Neonatal conjunctivitis secondary to Herpes simplex is an uncommon but potentially life-threatening illness. According to a survey of members of the American Association of Pediatric Ophthalmology and Strabismus, Herpes simplex virus accounted for 5.7% of the cases of neonatal conjunctivitis. The most common pathogens were Chlamydia trachomatis (35.37%), Staphylococcus aureus (19.65%) and Staphylococcus epidermidis (10.92%). The most common empiric treatments for neonatal conjunctivitis are systemic erythromycin and topical fluoroquinolones. Erythromycin ointment application is recommended after delivery for prevention of neonatal conjunctivitis.
According to National Health and Nutrition Examination Survey data, the seroprevalence for Herpes simplex virus in pregnant women ages 20-39 between 1999 and 2014 was estimated to be 59.3% for HSV-1 and 21.1% for HSV-2. Between 0.2% and 0.39% of all pregnant women regardless of seroprevalence are shedding Herpes simplex virus at the time of delivery. In pregnant women with a prior history of recurrent genital herpes, the rate of viral shedding at delivery increases to between 0.77% and 1.4%. Factors that have been shown to increase the risk of transmitting the Herpes simplex virus to the newborn include having a primary episode of Herpes infection during pregnancy, vaginal delivery, increased duration of rupture of membranes, and use of instrumentation during labor such as forceps or fetal scalp electrode placement. In the United States, there are approximately 1500 cases of neonatal Herpes simplex infection yearly.
In order to prevent transmission of Herpes simplex virus during delivery, the American College of Gynecology recommends performing a cesarean section if genital herpetic lesions are present at the time of delivery. They also recommend antiviral prophylaxis with oral acyclovir or valacyclovir during later stages of pregnancy for any woman with a history of recurrent Herpes simplex genital infections. However, there are numerous case reports of neonatal Herpes simplex infection despite performing Cesarean section and using maternal antiviral prophylaxis.
Since the introduction of effective antiviral therapies including acyclovir and valacyclovir, 45% of neonatal Herpes infections are confined to the skin, eye, and/or mouth. Neonatal Herpes infections typically present between 10 and 12 days postpartum. Vesicular rash is a notable feature in 80% of all neonatal Herpes infections. If the neonatal Herpes infection progresses to involve the central nervous system or becomes disseminated, there is a significantly increased rate of morbidity and mortality. The mortality rate is 29% for disseminated disease and 4% for central nervous system disease despite the use of high-dose intravenous acyclovir. The gold standard for diagnosis of Herpes simplex infection is a positive PCR from an active lesion. PCR testing of the serum and cerebrospinal fluid is recommended for cases of neonatal Herpes infection.
The recommended treatment for neonatal Herpes infections is high-dose intravenous acyclovir (60mg/kg/day) for 14 days if the disease is confined to skin, eyes, and/or mouth and for 21 days if there is involvement of the central nervous system. It is also recommended to treat with oral acyclovir for a minimum of 6 months after stopping intravenous treatment. Intravenous acyclovir may cause significant neutropenia, thrombocytopenia, and elevated creatinine. Although the risk of toxicity is reduced with oral acyclovir, ongoing serum testing and weight-checks to adjust dosing are recommended throughout treatment. While Herpes strains have been reported to show resistance to acyclovir, this continues to be rare.
In this current case, the newborn’s infection was confined to the eyes and skin only. He maintains a lifelong risk of recurrent Herpes simplex infection, which could lead to scarring, amblyopia, and other sight-threatening complications. However, due to the high suspicion for herpetic infection, he was started on antiviral treatment quickly and the infection did not become disseminated or involve his