Topic: Clinical Case Report
Kopstick, Avi1; Burns, Erin1; Lewis, Paul2; Milczuk, Henry3
1Division of Pediatric Critical care, Oregon Health Science University - Doernbech Children's Hospital, Portland, Oregon, United States; 2Division of Pediatric Infectious Disease, Oregon Health Science University - Doernbech Children's Hospital, Portland, Oregon, United States; 3Division of Pediatric Otolaryngology, Oregon Health Science University - Doernbech Children's Hospital, Portland, Oregon, United States
Introduction: Stridor in the newborn period suggests an anatomical deformity, such as tracheo-laryngomalacia or airway hemangiomas.1 By contrast, older children with laryngotracheitis (known as “croup”) have viral infections, such as human parainfluenza virus, influenza virus, or, atypically, herpesviridae (HSV).2,3 We report a neonate with stridor and respiratory distress from a supraglottic HSV-type 2 (HSV2) infection.
Case Description: A 6-day-old, ex-full term female, admitted for phototherapy treatment of jaundice, unexpectedly developed stridor, hypoxia, and respiratory distress. Her prenatal course had been complicated by maternal houselessness, tobacco use, trichomonas infection (status-post treatment), and hepatitis C; other routine maternal prenatal testing was negative. Vaginal delivery was complicated by a prolonged rupture of membranes. Prior to admission, her mother did report some “squeakiness”; her respiratory exam had been normal. When administration of nebulized racemic epinephrine and 4 L/min of oxygen via high flow nasal canula failed to improve symptoms, she was transferred to the pediatric intensive care unit (PICU) for further management.
In the PICU, the baby received 0.5 mg/kg of intravenous (IV) dexamethasone and noninvasive positive pressure ventilation (NIV), leading to resolution of her symptoms. After flexible fiberoptic laryngoscopy demonstrated swelling, erythema, and crème-colored plaques on the epiglottis and bilateral arytenoids, empiric therapy of IV acyclovir at meningitic dosing was initiated. Tissue samples collected later via microlaryngoscopy and bronchoscopy (see figures 1 and 2) revealed “ulcerations/viral cytopathology consistent with HSV,” and were positive for HSV2 via PCR testing. Blood PCR testing for HSV was negative and cerebral spinal fluid (CSF) PCR testing was deferred due to patient instability – however, when done on day 18 of acyclovir treatment, it was negative.
The patient was treated IV acyclovir for 21 days, 13 of which were in the PICU on NIV. She was discharged home with 6 months of oral acyclovir suppression therapy. 3 weeks after its completion, however, she developed lethargy, vomiting, and a bulging fontanelle, and was diagnosed with HSV2 meningoencephalitis by CSF PCR tesing. She received another 21 days of IV acyclovir, without apparent sequelae, and was discharged home on continued oral valacyclovir prophylaxis. She is currently being evaluated for TLR3-deficiency.
Discussion: 5 cases of neonatal HSV croup have been reported.4-7 Each baby was born vaginally at term, with no history of maternal HSV. Each case presented with stridor but no fever between day of life 6 to 24. Bronchoscopy revealed lesions similar to those illustrated here, including supraglottic erythema and edema, with white plaques on the false cords, arytenoids, epiglottis, and pharynx. All were positive for HSV2. 4 babies required intubation. Treatment duration with IV acyclovir ranged from 10-45 days, however two of the babies required foscarnet therapy due to persistent viral shedding and one received two months of oral valacylovir. One infant required readmission for HSV2 encephalitis – treated with 3 weeks of IV acyclovir – while the other 4 cases had uncomplicated post-neonatal courses.
Conclusion: In addition to anatomical malformations, the presentation of stridor in the neonatal period should raise concern for viral croup, including HSV. Such babies can be supported on NIV while they receive antiviral therapy.
Image Image
- Cohen LF. Stridor and upper airway obstruction in children. Pediatr Rev. 2000;21(1):4-5.
- Malhotra A, Krilov LR. Viral croup. Pediatr Rev. 2001;22(1):5-12.
- Buchan KA, Marten KW, Kennedy DH. Aetiology and epidemiology of viral croup in Glasgow,1966-72. J Hyg (Lond). 1974;73(1):143-50.
- Nadel S, Offit PA, Hodinka RL, Gesser RM, Bell LM. Upper airway obstruction in association with perinatally acquired herpes simplex virus infection. J Pediatr. 1992;120(1):127-9.
- Vitale VJ, Saiman L, Haddad J. Herpes laryngitis and tracheitis causing respiratory distress in a neonate. Arch Otolaryngol Head Neck Surg. 1993;119(2):239-40.
- Nyquist AC, Rotbart HA, Cotton M, et al. Acyclovir-resistant neonatal herpes simplex virus infection of the larynx. J Pediatr. 1994;124(6):967-71.
- Machin NW, Morgan D, Turner AJ, Lipshen G, Arkwright PD. Neonatal herpes simplex 2 infection presenting with supraglottitis. Arch Dis Child. 2013;98(8):611-2.
Topic: Clinical Case Report
Kopstick, Avi1; Burns, Erin1; Lewis, Paul2; Milczuk, Henry3
1Division of Pediatric Critical care, Oregon Health Science University - Doernbech Children's Hospital, Portland, Oregon, United States; 2Division of Pediatric Infectious Disease, Oregon Health Science University - Doernbech Children's Hospital, Portland, Oregon, United States; 3Division of Pediatric Otolaryngology, Oregon Health Science University - Doernbech Children's Hospital, Portland, Oregon, United States
Introduction: Stridor in the newborn period suggests an anatomical deformity, such as tracheo-laryngomalacia or airway hemangiomas.1 By contrast, older children with laryngotracheitis (known as “croup”) have viral infections, such as human parainfluenza virus, influenza virus, or, atypically, herpesviridae (HSV).2,3 We report a neonate with stridor and respiratory distress from a supraglottic HSV-type 2 (HSV2) infection.
Case Description: A 6-day-old, ex-full term female, admitted for phototherapy treatment of jaundice, unexpectedly developed stridor, hypoxia, and respiratory distress. Her prenatal course had been complicated by maternal houselessness, tobacco use, trichomonas infection (status-post treatment), and hepatitis C; other routine maternal prenatal testing was negative. Vaginal delivery was complicated by a prolonged rupture of membranes. Prior to admission, her mother did report some “squeakiness”; her respiratory exam had been normal. When administration of nebulized racemic epinephrine and 4 L/min of oxygen via high flow nasal canula failed to improve symptoms, she was transferred to the pediatric intensive care unit (PICU) for further management.
In the PICU, the baby received 0.5 mg/kg of intravenous (IV) dexamethasone and noninvasive positive pressure ventilation (NIV), leading to resolution of her symptoms. After flexible fiberoptic laryngoscopy demonstrated swelling, erythema, and crème-colored plaques on the epiglottis and bilateral arytenoids, empiric therapy of IV acyclovir at meningitic dosing was initiated. Tissue samples collected later via microlaryngoscopy and bronchoscopy (see figures 1 and 2) revealed “ulcerations/viral cytopathology consistent with HSV,” and were positive for HSV2 via PCR testing. Blood PCR testing for HSV was negative and cerebral spinal fluid (CSF) PCR testing was deferred due to patient instability – however, when done on day 18 of acyclovir treatment, it was negative.
The patient was treated IV acyclovir for 21 days, 13 of which were in the PICU on NIV. She was discharged home with 6 months of oral acyclovir suppression therapy. 3 weeks after its completion, however, she developed lethargy, vomiting, and a bulging fontanelle, and was diagnosed with HSV2 meningoencephalitis by CSF PCR tesing. She received another 21 days of IV acyclovir, without apparent sequelae, and was discharged home on continued oral valacyclovir prophylaxis. She is currently being evaluated for TLR3-deficiency.
Discussion: 5 cases of neonatal HSV croup have been reported.4-7 Each baby was born vaginally at term, with no history of maternal HSV. Each case presented with stridor but no fever between day of life 6 to 24. Bronchoscopy revealed lesions similar to those illustrated here, including supraglottic erythema and edema, with white plaques on the false cords, arytenoids, epiglottis, and pharynx. All were positive for HSV2. 4 babies required intubation. Treatment duration with IV acyclovir ranged from 10-45 days, however two of the babies required foscarnet therapy due to persistent viral shedding and one received two months of oral valacylovir. One infant required readmission for HSV2 encephalitis – treated with 3 weeks of IV acyclovir – while the other 4 cases had uncomplicated post-neonatal courses.
Conclusion: In addition to anatomical malformations, the presentation of stridor in the neonatal period should raise concern for viral croup, including HSV. Such babies can be supported on NIV while they receive antiviral therapy.
Image Image
- Cohen LF. Stridor and upper airway obstruction in children. Pediatr Rev. 2000;21(1):4-5.
- Malhotra A, Krilov LR. Viral croup. Pediatr Rev. 2001;22(1):5-12.
- Buchan KA, Marten KW, Kennedy DH. Aetiology and epidemiology of viral croup in Glasgow,1966-72. J Hyg (Lond). 1974;73(1):143-50.
- Nadel S, Offit PA, Hodinka RL, Gesser RM, Bell LM. Upper airway obstruction in association with perinatally acquired herpes simplex virus infection. J Pediatr. 1992;120(1):127-9.
- Vitale VJ, Saiman L, Haddad J. Herpes laryngitis and tracheitis causing respiratory distress in a neonate. Arch Otolaryngol Head Neck Surg. 1993;119(2):239-40.
- Nyquist AC, Rotbart HA, Cotton M, et al. Acyclovir-resistant neonatal herpes simplex virus infection of the larynx. J Pediatr. 1994;124(6):967-71.
- Machin NW, Morgan D, Turner AJ, Lipshen G, Arkwright PD. Neonatal herpes simplex 2 infection presenting with supraglottitis. Arch Dis Child. 2013;98(8):611-2.
Topic: Clinical Case Report
Kopstick, Avi1; Burns, Erin1; Lewis, Paul2; Milczuk, Henry3
1Division of Pediatric Critical care, Oregon Health Science University - Doernbech Children's Hospital, Portland, Oregon, United States; 2Division of Pediatric Infectious Disease, Oregon Health Science University - Doernbech Children's Hospital, Portland, Oregon, United States; 3Division of Pediatric Otolaryngology, Oregon Health Science University - Doernbech Children's Hospital, Portland, Oregon, United States
Introduction: Stridor in the newborn period suggests an anatomical deformity, such as tracheo-laryngomalacia or airway hemangiomas.1 By contrast, older children with laryngotracheitis (known as “croup”) have viral infections, such as human parainfluenza virus, influenza virus, or, atypically, herpesviridae (HSV).2,3 We report a neonate with stridor and respiratory distress from a supraglottic HSV-type 2 (HSV2) infection.
Case Description: A 6-day-old, ex-full term female, admitted for phototherapy treatment of jaundice, unexpectedly developed stridor, hypoxia, and respiratory distress. Her prenatal course had been complicated by maternal houselessness, tobacco use, trichomonas infection (status-post treatment), and hepatitis C; other routine maternal prenatal testing was negative. Vaginal delivery was complicated by a prolonged rupture of membranes. Prior to admission, her mother did report some “squeakiness”; her respiratory exam had been normal. When administration of nebulized racemic epinephrine and 4 L/min of oxygen via high flow nasal canula failed to improve symptoms, she was transferred to the pediatric intensive care unit (PICU) for further management.
In the PICU, the baby received 0.5 mg/kg of intravenous (IV) dexamethasone and noninvasive positive pressure ventilation (NIV), leading to resolution of her symptoms. After flexible fiberoptic laryngoscopy demonstrated swelling, erythema, and crème-colored plaques on the epiglottis and bilateral arytenoids, empiric therapy of IV acyclovir at meningitic dosing was initiated. Tissue samples collected later via microlaryngoscopy and bronchoscopy (see figures 1 and 2) revealed “ulcerations/viral cytopathology consistent with HSV,” and were positive for HSV2 via PCR testing. Blood PCR testing for HSV was negative and cerebral spinal fluid (CSF) PCR testing was deferred due to patient instability – however, when done on day 18 of acyclovir treatment, it was negative.
The patient was treated IV acyclovir for 21 days, 13 of which were in the PICU on NIV. She was discharged home with 6 months of oral acyclovir suppression therapy. 3 weeks after its completion, however, she developed lethargy, vomiting, and a bulging fontanelle, and was diagnosed with HSV2 meningoencephalitis by CSF PCR tesing. She received another 21 days of IV acyclovir, without apparent sequelae, and was discharged home on continued oral valacyclovir prophylaxis. She is currently being evaluated for TLR3-deficiency.
Discussion: 5 cases of neonatal HSV croup have been reported.4-7 Each baby was born vaginally at term, with no history of maternal HSV. Each case presented with stridor but no fever between day of life 6 to 24. Bronchoscopy revealed lesions similar to those illustrated here, including supraglottic erythema and edema, with white plaques on the false cords, arytenoids, epiglottis, and pharynx. All were positive for HSV2. 4 babies required intubation. Treatment duration with IV acyclovir ranged from 10-45 days, however two of the babies required foscarnet therapy due to persistent viral shedding and one received two months of oral valacylovir. One infant required readmission for HSV2 encephalitis – treated with 3 weeks of IV acyclovir – while the other 4 cases had uncomplicated post-neonatal courses.
Conclusion: In addition to anatomical malformations, the presentation of stridor in the neonatal period should raise concern for viral croup, including HSV. Such babies can be supported on NIV while they receive antiviral therapy.
Image Image
- Cohen LF. Stridor and upper airway obstruction in children. Pediatr Rev. 2000;21(1):4-5.
- Malhotra A, Krilov LR. Viral croup. Pediatr Rev. 2001;22(1):5-12.
- Buchan KA, Marten KW, Kennedy DH. Aetiology and epidemiology of viral croup in Glasgow,1966-72. J Hyg (Lond). 1974;73(1):143-50.
- Nadel S, Offit PA, Hodinka RL, Gesser RM, Bell LM. Upper airway obstruction in association with perinatally acquired herpes simplex virus infection. J Pediatr. 1992;120(1):127-9.
- Vitale VJ, Saiman L, Haddad J. Herpes laryngitis and tracheitis causing respiratory distress in a neonate. Arch Otolaryngol Head Neck Surg. 1993;119(2):239-40.
- Nyquist AC, Rotbart HA, Cotton M, et al. Acyclovir-resistant neonatal herpes simplex virus infection of the larynx. J Pediatr. 1994;124(6):967-71.
- Machin NW, Morgan D, Turner AJ, Lipshen G, Arkwright PD. Neonatal herpes simplex 2 infection presenting with supraglottitis. Arch Dis Child. 2013;98(8):611-2.
Topic: Clinical Case Report
Kopstick, Avi1; Burns, Erin1; Lewis, Paul2; Milczuk, Henry3
1Division of Pediatric Critical care, Oregon Health Science University - Doernbech Children's Hospital, Portland, Oregon, United States; 2Division of Pediatric Infectious Disease, Oregon Health Science University - Doernbech Children's Hospital, Portland, Oregon, United States; 3Division of Pediatric Otolaryngology, Oregon Health Science University - Doernbech Children's Hospital, Portland, Oregon, United States
Introduction: Stridor in the newborn period suggests an anatomical deformity, such as tracheo-laryngomalacia or airway hemangiomas.1 By contrast, older children with laryngotracheitis (known as “croup”) have viral infections, such as human parainfluenza virus, influenza virus, or, atypically, herpesviridae (HSV).2,3 We report a neonate with stridor and respiratory distress from a supraglottic HSV-type 2 (HSV2) infection.
Case Description: A 6-day-old, ex-full term female, admitted for phototherapy treatment of jaundice, unexpectedly developed stridor, hypoxia, and respiratory distress. Her prenatal course had been complicated by maternal houselessness, tobacco use, trichomonas infection (status-post treatment), and hepatitis C; other routine maternal prenatal testing was negative. Vaginal delivery was complicated by a prolonged rupture of membranes. Prior to admission, her mother did report some “squeakiness”; her respiratory exam had been normal. When administration of nebulized racemic epinephrine and 4 L/min of oxygen via high flow nasal canula failed to improve symptoms, she was transferred to the pediatric intensive care unit (PICU) for further management.
In the PICU, the baby received 0.5 mg/kg of intravenous (IV) dexamethasone and noninvasive positive pressure ventilation (NIV), leading to resolution of her symptoms. After flexible fiberoptic laryngoscopy demonstrated swelling, erythema, and crème-colored plaques on the epiglottis and bilateral arytenoids, empiric therapy of IV acyclovir at meningitic dosing was initiated. Tissue samples collected later via microlaryngoscopy and bronchoscopy (see figures 1 and 2) revealed “ulcerations/viral cytopathology consistent with HSV,” and were positive for HSV2 via PCR testing. Blood PCR testing for HSV was negative and cerebral spinal fluid (CSF) PCR testing was deferred due to patient instability – however, when done on day 18 of acyclovir treatment, it was negative.
The patient was treated IV acyclovir for 21 days, 13 of which were in the PICU on NIV. She was discharged home with 6 months of oral acyclovir suppression therapy. 3 weeks after its completion, however, she developed lethargy, vomiting, and a bulging fontanelle, and was diagnosed with HSV2 meningoencephalitis by CSF PCR tesing. She received another 21 days of IV acyclovir, without apparent sequelae, and was discharged home on continued oral valacyclovir prophylaxis. She is currently being evaluated for TLR3-deficiency.
Discussion: 5 cases of neonatal HSV croup have been reported.4-7 Each baby was born vaginally at term, with no history of maternal HSV. Each case presented with stridor but no fever between day of life 6 to 24. Bronchoscopy revealed lesions similar to those illustrated here, including supraglottic erythema and edema, with white plaques on the false cords, arytenoids, epiglottis, and pharynx. All were positive for HSV2. 4 babies required intubation. Treatment duration with IV acyclovir ranged from 10-45 days, however two of the babies required foscarnet therapy due to persistent viral shedding and one received two months of oral valacylovir. One infant required readmission for HSV2 encephalitis – treated with 3 weeks of IV acyclovir – while the other 4 cases had uncomplicated post-neonatal courses.
Conclusion: In addition to anatomical malformations, the presentation of stridor in the neonatal period should raise concern for viral croup, including HSV. Such babies can be supported on NIV while they receive antiviral therapy.
Image Image
- Cohen LF. Stridor and upper airway obstruction in children. Pediatr Rev. 2000;21(1):4-5.
- Malhotra A, Krilov LR. Viral croup. Pediatr Rev. 2001;22(1):5-12.
- Buchan KA, Marten KW, Kennedy DH. Aetiology and epidemiology of viral croup in Glasgow,1966-72. J Hyg (Lond). 1974;73(1):143-50.
- Nadel S, Offit PA, Hodinka RL, Gesser RM, Bell LM. Upper airway obstruction in association with perinatally acquired herpes simplex virus infection. J Pediatr. 1992;120(1):127-9.
- Vitale VJ, Saiman L, Haddad J. Herpes laryngitis and tracheitis causing respiratory distress in a neonate. Arch Otolaryngol Head Neck Surg. 1993;119(2):239-40.
- Nyquist AC, Rotbart HA, Cotton M, et al. Acyclovir-resistant neonatal herpes simplex virus infection of the larynx. J Pediatr. 1994;124(6):967-71.
- Machin NW, Morgan D, Turner AJ, Lipshen G, Arkwright PD. Neonatal herpes simplex 2 infection presenting with supraglottitis. Arch Dis Child. 2013;98(8):611-2.
