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17. Disseminated Neonatal Herpes Simplex Virus: Simplex Can Be Very Complex!
Keywords
Herpes simplexNeonatal herpes virusCongenital herpes virusAcyclovirCase
Poorly feeding infant
Pertinent History
A 7-day-old patient presented to the emergency department (ED) for decreased feeding and fussiness. The parents reported that the patient previously had been taking about 20–40 mL of formula every 2–3 hours, but over the past 2 days, this had been gradually decreasing, and the patient had to be awakened for the past 2 feeds. The infant was also fussy when awake today, although she would briefly improve when held by parents. She had developed a rash on her chest earlier today, and it had subsequently spread to the whole body. She has had no fevers and no cough. She has had congestion since birth, regular stools, and regular wet diapers.
Past Medical History
Full-term healthy neonate born at 39 weeks 3 days via normal spontaneous vaginal delivery. There were no preterm complications. She left the hospital with mother after about 36 hours.
Social History
Lives with parents, mother is 20 years old, G2P1, did receive prenatal care, does have a history of chlamydia as a teenager which was treated, mother denies smoking or drug usage during pregnancy.
Pertinent Physical Exam
Temperature 35.1 °C (95.2 °F), heart rate 110 beats per minute, blood pressure 76/48 mmHg, respiratory rate 40 breaths per minute, SpO2 95% on room air.
Except as noted below, the findings of a complete physical exam are within normal limits.
General:
Pale infant with grayish tint to the skin, minimally responsive to painful stimuli.
Head/Eyes/Ears/Nose/Throat:
Anterior fontanelle soft and flat. Moist mucous membranes, and no oral lesions appreciable.
Cardiovascular:
Regular rate and rhythm, normal heart sounds, no appreciable murmurs, faint femoral pulses bilaterally, capillary refill is 4–5 seconds.
Chest:
Mild subcostal and suprasternal retractions, clear breath sounds throughout, and no wheezing.
Abdomen:
Soft, no distension, no appreciable tenderness throughout, no guarding, and no appreciable hepatosplenomegaly.
Skin:
Pale, grayish tint to skin, appears to have jaundice to the mid torso, and diffuse erythematous maculopapular rash to the torso and extremities. Skin poke to the right heel still oozing, pressure applied.
Plan:
Intravenous (IV) line placement, IV dextrose bolus, IV fluid bolus, full septic work up including urine catheterization and lumbar puncture, start empiric antibiotics and acyclovir, and admit.
Triage Evaluation
The patient was taken to an intake room for vitals and triage by the nurse. The patient was noted to be minimally responsive and hypothermic. Glucose was obtained and was 40 mg/dL. The patient was immediately brought back to a resuscitation room.
Emergency Department Course
The patient was taken to a resuscitation room. An IV was placed with some difficulty and the patient was given a D10 5 mL/Kg IV bolus and IV NS 10 ml/kg bolus. The highest concern was for sepsis, but a cardiac anomaly was also considered so the patient was reassessed following fluid administration. Additionally, a chest x-ray was obtained and did not show pulmonary edema or cardiomegaly. The patient was noted to have continued oozing from any venipuncture attempts.
Pertinent Diagnostic Testing
Test | Results | Units | Normal Range |
|---|---|---|---|
WBC | 16.7 | K/μL | 3.8–11.0 103/mm3 |
Hgb | 11.7 | g/dL | (Male) 14–18 g/dL (Female) 11–16 g/dL |
Platelets | 83 | K/μL | 140–450 K/μL |
Na | 132 | mEq/L | 135–148 mEq/L |
Cr | 0.4 | mg/dL | 0.6–1.5 mg/dL |
Glucose | 40 | mg/dL | 65–99 mg/dL |
pH | 7.26 | – | 7.35–7.45 |
pCO2 | 52 | mmHg | 36.1–52.1 mmHg |
ALT | 3400 | IU/L | 8–32 IU/L |
AST | 7800 | IU/L | 6–21 IU/L |
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