of Pediatric Infectious Diseases and International Adoption, Vice Chair, Department of Pediatrics, Professor of Pediatrics, Winthrop University Hospital

Leonard R Krilov, MD is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Society for Pediatric Research

Disclosure: Medimmune Grant/research funds Cliinical trials; Medimmune Honoraria Speaking and teaching; Medimmune Consulting fee Consulting

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Mark R Schleiss, MD  American Legion Chair of Pediatrics, Professor of Pediatrics, Division Director, Division of Infectious Diseases and Immunology, Department of Pediatrics, University of Minnesota Medical School

Mark R Schleiss, MD is a member of the following medical societies: American Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Robert W Tolan Jr, MD  Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine

Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility

Disclosure: Novartis Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD  Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Sherman Alter, MD, to the original writing and development of this article.

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Primary herpes simplex virus (HSV) gingivostomatitis in an infant is shown. This same patient also had concomitant herpes whitlow as shown in Media file 2.
Herpes whitlow in an infant.
Cutaneous herpes simplex virus (HSV) lesions in a child in whom sexual abuse is suspected.
Vesicular scalp lesions caused by herpes simplex virus (HSV) in a 7-day-old infant.
Herpes gladiatorum in an adolescent wrestler.
MRI shows abnormal signal intensity in the left temporal lobe of an 18-year-old man with herpes simplex virus (HSV) encephalitis.
 
 
 
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