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Term 5: Infectious Disease > 5/26- Congenital Infections > Flashcards

5/26- Congenital Infections Flashcards

1
Q

Viruses that cause congenital infections

A

- Cytomegalovirus (CMV)

- Rubella

- Herpes simplex (HSV)

- Varicella-zoster (VZV)

  • Enteroviruses
  • HIV
  • Parvovivrus B19
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2
Q

Bacteria that cause congenital infections

A

- Treponema pallidum

  • Mycobacterium tuberculosis
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3
Q

Protozoa that cause congenital infection

A

- Toxoplasma gondii

  • Trypanosoma cruzi
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4
Q

TORCH infections

A
  • Toxoplasmosis
  • Other: syphilis
  • Rubella
  • CMV
  • Herpes, HIV
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5
Q

US Screening during pregnancy

A
  • Rubella
  • Syphilis (early and near delivery)
  • Hepatitis B
  • HIV
  • Testing for CMV immunity is not routine (some obstetricians will do, some don’t)
  • Some states screen for toxoplasma in newborns (not TX)
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6
Q

Congenital infections are usually associated with what stage of infection in the mother?

(e.g. primary, recurrent, latent)

A

Primary infections

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7
Q

What factors play a role in the manifestations of infection in infants?

A
  • More severe with infection earlier in gestation
  • Many infected infants asymptomatic at birth; must be screened
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8
Q

Pathogenesis of congenital infections

A
  • Maternal infection, then
  • Bloostream invasion, then
  • Fetal infxn, placental infxn, or both

(placental may lead to infecting fetus or not), then

  • Intrauterine death OR

premature infant OR

term infant

Outcomes:

  • Intrauterine growth retardation (IUGR)
  • Developmental anomalies
  • Congenital disease
  • Normal infant
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9
Q

Case

  • A term female infant born by precipitous NSVD to an 18 y/o woman who received no prenatal care
  • Mother reports using marijuana and alcohol early in pregnancy and was daignosed with 2 UTIs; had several “colds” late in pregnancy
  • Lives with boyfriend, 2 dogs, cat, and turtle
  • Infant is 2 kg, lethargic, jaundice, weak cry, microcephaly, distended abdomen, hepatosplenomegaly, diffuse petechial rash with areas of purpura on extremities
  • Elevated liver enzymes
  • Scattered intracerebral calcifications on head US

Most likely etiology?

A

Cytomegalovirus

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10
Q

What is the most common congenital viral infection? Stats?

A

Cytomegalovirus

~1% of al lnewborns

commonly asymptomatic; may develop later

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11
Q

How is CMV transmitted congenitally?

A
  • Transplacental
  • Intrapartum (during delivery)
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12
Q

Infection of CMV when results in the most severe sequelae?

A

Primary infection in 1st half of gestation

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13
Q

How many infants are symptomatic for CMV at birth?

A

10% symptomatic at birth

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14
Q

Do mother Abs protect fetus from CMV infection?

A

Not really

  • Infection can occur with recurrent disease (can be infected with new strain during pregnancy)
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15
Q

Symptoms of congenital CMV (7)?

A
  • Intrauterine growth restriction (small for age)
  • Jaundice
  • Skin: purpura, petechiae, blueberry muffin
  • Hepatosplenomegaly
  • Microcephaly
  • CNS calcifications
  • Retinitis
  • Sensorineural hearing loss
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16
Q

What is a blueberry muffin rash?

A

Sites of erythropoesis is neonate, possibly because virus invades bone marrow and kicks out the RBC-producing cells

(it is palpable)

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17
Q

What is the most common sequelae of congenital CMV?

Stats (number affected, timeframe)?

A

Sensorineural hearing loss

(more common sequelae if symptomatic at birth)

  • causes 21% of hearing loss at birth
  • 1/3 to 1/2 of hearing loss due to CMV is late-onset
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18
Q

How many infants with herpes of asymptomatic mothers?

A

2/3

(history absent in 2/3 of mothers of infected infants)

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19
Q

What is herpes’s risk of infection from mother to child?

A

Primary infxn: 25-60%

Reactivated: 2%

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20
Q

Transmission of congenital herpes?

Other methods of vertical transmission (not truly congenital)?

A

Congenital:

  • Transplacental
  • Ascending (rupture of membranes while mom has active outbreak)

Neonatal:

  • Intrapartum (86%)
  • Postnatal (10%)
  • Intrauterine/congenital (4-5%)– so this one is actually pretty rare
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21
Q

Key symptoms of congenital herpes? (since it is so rare)

A
  • Cutaneous findings (scarring from previous vesicles, )
  • CNS abnormalities
  • Eye abnormalities
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22
Q

Incidence of congenital Varicella (broadly speaking)?

A
  • Rare because most moms in US are immunized
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23
Q

When is a varicella infection most likely to be transmitted to the infant?

What is the percentage of infection during this time frame?

A
  • before 20 wks of gestation
  • 1-2%
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24
Q

Method of varicella transmission?

A

Transplacental

25
Q

Symptoms of congenital varicella?

A
  • Possibly associated w/ abortion and prematurity
  • Scars
  • Cataracts, retinitis, microphthalmos
  • Hypoplastic limbs (lesions as limbs develop)
  • Seizures and other nervous system abnormalities
  • At autopsy, skin, lung, and liver uniformly involved (it’s everywhere)
26
Q

How is congenital Rubella transmitted?

A

Transplacental

27
Q

When during pregancy is congenital Rubella infection most common?

A

Risk is limited almost exclusively to the 1st trimester

28
Q

What is the underlying mechanism of congenital Rubella symptoms?

A

Defects due to cytopathic damage to vessels and organ ischemia

29
Q

Incidence of congenital Rubella in US?

A
  • Very low (3 in 2012, none in 2009-2011)
  • This has occurred in mothers who have been in endemic areas (like mom contracting Rubella in Africa)
30
Q

Symptoms of Rubella?

A
  • Cataracts (can happen with others, but key for Rubella!), microphthalmos, glaucoma
  • Auditory: sensorineural loss
  • Neurologic: meningoencephalitis, microcephaly, retardation
  • Cardiac: PDA, peripheral pulmonary stenosis

Other manifestations:

  • Blueberry muffin rash
  • Intratuterine growth retardation
  • Pneumonitis
  • Bone dz
  • Hepatosplenomegaly
  • Thrombocytopenia
31
Q

Case

  • 2.52 kg, AGA, male infant born at 37 wks gestation via a stat C/S
  • At delivery thick meconium, poor tone, respiratory effort
  • Apgars are 3/6/8
  • Promptly intubated
  • Born to 30 yo G2P1 mom with cocaine addiction and Hx of herpes, syphilis, and gonorrhea; mother did not receive prenatal care
  • Multiple petechiae, round lesions on palms/soles with desquamation, distended abdomen, hepatosplenomegaly, bilateral axillary lymphadenopathy, decreased tone

Diagnosis?

A

Syphilis

(rash on palms/soles is key)

32
Q

What causes syphilis?

A

Treponema pallidum

33
Q

Transmission of congenital syphilis?

A

Transplacental

34
Q

Rates of transmission of the different stages of syphilis during pregnancy?

A
  • 1/2’: 50%
  • Early latent: 40%
  • Late latent: 10%
  • 3’: 10%
35
Q

Clinical manifestations of congenital syphilis?

A
  • Stillbirth, prematurity, hydrops fetalis (edematous)
  • Hepatosplenomegaly, lymphadenopathy
  • “Snuffles” (profuse runny nose)
  • Rash, condyloma lata, gumma, desquamation
  • Anemia, thrombocytopenia
  • Osteochondritis, pseudoparalysis (since so painful)
  • Meningitis
  • Pneumonia alba (can look totally white on CXR)
36
Q

Late manifestations for congenital syphilis

(even up to 9+ yrs later!)

A
  • Frontal bossing (enlarged frontal lobe), saddle nose
  • Keratitis, glaucoma, retinitis
  • Sensorineurla hearing loss
  • Hutchinson teeth (notched incisers), mulberry molars (outgrowths)
  • Rhagades (cracking of sides of mouth), gummas
  • Saber shins, clutton joints
37
Q

Hutchinson’s triad

A

Triad of manifestations for late syphilis:

  • Interstitial keratitis
  • Sensorineural hearing deafness
  • Hutchinson teeth
38
Q

Case:

  • 2 yo infant born at 37 wks gestation to a 33 yo G5 P3 Ab1 mother. RPR, HepB, and HIV negative, Rubella nonimmune
  • Mom exposed to mice, cats, and kittens while cleaning houses; ill in 2nd and 3rd month of pregnancy with “flu-like” illness, sore throat, and lymphadenopathy
  • US at 29 wks gestation revealed hydrocephalus and hepatosplenomegaly
  • Repeat US 1 wk prior to delivery was improved but persistent hydrocephalus
  • Weight and height 50%, no microcephaly
  • Split sutures
  • Pupils sluggish, retinal exam abnl
  • Hepatomegaly, but no jaundice
  • Decreased tone
  • No rash

Cause?

A

Toxoplasmosis

39
Q

What causes toxoplasmosis?

A

Toxoplasma gondii (a parasite)

40
Q

Incidence of congenital toxoplasmosis?

A
  • 1-5 cases per 10,000 live births (0.01 - 0.05%)
41
Q

Transmission of toxoplasma?

A

Transplacental

42
Q

When during pregnancy is transmission of toxoplasma most common?

A
  • When mom is parasitemic (primary infxn with parasites in blood)
  • Reactivation in immunocompromised mother (e.g. HIV)
43
Q

How is toxoplasmosis acquired?

A

Acquired via:

  • Undercooked meat
  • Soil, water, food contaminated with cat feces
44
Q

Life cycle of Toxoplasma?

A
  • Excreted in feces of cats
  • Oocytes may be ingested by many different animals and spread via their undercooked meat
  • Thus contaminated soil, kitty litter or undercooked food
45
Q

How many infants or asymptomatic with toxoplasmosis at birth?

A

70-90%

46
Q

Symptoms of congenital toxoplasmosis?

Classic triad?

A
  • Rash
  • Lymphadenopathy
  • Hepatosplenomegaly
  • Jaundice
  • Pneumonitis
  • Thrombocytopenia
  • CNS abnls: hydrocephalus, calcifications, microcephaly, seizures
  • Chorioretinitis, retinal scarring
  • Deafness

Classic triad:

  • Calcifications
  • Chorioretinitis
  • Hydrocephalus
47
Q

Sequelae of congenital toxo?

A
  • Chorioretinitis (retinal lesions in 85% of untreated congenital infxns)
  • Mental retardation
  • Motor deficits
  • Hearing loss
  • Seizures
48
Q

General evaluation for congenital infections?

A
  • Hearing evaluation (hearing screen mandated in US before leaving hospital, but may need something more sophisticated like ABR)
  • Ophthalmologic exam
  • Labs; CBC d/p (for anemia or thrombocytopenia), LFTs, specific serologies (Rubella IgM, toxoplasma…)
  • Lumbar puncture
  • CNS imaging (typ CT or MRI of brain; US may be useful)
  • Bone radiographs
49
Q

What dz is associated with pneumonia alba?

A

Syphilis

50
Q

What dz is associated with limb hypoplasia?

A

Varicella

51
Q

What dz is associated with cataracts?

A

Rubella

52
Q

What dz associated with cutaneous scars?

A

Herpes

(but also Varicella)

53
Q

What dz is associated with CNS calcifications?

A

Toxoplasmosis

54
Q

Question:

An infant is born small for gestational age, jaundiced, and is microcephalic. Another common physical exam finding is:

A. Dysmorphic features

B. Extra digits

C. Hepatosplenomegaly

D. Rales on auscultation of chest

A

C. Hepatosplenomegaly

55
Q

Question:

An essential test to establish the diagnosis for this infant (last ?) would be:

A. TORCH titers

B. Viral cultures

C. Otolaryngology evaluation

D. EKG

A

B. Viral cultures

56
Q

Question:

The most common congenital infection is?

A. Toxoplasmosis

B. Syphilis

C. Cytomegalovirus

D. Rubella

E. Herpes

A

C. Cytomegalovirus

57
Q

Question:

An infant is born with a congenital infxn transmitted to his mother by contact with cat feces. The pathogen is a:

A. Virus

B. Bacteria

C. Fungus

D. Parasite

A

D. Parasite

58
Q

Question:

Congenital infxns are associated with damage to the following organ systems:

A. Central Nervous System

B. Reticuloendothelial System

C. Cardiovascular System

D. Musculoskeletal System

E. All of the above

A

E. All of the above

Term 5: Infectious Disease (18 decks)

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