Congenital Infections - Exam 1 Flashcards
What is a congenital infection? How can it be transmitted?
An infection of the fetus typically caused by viruses, or less commonly other infections,that infect the pregnant mother and may be passed to the fetus.
through blood, vaginal secretions or breast milk
**What are the 2 CI to breastfeeding?
HIV and CMV
What are the 10 things tested for in a TORCH test?
Toxoplasmosis
Others: HIV, enterovirus, parvovirus, varicella, hepatitis, syphilis
Rubella
Cytomegalovirus
Herpes
What causes toxoplasmosis? What type of organism? How will it present in a newborn?
Toxoplasma gondii
protozoan parasite
ocular disease and neurological defects
Frequency of toxoplasmosis of fetal infection increases steeply with _____. 70-90% newborns with congenital toxoplasmosis have no _______
advancing gestational age
manifestations on routine PE
Should you screen for toxoplasmosis?
NO! not recommended to universally screen for it
you should screen mom’s for toxo if you have a high suspicion and they are displaying signs of _______ and ______.
significant cervical lymphadenopathy, and high fever
What is the MC US finding of a fetus who has toxo?
Such as calcifications and or cerebral ventricular dilation
What are 4 risk factors for maternal to fetal transmission of toxo?
Maternal infection at advanced gestational age
High Parasite load
Maternal parasite source
Maternal immunocompromise
What are the 3 ways to contract toxo? Which way has the highest risk of fetal infection?
cat feces** highest risk with cat feces
undercooked meat and eggs
Cataracts /Chorioretinitis
Abnormal CSF fluid
Anemia
Microcephaly / Hydrocephalus
Hearing loss
Small for gestational age (SGA)
Early onset jaundice
HSM-hepatosplenomegaly
Generalized maculopapular rash
Seizures
What should you do next?
What am I? What is the distinguishing symptom?
order TORCH titers
Toxo
Chorioretinitis
**What is chorioretinitis? **What dz?
is an inflammation of the choroid (thin pigmented vascular coating of the eye) and retina of the eye.
toxo
______ is typically used for detection of IgM and IgG antibodies. **How do you detect toxo on CT?
ELISA
Can use Skull films and CT head that will show diffuse cortical calcifications
In an acute infection, toxo IgM usually appear within _____ and stay elevated for ______
appear within 1 week
stay elevated for months
When does toxo IgG appear? When does it peak? How long does it last?
IgG specific Ab appear in 2 weeks
peak @ 8
persist for life
When toxo dx has been confirmed in mom, what do you do next?
Testing for fetal infection via amniocentesis can be helpful in decision making after 18 weeks preferred
then tx MOM with either spiramycin or Pyrimethamine and Sulfadiazine with folinic acid depending on age
What is the tx for toxo in MOM? give both tx with gestational ages
If less than 14 weeks gestation -> Spiramycin
If after 14 weeks gestation -> Pyrimethamine and Sulfadiazine with folinic acid until delivery
Once delivered, what is the toxo tx for baby? For how long? What other tx/monitoring is required for these infants?
pyrimethamine plus sulfadiazine and folinic acid
Treat for one year
Repeated eye examinations by an ophthalmologist experienced with identifying Toxoplasma chorioretinal lesions in infants and toddlers should be obtained every 3 months until 18 months. Then every 6-12 months
What are some preventative measures for toxo?
Cook meat until it’s well done
Peel and wash thoroughly all fruits and vegetables
Wash all surfaces after contact with raw meat
Avoid untreated drinking water
Wear gloves when gardening
Avoid changing cat litter
**______ infection 40% lead to fetal death or premature stillborn delivery
Rubella (German measles)
When is rubella the worst for growing fetus?
85% infected in FIRST trimester, congenital defects as high as 80-85%
What is the name of this syndrome? What are the spots called? What causes them?
Rubella
“Blueberry Muffin Syndrome”
thrombocytopenia with petechiae or purpura, LOW platelets
thrombocytopenia with petechiae or purpura
cataracts, retinopathy, glaucoma
PDA and Peripheral pulmonary artery stenosis
sensorineural hearing loss
behavior disorder, meningoencephalitis and mental retardation
Microcephaly
What am I?
**What is an important symptom to remember?
rubella
**causes sensorineural hearing loss
How can you confirm the dx of rubella? What bodily fluids can be used? How long does the infant shed the virus?
Measurement of IgG over several months can be confirmation
Cultures of blood, urine and CSF are detectable as well
Tend to shed live virus in urine, stool, and respiratory secretions for up to 1 year
What are common eye findings in rubella? Ear findings?
cataracts/glaucoma
will be deaf due to sensorineural hearing loss
**_____ is the MC congenital infection. What is the structure? How is it transmitted?
CMV
Double stranded DNA herpes virus
intimate contact: blood, saliva etc
**What trimester is the worst time to be exposed to CMV? Can it be transferred through breast milk? Is it typically worse for younger or older mothers?
Severe problems can occur at any trimester but greater if exposed FIRST trimester
YES!! do not breastfeed
WORSE in teen pregnancies
Microcephaly
Intracranial calcifications / periventricular
Hepatosplenomegaly / Jaundice
Mental Retardation
Retinal Disease
Sensorineural hearing loss
Cerebral Palsy
Thrombocytopenia / Petechiae
What am I?
**What is the best way to test for it?
CMV
aka: tiny head, rash, calcifications around the ventricles, big ventricles
**CMV detection in urine or saliva (within first 3 weeks of life)
**______ is the leading cause of non-hereditary sensorineural hearing loss. What additional labs are usually elevated?
CMV
Elevated liver transaminases, thrombocytopenia, elevated bilirubin
What will a head CT scan of a pt with CMV show? Why would you order a PCR test?
intracranial lesions - usually periventricular
to check viral load
How do you determine if CMV is congenital or perinatal?
Detection of CMV within first 3 weeks after birth is considered proof of congenital CMV infection
after first 3 weeks - think of perinatal exposure
**What is the APPROVED tx for congenital CMV?
**NO antivirals are currently approved!!
What is the tx that symptomatic CMV babies receive? Why?
ganciclovir and valganciclovir
which has shown to decrease progression of symptoms such as sensorineural hearing loss
How is CMV best isolated in the baby?
through urine and saliva
_____ of pregnant women have evidence of past HSV infection. Which type of HSV accounts for 70% of neonatal herpes infections. **If you have a vaginal birth, what is the risk of infecting the baby?
30-60%
HSV 2
25-50% risk of infecting the baby
What trimester does HSV carry the highest intrauterine risk? Is neonatal or congenital HSV more commmon?
3rd trimester
neonatal is MORE common
** ____ infants who acquire HSV infection are born to mothers with no previous history or clinical findings consistent with HSV infection. Where does the virus life for the entire life of the host?
75%
dorsal root ganglia
How can the fetus be exposed?
The fetus may be infected transplacentally or through retrograde spread through ruptured or seemingly intact membranes
If a neonate presents with symptoms of sepsis, liver dysfunction and negative bacteria culture OR fever, irritability and abnormal CSF findings what should you think? Are HSV infections in newborn typically mild or severe?
consider HSV infection!!!
SEVERE
**What is the congenital HSV triad? Give 3 additional symptoms. What are usually the first indication of HSV infection?
- Skin vesicles
- Ulcerations
- Scarring eye damage
other 3: large liver and lungs, CNS abnormalities, less than 36 weeks gestation
Localized infections of the skin, eyes and mouth is usually first indication of infection (45%
How do you dx HSV? What is the tx?
specimen culture the vesicle somewhere on the body
IV acyclovir
What percent of women have evidence of past HSV infection?
60%
Most cases of congenital Varicella Zoster disease occur in infants whose mothers were infected between ____ gestation. If infected in the first 20 weeks there is only a ____ chance of transmission
8-20 weeks
2%
Is it worse for the baby if mom has varicella zoster, early or late in pregnany?
worse outcomes for baby if mom had chickenpox LATE in pregnancy
Cicatricial skin lesions (zig zag skin scarring and limb atrophy)
Ocular defects - cataracts, retinitis
CNS - hydrocephalus, microcephaly, seizures, mental retardation
What am I?
What is a standout symptom?
congenital varicella syndrome
limp atrophy
How is varicella zoster usually diagnosed? When can IgM be detected? IgG?
varicella is usually based upon the characteristic appearance of skin lesions and scraping of vesicle base is sent out for PCR testing
IgM may be detected as soon as 3 days after symptoms appear
IgG increased in serum confirms diagnosis and may be present as early as 7 days after symptoms appear
What is the prophylactic tx for varicella zoster? Who is it given to?
VariZIG - varicella zoster immune globulin (IVIG)
Given to any infant with perinatal exposure and Given to all infants younger than 28 wks gestation following postnatal exposure
Is breastfeeding encouraged in varicella? why or why not? What is the tx for varicella?
breastfeeding is encouraged because it exposes the baby to antibodies in the breast milk
acyclovir
What are 3 different names for Parvo B19? **Who has the highest infection rates?
Human Parvovirus B19
Fifth’s Disease
Erythema Infectiosum
**teachers and daycare workers
What is the structure of Parvo B19? **What are 3 symptoms associated with it?
single-stranded DNA virus
fever, lacy rash and slapped cheeks
**lacy rash on arms and “slapped cheeks” appearance
In parvo B19, how long do systemic symptoms tend to last prior to the rash? _______ is also common
infected kids have 1-4 days of systemic symptoms
Arthropathy affecting joints of hands, wrists, knees and ankles
What is hydrops fetalis?
Hydrops fetalis (fetal hydrops) is a serious fetal condition defined as abnormal accumulation of fluid in 2 or more fetal compartments, including ascites, pleural effusion, pericardial effusion, and skin edema.
What should you do if a pregnant women is exposed to Parvo B19? What does a positive IgM test result indicate?
regnant women exposed should have serologic testing for IgG and IgM; ultrasound; percutaneous umbilical cord blood sampling of the fetus
infection probably occurred within the past 2-4 months
If mom is dx with parvo B19 and is further along than 20 weeks gestation, what should you do next?
receive periodic ultrasounds (weekly) looking for signs of fetal hydrops
Infants who survive should be given supportive treatment centered on management of hydrops. Aplastic crisis would require blood transfusions
What are the symptoms of Parvo B19 in infected kids?
fever, lacy rash, slapped cheeks
What organism causes syphilis? What type? How likely is the fetus to get it? **______ result in spontaneous abortion
Treponema pallidum
Spirochete
nearly 100% chance of passage to fetus
**40% result in spontaneous abortion
If a baby is born with syphilis is it likely to be picked up on at birth? Is it transferred through breast milk?
NO! 2/3rds are asymptomatic at birth but start showing symptoms by 3 months of age
NOT transferred through breast milk
What are the s/s of syphilis before 2 years old? **What is the highlighted symptom?
hepatomegaly
**Nasal Discharge - “Snuffles” (persistent): may be white and may be bloody
Rash
Generalized LAD-lymphadenopathy
Skeletal abnormalities
How does syphilis present after 2 years of age?
CNS abnormalities
Abnormalities to bones, teeth, eyes, skin
hutchinson’s triad
rhagades
bowing shins
saddle nose
mulberry molars
clutton joints
**What is Hutchinson’s triad? What dz is it associated with?
interstitial keratitis
8th cranial nerve deafness
Hutchinson’s teeth (smaller and more widely spaced with notches on biting surface)
What are rhagades? What dz are they associated with?
cracks and fissures around mouth and chin
syphilis after 2 years old
What are mulberry molars? What dz?
round cusps on enamel on permanent first molars
syphilis after 2 years old
What are clutton joints? What dz?
symmetrical joint edema/synovial inflammation
syphilis after 2 years old
What is this? What dz?
hutchinson’s teeth associated with syphilis after 2 years old
**How is syphilis diagnosed?
Serum quantitative nontreponemal titer more than fourfold the mother’s titer
**Direct visualization of T. Pallidum by dark field exam from bodily fluids
**What is the tx for syphilis? **When do you need to repeat testing?
IV PCN
Repeat antibody titers at 3, 6, 12 months to document falling titers
What is your percent chance of transplacental infection with syphilis if mom has active disease?
What % of kids born with syphilis will show symptoms in the first 3 months ?
nearly 100%
2/3rd will show symptoms by 3 months old
What organism is responsible for chlamydia? How does it present in newborns?
Chlamydia Trachomatis
conjunctivitis or pneumonia in newborns
______ is the most common cause of sexually transmitted genital infections in the US. What is the risk of passing it to the baby during vaginal birth?
chlamydia
50-70%
How does chlamydia present in a newborn?
bilateral conjunctivitis 5-14 days post delivery
or pneumonia
**What is the gold standard dx for chlamydia?
isolation of C trachomatis by culture and need to swab both conjunctival and nasopharyngeal areas
What is the tx for chlamydia? Should you screen pregnant women for it?
oral (NOT TOPICAL) Erythromycin
ALL preg pts should be screened for it at their first pregnancy visit
What organism is responsible for gonorrhea? What is the structure? What is the likelihood of transmission? When does the infection occur?
Neisseria Gonorrhoeae
Gram negative diplococci
30-40% cases usually due to vaginal delivery
usually within the first 5 days
How does gonorrhea present in the newborn? give 3 additional presentations
bilateral PURULENT conjunctivitis
scalp abscesses, vaginitis and bacteremia
**What pt populations need to be screened for gonorrhea?
previous STD infection
multiple sexual partners
inconsistent condom use
commercial sexual partners
drug use
those in communities with high prevalence of disease
_____ is used as neonatal gonorrhea prophylaxis. **What is the tx?
Erythromycin ophthalmic ointment
**Single dose of Ceftriaxone (25-50 mg/kg, not to exceed 125 mg IM or IV)
How do you dx gonorrhea?
Gram stain of conjunctival exudate
What 3 ways can HIV pass from mother to baby? ______ can help decrease the rate of transmission.** ______ increases the rate of transmission
in utero, during birth or by breastfeeding
antiretroviral tx
breastfeeding increases the risk of transmission
**What is the screening/diagnosis pathway for HIV in a newborn? When is HIV considered excluded?
HIV DNA PCR
<48 hrs of age, 2 weeks, 1-2 months, and at 2-4 months
If 4 months and older with a neg PCR - HIV excluded
What is the tx for HIV infected newborn?
Antiretroviral prophylaxis (Zidovudine) for 6 weeks for infants born to HIV-infected mothers
What is the structure of Hep C? _____ is the primary source of ped infections. What is the rate?
small, single stranded RNA virus
Vertical transmission
**5% transmission rate from mother to baby; HIV increases risk
______ present in blood after 18 months of age is indicator for Hep C; confirmed with HCV RNA test. What is the tx?
Anti-HCV (HCV antibody testing)
interferon and ribavirin
How does HPV present in children? What is the prevention?
May present as hoarseness in children later on in life
Gardasil vaccine
What is the chance of transmitting Hep C to the baby ? ____ increases risk of transfer
5% transmission rate from mother to baby; HIV increases risk
HIV
How is Zika syndrome transmitted? Why is it so detrimental to the fetus?
Arthropod-borne flavivirus transmitted by mosquitoes
Maternal infection -> placental transmission -> virus targets neural progenitor cells in fetal brain - > kills progenitor cells
Microcephaly: severe with partial skull collapse
Ventriculomegaly
Thin cerebral cortices with subcortical calcifications
Craniofacial disproportion
Craniosynostosis
optic nerve and retinal pathology
retinal scarring
sensorineural hearing loss
Arthrogryposis
Cardiac Abnormalities
neurogenic abnormalities (hypertonia, spasticity, hyperreflexia, seizures/epilepsy)
What am I?
Zika syndrome
What is Craniosynostosis? What dz?
skull sutures close too early and brain cannot grow
Zika
What is Arthrogryposis? What dz?
congenital joint contracture or club foot
if _____ is positive then the baby has Zika
Serum + Urine for Zika RNA via PCR
if _______ and _______ are both negative then likely the baby does NOT have Zika. But if either are positive than it is probable
Serum Zika IgM
CSF for RNA and IgM
______ is the primary screening tool for Congenital Zika Syndrome. What will a CT show?
head US is primary screening tool
CT: calcifications
What is the tx for Zika?
no specific tx outline
refer to:
Ophthalmology w/in 1 month of birth
Hearing screen - newborn (ABR preferred)
Neurology, ID, Genetics, Development
Labs - Zika detection, CBC, CMP, genetics
What is the protocol for infants born to Zika positive mother w/o clinical findings?
Head U/S and ophthalmologic exam and ABR hearing test by 1 month of age
What are the 3 major routes of perinatal infection that can lead to bacterial sepsis in the newborn? How will it present?
Bloodborne transplacental
Ascending with disruption of the amniotic barrier (PRM)
Infection via passage through birth canal
Resp distress most commonly, then hypotension, acidemia, and neutropenia usually at LESS than 24 hours old
What is the MC pathogen for bacterial sepsis in the newborn?
group B strep
If the baby is under 10 weeks of age, _____ is the best way to assess temperature. What is considered a fever?
rectal temp
Rectal temperature **100.4 degrees
**What is the tx for bacterial sepsis in the newborn? What part of the medication regimen is considered nephrotoxic?
Ampicillin and Cefotaxime (Claforan)
OR
Ampicillin and Gentamicin
+/- acyclovir
gentamicin is nephrotoxic!!
