A Newborn baby born to mother with herpes zoster (Page 1/1)

Prepared by... Virat Sirisanthana, M.D.

Department of Pediatrics, Chiang Mai University

History:
	The patient was born  to a 22-year-old mother, G3P0020. The mother received antenatal care at a community hospital. An ultrasonography was done 7 weeks prior to delivery with an indication of smaller uterine size compared to actual date. The gestational age at that time by ultrasounds was 26 weeks which she was further followed up accordingly. Laboratory investigations revealed non reactive VDRL and negative anti-HIV antibody.
	Two weeks before delivery, groups of burning, painful vesicles developed at the mother's right flank. She went to a private clinic and was given a diagnosis of Herpes Zoster infection. She was treated by two unknown topical medications, probably topical anesthetics and antifungal agent. The vesicles ruptured and healed without suppuration within that week.
	The mother was admitted one day before delivery with a complaint of amniotic fluid leakage. The physical examinations revealed normal vital signs, per vagina examination showed no gross leakage and negative fern test. There was enlargement of Bartholin glands with yellow exudate from the opening. The pus contained many PMN but no organism. Mild to moderate meconium stained amniotic fluid was found after artificial rupture of membrane. The fetal heart rate was normal.

Physical Examination:
	Normal labour , Apgar score 8,9 BW 2690 gm OFC 32 cm Lt 47 cm Laryngoscope: no meconium stain at vocal cord, ET suction: no content, NG tube suction: meconium stained fluid 2 cc V/S: T 37C PR 120/min RR 32/min A male newborn, active, no dyspnea Estimated GA 36 weeks by Dubowitz, AGA Heart, lungs: normal Abdomen: soft, no organomegaly Skin: normal appearance, no lesions

Problem list:
	1. Preterm 36 weeks, AGA 2. Maternal herpes zoster infection 3. Maternal Bartholin glands abscess 4. Mild meconium stained AF

Questions concerning maternal hisstory of herpes zoster infection:
	1. What can be expected to happen to the newborn after delivery? 2. What treatments does this newborn need? 3. Does the newborn need to be  isolated?
Clinical manifestation of varicella-zoster infections: if it is,
	primary infection ===> Chickenpox reactivation of latent virus ===> herpes zoster (Shingles)

Maternal VZV infection can cause three major manifestations:
	1.  Congenital defects secondary to  intrauterine VZV infection 2.  Neonatal chickenpox 3.  Zoster (shingles) in infants
Congenital Defect Syndrome
	Occurs if mother  is infeced with Varicella in first half of gestation Maternal Chickenpox at 0-12 week: 0.4% risk in newborn Maternal Chickenpox at 13-20 week: 2.0%   risk in newborn Abnormalities: cutaneous scars, ocular abnormalities, prematurity, LBW, hypoplastic of limb, cortical atrophy, mental retardation

Neonatal chickenpox
	Disease begins in the neonate within the first 10 days of life If an infant's mother develops varicella from 5 days before to 2 days after delivery, the infection is usually disseminated and fulminant , approximately 1/3 die, diffusepneumonia, severe hepatitis and meningoencephalitis are the most common clinical manifestations, skin vesicles DDx from neonatal HSV infection Milder form resembles the disease in older children

Indication for VZIG
>	Immunocompromised children without history of chickenpox
>	Susceptible, pregnant women
>	Newborn infant whose mother had onset of chickenpox within the 5 days before delivery or within 2 days after delivery
>	Hospitalized premature infant (>28 wk GA) whose mother has no history of chickenpox or seronegativity
>	Hospitalized premature infant (<28 wk GA), regardless of maternal history
Isolation: airbone and contact precaution
1.	Patient with varicella: minimum of 5 days after the onset of the rash and as long as the rash remains vesicular
2.	Exposed, susceptible to varicella: 8-21 days after the onset of rash in index patient (28 days if received VZIG)
3.	Immunocompromised patient with zoster (localized or disseminated)
4.	Normal patient with disseminated zoster ( localized, normal pt needs only standard precaution)

Summery of Management

Maternal	Time	Risk	Treatment	Isolation
- Varicella	1) 0-20 wk GA	Congential syndrome	Acyclovir, if life threatening to mother	No
	2) 13-36 wk GA	Zoster in infancy	same as #1	No
	3) 5 days before to 2 days after delivery	Severe neonatal chickenpox	VZIG to newborn, Acyclivir is symptomatic	Yes
	4) around delivery except #3	mild neonatal chickenpox	closed observation	No
- Zoster	0-36 wk GA	none	none	No

The critical period of the newborn is

Questions concerning maternal history of herpes zoster infection in the above case:
1.				What can be expected to happen to the newborn after delivery?
2.				What treatments does this newborn need?
3.				Dose the newborn need to be isolated?
Since the mother developed herpes zoster 16 days before the delivery, the Answer are:
1.				Healthy newborn
2.				No treatment needed
3.				No isolation needed

References
1.				American Academy of Pediatrics. Varicella-Zoster infections. In : Peter G, ed. 1997 Redbook : Report of the commitee on Infectious Diseases. 24 th ed.. Elk Grove Village, IL : Amer Acad of Ped;1997 : 573-585.
2.				Endres G , Miller E, Cradock-Watson J, Booley I, Ridehalgh M. Consequences of Varicella and Herpes Zoster in Pregnancy: Prospective study of 1739 cases. Lancet , 343(8912):1548-51.
3.				Overall,JC Jr. Viral infections of the fetus and neonate. In: Textbook of Pediatric Infectious Diseases , 3rd ed. WB Saunders Company, Philadelphia;1992:924-959.

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