Intrauterine latent herpes simplex virus infection

Intrauterine latent herpes simplex virus infection

Intrauterine Latent Herpes Simplex Virus Infection: II. Latent N e o n a t a l Infection .)AMES A. ROBB, MD,* KURT BENIRSCHKE,MD.t FRANK MANNINO, MD, ...

3MB Sizes 23 Downloads 406 Views

Recommend Documents

No documents
Intrauterine Latent Herpes Simplex Virus Infection: II. Latent N e o n a t a l Infection .)AMES A. ROBB, MD,* KURT BENIRSCHKE,MD.t FRANK MANNINO, MD, t AND JOSEPH VOLAND, MD t Herpes simplex virus (HSV, probably type 2) antigen has been detected in endometria and abortion tissue (companion paper) and in placentae, umbilical cords, and fetal and neonatal organs by avidin-biotin complex immunohistochemical studies. HSV cytologic a b n o r m a l i t i e s were not detected in any of the 12 normal and 64 abnormal cases analyzed, nor was HSV detected by culture or electron microscopy in selected cases. Antigen was present in single epithelial and, rarely, mesenchymal cells of

various organs. Clinically unexplained fetal or neonatal problems associated with HSV antigen positivity included intrauterine death, fetal growth retardation, cystic brain degeneration, hydrops, interstitial pneumonitis, necrotizing enterocolitis, hepatitis, encephalitis, myocarditis, and renal failure. Maternal floor infarct of placenta and calcifying funisitis are the manifestations of intrauterine HSV infection in most cases. Maternal history of HSV infection was uncommon. It is concluded that intrauterine HSV infection may persist in the fetus and neonate in a latent fashion without cytologic abnormalities or detectable virus. This latent infection may be associated with intrauterine and neonatal death, organ damage, and neonatal disease. HUM PATHOL 17:1210--1217, 1986. H e r p e s simplex virus (HSV), types 1 and 2, are the cause o f u n c o m m o n , b u t severe n e o n a t a l disease. 1 Most cases are t h o u g h t to be the result o f ascending infection d u r i n g labor a n d / o r delivery, l Rarely, i n t r a u t e r i n e HSV infection has been docum e n t e d , 2-7 but little direct p r o o f o f the possibility o f transplacental infection with HSV exists. 1,7 T h i s lack o f d o c u m e n t a t i o n m a y be d u e to the difficulty o f c o n f i r m i n g chronic o r latent intrauterine HSV infections by r o u t i n e culture a n d / o r pathologic examination. T h e index case f o r this study o f fetuses a n d neonates a n d the c o m p a n i o n study o f abortion and endometrial curettage material s was a case o f neonatal i n t r a u t e r i n e HSV infection d o c u m e n t e d by culture and transmission electron microscopy o f the skin and brain lesions. T h e placenta and cord, however, had no viral cytologic changes o r i n f l a m m a t o r y abnormalities. HSV-specific antigens were detected in the placenta and c o r d by a v i d i n - b i o t i n - g l u c o s e oxidase Received from the *Department of Pathology, Green Hospital of Scripps Clinic, La Jolla, California, and the tDepartments of Pathology and Pediatrics, University of California San Diego Medical Center. Accepted for publication April 22, 1986. Presented in part in poster format at the 1983 International Academy of Pathology annual meeting (Lab Invest 48:15P, 1983). Supported in part by institutional overhead for facilities. Address correspondence and reprint requests to Dr. Robb: Department of Pathology, Green Hospital of Scripps Clinic, La Jolla, CA 92037. 0046-8177/86 $0.00 + .25

i m m u n o h i s t o c h e m i s t r y . P r o o f o f the HSV specificity o f the t e c h n i q u e and the description o f a latent endometrial epithelial HSV infection are p r e s e n t e d in the c o m p a n i o n paper. 8 T h e present p a p e r is devoted to the fetal and n e o n a t a l complications associated with this f o r m o f HSV i n t r a u t e r i n e transplacental infection.

METHODS T h e placentae, umbilical cords, a n d neonatal or infant tissues f r o m 12 n o r m a l and 47 a b n o r m a l cases were fixed in e i t h e r 10 per cent b u f f e r e d formalin or Bouin's solution at the University o f California San Diego Medical Center; 17 additional a b n o r m a l cases were r e f e r r e d f r o m o t h e r physicians. T h e techniques for serial slide p r e p a r a t i o n and i m m u n o h i s t o c h e m ical staining, a n d the specificity o f the Dako rabbit a n t i - H S V 1 a n d 2 I g G are d e s c r i b e d in the companion paper, s T h e screening antibodies (polyclonal rabbit IgG) used in this study were Dako anti-HSV, types 1 and 2 (Dako, Santa Barbara, California; lots 059A and 1188, respectively) and n o n i m m u n e rabbit IgG (Cappell Labs, West Chester, Pennsylvania).

RESULTS As d e s c r i b e d in t h e c o m p a n i o n p a p e r , 8 t h e HSV-specific antigen, when present, is located in the p l a c e n t a in i n d i v i d u a l ceils o f t h e s u b a m n i o n i c chorion a n d / o r in individual H o f b a u e r cells in chorionic villi. In the umbilical cord, the antigen is located in individual cells o f the subamnionic m e s e n c h y m e a n d / o r perivascular m e s e n c h y m e . T h e staining was cytoplasmic, except f o r o n e case in which scattered amnionic nuclei were positive with tile rabbit antiHSV 2 IgG. T h e s e staining patterns are illustrated in tile c o m p a n i o n paper, s HSV cytologic abnormalities were not detected in any o f the tissues analyzed. All s.yncytiotrophoblastie tissue was negative f o r HSV anttgen. T h e results for 64 a b n o r m a l cases a n d 12 n o r m a l cases are s u m m a r i z e d in table 1. Eight o f the 12 (75 p e r cent) n o r m a l , p l a c e n t a e and cords f r o m n o r m a l f u l l - t e r m n e o n a t e s w e r e positive, b u t o n l y in the sttbamnionic chorion, not in the chorionic villi o r amnion. HSV cytologic changes were not observed in any o f the tissue. T h e lack o f positivity in tile chorionic villi s u p p o r t s the c o n c e p t that the infection was

1210

INTRAUTERINEHSV INFECTION:LATENTNEONATALINFECTION[i~obb et ol.} T/~BtE 1. Correlation Between Fetal or Neonatal Problem and Herpes Simplex Virus [HSV) Positivity No. o f Cases

Normal placenta and neonate Abnormat cases (67*) Intrat/terine death Small for gestational age Calcifying funisitis Maternal floor infarct Cystic brain Interstitial pneumonia Maternal HSV infection During pregnancy Before pregnancy Hydrops Congenital HSV syndrome Alagile syndrome Intraventricular bleed Myocarditis with CHF Clinical CMV placentitis Encephalitis Hepatitis Chronic leukopenia Listeria placentitis Necrotizing enterocolitis Premature rupture of membranes Renal failure Seizures Villitis, chronic

ttSV§

tlSV-

8/12

4/12

9/15 10/1 1 8/9 5/8 5/6 3/5

6/15 !/1 1 1/9 3/8 116 2/5

3/5 313 314 2/2

1/15 2/1 1 2/9 -P 3/5 -C 1/6

2/5 1/4 1/1 1/I

I/1 113

Placenta No Cord or Placenta

Cord

SAC+

VII +

SAM+

8/8

0/8

6/8

8/9 6/10 5/7 4/5 2/5 3/3

6/9 5/10 3/7 5/5 1/5 1/3

4/9 7/10 719 2/2 3t5 3/3

1/3 3/3 3/3 !/2

0/3 2/3 113 1/2

2/3 2/3 2/3 1/2

113

0/3

0/3

2/2

1/2

.2/2

Ill

1/1

1/1

2/2

2/2

1/2

1/I 1/1

2/3

1/1 2/2

1/1

Organs Positive

KT 3, SB 2, PA 1, OO 1, EMET 1 C C I , SB I, BR 1, BD 1 Concentric cordal debris !/9 B 0/1 positive BR 1/1

KT I, SB I, PA 1, BR 1, anmionic nuclens ! BR 1 Liver negative CC, SB, BR, BD Organs negative in 212 with positive CMV cuhures B, BR, BD, PA, S

1/1 1/1 2/2 2/3 1/1 1ll 1/3

2/2 1/3 1/1 1tl

Microabscesses negative SB 2 with positive macrophages KT B, S, PA, BD, BR

2/3

1/3

013

0/3

ABBREVIATIONS: B, brain neuroglia; BD, bile duct epithelium; BR, bronchial epithelium; CC, cardiac conduction system; EMET, endometrial epithelium; KT, kidney tubular epithelium; OO, ovarian oocytes; PA, pancreatic acinar cells; S, stonmch epithelial cells; SAC, subamnionic chorion; SAM, subamnionic mesenchyme of cord; SB, small bowel epithelimn; VH, Hofbauer cells of chorionic villus. * Some cases are listed more than once as muhiple problems were present.

limited to the amnionic sac and membranes and did not involve the fetus. T h e 64 abnormal cases were associated with a wide variety of placental abnormalities and/or neonatal problems. Sixty-one of these abnormal cases were analyzed because neither the etiology nor the pathogenesis of the problems was understood. Three cases of CMV placentitis and one case of listerial placentitis were analyzed as non-HSV placentitis controls. HSV cytologic changes were not observed in any tissue in the 64 abnormal cases. A strong association between several of these neonatal problems and HSV antigen positivity in the placenta and/or cord was detected: intrauterine death (nine of 15, 60 per cent positive); small for gestational age (10 of I 1, 91 per cent positive); funisitis with concentric inflammatory debris with calcification (eight of nine, 89 per cent positive); maternal floor infarct o f placenta (five o f eight, 62 per cent positive); cystic brain (five o f six, 83 per cent positive); interstitial pneumonia (three of five, 60 per cent positive); hydrops (three of four, 75 per-cent positive); and maternal genital HSV infection both before (three o f three, 100 per cent positive) and during (three of five, 60 per cent positive) pregnancy. The following miscellaneous problems were associated with antigen positivity in the placenta and/or cord, but the number of cases is small and more than

one problem may have been present in a case: hepatiffs (two o f two positive); p r e m a t u r e r u p t u r e o f membranes (two of three positive); and chronic nonspecific villitis (one of three positive). A latent form of HSV infection was discovered in neonatal organs in some o f the cases with positive placental and/or cordal tissue that are listed above. Cytologic HSV abnormalities were not observed in any positive tissue. Tile organ data are listed according to their association with placental abnormalities or clinical problems in table I. T h e same data are listed according to the placental and/or cord antigen posmvlty m table 2. Organs and/or placentae were not available for analysis in all cases. Positive organ tissue was not observed in the absence o f placental and/or cord positivity. T h e HSV antigen was found primarily in epithelial cells o f adrenal cortex, bile duct, kidney tubule, lung bronchus, pancreatic acinus, and small and large bowel. Neuroglia, hepatocytes, and ovarian oocytes were positive on occasion. Heart cells were positive in only one case, a case of "coxsackie-like" myocarditis with congestive heart failure in which the cells of the cardiac conduction system were focally positive. Cultures for enterovirus in tiffs case were all negative, and no cultures for HSV had been taken. Illustrations o f these forms o f latent infection are shown in figures 1 to 5. Occasional antigen-positive

1211

HUMAN PATHOLOGY

TABLE 2.

Volume 1L No. 12 (December 1986)

Herpes Simplex Virus [HSV] Antigen Positivily in Fetal a n d Neonatal Organ Tissues

Organ (No. Positive/Total No. Analyzed) HSV Antigen in Placenta/Cord

AD

BD

10 cases* 1/4 1/5 No placenta/cord available 9 cases 1/1 112

BR

liT

KT

LV

LU

PA

SB

SP

ST

Miscellaneous

3/7

0/4

3/7

0/3

I/5

2/5

2/6

0/1

2/3

1/i OO positive, 1/1 LN/ES negative

012

l/2t

212

112

1/3

NC

2/2~

0/1

NC

SB macrophages positive

ABBREVIATIONS:AD, adrenal cortex; BD, bile duct epithelium; BR, brain neuroglia; ES, esophagus; HT, heart; KT, kidney tubular epithelium; LN, lymph node; LV, liver hepatocytes; LU, hmg bronchial epithelium; NC, no cases; PA, pancreatic acinus; SB, small and large bowel epithelium; SP, spleen, ST, stomach epithelium. 9 * In 8 of the 10 placenta/cord-positive cases at least one organ was positive. In both cases in which organs were Hsv antigen-negative, macerated late first-trimester embryos were spontaneously aborted. One case had ttSV-positive endometrial epithelium and negative chorionic villi, while the other case had HSV-positive chorionic villi and fimisitis with concentric inflammatory debris with calcification. t Focal positivity in cells of the cardiac conduction system. :1:op rh cases with necrotizing enterocolitis with negative viral and bacterial cultures.

e m b r y o n i c o r g a n tissues (less than 16 weeks o f gestation) were present in the abortion material analyzed in the c o m p a n i o n paper, s Figure 6 shows the latent infection o f hepatocytes and small bowel epithelium observed in some o f these abortion specimens. T h r e e cases o f congenital CMV infection were analyzed. In two o f these cases both o r g a n and plac e n t a / c o r d tissues w e r e n e g a t i v e , while in the remaining case focal positivity was observed only in the subamnionic chorion, as in the n o r m a l placentae that were positive. T h e cells with cytologic c h a n g e s o f CMV infection were HSV-negative, as illustrated in the c o m p a n i o n p a p e r , s In o n e case o f listeria placentitis both the placenta a n d the cord were positive, but the listerial microabcesses were negative. T h e s e dual infections are not surprising, considering that the patient p o p u l a t i o n f r o m which the cases were derived is at high risk for n u m e r o u s infections (low socioeconomic class). T h e following miscellaneous cases were n e g a t i v e : AlagiIe s y n d r o m e ( o n e case, o n l y liver biopsy specimen analyzed); intraventricular h e m o r r h a g e in a p r e m a t u r e infant (one case); chronic leukopenia (one case); a n d chronic villitis (two o f t h r e e cases negative). DISCUSSION I n t r a u t e r i n e HSV infection is a rare event that has b e e n d o c u m e n t e d in fetal and neonatal tissues by

detection of HSV-specific cytologic alterations, growth o f the infecting virus in cell culture, a n d / o r detection o f the virus by transmission electron mic r o s c o p y . 1,7 M o r e r e c e n t l y , i m m u n o h i s t o c h e m i c a l studies have also b e e n used. 5,6 Congenital anomalies have b e e n associated with such infections. 2,3 T h e virus is t h o u g h t to a s c e n d f r o m the genital r e g i o n into the u t e r u s via the cervical os. Unequivocal evid e n c e for the o c c u r r e n c e o f transplacental infection has yet to be r e p o r t e d , x a h h o u g h the following rep o r t e d case is quite suggestive: Disseminated HSV 2 n e o n a t a l i n f e c t i o n was u n e x p e c t e d l y d i s c o v e r e d d u r i n g a c e s a r e a n section p e r f o r m e d at 36 weeks, prior to r u p t u r e o f m e m b r a n e s , in a w o m a n without a history o f orogenital HSV lesions or o f active lesions d u r i n g the p r e g n a n c y . 4 T r a n s p l a c e n t a l infection might also o c c u r d u r i n g the viremia o f a p r i m a r y H S V infection, by transneural migration o f the virus f r o m persistently infected dorsal r o o t ganglia to the e n d o m e t r i u m and placenta, o r by direct placental infection f r o m a latently infected e n d o m e t r i u m that is activated d u r i n g pregnancy. Our companion paper, s which reports the findings o f a s t u d y o f 180 e n d o m e t r i a l c u r e t t a g e specimens f r o m n o n p r e g n a n t w o m e n and 200 specimens f r o m s p o n t a n e o u s a n d therapeutic abortions, d e m o n s t r a t e d the existence o f a latent e n d o m e t r i a l H S V infection, p r o b a b l y type 2, in 40 p e r cent o f n o r m a l late secretory e n d o m e t r i a a n d 40 to 48 per

FIGURE 1 [top left). Serial sections of hepatic triad showing the absence of herpes simplex virus [HSV] type 1 staining (left) and HSV 2 positivity [right] in the apical cytoplasm of bile duct epithelial cells and luminal secretion. The artery (upper right] and hepatic parenchyma (arrow] are both negative. Necrosis, inflammatory reaction, and viral cytologic abnormalities are not present. (Original magnification, x 125.) FIGURE 2 (top right]. Top,negative [HSV1] serial section of lung. Middle, serial section of lung showing HSV 2 antigen staining in the apical cytoplasm of epithelial cells in both mucous glands [upper left} and bronchi [lower right). Boftor~ higher magnification showing HSV 2 antigen located uniquely in the basal plate region of scattered bronchothelial cells. Necrosis, inflammatory reaction, and viral cytologic abnormalities are not present. (Original magnification: top and middle, x 125; bottorr~ x 400.) FIGURE 3 [bottom left}. Le~ negative [HSV 1] serial section of kidney. Right, serial section of kidney showing HSV 2 antigen in the apical cytoplasm of the collecting tubule epithelial cells in the medullary rays. Glomeruli, interstitial cells, and both proximal and distal collecting duct epithelia are negative. Necrosis, inflammatory reaction, and viral cytologic abnormalities are not present. [Original magnification, x 400.] FIGURE 4 (boflom right}. Left, negative (HSV 1] serial section of small bowel. Right, serial section of small bowel showing HSV 2 antigen in autolyzed mucosal epithelial cel~s. Inflammatory reaction and viral cytologic abnormalities are not present. [Original magnification, x '125.}

1212

INTRAUTERINE HSV INFECTION: LATENT NEONATAL INFECTION ( R o b b e t

aL]

' ~!.:.~ 9:.. - ~:'~,.'.r.-~.-':~:.< " .~ . '.: - { .. 9 "7", ~, , ~'i'.- ' . . ', <;i~'"

i,, :~,'~

, . . ; , ..

..

I

7

31

,

.

,?.

L=,<

......

9 -

"..

. ; 1 <. , " , ~

.~.

~'
t~(;,*~ '~ :,'-'D.

9

.

1t

;h~l

~,:,', -,>:# t + d /

9 ~-.~*# " ' - / " , " " t , ~

S,,> <'. 3 ' ;

~

" :'-A; ('~;'L'.':~" i" ~ ' .

t ,,i,,,,

9 !':~-i~K',%'i

"-+.* ~ * U 7 :,

~'[~-LTM
,/

7.7+*-. ,.1

.-.- ,.,. ,,;.;.~:7 ~ ., '.~,~-~ . 9

1213

~,

.

:~-

,.

HUMAN PATHOLOGY

Volume 17, No. 12 (December 1986)

"'

-,

1~>. "~r' . ~ ,

,," ""5".:.~z~_~,~

,'~

.~::.'~.:~,,"

r~,~

i r ~ ' . e : ~ ,"

~. % "..,; ~"3 ,~

~! ~"-'";'"~:~ 9

FIGURE 5 (left). Left, negative (HSV 1) serial section of heart. Right, serial section of heart showing moderate HSV 2 antigen positivity in the subendocardial conduction fibers of the left ventricular septum. Necrosis, inflammatory reaction, and viral cytologic abnormalities are not present. (Original magnification, x 125.) FIGURE 6 (right]. Embryonic liver [top] and small bowel [bottoml in therapeutic abortion tissue obtained at 10 weeks of gestation from a woman with no clinical history of orogenital HSV infection. Left, absence of staining with HSV 1. Right, HSV 2 positivity in hepatocytes [top) and scattered epithelial cells of the small bowel [bottom]. (Original magnification, x 100.)

cent of first-trimester pregnancies. No cytologic evidence of HSV was detected in the positive tissues. This high percentage of infected endometria is not entirely unexpected, because activation of genital HSV infection and asymptomatic shedding of infectious virus are increased d u r i n g pregnancy. 9 Furthermore, persistent CMV infection has been detected in h u m a n tissues that appear normal histologically.X0,11 The data presented in this paper demonstrate that intrauterine HSV infection, defined as the presence o f HSV antigen in chorionic cells, is quite common: 75 per cent of the 12 normal control placentae were positive. In these normal cases, however, HSV antigen was not found in the Hofbauer cells of chorionic villi, an indication that fetal infection had not occurred. Maternal anti-HSV antibody may have helped to restrict the HSV infection to the amnionic cavity and membranes. 12 T h e most common site for HSV antigen, and the site with the greatest number of positive cells, was the basal chorionic decidual junction, although cytologic HSV alterations were never observed. Recently, by immunohistochemical methods, two cases of acute HSV endometrial infec-

tion at the time of delivery5 and one case of placental infection,6 including positive Hofbauer cells in chorionic villi,, were observed. In the first two cases HSV antigen was detected with acute infection anti-HSV antibody at the choriodecidual junction, but not in the chorion, chorionic villi, or cord. HSV 2 antigen was detected by us (J.A.R.) only in the subamnionic chorion (no cord available) and acutely infected organs (HSV 2 staining much greater than HSV 1 staining) in one case and in the subamnionic chorion, cord, and H o f b a u e r cells o f chorionic villi in the other case (Dr. Bendon, unpublished data). In the 64 cases in which placental abnormalities and/or neonatal problems were present, however, a strong association was found between the detection of HSV antigen and these abnormalities, especially when HSV antigen was detected in the Hofbauer cells of chorionic villi. T h e presence of HSV antigen in the chorionic villi is unequivocal evidence that the fetus or neonate has been infected by the virus. No acute HSV infection, as defined by the presence of HSV cytologic changes, was detected in any of the placental, cordal, or organ tissues analyzed. T h e detected antigen represents debris from acute infection

1214

INTRAUTERINE HSV INFECTION: LATENTNEONATAL INFECTION [Robb et al.]

earlier in the pregnancy that was subsequently taken up in the phagocytic cells of the chorion and villi. In one case unequivocally positive amnionic nuclear positivity was observed with the rabbit anti-HSV 2 IgG. This finding indicates a latent HSV infection in the amnion, rather than residual antigenic debris, as seen in.the cytoplasm of chorionic and villous cells. This evidence for latent amnionic infection supports our hypot,hesis that the infection spreads from the e n d o m e t r i a l epithelium into the anmiochorionic tisstie and then to the embryo or fetus, if the infection is not inhibited in the amnionic fluid or tissue, possibly by maternal antibody. 12 Two forms of uncommon placental and cord abnormalities were strongly associated with HSV antigen positivity. Maternal floor infarct of the placenta 13-- 15 and funisitis with concentricinflammator) debris with calcification 16,17 were associated with HSV antigen positivity in five of eight and eight of nine cases, respectively. Intrauterine HSV infection has probably occurred when either of these two relatively rare conditions is encountered. No other placental abnormalities were strongly associated with HSV antigen positivity. Only one of three cases of c h r o n i c nonspecific villitis was antigen-positive. Mixed placental infections can occur, as evidenced by the presence of HSV antigen in one case of CMV infection and one case of listerial placentitis. Mixed infections with HSV, CMV, Chlamydia, and o t h e r pathogens are probably found throughout all socioeconomic groups. Clinically unexplained neonatal problems associated with HSV antigen positivity included the following: infant small for the gestational age (10 of 11, 91 per cent positive); cystic brain (five of six, 83 per cent positive); hydrops (three of four, 75 per cent positive); intrauterine death (nine of 15, 60 per cent positive); interstitial pneumonia (three of five, 60 per cent positive); hepatitis (two of two, 100 per cent positive); encephalitis (one of one, 100 per cent positive); renal failure (one of one, 100 per cent positive); and premature rupture of membranes (two of three, 67 per cent positive). T h e HSV antigen detected in neonatal organs was found predominantly in epithelial cells, including neuroglia and hepatocytes. T h e antigen was present in the apical portion o f bile duct, bronchial, and kidney tubular cells, while its location was more cytoplasmic in the adrenal cortex, bowel, and pancreatic acini, and stomach. O f the two cases of "pathogen-negative" necrotizing enterocolitis in which perforation and small bowel resection had occurred, HSV antigen was detected in the small bowel epithelium in both and in the epithelium of a rectal biopsy specimen in one. Positivity in nonepithelial cells, i.e., cardiac conduction system cells, was found in only one case, a case of enterovirus culture-negative "coxsackie-like" myocarditis and heart failure. Maternal HSV infection during pregnancy or at the time of delivery by cesarean section was associated with HSV antigen in the chorion and cord in three of five cases, but antigen was not found in the

chorionic villi. T h e neonate in one negative case was normal, while the infant in the other negative case had interstitial pneumonia and survived. T h e mother in the first positive case had primary genital HSV 2 infection at 13 weeks o f gestation and delivered a full-term infant with a cystic brain and positive skin vesicles. T h e mother in the second positive case had recurrent HSV 2 infection at 10 weeks and delivered a stillborn infant at 42 weeks. T h e m o t h e r in the third positive case had recurrent HSV 2 infection at 20 weeks and delivered an infant, small for tile gestational age, who had necrotizing enterocolitis and myocarditis at nine days and died at 14 days; no enteroviruses or other pathogens were detected. Cultures for HSV had not been taken. In all three cases in which maternal histories of genital HSV infection before pregnancy, had been elicited, the chorion, chorionic villi, and cord were HSV antigen-positive; the results in these three cases were interstitial pneumonia during the first two months with sudden infant death syndrome at 7.5 months; premature rupture of membranes at 29 weeks, with the neonate small for the gestational age; and intrauterine death in the second trimester. Any clinical history of genital HSV infection suggests that asymptomatic shedding of infectious virus during pregnancy is quite Iikely.~ T h e following facts strongly suggest that each activation of the latent endometrial HSV infection is a unique event that does not affect future activation events or depend on previous activation events: 1) Two patients had HSV antigen-positive spontaneous abortions with their first pregnancies and normal full-term neonates with their second pregnancies, although the placentae from the second pregnancies were both positive for HSV antigens in the chorion and cord, but negative in the chorionic villi. 2) Recurrent spontaneous abortions were not found to be statistically associated with HSV antigen positivity in our companion paper, s although some women did have recurrent spontaneous abortions with HSV antigen positivity in each case. 3) Recurrent neonatal HSV infection has not been d o c u m e n t e d in successive pregnancies of the same mother. Is 4) No difference in the number of congenital or neonatal problems in children of mothers with or without HSV antigenpositive spontaneous or therapeutic abortion speclinens was detected by questionnaire, as described in the companion paper, s T h e mechanism of the initial infection of the endometrial epithelium o f the mother by HSV is not known. Several routes o f infection are possible: viremia from a primary infection; ascending infection from the cervicogenital region; transneural migration from the dorsal root ganglia; and intrauterine infection of the mother as an embryo or fetus. Although ascending infection appears to be the most likely possibility, only 4 per cent of the 83 women with HSV antigen-positive abortion material had clinical histories of genital HSV infection. This percentage was statistically similar to that for the women with HSV antigen-negative abortion specimens (107

1215

HUMAN PATHOLOGY

Volume 17, No. 12 (December '1986]

women, 5.6 p e r cent positive). T h e i n t r a u t e r i n e infection o f the m o t h e r as an e m b r y o or fetus is an appealing hypothesis but would be difficult to verify experimentally. O f interest is the one neonatal case in which ovarian tissue was available for analysis. T h e oocytes were HSV antigen-positive, raising the possibility.of germline transmission. No testicular tissue was available for analysis. T h e p r e s e n c e o f latent H S V infection in num e r o u s organs raises the possibility o f acute, chronic, oi- r e l a p s i n g d i s e a s e in t h e s e o r g a n s d u r i n g t h e person's lifetime. Activation o f an acute a n d , possibly, r e c u r r i n g infection in the bowel, stomach, pancreas, liver, kidney, o r lungs could possibly p r o d u c e ulceration and i n f l a m m a t i o n in these organs. An abn o r m a l r e a c t i o n o f the p e r s o n ' s i m m u n e system c o u l d p r o v i d e a f r a m e w o r k f o r the p r o d u c t i o n o f chronic o r relapsing diseases, such as gastric o r duodenal ulcers, C r o h n ' s disease, chronic ulcerative colitis, sclerosing cholangitis, interstitial p n e u m o n i t i s and nephritis, hepatitis, and pancreatitis. Focal acute HSV infections in these organs would be so transient (e.g., days) as to be u n d e t e c t a b l e by such c o n v e n tional means as viral cytopathology, culture, o r transmission electron microscopy. T h e s e infections, however, could possibly be d e t e c t e d by i m m u n o h i s t o chemistry, as in o u r investigations. Such studies are in progress. Final p r o o f o f this h y p o t h e s i s will require identification o f the HSV DNA g e n o m e in the H S V a n t i g e n - p o s i t i v e cells. E i t h e r H S V - s p e c i f i c D N A / R N A isolation o r in situ h y b r i d i z a t i o n techniques would be suitable, b u t the localization capability o f the isolation t e c h n i q u e and the sensitivity o f the hybridization t e c h n i q u e must be significantly imp r o v e d to d e t e c t a few H S V g e n o m e s p e r cell (D. M y e r s o n , u n p u b l i s h e d data), ill~176 S o m e a n i m a l models are being d e v e l o p e d for study o f the late sequelae o f acute HSV infection. 2t-23 In conclusion, i n t r a u t e r i n e HSV infection can be d o c u m e n t e d by i m m u n o h i s t o c h e m i s t r y in the absence o f positive viral cultures, viral cytologic abnormalities, o r transmission electron microscopic studies. O u r data s u p p o r t the c o n c e p t that an i n t r a u t e r i n e HSV infection in the e m b r y o or fetus can p r o d u c e latent neonatal infection. This newly d e f i n e d type o f infection may be associated with i n t r a u t e r i n e death, fetal growth retardation, cystic brain d e g e n e r a t i o n , hydrops, p r o l o n g e d interstitial pneumonitis, necrotizing enterocolitis, hepatitis, encephalitis, myocarditis, renal failure, and, possibly, subtle o r subclinical brain dysfunction. "Maternal f l o o r infarct o f the plac e n t a " o r funisitis with c o n c e n t r i c i n f l a m m a t o r y debris with calcification is usually the result o f intrau t e r i n e HSV infection o f this type. F u t u r e studies should include the following investigations to c o n f i r m a n d e x t e n d o u r findings: determination o f m a t e r n a l H S V antibody status; culture o f placental and fetal tissues for HSV; extraction o f D N A f r o m p l a c e n t a l , fetal, a n d e n d o m e t r i a l tissues f o r detection o f HSV D N A sequences; in situ DNAJRNA hybridization o f placental, fetal, a n d en-

dometrial tissues to detect HSV-specific sequences; and clinical and long-term follow-up evaluation o f a significant n u m b e r o f " n o r m a l " neonates to detect any subtle or subclinical neurologic abnormalities o r idiopathic i n f l a m m a t o r y diseases, and correlation o f these abnormalities with the presence o f HSV-specific antigen a n d / o r nucleic acids.

Acknowledgments. The authors are grateful to Karen Gray, Linda Kitabayashi, Jean Langworthy, Brenda Robb, Maria Robb, Pamela Sam-Fong, Christine Shawger, and Kimberly Stecker for their technical assistance, to Dr. Brian Satmders for submission of the index case to Drs. Voland and Benirschke, and to the following physicians for their submission of referral cases: Michael Bonin, Frank Foss, Steven Gabbe, Neva Gould, Marylin Jones, Cynthia Kaplan, Ahmad Mahrou, John Mayo, Howard Robin, Charles Sanders, and Roger Williams. T h e use o f Dr. Frank Howell's photomicroscope and the support of the Department of Academic Affairs of the Scripps Clinic Research Foundation for photographic printing are also gratefully appreciated. Dr. Fred Rapp is thanked for his thoughtful presubmission review of the manuscript. REFERENCES

1216

1. Nahmias AJ, Keyserling HL, Kerrick GM: Herpes simplex. In Remington JS, Klein JO (eds): Infectious Diseases of the Fetus and Newborn Infant. Philadelphia, WB Saunders, 1983, pp 636-678 2. South MA, Tompkins WA, Morris CR, et ah Congenital malformation of the central nervous system associated with

genital type (type 2) herpesvirus. J Pediatr 75:13, 1969 3. Florman AL, Gershon AA, Blackett PR, et al: Intranterine infection with herpes simplex virus: resultant congenital malformations. JAMA 225:129, 1973 4. Von Herzen JL, Benirschke K: Unexpected disseminated herpes simplex infection in a newborn. Obstet Gynecol 50:728, 1977 5. Bendon RW, Perez F, Ray M: Herpes simplex virus in maternal decidua (abstract). Soc Ped Pathol Annual Meeting, 1985. Submitted toJ Pediatr Pathol 6. Nakamura Y, Yamamoto S, Tanaka S, et al: Herpes simplex viral infection in human neonates: an immunohistochemical and electron microscopic stud)'. Hut, t PATtIOL 16: 1091, 1985 7. Stagno S, Whitley RJ: Herpesvirus infections of pregnancy. N EnglJ Med 313:1270 (part I) and 1327 (part II), 1985 8. Robb JA, Benirschke K, Barmeyer R: Intrauterine latent herpes simplex virus infection. I. Spontaneous abortion. HUM PATHOL 17:000, 1986 9. Brown ZA, Vontver LA, Benedeni J, et al: Genital herpes in pregnancy: risk factors associated with recurrences and asymptomatic viral shedding. Am J Obstet Gynecol 153:24, 1985 10. MelnickJL, Dreesman GR, McCollum CH, et al: Cytomegalovirus antigen witlfin human arterial smooth muscle cells. Lancet 2:644, 1983 11. Myerson D, Hackman RC, Nelson JA, et al: Widespread presence of histologically occult cytomegalovirus. HUM PATtIOL 15:430, 1984 12. Bradley JS, Yeager AS, Dyson DC, et ah Neutralization of herpes simplex virus by antibody in amniotic fluid. Obstet Gynecol 60:318, 1982 13. Benirschke K, Driscoll SG: The Patlmlogy of the Human Placenta. New York, Springer-Verlag, 1967, pp 232-234 14. Clewell WH, Manchester DK: Recurrent maternal floor in-

INTRAUTERINEHSV INFECTION:LATENTNEONATALINFECTION[Robb et al.]

15. 16. 17. 18.

19.

farction: a preventable cause of fetal death. Am J Obstet Gynecol 147:346, 1983 Naeye RL: Maternal floor infarction. HUM PATHOL 16:823, 1985 Perrin EVD, Kahn-Vander J: Degeneration and calcification of tile umbilical cord. Obstet Gynecol 26:371, 1965 Navarro C, Blanc WA: Subacute necrotizing funisitis. A variant of cord inflammation with a high rate of perinatal infdction. J Pediatr 85:689, 1974 Nahmias AJ, Keyserling HL, Kerrick G*I: Herpes simplex. In Remington JS, Klein JO (eds): Infectious Diseases of the Fetus and Newborn Infant. Philadelphia, WB Saunders, 9 1983, p 645 Redfield DC, Richman DD, Albanil S, et ah Detection of

20.

21. 22. 23.

1217

herpes simplex virus in clinical specimens by DNA hybridization. Diagn Microbiol Infect Dis 1:117, 1983 Stroop WG, Rock DL, Fraser NW: Localization of herpes simplex virus in the trigeminal and olfactory systems of the mouse central nervous system during acute and latent infections by in situ hybridization. Lab Invest 51:27, 1984 Zheng ZM, Hsiung GD: Complement-reqniringneutralization antibody in guinea pigs with primary and recurrent genital herpes. Proc Soc Exp Biol Med 177:332, 1984 Nachtigal M, Caulfield JB: Early and late pathologic changes in the adrenal glands of mice after infection with herpes simplex virus type 1. AmJ Pathol 115:175, 1984 Chow TC, Hsiung, GD: Neonatal herpes simplex virus infection in guinea pigs. Proc Soe Exp Biol Med 170:459, 1982