Preventing herpes simplex virus in the newborn

Challenges for early diagnosis of neonatal herpes infection in Japan

Background

This study aimed to analyze the recent prevalence of neonatal herpes simplex virus infection, maternal symptoms in the presence of neonate who has herpes simplex virus infection, and mode of delivery in Japan.

Methods

We requested 2.078 obstetrical facilities that are members of the Japan Association of Obstetricians and Gynecologists (JAOG) to provide information on neonatal herpes simplex virus infection involving deliveries at or after 22 weeks of gestation between 2020 and 2022. Of these, 1.371 (66.0%) facilities responded with information that could undergo statistical analysis.

Results

There were 10 cases of neonatal herpes simplex virus infection, and the incidence of neonatal herpes simplex virus infection in Japan was about 1 in 1.4 × 105 live births. There were no characteristic maternal findings common to cases of neonatal herpes simplex virus infection.

Conclusion

The incidence of neonatal herpes simplex virus infection in Japan was low. We could not identify any characteristic maternal findings common to cases of neonatal herpes simplex virus infection.

Colposcopy-A Valuable Diagnostic Tool for Pregnant Women With Unexplained Vaginal Bleeding

OBJECTIVES

We aimed to examine the diagnostic value of colposcopy in a large cohort of pregnant women with unexplained vaginal bleeding during the second or third trimester.

MATERIALS AND METHODS

This retrospective study included women who underwent colposcopy due to vaginal bleeding in the second and third trimesters during 2012-2022 at a tertiary care hospital. Demographics, obstetric data, bleeding characteristics, colposcopy results, cervical cytology testing, a sonogram directed at the placenta, and birth details were collected.

RESULTS

In total, 364 women were included. The mean maternal age was 29.7 years and the mean gestational age at examination was 30.7 weeks. Vaginal bleeding was mild in 80.8%, moderate in 14.6%, and severe in 4.7%. Only 3.3% had been vaccinated against human papilloma virus and 25.5% underwent a Pap smear study before pregnancy. Colposcopy diagnosed the bleeding source in 83 women (22.8%). The colposcopic examination revealed vaginal bleeding due to contact bleeding from ectropion in 46 (12.6%), a decidual/cervical polyp in 37 (10.2%), acetowhite epithelium in 12 (3.3%), herpes genetalis in 2 (0.5%), and bleeding from vaginal varices in 2 (0.5%). Of those who were recommended a follow-up examination after the postpartum period, only 49.1% completed such.Among women with compared to without postcoital bleeding ( N = 72), the risk of abnormal colposcopic findings was higher (24 [33.3%] vs 54 [19.7%], p = .017) and the rate of abnormal Pap smear was higher (7 [13.2%] vs 7 [3.2%], p = .008).

CONCLUSIONS

Colposcopy can be a valuable diagnostic tool for women with unexplained vaginal bleeding in the second or third trimester.

A broad-based probe-free qPCR assay for detection and discrimination of three human herpes viruses

Primary infection or reactivation of latent human cytomegalovirus (HCMV) or herpes simplex viruses (HSV) 1 or 2 during pregnancy can transmit the virus in utero or during natural childbirth to the fetus. The majority of these infections are asymptomatic at birth but may present later with potentially lethal disseminated infection or meningitis (HSV), or long-term neurodevelopmental sequelae including sensorineural hearing loss or neurodevelopmental impairments (HCMV). Unfortunately, early signs and symptoms of disseminated viral infections may be misdiagnosed as bacterial sepsis. Therefore, immediate testing for viral etiologies may not be ordered or even considered by skilled clinicians. In asymptomatic HCMV infections, early detection is necessary to monitor for and treat future neurologic sequelae. In acutely ill-appearing infants, specific detection of viruses against other disease-causing agents is vital to inform correct patient management, including early administration of the correct antimicrobial(s). An ideal test should be rapid, inexpensive, require low sample volumes, and demonstrate efficacy in multiple tissue matrices to aid in timely clinical decision-making for neonatal infections. This work discusses the development of a rapid probe-free qPCR assay for HSV and HCMV that enables early and specific detection of these viruses in neonates. The assay's probe free chemistry would allow easier extension to a broad-based multiplexed pathogenic panel as compared to assays utilizing sequence-specific probes or nested PCR.

Neonatal herpes simplex virus infection: From the maternal infection to the child outcome

This review examines the recent literature on the management of herpes simplex virus (HSV) infections in neonates. We summarized the three clinical categories of maternal HSV infection during pregnancy (primary first episode, nonprimary first episode, or recurrent episode) and the mechanisms of fetal damage. Considering when the transmission of the infection from the mother to the fetus/newborn occurs, three types of neonatal infection can be distinguished: intrauterine infection (5% of cases), postnatal infection (10% of cases), and perinatal infections (85% of cases). Neonatal presentation could range from a limited disease with skin, eye, and mouth disease to central nervous system disease or disseminated disease: the treatment with acyclovir should be tailored according to symptoms and signs of infection, and virological tests. These children need a multidisciplinary follow-up, to timely intercept any deviation from normal neurodevelopmental milestones. Prevention strategies remain a challenge, in the absence of an available vaccine against HSV.

Characteristics of neonatal herpes simplex central nervous system disease in Australia (1997-2020)

BACKGROUND

Neonatal herpes simplex virus (HSV) central nervous system (CNS) disease can occur in isolation or as part of disseminated infection. We sought to describe neonatal HSV CNS disease in Australia over 24 years.

METHODS

Neonates (≤28 days) with confirmed HSV infection, reported prospectively to the Australian Paediatric Surveillance Unit (1997-2020), were evaluated for HSV CNS disease (laboratory confirmation with clinical evidence of encephalitis, e.g., lethargy, seizures, focal signs; and/or abnormalities on neuroimaging or electroencephalogram), and compared with neonates without CNS disease. CNS-restricted disease was compared with CNS-disseminated disease.

FINDINGS

Of 195 neonates with HSV disease; 87 (45%) had CNS disease (1.29 cases/100,000 live births per year, 95% CI: 1·04-1·59). Neonates with CNS disease were significantly more likely to be male than neonates without CNS disease (60% versus 39%, OR=2·32, 95% CI 1·29-4·18). Of the neonates with CNS disease, those with CNS-restricted disease (52/87, 60%) presented later than neonates with CNS-disseminated disease (35/87, 40%), (mean 12 versus 6 days). Twenty (23%) neonates with CNS disease died, the majority with CNS-disseminated disease (n = 19). Most neonates received aciclovir therapy (94·3%), however five neonates with unrecognised CNS disseminated disease (diagnosed at autopsy) had not been treated. Survivors of CNS disease were significantly more likely to have adverse neurological sequelae, compared with those without CNS disease (30% versus 4%, OR: 9·60, 95% CI: 2·6-35·0).

INTERPRETATION

Male neonates have a higher burden of HSV CNS disease. Despite the use of antiviral agents, morbidity following neonatal HSV CNS disease remains high. Evaluation of adjunctive therapies to improve outcomes is needed.

Roles of TGF-β1 in Viral Infection during Pregnancy: Research Update and Perspectives

Transforming growth factor-beta 1 (TGF-β1) is a pleiotropic growth factor playing various roles in the human body including cell growth and development. More functions of TGF-β1 have been discovered, especially its roles in viral infection. TGF-β1 is abundant at the maternal-fetal interface during pregnancy and plays an important function in immune tolerance, an essential key factor for pregnancy success. It plays some critical roles in viral infection in pregnancy, such as its effects on the infection and replication of human cytomegalovirus in syncytiotrophoblasts. Interestingly, its role in the enhancement of Zika virus (ZIKV) infection and replication in first-trimester trophoblasts has recently been reported. The above up-to-date findings have opened one of the promising approaches to studying the mechanisms of viral infection during pregnancy with links to corresponding congenital syndromes. In this article, we review our current and recent advances in understanding the roles of TGF-β1 in viral infection. Our discussion focuses on viral infection during pregnancy, especially in the first trimester. We highlight the mutual roles of viral infection and TGF-β1 in specific contexts and possible functions of the Smad pathway in viral infection, with a special note on ZIKV infection. In addition, we discuss promising approaches to performing further studies on this topic.

Australian Paediatric Surveillance Unit (APSU) Annual Surveillance Report 2020

Abstract

For 27 years, national prospective data on selected rare childhood diseases have been collected monthly by the Australian Paediatric Surveillance Unit (APSU) from paediatricians and other clinical specialists who report cases in children aged up to 16 years. We report here the annual results of APSU surveillance in 2020 for ten rare communicable diseases and complications of communicable diseases, namely: acute flaccid paralysis (AFP); congenital cytomegalovirus (CMV) infection; neonatal herpes simplex virus (HSV) infection; perinatal exposure to human immunodeficiency virus (HIV); paediatric HIV infection; severe complications of seasonal influenza; juvenile onset recurrent respiratory papillomatosis (JoRRP); congenital rubella syndrome; congenital varicella syndrome; and neonatal varicella infection. We describe the results for each disease in the context of the total period of study, including demographics, clinical characteristics, treatment and short-term outcomes. Despite challenges presented by the coronavirus disease 2019 (COVID-19) pandemic in 2020, more than 1,400 paediatricians reported regularly to the APSU and an overall monthly reporting rate of > 90% was achieved. The minimum AFP target of 1 case per 100,000 children aged less than 15 years was achieved and there were few cases of vaccine-preventable diseases (JoRRP, rubella, varicella). However, high cases of congenital CMV, neonatal HSV and perinatal exposure to HIV persist. There were no severe complications of seasonal influenza reported for the first time in 13 years. This is consistent with other surveillance data reporting a decline of influenza and other communicable diseases in 2020, and likely reflects the wider effects of public health measures to reduce transmission of SARS-CoV-2 in the Australian community.

Pregnancy and viral infections: Mechanisms of fetal damage, diagnosis and prevention of neonatal adverse outcomes from cytomegalovirus to SARS-CoV-2 and Zika virus

Some maternal infections, contracted before or during pregnancy, can be transmitted to the fetus, during gestation (congenital infection), during labor and childbirth (perinatal infection) and through breastfeeding (postnatal infection). The agents responsible for these infections can be viruses, bacteria, protozoa, fungi. Among the viruses most frequently responsible for congenital infections are Cytomegalovirus (CMV), Herpes simplex 1–2, Herpes virus 6, Varicella zoster. Moreover Hepatitis B and C virus, HIV, Parvovirus B19 and non-polio Enteroviruses when contracted during pregnancy may involve the fetus or newborn at birth. Recently, new viruses have emerged, SARS-Cov-2 and Zika virus, of which we do not yet fully know the characteristics and pathogenic power when contracted during pregnancy.

Viral infections in pregnancy can damage the fetus (spontaneous abortion, fetal death, intrauterine growth retardation) or the newborn (congenital anomalies, organ diseases with sequelae of different severity). Some risk factors specifically influence the incidence of transmission to the fetus: the timing of the infection in pregnancy, the order of the infection, primary or reinfection or chronic, the duration of membrane rupture, type of delivery, socio-economic conditions and breastfeeding. Frequently infected neonates, symptomatic at birth, have worse outcomes than asymptomatic. Many asymptomatic babies develop long term neurosensory outcomes.

The way in which the virus interacts with the maternal immune system, the maternal-fetal interface and the placenta explain these results and also the differences that are observed from time to time in the fetal‑neonatal outcomes of maternal infections. The maternal immune system undergoes functional adaptation during pregnancy, once thought as physiological immunosuppression. This adaptation, crucial for generating a balance between maternal immunity and fetus, is necessary to promote and support the pregnancy itself and the growth of the fetus. When this adaptation is upset by the viral infection, the balance is broken, and the infection can spread and lead to the adverse outcomes previously described. In this review we will describe the main viral harmful infections in pregnancy and the potential mechanisms of the damages on the fetus and newborn.

Herpes simplex virus infection in pregnancy - An update

Herpes Simplex virus (HSV) infection is one of the most common sexually transmitted infections among women of the reproductive age. It is estimated to affect about 2-3% of pregnant women. Vertical transmission during pregnancy is rare occurring in less than 1% of cases but for those with active lesions or shedding the virus asymptomatically the risk of vertical transmission intrapartum is high. Neonates with HSV may develop severe consequences such as disseminated, central nervous system and skin, eye mouth/mucous disease or suffer mortality. A high index of suspicion, timely diagnosis and institution of appropriate treatment during acute and recurrent episodes will reduce the risk of vertical transmission and therefore neonatal consequences. Routine screening for HSV in pregnancy is not recommended. This review provides an overview of HSV in pregnancy, diagnosis and management especially around unique scenarios such as prelabour preterm rupture of fetal membranes and presentation with active disease in labour.

Multimodal Imaging of a Severe Case of Neonatal Acute Retinal Necrosis and Lens Vacuoles Associated with Herpes Simplex Virus Infection

PURPOSE

To report a case of a neonate with acute retinal necrosis, lens vacuoles, and encephalitis associated with herpes simplex virus (HSV) infection.

DESIGN

Case report.

METHODS

Retrospective chart review.

RESULTS

A male neonate was brought for screening for retinopathy of prematurity at the corrected age of 32 weeks. Slit-lamp examination showed lens vacuoles in both eyes. Fundus examination revealed extensive retinal detachments with prominent retinal whitening, subretinal exudates, and retinal hemorrhage. Computed tomography of the brain showed encephalomalacia. Polymerase chain reaction of cerebrospinal fluid and anterior chamber fluid was both positive for HSV-1. Despite systemic anti-viral therapy, a rhegmatogenous retinal detachment and subsequent proliferative vitreoretinopathy developed in the patient's right eye. The retinal detachment in the left eye resolved, but significant chorioretinal degeneration occurred. With time lens vacuoles decreased in number.

CONCLUSIONS

Clinicians should remember this rare, but devastating condition without specific prodromal symptoms.

Modeling SARS-CoV-2 infection in individuals with opioid use disorder with brain organoids

The COVID-19 pandemic has aggravated a preexisting epidemic: the opioid crisis. Much literature has shown that the circumstances imposed by COVID-19, such as social distancing regulations, medical and financial instability, and increased mental health issues, have been detrimental to those with opioid use disorder (OUD). In addition, unexpected neurological sequelae in COVID-19 patients suggest that COVID-19 compromises neuroimmunity, induces hypoxia, and causes respiratory depression, provoking similar effects as those caused by opioid exposure. Combined conditions of COVID-19 and OUD could lead to exacerbated complications. With limited human in vivo options to study these complications, we suggest that iPSC-derived brain organoid models may serve as a useful platform to investigate the physiological connection between COVID-19 and OUD. This mini-review highlights the advances of brain organoids in other neuropsychiatric and infectious diseases and suggests their potential utility for investigating OUD and COVID-19, respectively.

Viral Infections of the Central Nervous System in Children: A Systematic Review

Viral infections of the central nervous system such as meningitis, encephalitis or meningoencephalitis, are important causes of significant morbidities and mortality worldwide. Early diagnosis and prompt treatment will lead to better outcomes, but any delay may results in high fatality with serious neurologic sequelae among survivors. We conducted a systematic review of published literature on the clinical presentation, diagnosis, treatment and complications of viral infections of the central nervous system from 1980 to 2019 on four databases comprising of PubMed, PubMed Central, Google Scholar and Medline to give the current understanding for better patient management. This systematic review demonstrates the management approach of viral infections of the central nervous system in children from the point of clinical presentation, diagnosis, treatment and complications. Definitive treatment remained unknown; however, certain antiviral drugs were proved to be effective. Therefore, prevention through childhood vaccination is the best management option.

Herpes simplex virus type 1 infection leads to neurodevelopmental disorder-associated neuropathological changes

Neonatal herpes simplex virus type 1 (HSV-1) infections contribute to various neurodevelopmental disabilities and the subsequent long-term neurological sequelae into the adulthood. However, further understanding of fetal brain development and the potential neuropathological effects of the HSV-1 infection are hampered by the limitations of existing neurodevelopmental models due to the dramatic differences between humans and other mammalians. Here we generated in vitro neurodevelopmental disorder models including human induced pluripotent stem cell (hiPSC)-based monolayer neuronal differentiation, three-dimensional (3D) neuroepithelial bud, and 3D cerebral organoid to study fetal brain development and the potential neuropathological effects induced by the HSV-1 infections. Our results revealed that the HSV-1-infected neural stem cells (NSCs) exhibited impaired neural differentiation. HSV-1 infection led to dysregulated neurogenesis in the fetal neurodevelopment. The HSV-1-infected brain organoids modelled the pathological features of the neurodevelopmental disorders in the human fetal brain, including the impaired neuronal differentiation, and the dysregulated cortical layer and brain regionalization. Furthermore, the 3D cerebral organoid model showed that HSV-1 infection promoted the abnormal microglial activation, accompanied by the induction of inflammatory factors, such as TNF-α, IL-6, IL-10, and IL-4. Overall, our in vitro neurodevelopmental disorder models reconstituted the neuropathological features associated with HSV-1 infection in human fetal brain development, providing the causal relationships that link HSV biology with the neurodevelopmental disorder pathogen hypothesis.

HSV-1 is one of the most prevalent human pathogens that can spread into the fetal central nervous system by maternal-fetal transmission, and thus resulting in long-term neurological sequelae in adult, including cognitive dysfunction and learning disabilities. However, there is a very limited progress in understanding the role of HSV-1 on human fetal brain development due to limited access to fetal human brain tissue as well as the limitations of existing neurodevelopmental and infection models. Here, we generated the in vitro neurodevelopmental disorder models including hiPSC-based monolayer neuronal differentiation, three-dimensional (3D) neuroepithelial bud, and 3D cerebral organoid to study the neurodevelopmental disorder-associated neuropathological changes with HSV-1 infection in human fetal brain development. Our results revealed that HSV-1 infection led to impaired neural differentiation and dysregulated neurogenesis in the fetal neurodevelopment. Additionally, HSV-1 infection impaired neuronal differentiation and dysregulated brain regionalization in our cerebral organoid model. Furthermore, the cerebral organoid model showed that HSV-1 infection led to the abnormal microglial proliferation and activation, accompanied by the induction of inflammatory factors including TNF-α, IL-6, IL-10, and IL-4. Taken together, our study provides novel evidence that HSV-1 infection impaired human brain development and contributed to neurodevelopmental disorder pathogen hypothesis, and would have implications for raising the therapeutic opportunities for targeting of viral reservoirs relevant to neurodevelopmental disorder.

Molecular Biology and Epidemiology of Neurotropic Viruses

Neurotropic viruses are those viruses that can cause central nervous system (CNS) diseases with both neuroinvasive and neurovirulence properties. It comprises a wide range of viruses, including herpes simplex virus, poliovirus, enteroviruses, parechovirus, West Nile virus, Japanese encephalitis virus, measles, and mumps viruses among others. Some of these viruses are highly neuroinvasive and neurovirulent, while others are weakly neuroinvasive and neurovirulent. Moreover, some of them, like herpes simplex viruses, are highly neuroinvasive but weakly neurovirulent for the peripheral nervous system and highly neurovirulent but weakly neuroinvasive for the central nervous system. All these disparities are a result of differences in their genomic constitution, associated vectors, geographical region, and environmental factors. Therefore, a successful intervention will be almost impossible without a clear understanding of the molecular biology and epidemiology of these viruses. Thus, we conducted a review of the published studies on the molecular biology and epidemiology of the common neurotropic viruses to make the viral genetic makeup more understandable for targeted intervention and provide the morbidity and mortality data of the different neurotropic viruses for more serious action.

Congenital Cytomegalovirus and Neonatal Herpes Simplex Virus Infections: To Treat or Not to Treat?

Congenital cytomegalovirus infections are among the most common of the newborn in the developed world. These infections are the most common cause of sensorineural hearing loss. Studies utilizing ganciclovir and valganciclovir demonstrate improved hearing and Bailey Developmental scores. Because of the ease of administration, valganciclovir is the recommended treatment of choice for 6 months. Therapy should be reserved for those babies with symptomatic disease; no data are available regarding the impact of treatment on those babies with asymptomatic disease.

Pathogenesis of Non-Zika Congenital Viral Infections

A widespread epidemic of Zika virus (ZIKV) infection was reported in 2015 from South and Central America and the Caribbean. Although the full spectrum of ZIKV infection of the newborn has yet to be determined, other maternal viral infections resulting in transmission to the fetus provide instructive lessons that can be applied to the prospective evaluation of individuals with ZIKV infection. This review focuses on those other congenital infections, including rubella, congenital cytomegalovirus, human immunodeficiency virus, hepatitis B virus, and neonatal herpes simplex virus, from which lessons for the evaluation of ZIKV in the newborn can be applied.

Genotypic and Phenotypic Diversity of Herpes Simplex Virus 2 within the Infected Neonatal Population

More than 14,000 neonates are infected with herpes simplex virus (HSV) annually. Approximately half display manifestations limited to the skin, eyes, or mouth (SEM disease). The rest develop invasive infections that spread to the central nervous system (CNS disease or encephalitis) or throughout the infected neonate (disseminated disease). Invasive HSV disease is associated with significant morbidity and mortality, but the viral and host factors that predispose neonates to these forms are unknown. To define viral diversity within the infected neonatal population, we evaluated 10 HSV-2 isolates from newborns with a range of clinical presentations. To assess viral fitness independently of host immune factors, we measured viral growth characteristics in cultured cells and found diverse in vitro phenotypes. Isolates from neonates with CNS disease were associated with larger plaque size and enhanced spread, with the isolates from cerebrospinal fluid (CSF) exhibiting the most robust growth. We sequenced complete viral genomes of all 10 neonatal viruses, providing new insights into HSV-2 genomic diversity in this clinical setting. We found extensive interhost and intrahost genomic diversity throughout the viral genome, including amino acid differences in more than 90% of the viral proteome. The genes encoding glycoprotein G (gG; US4), glycoprotein I (gI; US7), and glycoprotein K (gK; UL53) and viral proteins UL8, UL20, UL24, and US2 contained variants that were found in association with CNS isolates. Many of these viral proteins are known to contribute to cell spread and neurovirulence in mouse models of CNS disease. This report represents the first application of comparative pathogen genomics to neonatal HSV disease.IMPORTANCE Herpes simplex virus (HSV) causes invasive disease in half of infected neonates, resulting in significant mortality and permanent cognitive morbidity. The factors that contribute to invasive disease are not understood. This study revealed diversity among HSV isolates from infected neonates and detected the first associations between viral genetic variations and clinical disease manifestations. We found that viruses isolated from newborns with encephalitis showed enhanced spread in culture. These viruses contained protein-coding variations not found in viruses causing noninvasive disease. Many of these variations were found in proteins known to impact neurovirulence and viral spread between cells. This work advances our understanding of HSV diversity in the neonatal population and how it may impact disease outcome.

Herpesviridae Infection: Prevention, Screening, and Management

Bacterial, viral, and parasitic pathogens add significant morbidity and even mortality to pregnancy-with adverse effects extending to both the gravida and the newborn. Three herpesviruses deserve considerable attention given the effects of perinatal infection on obstetric outcomes, specifically maternal and neonatal morbidity. In the following review, we will provide a description of cytomegalovirus, herpes simplex virus, and varicella zoster virus. For each viral pathogen, we will describe the epidemiology, natural history, screening and diagnosis modalities, treatments, and implications for antepartum care. Furthermore, we will highlight future directions of work in reducing the morbidities associated with these viral pathogens.

Seasonal influence on TORCH infection and analysis of multi-positive samples with indirect immunofluorescence assay

Background

TORCH including the pathogens of Toxoplasma gondii (TOX), rubella virus (RV), cytomegalovirus (CMV), and herpes simplex virus (HSV) causes intrauterine infections and poses a worldwide threat to women especially in pregnancy. In this study, we described the seasonal difference in TORCH infection and analyzed the anti‐TORCH IgM multipositive serum samples by the indirect immunofluorescence assays (IFA).

Methods

To observe the seasonal influence of the anti‐TORCH IgG and IgM antibodies, a retrospective study was conducted with 10 669 women (20–40 y old) before pregnancy from August 2016 to July 2017. Totally 199 ELISA anti‐TORCH IgM multipositive serum samples were further tested by IFAs for false‐positive analysis.

Results

The prevalence of positive HSV1‐IgM, RV‐IgM, HSV2‐IgM, CMV‐IgM, and TOX‐IgM in the present population was 6.30%, 2.55%, 1.94%, 1.24%, and 0.67%, respectively. Additionally, the prevalence of positive RV‐IgM, CMV‐IgM, and HSV1‐IgM was statistically different among four seasons, with the highest positive rates of RV‐IgM (4.12%) in autumn, CMV‐IgM (1.75%) in summer, and HSV1‐IgM (7.53%) in winter. The confirmatory IFAs showed that the positive rates of RUV‐IgM, CMV‐IgM, and HSV2‐IgM were significantly different from those in ELISA screening experiments. Interestingly, only 32.7% (65/199) of the TORCH IgM multipositive results were consistent with those by the IFA, indicating that cross‐reaction caused false positives were common in ELISA IgM antibody screening.

Conclusion

The TORCH infection displayed different prevalence among four seasons in our 12‐month retrospective study. The IgM multipositives by ELISA screening may need further confirmation analysis due to its relatively high cross‐reaction rate.

Vertikale Übertragung des Herpes-simplex-Virus: eine Aktualisierung

Infektionen mit den Herpes-simplex-Viren (HSV)-1 und -2 haben weltweit eine hohe Prävalenz. Eine HSV-Infektion während der Schwangerschaft kann eine neonatale Herpes-Infektion verursachen, die durch eine lebenslange Infektion mit Latenz- und Reaktivierungsperioden gekennzeichnet ist. Ein Säugling kann sich in utero (5 %), peripartal (85 %) oder postnatal (10 %) mit dem HS-Virus infizieren. Herpes neonatorum ist eine seltene aber bedeutsame Infektion, die mit schwerer Morbidität und Mortalität assoziiert sein kann, insbesondere bei Dissemination oder Beteiligung des zentralen Nervensystems. Fortschritte bei Diagnose und Therapie haben zur Verringerung der Mortalität sowie, in geringerem Ausmaß, zu einem verbesserten neurologischen Outcome geführt. Dennoch sind weitere Verbesserungen wünschenswert. Dabei ist es entscheidend, Ärzte in die Lage zu versetzen, diejenigen Säuglinge, die einem erhöhten Risiko einer HSV-Infektion ausgesetzt sind, zu erkennen und die Mutter-Kind-Übertragung effektiver zu verhindern. Ein lohnendes Ziel für die Zukunft ist die Entwicklung neuer antiviraler Wirkstoffe mit höherer Wirksamkeit.

Vertical transmission of herpes simplex virus: an update

Herpes simplex virus (HSV)-1 and -2 infections are highly prevalent worldwide. HSV infection during pregnancy can result in neonatal herpes infection, which is characterized by lifelong infection with periods of latency and reactivation. HSV can be acquired by an infant during one of three periods: in utero (5 %), peripartum (85 %), or postnatal (10 %). Neonatal HSV is a rare but significant infection that may be associated with severe morbidity and mortality, especially if there is dissemination or central nervous system involvement. Diagnostic and therapeutic advances have led to a reduction in mortality and, to a lesser extent, improvement of neurodevelopmental outcomes, but further developments are still needed. It is essential to improve the clinician's ability to identify infants who are at increased risk of HSV infection and to prevent mother-to-child transmission. The development of novel antiviral agents with higher efficacy is a worthwhile aim for the future.

[Genital herpes and pregnancy: Serological and molecular diagnostic tools. Guidelines for clinical practice from the French College of Gynecologists and Obstetricians (CNGOF)]

OBJECTIVES

To describe serological and molecular tools available for genital and neonatal herpes, and their use in different clinical situations.

METHODS

Bibliographic investigations from MedLine database and consultation of international clinical practice guidelines.

RESULTS

Virological confirmation of genital herpes during pregnancy or neonatal herpes must rely on PCR (Professional consensus). HSV type-specific serology (IgG) will allow determining the immune status of a patient (in the absence of clinical lesions). However, there is currently no evidence to justify universal HSV serological testing during pregnancy (Professional consensus). In case of genital lesions in a pregnant woman that do not report any genital herpes before, it is recommended to perform a virological confirmation by PCR and HSV type-specific IgG in order to distinguish a true primary infection, a non-primary infection associated with first genital manifestation, from a recurrence (Grade C). HSV IgM is useless for diagnosis of genital herpes (Grade C). If a pregnant woman has personal history of genital herpes but no lesions, whatever the gestational age, it is not recommended to perform genital sampling nor serology (Professional consensus). In case of recurrence, if the lesion is characteristic of herpes, virological confirmation is not necessary (Professional Agreement). However, if the lesion is not characteristic, virological confirmation by PCR should be performed (Professional consensus). At birth, HSV PCR samples should be collected as soon as neonatal herpes is suspected (symptomatic neonate) (best before beginning antiviral treatment but must not delay the treatment), or after 24hours of life in case of asymptomatic neonate born to a mother with herpes lesions at delivery (Professional consensus). Clinical samples for virological confirmation should include at least blood and a peripheral location. In case of clinical manifestations of herpes in the neonate, first samples PCR positive, preterm birth, or maternal primary infection or non-primary infection associated with first genital manifestation at delivery, CSF should also be collected as well as samples of lesions in the neonate if present (Professional consensus). Sampling should be repeated in case of PCR negative but strong evidence of neonatal herpes (Professional consensus). HSV serology is useless for diagnosis of neonatal herpes (Grade C).

CONCLUSIONS

Virological confirmation for diagnosis of genital herpes during pregnancy or neonatal herpes must rely on PCR. PCR assays available in France are very reliable. Specific IgG are dedicated to restricted indications.

[Neonatal herpes: Epidemiology, clinical manifestations and management. Guidelines for clinical practice from the French College of Gynecologists and Obstetricians (CNGOF)]

OBJECTIVES

To describe the epidemiology of neonatal herpes and its risk factors, clinical and paraclinic manifestations, propose guidelines for a newborn at risk of neonatal herpes, describe treatment modalities, describe post-natal transmission and its prevention.

METHODS

Bibliographic search from Medline, Cochrane Library databases and research of international clinical practice guidelines.

RESULTS

Neonatal herpes is rare (about 20 cases per year in France) and mainly due to HSV 1 (level of evidence LE3). The main risk factors for mother-to-child transmission are maternal primary episode of genital herpes close to delivery and serotype HSV 1 (LE3). There are three clinical forms of neonatal herpes : SEM infection for skin, eyes and mucosa, central nervous system (CNS) associated infection, and the disseminated infection. Neurological mortality and morbidity depend on the clinical form and the HSV serotype (LE3). In most of the case of neonatal herpes, the mothers have no history of genital herpes (LE3). Fever and vesicular rash may be absent at the time of diagnosis (LE3). In case of suspicion of neonatal herpes, different samples (blood and cerebrospinal fluid) for HSV PCR must be carried out to confirm the diagnosis (Professional consensus). Any newborn suspected of neonatal herpes should be treated with intravenous aciclovir (Grade A) prior to the results of HSV PCR (Professional consensus). In case of maternal genital herpes at delivery, the management of an asymptomatic newborn depends on the evaluation of the risk of transmission. In case of maternal reactivation (low risk of transmission), HSV PCR samples are taken at 24hours of life and the newborn must be follow closely until results. In the case of maternal primary episode or non-primary infection first episode (high risk of transmission), the samples are taken at 24hours of life and intravenous treatment with aciclovir is started (Professional consensus). The treatment of neonatal herpes is based on intravenous aciclovir (60mg/kg/day divided into 3 injections) (Grade C). The duration of the treatment depends on the clinical form (14 days for the SEM infection, 21 days for the other forms) (Professional consensus). A relay with aciclovir per os (300mg/m²/day) for 6 months is recommended to improve the neurological outcome and reduce the risk of reactivation (grade B). Post-natal transmission is mainly due to HSV 1. The rules for the prevention of post-natal transmission must be known by parents and family, but also by nursing staff (Professional consensus). Breastfeeding is not contraindicated in cases of maternal herpes, except if there is herpetic lesion on the nipple (Professional consensus). Parents of newborns at risk for neonatal herpes should receive information on the clinical signs to be monitored at home after hospital discharge (Professional consensus).

CONCLUSIONS

Neonatal herpes is a rare disease with a high morbidity and mortality. The management of a newborn at risk requires good coordination between the obstetric and pediatric teams and parent's information.

Neonatal and Perinatal Infections

Lack of success in achieving considerable reductions in neonatal mortality is a contributory factor in failing to achieve Millennium Development Goal 4.2.6 million neonates still die each year, with preterm birth and infections the two leading causes. Maternal infections and environmental and infant factors influence acquisition of viral and bacterial infections in the perinatal and neonatal period. Scaling up evidence-based interventions addressing maternal risk factors and underlying causes could reduce neonatal infections by 84%. The emergence of new infections and increasing antimicrobial resistance present public health challenges that must be addressed to achieve substantial reductions in neonatal mortality.

Neonatal Herpes Simplex Viral Infections and Acyclovir: An Update

Neonatal herpes simplex virus (HSV) infections have high morbidity and mortality rates. Optimization of treatment and prevention strategies are imperative to improve the care and outcomes of neonates infected with HSV. Management of HSV includes reducing neonatal transmission, treating acute infections, and limiting adverse neurodevelopmental outcomes and future cutaneous outbreaks after acute infections. Transmission risk may be affected by route of delivery and maternal suppressive therapy. Neonatal HSV infections are divided into 3 categories: localized skin, eyes, or mouth; localized central nervous system; or disseminated infections. Parenteral acyclovir, the pharmacologic agent of choice, is used when treating each type of infection. However, dosage strategies and durations of therapy may vary based on disease state severity, presentation, and patient characteristics. Oral acyclovir may be used as suppressive therapy after acute treatment completion in specific neonatal populations, reducing long-term adverse neurodevelopmental outcomes and future skin eruptions. The mortality rate remains high even with treatment.

Is Herpes Simplex virus (HSV) a sign of Encephalitis in Iranian Newborns? Prevalence of HSV Infection in Pregnant Women in Iran: A Systematic Review and Meta-Analysis

OBJECTIVE

Herpes Simplex virus (HSV) is one of the most common sexually transmitted diseases in the world. This study aimed to determine the prevalence of herpes simplex virus in pregnant women in Iran.

MATERIALS & METHODS

A systematic literature review was conducted to study the HSV subtypes in Persian and English papers through several databases. We searched Pub Med, Scopus, Ovid, Science Direct and national databases as Magiran, Iranmedex and Science Information Database (SID) up to October 2015. Random-effects model were applied to calculate the pooled prevalence of HSV subtypes.

RESULTS

Five eligible studies were identified, including 1140 participants. The pooled prevalence of HSV infection in pregnant women was 0.64% (95% CI: 0.10- 1.18) in Iran. The pooled prevalence of studies on both HSV-1 and HSV-2 was 0.91% (CI: 0.81-1.02) and studies on only HSV-2 was 0.23% (CI: -0.61-0.63), respectively.

CONCLUSION

The prevalence of HSV infection in pregnant women in Iran was higher. HSV infection of the central nervous system, especially with HSV-2, can also cause recurrent aseptic meningitis and monophasic, as well as radiuculitis or myelitis. The performance of screening to detect infection in pregnant women can play an important role in the prevention and treatment of patients and help to prevent the transmission of HSV infection to infants in Iran.

Congenital and perinatally-acquired infections in resource-constrained settings

INTRODUCTION

Congenital and perinatal infections are a leading cause of neonatal and infant morbidity and mortality. Maternal screening, vaccines or treatment where available, constitute effective prevention strategies to reduce the burden of these diseases. Data on the burden of congenital and perinatal infections are very limited for low and middle-income regions.

AREAS COVERED

This review aims to summarize the burden of congenital and perinatal infections and the main challenges for their control in resource-limited settings. Articles were identified through the main electronic databases and cover the period 1971-2016. Expert commentary: Estimates from low and middle-income countries indicate that the burden of congenital infections may be higher in these regions than in industrialized countries. As preventive and curative strategies are available to tackle some of these infections, efforts at the international and national levels must be made to implement those and thus reduce their burden in resource-limited countries.

Multicenter Evaluation of Meridian Bioscience HSV 1&2 Molecular Assay for Detection of Herpes Simplex Virus 1 and 2 from Clinical Cutaneous and Mucocutaneous Specimens

Herpes simplex virus (HSV) causes acute and relapsing symptoms characterized by ulcerative lesions. Laboratory diagnosis of HSV in cutaneous or mucocutaneous lesions has historically been performed with the use of viral cell culture systems; however, these tests are laborious and suffer decreased sensitivity for advanced-stage lesions. The recent availability of FDA-cleared moderately complex assays has resulted in the increased use of molecular diagnostics for the routine detection of HSV in superficial swab specimens. We performed a clinical evaluation of the recently FDA-cleared illumigene HSV 1&2 loop-mediated isothermal amplification (LAMP) assay (Meridian Bioscience, Cincinnati OH) for the detection and differentiation of HSV-1 and HSV-2 in cutaneous and mucocutaneous swab specimens. A total of 1,153 clinical swab specimens were collected and tested at 7 different clinical centers. Each specimen was tested for the presence of HSV-1 and HSV-2 using the illumigene assay, and results were compared to those of the enzyme-linked virus-inducible system (ELVIS) as the reference method. Overall, the illumigene assay demonstrated a sensitivity and specificity of 94.8% and 95.5%, respectively, for the detection of HSV-1. Detection of HSV-2 was similar, with a sensitivity of 98.9% and a specificity of 95.5%. Discrepant analysis was performed using an alternative molecular test (AmpliVue HSV1+2 assay; Quidel Molecular, San Diego, CA) on 91/99 specimens that were recorded as false positive (FP) or false negative (FN) compared to the reference method. In total, 57/78 (73%) FP and 9/13 (69%) FN illumigene results were supported by the AmpliVue result. The illumigene HSV 1&2 assay demonstrated high sensitivity and specificity to detect and differentiate HSV in clinical specimens and identified 57 additional specimens that were positive for HSV compared to culture. The use of LAMP eliminates the need for the cycling of temperatures and provides results in less than 60 min, with approximately 2 min of hands-on time per specimen.