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Potential Transmission of Herpes Simplex Virus Via Vaginal Seeding

Huynh, Julie, MB BS, FRACP; Palasanthiran, Pamela, MB BS, MD, FRACP; McMullan, Brendan, MB BS, FRACP, FRCPA

The Pediatric Infectious Disease Journal: November 2018 - Volume 37 - Issue 11 - p e278
doi: 10.1097/INF.0000000000001965
Letters to the Editor

Department of Immunology and Infectious Diseases, Sydney Children’s Hospital, Randwick, New South Wales, Australia, Department of Infectious Diseases and Microbiology, Children’s Hospital at Westmead, Westmead, New South Wales, Australia

Department of Immunology and Infectious Diseases, Sydney Children’s Hospital, School of Women's and Children's Health, University of New South Wales, Randwick, New South Wales, Australia

The authors have no funding or conflicts of interest to disclose.

Address for correspondence: Julie Huynh, MB BS, FRACP, Department of Infectious Diseases and Microbiology, Children’s Hospital Westmead, 170 Hawkesbury Rd, Westmead, NSW, Australia. E-mail: Julie.Huynh@health.nsw.gov.au.

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To the Editors:

We report a case of neonatal herpes simplex infection following vaginal seeding after elective cesarean section.

A 2-week-old female infant was referred to a tertiary pediatric hospital with confirmed herpes simplex virus (HSV) infection, initially presenting with vesicles in a symmetrical distribution over both eyelids at 10 days of life. She was delivered by elective cesarean section, with intact amniotic membranes at 38 weeks’ gestation and had received “vaginal seeding” at birth whereby her eyelids, mouth and skin were rubbed with a swab, incubated in her mother’s vagina, before delivery. Her mother reported a history of occasional oral “cold sores” but no history of genital herpes. She reported no oral HSV lesions since the infant’s birth.

Vesicular lesions were clustered over the infant’s eyelids only, with no lesions in other areas. HSV-1 was detected from vesicular fluid by polymerase chain reaction. The infant appeared systemically well with normal complete blood count and liver function tests. Cerebrospinal fluid examination demonstrated 7 white cells/μL (0 polymorphonuclear cells and 7 mononuclear cells) and 1845 red cells, with a negative HSV polymerase chain reaction. An ophthalmologic examination confirmed no corneal lesions. The infant was admitted for management of neonatal HSV disease (skin, eye, mucous membrane type - SEM) and received standard treatment with intravenous aciclovir 20 mg/kg thrice daily for 14 days.

Neonatal HSV is an important infection with high morbidity and mortality. The proportion of genital HSV-1 to HSV-2 infection is increasing,1 and genital HSV may be asymptomatic. Approximately 60%–80% of women who deliver a HSV-infected infant have no evidence of genital HSV infection at the time of delivery nor have a history or a partner reporting a history of genital herpes.2 The neonate in our case acquired HSV infection after vaginal seeding, and her mother was not counseled about HSV. It is fortunate that the HSV infection was limited to SEM type disease in our case; however, neonatal herpes infection should always be considered a serious, sometimes fatal infection, with potential for disseminated or central nervous system disease and associated neurodevelopmental sequelae. While we cannot prove the vaginal seeding led to infection, there are a number of considerations that raise this important possibility. These include the prominent symmetrical localization of vesicles over both eyelids where she was swabbed, and the timing of infection within the first 2 weeks of life (suggesting peripartum acquisition).

Vaginal seeding is a practice that aims to transfer a mother’s vaginal microbiome to newborns delivered by cesarean section.3 This technique involves incubating sterile gauze in the mother’s vagina, removing it before delivery and rubbing it against the skin, eyelids and mouth of the newborn soon after birth. This practice is occurring against a background of increasing rates of cesarean section (up to 30% of live births)4 and increasing research attention on the development of the infant microbiome.5 The long-term health outcomes and harms of vaginal seeding have not yet been reported. It is important that this lack of safety data is emphasized as part of antenatal care for pregnant women considering vaginal seeding.

To our knowledge, this is the first case of neonatal herpes simplex infection, documented following vaginal seeding. We believe that further study on benefits and harms of vaginal seeding should be conducted before introducing this practice outside a carefully monitored research setting.

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ACKNOWLEDGMENTS

The authors thank the family of their patient who provided consent for this publication.

Julie Huynh, MB BS, FRACP

Department of Immunology and Infectious Diseases

Sydney Children’s Hospital

Randwick, New South Wales, Australia

Department of Infectious Diseases and Microbiology

Children’s Hospital at Westmead

Westmead, New South Wales, Australia

Pamela Palasanthiran, MB BS, MD, FRACP

Brendan McMullan, MB BS, FRACP, FRCPA

Department of Immunology and Infectious Diseases

Sydney Children’s Hospital

School of Women's and Children's Health

University of New South Wales

Randwick, New South Wales, Australia

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REFERENCES

1. Haddow LJ, Dave B, Mindel A, et alIncrease in rates of herpes simplex virus type 1 as a cause of anogenital herpes in Western Sydney, Australia, between 1979 and 2003. Sex Transm Infect. 2006;82:255–259.
2. Whitley RJ, Corey L, Arvin A, et alChanging presentation of herpes simplex virus infection in neonates. J Infect Dis. 1988;158:109–116.
3. Cunnington AJ, Sim K, Deierl A, et al“Vaginal seeding” of infants born by caesarean section. BMJ. 2016;352:i227.
4. Centers for Disease Control and Prevention. National vital statistics system—birth data. 2016. Available at: http://www.cdc.gov/nchs/births.htm. Accessed October 22, 2016.
5. Dominguez-Bello MG, De Jesus-Laboy KM, Shen N, et alPartial restoration of the microbiota of cesarean-born infants via vaginal microbial transfer. Nat Med. 2016;22:250–253.
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