Atypical Presentation of Orbital Herpes Simplex Virus Infection

Steven Dennis, BS; Dustin Paul, DO;
and Jean H. Hsu, DO

University of Texas Health Science Center at Houston

One week prior to admission, a 7-month-old, unimmunized, typically developing girl with no past medical history presented to a community hospital with fever up to 38°C, cough, rhinorrhea, and clear eye drainage. She received a diagnosis of acute otitis media and was sent home with a 10-day course of amoxicillin. Two days later, she developed a facial rash and nonbloody, nonbilious vomiting approximately 3 to 4 times a day, which progressed to nonbloody diarrhea.

The patient had an uncomplicated vaginal birth with regular prenatal care. The mother has a history of genital herpes and during her prior pregnancy had taken antiviral medications for 6 to 7 months. The patient’s sibling has had no evidence of infection. The mother had no grossly apparent herpetic lesions during this pregnancy and had not been on antiviral medications.

The patient had been breastfed. She had had no exposure to people with cold sores or herpes, except for the asymptomatic mother. 

On physical examination, the patient had a facial rash of enlarging vesicles with an erythematous base, a 1 × 2-cm primary lesion approximately 5 mm lateral to the outer canthus of the right eye. Extraocular movements were intact bilaterally. There were no epithelial or dendritic defects noted. Otoscopic evaluation revealed unresolved otitis media with erythematous and mildly bulging tympanic membranes. There were no other lesions on her body.

Results of laboratory tests were unremarkable except for  slight thrombocytosis. 

The gross appearance of the primary lesion was highly suspicious for herpes simplex virus (HSV).

An ophthalmologists was consulted, who concluded that there was no ocular involvement of the herpes infection. The patient was discharged and continued on oral acyclovir.


The time of HSV transmission between mother and neonate has been classified into 3 intervals: intrauterine (5%), peripartum (approximately 85%), and postpartum (10%).1 Peripartum and postpartum acquired infections also can be classified as skin, eyes, and/or mouth only (SEM, approximately 45%); encephalitis with or without SEM (approximately 30%); or disseminated infection involving multiple organs (approximately 25%).1 The American Academy of Pediatrics recommends that the specimen from the lesion be sent for both viral culture and polymerase chain reaction testing.2 

This patient’s infection likely falls into the postpartum category, with only skin findings, sparing the eyes. However, due to the relatively mild manifestation of this infection, it is questionable whether this is a primary or latent infection. While the cutaneous manifestation for this patient was classic, with grouped vesicular lesions on an erythematous base, there are wide-ranging cutaneous and systemic manifestations of HSV.3 Due to this varied presentation and the possibility of encephalitis if not treated, children presenting with symptoms such as fever/hypothermia, poor feeding, or lethargy must raise clinical suspicion for HSV even in the absence of cutaneous findings.3 

In this case, the mother likely either kissed the patient or mechanically transmitted a labial lesion via her hand, thereby inoculating the patient. While the mother was on antiviral therapy during the course of her first pregnancy, she did not receive any medication during the second pregnancy. While the timeline likely points to a postpartum inoculation, a peripartum origin cannot be ruled out. The discussion may be raised on treating asymptomatic mothers in the peripartum period to decrease rates of maternal-fetal transmission even further.


1. Kimberlin DW. Herpes simplex virus infections of the newborn. Semin Perinatol. 2007;31(1):19-25.

2. Cantey JB, Mejias A, Wallihan R, et al. Use of blood polymerase chain reaction testing for diagnosis of herpes simplex virus infection. J Pediatr. 2012;161(12):357-361.

3. Koch LH, Fisher RG, Chen C, Foster MM, Bass WT, Williams JV. Congenital herpes simplex virus infection: two unique cutaneous presentations associated with probable intrauterine transmission. J Am Acad Dermatol. 2009;60(2):312-315.