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A 12-day-old male neonate was admitted to the hospital for evaluation and treatment of a rash. We believe in a holistic clinical approach, which involves first listening to patients concerns, then thoroughly diagnosing and explaining their individual treatment options. Herpes zoster (or simply zoster), commonly known as shingles and sometimes referred to as zona, is a viral disease characterized by a painful skin rash with blisters in a limited area on one side of the body, often in a stripe. Varicella zoster virus can become latent in the nerve cell bodies and less often in non-neuronal satellite cells of dorsal root, cranial nerve or autonomic ganglion, without causing any symptoms. The history of this rash began two days earlier when the mother noted the appearance of three crusted spots on the baby’s chest.
The initial infection with varicella zoster virus (VZV) causes the acute (short-lived) illness chickenpox which generally occurs in children and young people.
Years or decades after a chickenpox infection, the virus may possibly break out of nerve cell bodies and travel down nerve axons to cause viral infection of the skin in the region of the nerve. Antiviral drug treatment can reduce the severity and duration of herpes zoster if a seven- to ten-day course of these drugs is started within 72 hours of the appearance of the characteristic rash.
The virus may possibly spread from one or more ganglia along nerves of an affected segment and infect the corresponding dermatome (an area of skin supplied by one spinal nerve) causing a painful rash.

Although the rash usually heals within two to four weeks, some sufferers experience residual nerve pain for months or years, a condition called postherpetic neuralgia.
Exactly how the virus remains latent in the body, and subsequently re-activates is not understood. Examination upon arrival revealed normal vital signs and a normal-appearing, 12-day-old male with the rash described above, as well as a generalized maculopapular rash involving the face and trunk with much confluence similar to a morbilliform pattern, as shown in figures 1–4. Brien, DO Pediatric Infectious Disease, Scott and White's Children's Health Center and Associate Professor of Pediatrics, Texas A&M University, College of Medicine, Temple, Texas. Polymerase chain reaction (PCR) for herpes simplex virus (HSV) on the spinal fluid was negative, but positive on skin lesions (HSV type 2). Up to half of these patients will develop significant neutropenia, which may require stopping or at least reducing the dose of acyclovir to perhaps twice a day. Although this infection can occur anywhere on the body, the face is a common site for this problem to occur in neonates, which start out with a primary infection much like that seen in figures 5 & 6.
However, older children can also have troublesome recurrences of cutaneous HSV after a primary as shown in figure 7. After the visit shown in figure 9, she was placed on acyclovir prophylaxis for six months with good results and no recurrences over the last several years.

The choice of valacyclovir, which is often used in adults for recurrent HSV infections, is not FDA-approved for children. It is a prodrug of acyclovir that is converted into acyclovir after absorption, but simply has not been adequately studied in children. Finally, the generalized maculopapular rash noted in the patient presented probably represented a viral exanthem due to the HSV, as it resolved with the primary episode, and I cannot think of any other reason the baby would have had the rash. HSV is not listed as one of the common causes of a morbilliform rash, but certainly other herpes viruses are associated with this type of eruption. Richard Whitley, the director of the division of pediatric infectious diseases at the University of Alabama School of Medicine in Birmingham, the NIAID Collaborative Antiviral Study Group has contributed the vast majority of the information used to advance the treatment and prophylaxis of neonatal HSV infections being used today, and is responsible for immeasurable benefits to those babies infected with this potentially lethal virus.

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