We studied the risk of herpes simplex virus (HSV) infections in neonates exposed to HSV at the time of vaginal delivery to mothers with a history of recurrent genital HSV infections. None of 34 infants exposed to HSV type 2 acquired an HSV infection. On the basis of this sample, the 95 percent confidence limit for the theoretical maximum infection rate is 8 percent. Cord blood or blood obtained during the first two weeks of life was available from 33 of the 34 exposed, uninfected neonates. All 33 of the samples possessed demonstrable neutralizing antibody to HSV type 2, and 79 percent had titers above 1:20. These results were compared with those in a previously studied group of neonates with HSV infections; the latter infants were significantly less likely at the onset of symptoms to have demonstrable neutralizing antibody to HSV type 2 (P = 0.000148) or to have titers above 1:20 (P less than 0.00001). We conclude that given the low attack rate, empirical antiviral therapy is not warranted in all infants of mothers with recurrent genital HSV infection who are exposed to the virus in the birth canal. Our findings suggest that the presence and titer of neutralizing antibody to HSV contribute to the low attack rate.

The role of antiviral antibodies in protection against neonatal herpes simplex virus (HSV) infection remains controversial. The relationship between neonatal and maternal anti-HSV antibodies and disease presentation was analyzed in 47 babies. Of the neonates, 77% had localized and 23% had disseminated HSV infection. Antibody-dependent cellular cytotoxic (ADCC) antibodies were evaluated in comparison with HSV neutralizing antibodies. High maternal (greater than 1:10(4)) or neonatal (greater than 1:10(3)) anti-HSV ADCC antibody levels or high neonatal antiviral neutralizing levels (greater than 1:20) were independently associated with an absence of disseminated HSV infection. Cochran-Mantel-Haenszel analysis demonstrated that ADCC levels were associated with disease status (P less than .02) while controlling for the level of neutralizing antibody.

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Review of 31 computed tomographic (CT) scans in 15 neonates with herpes simplex encephalitis (HSE) type 2 revealed the most characteristic early findings to be patchy and widespread areas of low attenuation, primarily in white matter, with minimal contrast material enhancement in a meningeal pattern. The low-attenuation lesions increased rapidly in size and prominence during the course of the disease. This was usually accompanied by increased attenuation of cortical gray matter that persisted for weeks to months. Atrophic changes appeared rapidly, being evident in the 3d week. Late findings consisted of very extensive, diffuse, low attenuation of white matter with cortical atrophy. Calcification assumed a variety of distributions, from punctate to an extensive gyral pattern. The cerebellum was involved in nine patients. Early CT findings were not good predictors of outcome, but later serial CT scans showing progression or stability of findings were more accurate in prognosis. CT serves primarily to confirm the diagnosis of neonatal HSE.