eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Herpes Simplex Virus Infection: Follow-up

Author: Sherman Alter, MD, Associate Professor, Department of Pediatrics, Wright State University Boonshoft School of Medicine; Director, Division of Infectious Diseases, Director, Continuing Medical Education, Children's Medical Center of Dayton
Contributor Information and Disclosures

Updated: Aug 6, 2009

Follow-up

Further Inpatient Care

  • Admission to the hospital is mandatory for select patients with herpes simplex virus (HSV) infections.
  • Criteria for admission are addressed below.
    • Recent recommendations indicate that all patients with neonatal CNS herpes simplex virus infection should undergo repeat lumbar puncture (LP) at the end of intravenous (IV) acyclovir therapy to determine that the cerebrospinal fluid (CSF) specimen is negative for herpes simplex virus on polymerase chain reaction (PCR) testing at a reliable laboratory and to document end-of-therapy CSF indices.
    • Many children with severe herpes simplex virus gingivostomatitis have difficulty drinking fluids because of severe oropharyngeal discomfort. These children require hospitalization for IV fluids and pain control.
    • Infants with neonatal herpes simplex virus infections may present with or develop serious disease, including herpes simplex virus CNS infection and/or disseminated disease.
    • Patients with encephalitis may be very ill at presentation and need inpatient evaluation and intensive care.
    • Herpes simplex virus infection in patients who are immunocompromised requires aggressive inpatient management.

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 are surviving and require careful 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.

Inpatient & Outpatient Medications

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

Deterrence/Prevention

  • Genital herpes simplex virus infections are among the most common sexually transmitted diseases (STDs) 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.
    • Daily suppressive treatment with oral antiviral agents reduces the frequency of recurrences and viral shedding in persons with genital herpes simplex virus infection. It also may improve psychosocial functioning.
    • Limited evidence indicates that condom use may decrease the risk of sexual transmission of herpes simplex virus type 2 (HSV-2). 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 STDs. 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 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%. The risk of infection is estimated to be 1 in 2000-5000 births.
    • Because laboratory methods cannot be used to detect asymptomatic shedding in a timely manner, perform cesarean delivery if a mother has signs or symptoms of primary or recurrent herpes simplex virus disease at delivery. 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.
    • Observe infants delivered vaginally by mothers with active genital herpes. Within 24-48 hours and possibly later, obtain culture samples from the eye, oropharynx, and skin. 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.
    • In women with symptomatic genital herpes, antiviral suppressive treatment initiated at 36 weeks' gestation reduced both the rates of cesarean delivery due to herpes simplex virus lesions and positive viral cultures or PCR tests and also reduced the time of delivery. However, data are insufficient to recommend antiviral suppressive therapy to pregnant women who are HSV-2 seropositive and asymptomatic.

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. herpes simplex virus 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.
  • Although the incidence of serious residua is decreasing during the era of effective antiviral therapy, long-term neurologic impairment may be encountered in children whose herpes simplex virus infection appears localized to the skin, eye, and/or mouth as a neonate. Despite apparently normal findings on clinical examination during the newborn period, neurologic impairment (eg, quadriplegia, microcephaly, blindness) is noted in infants aged 6-12 months.
  • 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. Current data are insufficient to recommend routine use of antiviral suppressive therapy after neonatal herpes simplex virus disease is managed.

Prognosis

Herpes simplex virus infections beyond the fetal and neonatal period are usually annoying but 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. 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 mucous membranes (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.
  • Genital herpes simplex virus infection may not be life threatening, but it is an important cause of physical and psychological morbidity.
  • Herpes simplex virus is one of the most common causes of infectious blindness in the United States.

Patient Education

  • Because increasing rates of STDs, including skin, eye, or to mucous membranes infections, 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 STD should prompt assessment and potential treatment for other infections (eg, chlamydia, HIV infection, syphilis, hepatitis B).
  • Antiviral therapy may decrease the 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 may decrease the risk of the sexual transmission of HSV-2.
  • For excellent patient education resources, visit eMedicine's Sexually Transmitted Diseases Center. Also, see eMedicine's patient education articles Genital Herpes, Birth Control Overview, and Birth Control FAQs.

Miscellaneous

Medicolegal Pitfalls

  • Failure to identify active vaginal herpes simplex virus (HSV) lesions in a mother at the time of labor to perform cesarean delivery and to decrease the risk of transmission to the newborn
  • Failure to refer patients with herpes simplex virus genital infections and all sexual contacts for follow-up care
  • Failure to diagnose, treat, and arrange appropriate counseling for associated sexually transmitted diseases (STDs)
  • Failure to diagnose and aggressively treat disseminated herpes simplex virus disease in a child or adolescent who is immunocompromised
  • Failure to diagnose a herpetic keratoconjunctivitis in a patient presenting with a red eye

Special Concerns

  • Pregnancy and herpes simplex virus disease
  • Neonates and herpes simplex virus disease
  • Immunocompromised patients with herpes simplex virus disease
 


More on Herpes Simplex Virus Infection

Overview: Herpes Simplex Virus Infection
Differential Diagnoses & Workup: Herpes Simplex Virus Infection
Treatment & Medication: Herpes Simplex Virus Infection
Follow-up: Herpes Simplex Virus Infection
Multimedia: Herpes Simplex Virus Infection
References
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Further Reading

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Keywords

HSV, herpes, Herpesvirus hominis, human herpesvirus, herpesvirus type 1, herpesvirus type 2, HSV-1, HSV-2, herpes catarrhalis, herpes facialis, herpes febrilis, herpes labialis, orolabial herpetic infection, Simplex virus, Simplexvirus, neonatal HSV infection, SEM HSV disease, herpetic whitlow, herpes gladiatorum, meningitis, encephalitis, erythema multiform, EM, acuteherpetic pharyngotonsillitis, acute herpetic gingivostomatitis, genital herpes, Mollaret meningitis, keratoconjunctivitis, sexually transmitted disease, STD, genital HSV infections, neonatal HSV infection, orofacial infections, HSV encephalitis, disseminated HSV, odynophagia, orolabial vesicles, painful inguinal lymphadenopathy, aseptic meningitis syndrome, recurrent genital HSV, recurrent genital infections, transverse myelitis, HSV pneumonitis, HSV esophagitis, acute retinal necrosis, erythema multiforme, HSV keratoconjunctivitis, microphthalmos, retinal dysplasia, quadriplegia, microcephaly, recurrent HSV vesicular lesions, orolabial HSV infections, HSV pharyngotonsillitis, recurrent orolabial herpetic infection, HSV CNS disease, HSV-induced aseptic meningitis, HSV hepatitis, blepharitis, follicular conjunctivitis, uveitis, retinitis, punctate retinal lesions, congenital HSV infection

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Contributor Information and Disclosures

Author

Sherman Alter, MD, Associate Professor, Department of Pediatrics, Wright State University Boonshoft School of Medicine; Director, Division of Infectious Diseases, Director, Continuing Medical Education, Children's Medical Center of Dayton
Sherman Alter, MD is a member of the following medical societies: American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Society for Healthcare Epidemiology of America
Disclosure: Glaxosmithkline Grant/research funds Other; Merck Honoraria Speaking and teaching; Novartis Grant/research funds Speaking and teaching; SanofiPasteur Honoraria None

Medical Editor

Leonard R Krilov, MD, Chief of Pediatric Infectious Diseases, 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

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

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.

CME Editor

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: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; sanofi pasteur Honoraria Speaking and teaching; Baxter Healthcare 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: None None None

 
 
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