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Anyone can submit a comment any time after publication, but only those submitted within 4 weeks of an article’s publication will be considered for print publication. Almost two-thirds of women who acquire genital herpes during pregnancy are asymptomatic and have no clinical findings to suggest genital HSV infection, as they have never had an HSV outbreak, nor have their partners had an outbreak. While the presence of red blood cells and xanthochromia on a lumbar puncture may be seen on CSF studies in patients with HSV encephalitis or CNS involvement, 5% to 10% of patients have normal CSF studies. While Cesarean delivery has success­fully reduced the number of neonatal herpes cases, HSV may be transmitted to an infant despite Cesarean delivery.
All patients who are suspected of having ocular herpes should be evaluated by an ophthalmologist. While the Tzanck prep may be a relatively reliable test for cutaneous lesions, it does not definitively rule out neonatal herpes. CT scans are less sensitive than MRI, but they may show changes (such as edema and hemorrhage) in patients with herpes encephalitis.

Elevation of serum aspartate transaminase levels >10 times normal have been associated with increased mortality in neonates with disseminated herpes.
The Emergency Medicine Residents' Association is the voice of emergency medicine physicians-in-training and the future of our specialty.
Richard Baringer, MD, Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT 84132. Thus, involvement of the seventh nerve in its peripheral portion is well recognized as a complication of pyogenic meningitis, syphilis, and Lyme disease. One month after publication, editors review all posted comments and select some for publication in the Letters section of the print version of Annals. Red blood cells in the CSF is not a feature of neonatal infection, even with CNS involvement. Pustular melanosis and erythema toxicum are both benign pustular eruptions that can mimic HSV. Findings may be subtle, and those with expertise in the evaluation of the cornea should be involved when there is any clinical concern for ocular HSV infection. If lesions are not noted, a pelvic examination should be performed to evaluate for the presence of cervical lesions.

However, early in the illness, CT and MRI may be normal, so clinical suspicion should guide management and workup.
Elevation of LFTs has been noted in neonates with disseminated HSV, and LFT levels may serve as a screening tool for disseminated disease in those infants undergoing a sepsis rule-out. EMRA was founded in 1974 and today has a membership of nearly 13,000 residents, medical students, and alumni. In these conditions, the inflammatory process within the subarachnoid space is thought to involve the facial nerve, causing an acute inflammatory reaction and paralysis of the muscles that the facial nerve innervates.
Polymerase chain reaction should be completed on the CSF of all patients suspected of having HSV encephalitis or CNS involvement.
In most cases of herpes with CNS involvement, patients have either an elevated CSF white blood cell count or elevated CSF protein level, which may heighten the emergency clinician’s suspicion for CNS herpes infection.

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