Transcript Case Conference

Case Conference
Sheryl Kho, M.D.
PGY-3
15 year old female
Chief complaint:
rash
HPI
2 wks
Genital area
No itchiness, no foul smelling vaginal
discharge
+pain, burning sensation
No fever, no malaise, no dysuria, no
hematuria, no frequency, urgency,
hesitancy
Applied topical antibiotic, no relief
 PMHx: noncontributory
 PSHx: noncontributory
 Imm:UTD
 FHx: noncontributory
 HEADS: lives with mother, father, sister, in 11th
grade, average student, hangs out with friends,
stay at home, denies drugs, EtOH, cigarettes, no
suicidal/homicidal ideation, no body dysmorphic
disorder, no anorexia, bulimia
Sexual Hx
+ boyfriend, 17 years old
+ sexual activity, last 5 days ago
Seldom uses condoms, no other
contraception
Never been tested for STD
Gyn Hx
Menarche:12 yo
Interval: q 30 days
Duration: 5-6 days
Amount: 3 pads per day, medium soaked
Symptoms: no dysmenorrhea
LMP: ? 1 month ago
Physical Exam
 VS: T99.7 HR 78 RR 18 BP 110/75
 Gen: NAD, AAO
 HEENT: NCAT, EOMI, PERRLA, intact TM,
MMM, no exudates, supple neck
 Lungs:CTA B/L, no W/R/R
 Heart: NRRR, N S1/S2, no murmur
 Abdo: soft, NT, ND, no HSM
 Ext:good cap ref, pulses full&equal, no cyanosis,
no edema
 GU:+multiple shallow ulcers on both labia
majora, no crusting, no vesicles, no discharge,
tanner 4
Labs:
Urine Preg Test: +
HSV Viral Culture: + HSV 2
Quantitative B-HCG: 1400
Neonatal Herpes Simplex
Infections
Herpes Simplex Virus
Herpesviridae family, DNA
Also known as HHV 1 and
HHV 2
HSV 1: establishes latency
in the trigeminal ganglion
HSV 2: sacral ganglion at
the base of the spine
Neonatal Herpes Simplex Infection
High morbidity and mortality in the
absence of therapy ~ 80%
Most infants surviving CNS or
disseminated disease are neurologically
impaired
TORCH infection
Epidemiology of Neonatal HSV
Infection
Differs between countries
Rare in UK, higher incidence in USA
1.65/100,000 live births vs. 20-50/100,000
live births
Infection can be from HSV 1 or 2
Epidemiology
HSV 2--> genital herpes, ~85% of cases,
involved in 70% of neonatal herpes
Incidence: one in every 3,000-20,000 live
births
Of known infected infants, only 30% of
mothers have symptomatic HSV or a
partner with clinical infection
Transmission to the Neonate
Most often occurs
during delivery
(intrapartum)
In utero
(congenital)
Following delivery
(postpartum)
Transmission to the Neonate
Intrauterine
5%
A. Ascending infection
from cervix or vulva
B. Transplacental
transmission
First 20 wksspontaneous
abortions, stillbirth,
congenital
malformations
Transmission to the Neonate
Intrapartum
85%
Transmitted during labor
Direct contact with maternal secretions in birth
canal
Transmission to the Neonate
Postpartum
10%
Environmental source
 Family member with orolabial herpes, herpetic
whitlow or lesions at other sites e.g. breast
Factors Influencing Transmission to
the Neonate
 Type of maternal genital infection at the time of
delivery
First episode: 50%
symptomatic reactivation: 2-5%
asymptomatic virus shedding: 33%
 Transmission of maternal transplacental
antibodies
Quantity and quality of maternal Ab
Seroconversion of mother vs. absence of maternal
anti HSV Ab
Factors Influencing Transmission to
the Neonate
 Duration of ruptured membranes in the presence
of active infection
More than 6 hours
Ascending infection
 Use of fetal scalp monitor at delivery
Site of inoculation for virus
 Young maternal age <25 years old
Clinical Manifestations
3 Categories:
disease localized to the skin, eyes, mucous
membranes (SEM)
CNS disease (with or without SEM)
Disseminated infection- multiorgan
Clinical Manifestations
HSV should be considered in all neonates
who present with nonspecific symptoms
ie. Poor feeding, fever, lethargy or seizures
in the first month of life
HIGH INDEX OF SUSPICION!
SEM Disease
Presents around 10-11 days of age
Localized to the SEM
Discrete vesicles and keratoconjunctivitis
SEM Disease: Complications
Spastic quadriplegia, microcephaly,
blindness: 30-40%
Neurological impairment can become
apparent in the following 6-12 months
May appear normal but have subclinical
infection of the CNS
CNS Disease/ Encephalitis
Seizures, lethargy, irritability, tremors,
poor feeding, temperature instability,
bulging fontanelle
Neuronal spread
Unitemporal --> bitemporal -->
panencephalitis
50% present with seizures
50% mortality due to brainstem involvement
70% have neurological sequelae
Disseminated Disease
9-11 days of age
Worst prognosis
Multiple organ involvement
Irritability, seizures, respiratory distress,
jaundice, bleeding, shock, vesicular
exanthem
Brain infected via blood borne route
Predictors of Mortality
Disseminated> CNS> SEM
(57%>15%>0%)
Disseminated Disease:
Reduced level of consciousness
DIC
HSV Pneumonia
Predictors of Mortality
CNS Disease
Semicomatose or comatose at therapy initiation
Prematurity
seizures
Predictors of Morbidity
 Disseminated Disease
4 fold increase: semicomatose or comatose
 CNS Disease
3.4 fold increase: seizures
 SEM Disease
3 or more recurrences of SEM disease (HSV2) in the
first 6 months were 21x likely to develop neurological
impairment vs. those with less than 3 recurrences
Presentation & Outcomes in
Neonatal Herpes in the absence of
antiviral therapy
Category of
HSV Infection
%
affected
Mortality
Neurological
impairment
SEM
18
0
38
Encephalitis
34
50
67
Disseminated
48
85
50
Diagnosis
May occur in the absence of skin lesions
High index of suspicion
Viral culture swabs from skin,
oropharyngeal, conjunctiva, rectal, urine
Diagnosis
Liver function tests- elevated
CBC
CSF analysis
CXR
Gold standard: HSV DNA PCR for CNS
disease
Management
Born vaginally
or after PROM,
1st episode
Born vaginally
or after PROM,
recurrent
lesions @ birth
Surface
specimens at
24hrs of life
Surface cultures
Surface
specimens + CSF
IV acyclovir
(60mkd q8) x 14
days
If +, tx for 14 days
IV acyclovir x 14
days
If +, CSF PCR
sent, tx for 21 days
Born vaginally
or after PROM
with a hx of
HSV but none
at birth
Infant with HSV
presentation
If +CNS or
disseminated, tx
for 21 days
Strategies To Prevent Neonatal
Acquisition of HSV Infection
 Primary Infection/Symptomatic Recurrent
Infection
Acyclovir (200mg QID or 400mg TID x 10days)
 Decreases the clinical recurrence rate
 Lowers c-section rate in women with with recurrent genital
herpes
Valacyclovir: Category B-no evidence of adverse effects
in humans
Famciclovir
Prophylactic acyclovir in the 3rd trimester for pregnant
women with frequent outbreaks
Strategies To Prevent Neonatal
Acquisition of HSV Infection
Delivery by Caesarean section
Not 100% protective, atleast 70% decrease in
transmission
Suppressive therapy in the sero+ partner
of a sero- gravid woman
Condoms: if used more than 70% of the time,
transmission is reduced to 60% in the seropartner
Antivirals ie. Valacyclovir
In Summary
 Neonatal herpes: HSV 1 or HSV 2
 Risk of transmission of HSV to the neonate is
low in women with a hx of genital herpes in the
absence of identifiable lesions (3%) but is
increased to ~50% in pregnant women with a
primary infection in the 3rd trimester
 Delivery by CS decreases te risk of HSV
infection in the presence of an active lesion
In Summary
Early recognition and treatment of
neonatal HSV to decrease morbidity and
mortality
Diagnosis is thru viral cultures, CSF HSV
DNA PCR
Disseminated/CNS Disease: treated for 21
days
Questions
?
A. Prematurity
B. Invasive fetal monitoring
C. Cesarean delivery
D. First episode of primary genital maternal
HSV infection
1. All the following situations are
associated with an increased risk
of vertical transmission of HSV
infection, except:
A. Prematurity
B. Invasive fetal monitoring
C. Cesarean delivery
D. First episode of primary genital maternal
HSV infection
2. Which of the following regimens is the
treatment for disseminated neonatal HSV
infection?
A. Acyclovir, 60 mg/kg daily in 3 divided
doses for 21 days
B. Acyclovir, 30 mg/kg daily in 3 divided
doses for 21 days
C. Acyclovir, 30 mg/kg daily in 3 divided
doses for 14 days
D. Acyclovir, 60 mg/kg daily in 3 divided
doses for 14 days
A. Acyclovir, 60 mg/kg daily in 3
divided doses for 21 days
B. Acyclovir, 30 mg/kg daily in 3 divided
doses for 21 days
C. Acyclovir, 30 mg/kg daily in 3 divided
doses for 14 days
D. Acyclovir, 60 mg/kg daily in 3 divided
doses for 14 days
3. You are asked to review a case for morbidity and
mortality conference. The infant was born at term to a
19-year-old gravida 1, para 1 woman by normal
spontaneous vaginal delivery. The mother was known
to be group B Streptococcus-negative, but she did
have genital warts. The Apgar scores were 9 at 1
minute and 10 at 5 minutes. On the seventh postnatal
day, the infant developed a temperature of 103°F
(39.4°C) and was brought to the emergency
department. At this time, the infant was in shock and
required mechanical ventilation. Physical examination
revealed scleral icterus and hepatosplenomegaly but
no skin lesions. A lumbar puncture could not be
performed. Laboratory results include
9
• White blood cell count of 2.34x10³/mcL (2.34x10 /L),
with 32% lymphocytes, 41% neutrophils, 8% bands,
15% monocytes, 3% eosinophils, and 1% basophils
• Hemoglobin of 7.1 g/dL (71 g/L)
• Hematocrit of 21% (0.21)
9
• Platelet count of 40x10³/mcL (40x10 /L)
• Prothrombin time of 41.2 seconds
• Activated partial thromboplastin time of >6 seconds
• Aspartate aminotransferase concentration of 3,086
U/L
• Alanine aminotransferase concentration of 456 U/L
• Total bilirubin of 4.4 mg/dL (75.2 mcmol/L)
• The chest
radiograph
demonstrated
diffuse interstitial
infiltrates bilaterally.
The patient did
poorly over the next
3 days and died
despite aggressive
management in a
pediatric intensive
care unit.
Of the following, the MOST likely cause of this
patients' death is
a. Adenovirus
b. Escherichia coli
c. Group B Streptococcus
d. Herpes simplex virus
e. Listeria monocytogenes
Of the following, the MOST likely cause of
this patients' death is
a. Adenovirus
b. Escherichia coli
c. Group B Streptococcus
d. Herpes simplex virus
e. Listeria monocytogenes
4. A 1-week-old infant
presents for his first
newborn evaluation. He
had been discharged
apparently well and
thriving at 48 hours of age.
He now exhibits grouped
vesicles on an
erythematous base that
were not present at birth.
Wright stain of scrapings
from the floor of the
vesicles reveals
multinucleated giant cells
and balloon cells.
Of the following, the MOST likely
diagnosis is
a. Bullous impetigo
b. Congenital varicella
c. Herpes simplex virus infection
d. Incontinentia pigmenti
e. Recessive dystrophic epidermolysis
bullosa
Of the following, the MOST likely diagnosis is
a. Bullous impetigo
b. Congenital varicella
c. Herpes simplex virus infection
d. Incontinentia pigmenti
e. Recessive dystrophic epidermolysis bullosa
5. A nurse asks you to examine
a 26-hour-old infant who
recently developed a rash. On
physical examination, you
note erythematous macules
over the trunk, face, and
proximal extremities. Most of
the macules have tiny central
pustules. The infant is
breastfeeding well, and the
remainder of the physical
examination findings are
normal. No lesions were
present at birth.
Of the following, analysis of the pustular
contents is MOST likely to reveal
a. Eosinophils
b. Gram-positive cocci
c. Multinucleated giant cells
d. Polymorphonuclear leukocytes
e. Pseudohyphae and budding yeast
Of the following, analysis of the pustular
contents is MOST likely to reveal
a. Eosinophils
b. Gram-positive cocci
c. Multinucleated giant cells
d. Polymorphonuclear leukocytes
e. Pseudohyphae and budding yeast
6. A 1-month-old infant
presents with frecklelike
macules over his face
and extremities. The
hospital record reveals
that he had multiple
papules and pustules
distributed over his
entire body, including
palms and soles, at
birth. The infant
appears to be very
healthy and thriving.
Of the following, analysis of the pustular
contents in the newborn period MOST
likely would have revealed:
a. Eosinophils
b. Gram-positive cocci
c. Multinucleated giant cells
d. Polymorphonuclear leukocytes
e. Pseudohyphae and budding yeast
Of the following, analysis of the pustular
contents in the newborn period MOST
likely would have revealed:
a. Eosinophils
b. Gram-positive cocci
c. Multinucleated giant cells
d. Polymorphonuclear leukocytes
e. Pseudohyphae and budding yeast
Thank you…