Fulminant Hepatic failure due to Neonatal Herpes Simplex Virus Type 1: Unusual presentation of newborn sepsis

Neonatal Herpes infection is divided into three categories: SEM, CNS disease and Disseminated Disease. Infection is usually through intrapartum transmission and carries a high mortality and morbidity rate. We report the case of a 12-day-old female patient born at 39 WGA via SVD with no complications. Patient was discharged from nursery ward after 48 hours of observation. Maternal prenatal laboratories reported as negative, including GBS. Father does mention history of "cold sores". Mother denies any previous history of genital herpetic lesions, but states having a painful rash at genital area at 2nd to 3rd trimester. Bacterial Vaginosis was diagnosed and treated at 35 WGA. Patient was taken to Emergency Department at tenth day of life with chief complaint of fever (39C rectally). Upon evaluation, patient was found acutely ill and febrile. Sepsis evaluation was done, including LP for CSF analysis. At ER, patient received ampicillin and gentamycin. CSF analysis showed pleocytosis. No organisms reported on gram stain. Small vesicles were noted on left side of scalp for which infectious disease specialist advised on acyclovir therapy and HSV PCR (Blood and CSF). Liver enzymes were found elevated, suggestive for hepatic failure. On day of life 12, patient presented with hypothermia and active bleeding from venipuncture sites. At PICU, patient intubated after presenting with worsening agonic breathing. An O negative unit as emergency base started. Active bleeding noted at endotraqueal tube suggestive of pulmonary hemorrhage. Cardiologist performed bedside ECHO showing; a PFO, empty RV, severe dyskinesia of the apex, akinetic LVPW and paradoxical septal movement of the interventricular septum most likely due to blood loss. Patient died despite CPR cardiac massage and inotropic support (i.e., dopamine and epinephrine drip). CSF PCR analysis was reported positive for HSV type I infection. High clinical suspicion is necessary to avoid lethal and fatal complication of this preventable and treatable condition. Pregnant women with active genital lesions should undergo serologic and/or virological testing for HSV infection. The vulnerable patient (i.e., maternal or neonatal identification of virus, skin lesion) should be started on IV acyclovir to avoid disseminating disease. It is important to consider and rule out HSV infection in a neonatal septic patient with increasing liver enzymes and cutaneous findings, since early administration of antiviral therapy can be life