Unusual concurrence of heterotopic glial nodule of the scalp and congenital herpes simplex virus type-2 infection.

Heterotopic glial nodules are rare congenital cutaneous lesions; only 13 cases of scalp localized lesions of this kind are reported in the English medical literature. Herpes simplex virus is a rare cause of neonatal morbidity and mortality and is a rare cause of intrauterine infection. We report the first case of concurrent presence of a heterotopic glial nodule of the scalp and neonatal, in utero-acquired, fatal herpes simplex virus type-2 infection.

Pediatric intracranial infections.

Infection of the central nervous system (CNS) in children is an important entity and early recognition is paramount to avoid long-term brain injury, especially in very young patients. The causal factors are different in children compared with adults and so are the clinical presentations. However, imaging features of CNS infection show similar features to those of adults. This article reviews some of the common types of pediatric infections, starting with the congenital (or in utero) infections followed by bacterial infections of the meninges and brain parenchyma.

HSV-2: in pursuit of a vaccine.

Herpes simplex virus type 2 (HSV-2) is one of the most prevalent sexually transmitted infections worldwide. In addition to recurrent genital ulcers, HSV-2 causes neonatal herpes, and it is associated with a 3-fold increased risk for HIV acquisition. Although many HSV-2 vaccines have been studied in animal models, few have reached clinical trials, and those that have been tested in humans were not consistently effective. Here, we review HSV-2 pathogenesis, with a focus on novel understanding of mucosal immunobiology of HSV-2, and vaccine efforts to date, in an attempt to stimulate thinking about future directions for development of effective prophylactic and therapeutic HSV-2 vaccines.

Acyclovir prophylaxis in late pregnancy to prevent neonatal herpes: a cost-effectiveness analysis.

OBJECTIVE: To compare the cost-effectiveness of oral acyclovir prophylaxis in late pregnancy to the current strategy of cesarean delivery for genital herpes lesions in the prevention of neonatal herpes transmission from mothers with recurrent genital infections. METHODS: Decision analysis was used to evaluate the clinical outcomes and direct costs of a prevention program from the health care payer's perspective. Probabilities were obtained from the literature and experts. Cost data were based on hospital costs and a cohort of herpes-infected neonates. RESULTS: Acyclovir prophylaxis during late pregnancy followed by cesarean delivery for genital lesions at delivery in women with recurrent genital herpes requires 1818 women to follow this strategy to prevent one neonatal infection and 7.4 women to take acyclovir to prevent one outbreak of genital herpes at delivery, at a cost (above no intervention) of over $493,000 per neonatal infection prevented, $1.1 million per neonatal death or disability prevented, and $1444 per maternal outbreak prevented. Cesarean delivery for genital herpes lesions requires 386 women with recurrent herpes to undergo cesareans to prevent one neonatal infection, at a cost of more than $1.3 million per neonatal infection prevented and more than $3 million per neonatal death or disability prevented. If acyclovir is given and herpes lesions still occur, the incremental cost of requiring cesarean delivery for these women over vaginal delivery with culture and follow-up of exposed infants is more than $1.4 million per neonatal infection prevented. CONCLUSION: Oral acyclovir prophylaxis in late pregnancy for women with recurrent genital herpes is more cost-effective than the current strategy of cesarean delivery for all women presenting with genital herpes lesions.

Frequent detection of genital herpes simplex virus DNA by polymerase chain reaction among pregnant women.

OBJECTIVE: To investigate the prevalence and level of genital herpes simplex virus (HSV) among women at delivery. DESIGN, PATIENTS, AND SETTING: A prospective analysis of HSV by culture and by polymerase chain reaction (PCR) of genital specimens and by HSV serologic studies in 100 asymptomatic women in labor; prospective analysis of HSV by PCR among 50 seronegative nonpregnant women at a student health center; and retrospective analysis of genital specimens for HSV by PCR from 17 HSV culture-positive women with uninfected neonates and from two HSV culture-negative women with HSV-infected neonates. All pregnant women were at a university hospital. MAIN OUTCOME MEASURES: Presence of HSV by culture and levels of HSV by quantitative, type-specific PCR in cervical and vulvar specimens; HSV serologic testing by Western blot. RESULTS: All of the 100 asymptomatic women in labor who were studied prospectively were HSV culture negative. In nine HSV was recovered by PCR. Herpes simplex virus was recovered by PCR in one of the 50 seronegative nonpregnant women; she soon became seropositive. All 17 culture-positive women had HSV recovered by PCR. High levels of HSV DNA were obtained by PCR from the two culture-negative women with infected neonates. Among those from whom HSV was recovered by PCR, HSV DNA levels were 250 times higher from culture-positive samples than from culture-negative samples (11,571 genome equivalents vs 46 genome equivalents; P < .001). CONCLUSIONS: The frequency of infant exposure to HSV DNA-containing secretions from HSV-seropositive mothers is about eight times higher than previously reported using HSV culture methods. High maternal levels of HSV DNA may be associated with an increased frequency of transmission of HSV to the infant.

Genital herpes and pregnancy--preventive measures.

Genital herpes is particularly dangerous during pregnancy because of the risk of neonatal infection. This is discussed in four situations of genital herpes associated with pregnancy. Choosing the most appropriate method of delivery, i.e. carrying the least risk of transmission from mother to baby, is based on our knowledge of the natural history of genital herpes infection, the risk to the newborn (estimated from epidemiological studies), and, lastly, the possible preventive measures available.

The management of pregnancies complicated by genital infections with herpes simplex virus.

In this review we summarize current knowledge related to the identification of pregnancies that may be complicated by genital herpes and describe the consequences of maternal infections with genital herpes. We address the implications of this information for the management of genital herpes during pregnancy and at delivery and for the care of neonates exposed to herpes simplex virus at delivery. On the basis of the current data, we cannot make specific recommendations concerning many of the clinical problems that are caused by herpes simplex virus infections in pregnant women. We identify and discuss unresolved questions about optimal management.

Epidemiology of genital herpes simplex virus infection.

PIP: This paper offers a comprehensive review of the literature on the epidemiology of genital herpes simplex virus infection. Topics covered include its microbiology, immunology, incidence, prevalence, pathogenesis and clinical course, diagnosis, treatment, transmission, prevention, and effect on pregnancy outcome. The prevalence of genital herpes is estimated at 20 million persons in the US, about 25% of whom are symptomatic. Determination of the actual incidence and prevalence of genital herpes requires the availability of methods able to distinguish precisely between type 1 and type 2 antibody. Indirect evidence suggests an increasing incidence of the disease over the past 15 years. Asymptomatic infected persons may shed virus in the absence of lesions and thus transmit genital herpes to their sexual partners. Of particular concern is vertical transmission of virus from the maternal genital tract to newborns. In the majority of documented cases of neonatal herpes, the mothers were asymptomatic at the time of delivery. Because of the severe morbidity and mortality associated with neonatal herpes infection, studies are urgently needed to identify risk factors for vertical transmission and to design and test appropriate preventive intervention strategies. At present, treatment of genital herpes is limited to palliative therapy. No known antiviral agent either prevents or eliminates viral latency, although vaccines are under development for primary prevention. The role of contraceptive practice in the prevention of genital herpes infection is unclear. Although theoretically plausible, the efficacy of barrier methods in decreasing the risk of acquiring or transmitting infection has not yet been demonstrated. Virus may be present in areas not covered by condoms. Use of a spermicidal cream or jelly with a diaphragm may reduce the risk of virus infection and transmissions, but, again, this method cannot protect from virus transmission to or from the external genitalia.^ieng

Maternal and infant sexually transmitted diseases.

Sexually transmitted infection may result in serious damage to the reproductive tract of the mother, damage to the fetus, wastage of pregnancy, or illness or death of the infant. The effects of gonorrhea, Chlamydia trachomatis infection, mycoplasmal infections, group B streptococcus infections, syphilis, and viral infections are discussed separately for both mother and infant.

Reasons for the absence of a history of recurrent genital infections in mothers of neonates infected with herpes simplex virus.

Thirty-one cases of neonatal herpes simplex (HSV) infection were evaluated to determine how often mothers of infected infants lacked a history of recurrent genital infections and the reasons for its absence. A history of recurrent genital infections was elicited from eight (26%) of the mothers. Nine (29%) of the mothers had primary infections; three of these were oral and six were genital. The mother was not the source of infection in three (9.6%) cases. In eleven (35%) cases, the mother had antibody to HSV but did not have a history or findings of primary or recurrent infection. Two of these mothers had positive cervical or vaginal cultures, but neither had genital lesions typical of HSV in the perinatal period. Two mothers had recurrent HSV infections documented later. The source of the HSV infection remained uncertain in 23% of cases including two in which only the father had a history of recurrent genital infection. When mothers with primary infections in the perinatal period were excluded, the HSV neutralization titers of the mothers of infected infants were similar to the titers of the mothers with recurrent genital infections whose infants were not infected. In contrast, the infected infants had titers fourfold lower than their mother's titer as well as fourfold lower than the 16 infants exposed to HSV who remained uninfected. This discrepancy suggests that the mothers may have had a rise in titer late in pregnancy or that placental transport of antibody was limited. Although 26% of the mothers of infected infants had recurrent genital infections, only three (9.6%) had an easily elicitable history.(ABSTRACT TRUNCATED AT 250 WORDS)

Increase in laboratory-confirmed cases of herpes genitalis and neonatal herpes infections in Israel.

Jewish women have been considered to be at low risk for genital herpes simplex virus Type 2 (HSV-2) infections. During the period 1973 to 1981, genital herpes simplex infections were laboratory confirmed in 129 cases (81 women and 48 men). Until 1976, only sporadic cases were reported to our laboratory. Since then, the number of cases has gradually increased, reaching 31 new reported cases in 1981. The age distribution was typical for a sexually transmitted disease, with the peak of infection at childbearing age (20 to 39 years). As a result, rising morbidity of neonates--due to active genital herpes virus infection in the mother during delivery--could be expected, and monitoring of high-risk pregnancies for prevention of perinatal infections was introduced. Of 14 pregnant women monitored, herpesvirus was isolated in 4 in the last week before delivery, and cesarean section was advised. In addition, during the last 3 years, neonatal herpes was confirmed in six, and suspected in three neonates whose mothers were not monitored for genital herpesvirus infection during pregnancy.