Endgames Case Report

Skin rash in a preterm infant

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e5390 (Published 30 August 2012) Cite this as: BMJ 2012;345:e5390

Re: Skin rash in a preterm infant

BMJ Endgames 8 Sep 2012 "skin rash in a preterm infant" presents a case of neonatal herpes simplex virus infection in which the diagnosis was suggested by the presence of vesicles. We would like to highlight to readers the difficulty faced in diagnosing neonatal herpes simplex infection (HSV) because it may not present in a typical way.

For example, a significant number of neonates (approximately 40%, Kimberlin 2004) do not present with vesicles, have a normal CRP and are apyrexial. Coagulopathy / disseminated intravascular coagulation (DIC), pneumonitis and CNS involvement occur later in the course of infection by which time the role of antiviral agents may be limited. Fidler et al 2004 reviewed all the cases of disseminated HSV in their unit (Great Ormond Street Hospital for Children) over 10 years and all 8 cases they identified died. Cases presented between 5 to 9 days of life (median 7 days). A prospective survey performed by the same authors showed that the diagnosis of disseminated HSV is often overlooked by clinicians when faced with a neonate presenting with non-specific signs of sepsis.

Not considering the diagnosis could result in a significant delay in starting antiviral therapy. We suggest that features such as hypothermia, poor feeding, lethargy, deranged liver function tests and jaundice should alert the clinician to a possible diagnosis of neonatal HSV.

Appropriate samples should be urgently collected (eyes/throat/rectal swab/blood +/- CSF). Access to same day PCR results could solve the clinical dilemma about whether to "blindly" treat neonates with acyclovir or not.

Vijay Baral consultant in neonatal intensive care
Darren J Fowler consultant paediatric pathologist
Emanuela Pelosi consultant medical virologist
Sanjay Patel consultant in paediatric infectious disease.

References
Endgames BMJ 2012;345:e5390
Fidler KJ et al Could neonatal disseminated herpes simplex virus infections be treated earlier? Journal of Infection 2004; 49:141-146.
Kimberlin DW. Neonatal Herpes Simplex Infection. Clinical Microbiology Reviews 2004; 17:1-13.

Competing interests: No competing interests

23 November 2012
Darren J Fowler
Consultant Paediatric Pathologist
Vijay Baral, Emanuela Pelosi, Sanjay Patel
University Hospital Southampton NHS Foundation Trust
Tremona Road, SO16 6YD
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