Paeds · infectious-diseases
Herpes simplex infection in children
Also known as Herpes simplex virus infection · HSV-1 and HSV-2 infection · Primary herpetic gingivostomatitis · Cold sores · Neonatal herpes · Eczema herpeticum
Fellowship topic on herpes simplex virus infection in children: HSV-1 and HSV-2 as neurotropic herpesviruses that establish lifelong latency in sensory ganglia; the disease spectrum from primary herpetic gingivostomatitis and recurrent cold sores to eczema herpeticum, HSV keratitis, herpes simplex encephalitis and the three classes of neonatal HSV (skin-eye-mouth, CNS and disseminated); the mucosal-entry, ganglionic-latency and dermatomal-reactivation biology; PCR diagnosis of CSF and surface disease; the tiered aciclovir strategy from supportive care and oral therapy to high-dose intravenous aciclovir for neonatal and CNS disease with post-treatment suppression; and the maternal-neonatal prevention pathway of suppressive therapy, caesarean for active lesions and the exposed-neonate assessment — with ANZ, UK, US and Canada guidance.
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Target exams
Red flags
- A febrile neonate (under 4-6 weeks) with lethargy, poor feeding, seizures or vesicles — neonatal HSV is missed because the early signs mimic bacterial sepsis; hold HSV high on the differential, send surface and CSF PCR, and start high-dose intravenous aciclovir if the picture is convincing
- Herpes simplex encephalitis — fever with altered consciousness, behavioural change or focal temporal-lobe seizures; outcome worsens with every hour of delay, so start high-dose intravenous aciclovir before PCR returns when the picture fits
- Eczema herpeticum in a child with atopic dermatitis — rapidly spreading, painful, monomorphic punched-out erosions; a dermatological emergency needing systemic aciclovir, never topical steroid alone
- Neonatal disseminated HSV — a sepsis-like illness with hepatitis, pneumonitis and coagulopathy; high mortality if high-dose aciclovir is delayed
- HSV keratitis — a red eye with dendritic ulcers threatens corneal scarring and vision loss; urgent ophthalmology and topical antiviral, never topical steroid without antiviral cover
Life stages
Care settings
Clinical exam formats
Board mappings
- General Paediatrics and Infectious Diseases: herpes simplex infection in children — clinical recognition, complications, aciclovir therapy and prevention
- Neonatology: neonatal HSV recognition, high-dose aciclovir and the maternal-neonatal prevention pathway
- Renewed curriculum — Infectious diseases: HSV latency and reactivation biology, PCR diagnosis and tiered antiviral therapy
- Neurology and neonatology: herpes simplex encephalitis and neonatal HSV diagnosis, treatment and outcome
- General Paediatrics: HSV gingivostomatitis, eczema herpeticum and ocular HSV — diagnosis and tiered management
- Neonatal and emergency care: the febrile neonate — recognising and treating neonatal HSV and encephalitis
- Long Case / Structured discussion: a neonate with proven HSV or a child with herpes simplex encephalitis — diagnosis, high-dose aciclovir, complications and prevention
- Communication station: explaining neonatal HSV, maternal suppression, caesarean and the exposed-neonate pathway to a family
- Level 2 / 3 — Infection: herpes simplex as a cause of orolabial, neonatal and CNS disease; clinical features, complications, treatment and prevention
- Neonatology and public health: neonatal HSV prevention through maternal suppressive therapy, caesarean and the neonatal exposure pathway
- Foundation of Practice (FOP): HSV gingivostomatitis, eczema herpeticum, neonatal HSV and encephalitis — clinical features and the oral-vesicle differential
- Applied Knowledge in Practice (AKP): tiered aciclovir therapy, PCR diagnosis and the maternal-neonatal prevention strategy
- History-taking and management: the dehydrated child with gingivostomatitis or the febrile neonate with possible HSV
- Communication: explaining neonatal HSV, suppression, caesarean and the exposed-neonate pathway to a family
- General Pediatrics Content Outline — herpes simplex infection: diagnosis, complications, treatment and prevention
- Infectious Diseases and Neonatology: neonatal HSV high-dose aciclovir, CSF PCR and the AAP exposed-neonate pathway
- Dermatology and Ophthalmology: eczema herpeticum and HSV keratitis as emergencies
- Patient Care: diagnosis and tiered management of HSV infection across age, syndrome and immune status
- Medical Knowledge: HSV latency and reactivation biology, neonatal HSV disease classes, and aciclovir pharmacology
- Systems-Based Practice and Population Health: maternal-neonatal HSV prevention, suppression, caesarean and the neonatal exposure pathway
- Medical Expert: HSV gingivostomatitis, eczema herpeticum, neonatal HSV and encephalitis diagnosis and treatment
- Health Advocate and Collaborator: maternal-neonatal HSV prevention and the exposed-neonate pathway
- Communicator: explaining neonatal HSV, suppression and caesarean to families
One virus, two faces — primary then recurrent
Primary herpetic gingivostomatitis
Recurrent herpes labialis
"Anterior is HSV, posterior is coxsackie." Herpes gingivostomatitis strikes the anterior mouth — gums, tongue, inner lip — with high fever, tender bleeding gums, marked drooling and a miserable child who stops drinking. Herpangina (coxsackievirus) strikes the posterior pharynx — soft palate, tonsillar pillars — with discrete shallow ulcers, a brief fever and a child who is far less unwell. Add the "gums bleed, child cannot drink" sign and gingivostomatitis is the call: dehydration, not the ulcers, is what brings these children to hospital. [10] [9]
Overview & Definition
Picture an eighteen-month-old brought to the emergency department with a fever, drooling, and a mouth so painful she has not drunk for a day. Inside her lips and on her gums are clusters of shallow grey ulcers on inflamed bases, and her cervical nodes are enlarged and tender. This is primary herpetic gingivostomatitis — the commonest first encounter with herpes simplex virus in childhood — and recognising it instantly sets two priorities: relieve the pain and protect the hydration, and remember that this child now carries the virus for life. [10] [9]
Herpes simplex virus types 1 and 2 are neurotropic double-stranded DNA human herpesviruses. HSV-1 is transmitted mainly through oral secretions and causes most orolabial and central nervous system disease in childhood; HSV-2 is transmitted mainly sexually and causes most genital and neonatal disease. After primary infection the virus travels up sensory nerves to a ganglion — the trigeminal for orolabial disease, the sacral for genital — and establishes lifelong latency. Reactivation sends it back down the same nerve to the same dermatome, producing recurrent lesions at the original site. [1] [3]
For most children the encounter is a self-limiting mucocutaneous illness. The clinician's job has two halves, and the second is what the fellowship examiner tests. The acute half is to recognise the syndrome, gauge the host-risk tier, treat with the right strength of aciclovir, and protect hydration and vision. The preventive half is to understand that the same virus can devastate a neonate or a temporal lobe, and to run the maternal-neonatal prevention pathway that stops that happening. [1] [2]
References12ShowHide
- [1]Corey L; Wald A Maternal and neonatal herpes simplex virus infections. N Engl J Med, 2009.PMID 19797284
- [2]Pinninti SG; Kimberlin DW Neonatal herpes simplex virus infections. Semin Perinatol, 2018.PMID 29544668
- [3]James SH; Kimberlin DW Neonatal Herpes Simplex Virus Infection. Infect Dis Clin North Am, 2015.PMID 26154662
- [4]Samies NL; James SH; Kimberlin DW Neonatal Herpes Simplex Virus Disease: Updates and Continued Challenges. Clin Perinatol, 2021.PMID 34030813
- [5]Kimberlin DW; Whitley RJ; Wan W; Powell DA; et al Oral acyclovir suppression and neurodevelopment after neonatal herpes. N Engl J Med, 2011.PMID 21991950
- [6]Pinninti SG; Kimberlin DW Preventing herpes simplex virus in the newborn. Clin Perinatol, 2014.PMID 25459782
- [7]Kimberlin DW; Baley J; Committee on Infectious Diseases; Committee on Fetus and Newborn Guidance on management of asymptomatic neonates born to women with active genital herpes lesions. Pediatrics, 2013.PMID 23359576
- [8]James SH; Kimberlin DW; Whitley RJ Antiviral therapy for herpesvirus central nervous system infections: neonatal herpes simplex virus infection, herpes simplex encephalitis, and congenital cytomegalovirus infection. Antiviral Res, 2009.PMID 19414035
- [9]Amir J; Harel L; Smetana Z; Varsano I Treatment of herpes simplex gingivostomatitis with aciclovir in children: a randomised double blind placebo controlled study. BMJ, 1997.PMID 9224082
- [10]Amir J; Harel L; Smetana Z; Varsano I The natural history of primary herpes simplex type 1 gingivostomatitis in children. Pediatr Dermatol, 1999.PMID 10469407
- [11]Nasser M; Fedorowicz Z; Khoshnevisan MH; Shahiri Tarestani M Acyclovir for treating primary herpetic gingivostomatitis. Cochrane Database Syst Rev, 2008.PMID 18843726
- [12]Hsu DY; Shinkai K; Silverberg JI Epidemiology of Eczema Herpeticum in Hospitalized U.S. Children: Analysis of a Nationwide Cohort. J Invest Dermatol, 2018.PMID 28927889