Baylor University Medical Center Proceedings October 2017 - 464

Figure 3. Neonatal MRI confirming ultrasound finding of hydrocephalus.

Figure 2. (a) Left and (b) right lateral ventriculomegaly at 33 weeks of gestation.

to increase. In an eﬀort to prevent HSV transmission during
delivery, patients have been widely counseled to consider a cesarean section instead of vaginal delivery. Prevention of intrauterine
transmission of HSV to the fetus is not well understood. Alternatively, it is known that a primary HSV outbreak during pregnancy
increases the transmission rate to the neonate and that a primary
outbreak is linked to increased risk of perinatal morbidity (2). In
this case, the standard of care regarding HSV in pregnancy was
followed: the patient was given a course of acyclovir at the time
of her primary HSV outbreak with plans to start suppression at
36 weeks (3). Sadly, in this case, the fetus developed multiple
terminal complications from the in utero herpes infection, which
included the discovery of fetal ventriculomegaly.
Complications related to HSV in pregnancy are both rare
and serious. Rates of neonatal HSV from maternal-fetal transmission are approximately 31:100,000 births-a rate that
includes the risk of herpetic meningitis contracted by infants
exposed to HSV during vaginal delivery (4). Intrauterine or
transplacental transmission of HSV to the fetus is even rarer,
and what is known largely comes to us through case reports.
Known complications of intrauterine HSV infection include
seizures, lethargy, irritability, tremors, poor feeding, temperature
instability, bulging fontanelle, chorioretinitis, microcephaly,
microphthalmia, and hydranencephaly (5-7). Hydranencephaly
is deﬁned as the "absence of cerebral hemispheres, which have
been replaced by ﬂuid-ﬁlled sacs" (8). In this case, the infant was
found to have hydrocephalus, "a condition marked by an exces464

sive accumulation of cerebrospinal ﬂuid resulting in dilation
of the cerebral ventricles and raised intracranial pressure" (8).
This case demonstrates that ventriculomegaly (hydrocephalus) is an additional ﬁnding of intrauterine transmission
of HSV to the fetus. We speculate that the ﬁndings detailed
in this case report may be explained, at least in part, by viral
replication in brain tissue that mediated neural cell death and
destruction, which led to late-presenting ventriculomegaly as a
space-occupying eﬀect. This is not an uncommon ﬁnding with
other viral infections. However, ventriculomegaly had not been
previously described in primary HSV infection. Based on our
experience, we would recommend repeat cerebral imaging in the
third trimester for patients with a known primary HSV infection.
1.

4.
5.
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