Congenital Infections Flashcards
What are TORCH Infections?
Congenital viral infections T - Toxoplasmosis R - Rubella C - CMV H - HSV
Characteristics of congenital viral infections (in-utero):
- Microcephaly
- Intracranial calcifications
- Rash
- Intrauterine growth restriction (IUGR)
- Jaundice
- Hepatosplenomegaly
- Elevated transaminases
- Thrombocytopenia
What causes Toxoplasmosis and what is the route of infection?
Toxoplasma gondii
Route:
- Fecal oral route
- Ingested oocysts in cat feces (liter box), water, soil, or inappropriately prepared meat
- Cysts viable in soil for up to 18 hours
Presentation of Toxoplasmosis?
Acute infection is usually asymptomatic
33% risk of fetal infection with primary maternal infection in pregnancy
- Infection rate higher in 3rd trimester
- Symptomatic really only in second trimester
What are the detailed clinical manifestations of toxoplasmosis in each trimester?
First
- Death
- CNS/Opthamologic findings
Second
- Hydrocephalus
- Intracranial calcifications
- Chorioretinitis (May develop late)
- May have classic congenital infection issues like jaundice from hepatosplenomegaly, anemia, small head, visual/hearing issues
Third
- Asymptomatic
How do we diagnose toxoplasmosis?
Gold standard - Isolation of the organism from placenta, serum, or CSF.
Classic triad (hydrocephalus, intracranial calcifications, chorioretinitis) on PE
Serologies that support toxoplamosis (hard to use and hard to interpret due to bad standards)
Maternal enzyme-linked imunosorbent assay suggestiveInfant IgG persisting beyond 6 months
Treating toxoplasmosis
Pregnant mothers with acute toxo:
- Daily spiramycin to reduce congenital transmission up to 50%
If infant diagnosed prenatally, treat mom
- Spiramycin, pyrimethamine with leucovorin rescue, sulfadiazine
Symptomatic infants
- pyrimethamine with leucovorin rescue, sulfadiazine for 12 months
If asymptomatic infant, same idea but perhaps not 12 months of it.
What type of virus is Rubella and how bad is it?
This is a single stranded RNA Toga virus.
Vaccine preventable and mild, self limiting in nature.
How can rubella manifest clinically?
Eyes
- Cataracts, glaucoma (leucocoria on exam)
Cardiac
- PDA, peripheral pulmonary artery stenosis
Auditory
- Sensorineural hearing impairment
Neurologic
- Behavioral d/o, meningoencephalitis
Other
- Growth retardation
- Big liver and spleen
- Thrombocytopenia
- Purpuric skin lesions
Clinical manifestations of CMV
- Low birth weight
- petechiae
- Thrombocytopenia
- Hepatosplenomegaly
- Direct hyperbilirubinemia
- Elevated transaminases
CT scan of CMV vs. Toxoplasmosis
CMV gives this peripheral outline calcification pattern around the ventricles and brain mass
Toxo makes nodules within the brain parenchyma
Two big defects caused down the road from CMV
- Hearing loss after 6 months
- Most frequently identified viral cause of developmental delay in developed countries
CMV retinitis is a little different than the others. What dos it present with?
- Chorioretinitis (same)
- Retinal scars
- Optic atrophy
- Central vision loss
How often do symptoms present for CMV?
- 90% asymptomatic at birth, with up to 15% developing symptoms later on, notably the sensorineural hearing loss
How do we diagnose CMV?
- Maternal IgG may represent immunization or past infection so this is USELESS
- You can isolate virus from nasal secretions (less frequently from throat, blood, urine, CSF)
- Serologic testing (IgM = recent postnatal or congenital infection. IgG = Rising monthly IgG titers suggests congenital infection)
How the hell do we treat CMV?
Remember ganciclovir? We’re gonna give it for 6 weeks in symptomatic infants with CNS involvement.
- Protects against progression of hearing loss
- Improves developmental outcomes at 1-2 years
- Neutropenia often leads to cessation of therapy
Side effects are rough buddy, don’t give it to the infant if there are no symptoms.
Describe the structure of Herpes Simplex virus and how it is usually transmitted
This is an enveloped double stranded DNA virus primarily transmitted through infected maternal genital tract at time of delivery.Usually, primary infection is what causes issues, so mom will have no predisposing symptoms for HSV at all
How does congenital HSV present?
Most are asymptomatic at birth
We see, if there are symptoms, 3 disease patterns by 4 weeks
- Skin, eyes, mouth (SEM-40-45%)
- CNS disease (33%)
- Disseminated disease (20%, presents earliest)
Initial manifestations very nonspecific with skin lesions not necessarily present
How do we diagnose HSV?
- Culture maternal lesions if present at delivery
- Cultures in infant (>12-24 hours) (skin lesions, oro/nasopharynx, eyes, rectum, or Blood/CSF, urine)
- PCR
- CSF usually, can use blood
- DFA (direct flourescent antibody) of lesions if present
- No serologies for neonates
How do we treat HSV?
High dose IV acyclovir 60mg/kg/day delivered divided into every 8 hour increments
- 21 days for disseminated or CNS disease
- 14 days for SEM
Ocular involvement requires topical therapy as well
What causes syphilis?
Too much fun!
What causes Syphilis and how can it be transmitted?
Treponema pallidum (a spirochete)
- Transmitted via sexual contact
- Placental transmission as early as 6 weeks gestation.
Typically occurs during 2nd half of pregnancy, and it is usually a mother with primary or secondary syphilis than one with the latent disease
Clinical lethal manifestations of syphilis in fetus
- Stillbirth
- Neonatal death
- Hydrops fetalis, which is where abnormal accumulation of fluid occurs in 2 or more fetal compartments, including ascites, pleural effusion, pericardial effusion, and skin edema
quick note, this is also seen in CMV, a lot, so keep that in mind
About 25% of the time there is intrauterine death and perinatal death in 25-30%
If the baby with syphilis gets born, it doesn’t mean that they are free and healthy. What are some clinical manifestations in the early congenital phase (first 5 weeks)
- Cutaneous lesions (palms and soles)
- HSM
- Jaundice
- Anemia
- Snuffles
- Periostitis and metaphysial dystrophy
- Funisitis (umbilical cord vasculitis)
Clinical manifestations of late congenital form of syphilis…like you have dropped the ball for a while and are the worst doctor ever for letting it get this far.
- Frontal bossing
- Short maxilla
- High palatal arch
- Hutchinson teeth (shark teeth)
- 8th nerve deafness
- Saddle nose
- Perioral fissures(Centered around fact that syphilis attacks cartilage)
Could have been prevented with appropriate treatment
Treating syphilis
PCN
Serologic testing for Syphilis
- RPR/VDRL: Nontreponemal test, sensitive but not specific (makes it great for screening). Quantitative, can follow for disease activity and treatment response
- MHA-TP/FTA-ABS: specific treponemal test. This is confirmatory. Qualitative, once positive always positive.
Use the RPR/VDRL screen in ALL pregnant women early in pregnancy and at time of birth. This is an easily treated thing!
