Indian Pediatrics 1999; 36:710-711 

Herpes Simplex Meningoencephalitis and HIV Infection in a Newborn

Mothers of HIV infected infants tend to have other sexually transulted disease (STDs). Therefore, they can transmit more than one agent to their newborn. We report a newborn with concomitant HSV meningoencephalitis and HIV infection.

Case Report

A 39-day-old male baby weighing 4.2 Kg was admitted with high grade fever and recur- rent convulsions. The baby was drowsy and his breathing was shallow, irregular and jerky. The baby was resuscitated with bag-mask ventilation and given supportive treatment and phenobarbitone was administered. Respiration became regular and spontaneous. A provisional diagnosis of bacterial meningitis was made and cefotaxime was started.

Clinical examination did not reveal any abnormality except palpable spleen. The baby was born vaginally at term with birth weight of 2.5 kg. History of clinical examination did not suggest genital or muco-cutaneous Herpes simplex infection in the mother. Over the next 4 days there were repeated convulsions despite administration of phenytoin, clonazepam and sodium valproate.

Blood counts were normal and peripheral smear did not show malarial parasite. Cerebrospinal fluid examination revealed 50 cells. (90% polymorphs and 10% lymphocytes), proteins of 9.93 g/I and sugar 1.22 mmol/I. No organisms were seen or grown. CSF examination for HSV - immune titers was positive for HSV -1 IgM antibodies by ELISA method. CT scan showed widespread symmetrical hypodense lesions in the supraventricular white matter with minimal grey matter involvement. There were areas of focal cystic encephalomalacia is the temporal and occipital lobe. Meningeal enhancement was seen in right temporal and left fronto-temporo-parietal regions. Based on the CSF and CT findings, diagnosis of HSV meningo-encephalitis was made. Fever and convulsions were completely controlled only after 5 days of acyclovir administration. Both the parents tested positive for HIV by ELISA method. The baby tested positive for HIV -I gag amplification by polymerase chain reaction at 13 weeks and again at 19 weeks. CD 4 positive lymphocytes were 43% with an absolute count of 3808 celIs/dI. CD/COx ratio was 0.97. At 22 months of age, child was found to be grossly handicapped neurodevelopmentalIy. EEG showed evidence of atrophy (RL).

Discussion

Any infant suspected to have meningo-encephalitis in whom laboratory investigations rule out bacterical infection and there is no response to anti-bacterial therapy, should be screened for Herpes simplex infection(1). Persistent convulsions with no evidence of bacterial meningitis or response to antibiotics made us suspect Herpes simplex meningo-encephalitis. CT scan, CSF serology and prompt response to Acyclovir supported the diagnosis. HSV -I accounts for one-third of neonatal HSV infections. while HSV -2 is responsible for the rest(2). HSV -I accounts for one-third of neonatal HSV infections, while HSV-2 is responsible for the rest(2). Our patient had HSV -I infection. Three general patterns of infection, each of which occurs in approximately one third of cases were described(2). These are disseminated infections with or without CNS involvement, infection locallized to the CNS and infection localized to the skin, eye or mouth. The first clinical signs and symptoms of HSV develop in 67% of patients within the first week of life, in 16% during the second week of life and in 14% during the third week of Iife(3). Thus, our patient had localized CNS infection with late presentation.

Acyclovir is the drug of choice for treatment of HSV infection at a dose of 30 mg/kg/ day, given intravenously, in divided doses, every eight hours for 10-14 days. Encouraged by earlier experience(4), we used oral acyclovir, to which the patient promptly responded. HIV screening was performed to see if, as in adults, HSV was associated with immunodeficiency disorders. PCR was per- formed to differentiate between transplacental transfer of antibodies from seropositive mother and a true HIV infection by detecting proviral DNA. This method has been shown to be highly sensitive (99.4%) in infants vertically infected with HIV when sample is taken after 15 days of age and specific (100%)(5). The present case suggests the importance of HIV screening in newborns in presence of congenitally transmitted sexually transmitted diseases like syphilis and Herpes simplex. The co-infection in our case seems to be co- incidental and not necessarily due to immunosuppresion.

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