Lecture 4: Congenital Infections Flashcards
What characterizes a congenital infection?
- Growth retardation
- Congenital malformation
- Fetal loss
What are the ToRCHeS VP infections?
- TOxoplasmosis
- Rubella
- CMV
- HIV
- HErpes
- Syphilis
- Varicella
- Parvo
Hep
What kind of pathogen is toxoplasmosis?
Protozoan, toxoplasma gondii
When is toxoplasmosis screening indicated?
- High index of suspicion + significant cervical LAN and high fever
- US of fetus shows calcifications or effusions
What risk factors are associated with toxoplasmosis transmission for maternal to fetal?
- Maternal infection at advanced gestational age
- High parasite load
- Cat feces more infective than meat
- Maternal immunocompromised
What are the S/S of congenital toxoplasmosis infection?
- Cataracts/chorioretinitis
- Calcifications in brain
- Hearing loss
- Anemia
- Seizures
- Hydrocephalus
- Microcephaly
What is the typical lesion seen in congenital toxoplasmosis?
Focal necrotizing retinitis
Cataracts/chorioretinitis is the primary sign of congenital toxo
How is congenital toxoplasmosis diagnosed?
- ELISA
- CT/XRAY showing diffuse cortical calcifications
- IgM will appear within 1 week
- IgG Ab will appear after 2 weeks and persist.
How is congenital toxoplasmosis treated?
- < 14wks gestation = spiramycin
- > 14wks gestation = pyrimethamine + Sulfadiazine + folic acid
TREAT MOTHER
Young SPYro the dragon
PYRo and SULFur are FOUL
If a infant is diagnosed with congenital toxoplasmosis prenatally, what is the postnatal tx?
- Pyrimethamine + sulfadiazine + folinic acid for 1 yr
- Must treat even if mother was not treated
- Eye exams every 3 months until 18 months.
Same as mom’s tx after 14wk gest
How do we prevent toxoplasmosis?
- No raw meat or exposure
- Avoid cat litter
- Wash stuff
What is rubella also known as?
German measles
What is the main concern with congenital rubella infection?
High risk of fetal death or preemie stillborn
What are the two main infections that lead to miscarriage?
- Toxoplasmosis
- Rubella
What are the findings associated with congenital rubella?
- Blueberry muffin syndrome (bluish hue with purpura
- Ophthalmologic (Cataracts)
- Cardiac (PDA and pulm artery stenosis)
- Hearing loss (sensorineural)
- Mental retardation
- Microcephaly
Eye Heart Ruby Earrings
I heart Ruby Earrings
Eye, heart, rubella, hearing!
How is rubella diagnosed?
Antibody tests
How does plt count present in a newborn?
Low, seen with petechiae and purpura
What kind of virus is CMV and how is it transmitted?
- Doublestranded DNA Herpes Virus
- Intimate contact (blood, saliva)
- Transmissible through breast milk
How common is CMV and when is exposure the most risky?
- MC congenital infection!
- Occurs worse if first trimester
Rarely symptomatic, but if it is, it is severe
What is the leading cause of non-hereditary sensorineural hearing loss?
CMV
All congenital infections seem to affect hearing ):
Image of baby with congenital CMV
Reminds me of dave bautista
How is CMV diagnosed?
- Elevated LFTs
- Thrombocytopenia
- Elevated bilirubin
- Urine/Saliva within first 3 weeks of life
- CT showing periventricular lesions
- If found within first 3 weeks, congenital. If after, perinatal
How is congenital CMV treated?
- Ganciclovir and Valganciclovir for symptoms.
- Must request approval for tx for severe symptoms.
Which HSV is the primary cause of congenital herpes?
HSV2
What combination in reference to herpes is the highest risk of infecting a baby?
Primary genital herpes + vaginal birth
25-50%
What is more common: neonatal or congenital?
Neonatal
What is unique about up to 75% of all infants with acquired HSV infections?
Mothers had no previous hx or clinical findings.
Who should we consider disseminated HSV infection in?
- Sepsis
- Liver dysfunction
- Negative bacteriologic cultures
- Fever
- Abnormal CSF
- Irritability
HSV is often very severe.
What is the triad of congenital herpes?
- Skin vesicles
- Ulcerations
- Scarring eye damage
Herpes is SUS
How is congenital HSV diagnosed?
- Specimen cultures (practically anything amniotic fluid touched)
- PCR for blood/urine/CSF detection
What is the TOC for congenital HSV?
IV Acyclovir (60mg/kg/d) for 2-3 weeks
Give to any infant that is suspected to have it.
What is the primary intervention for a mother if she has active genital lesions?
C-section!
When does an infant MC get VZV infections?
Mother infected between weeks 8-20.
Perinatal transmission is severe and disseminated.
Perinatal VZV = 5 days prior or 2 days post delivery.
How does congenital varicella present?
- Cicatricial skin lesions (zig zag lesion + limb atrophy)
- Cataracts, retinitis
- Hydrocephalus, microcephaly, seizures, mental retardation
- High death rate if Mother develops VZV 5-7 days postpartum.
Congenital VZV looks BAD
How is congenital varicella diagnosed?
- Characteristic skin lesion
- PCR of vesicle base
How is congenital varicella treated?
- Prophylaxis: VariZIG given to infants younger than 28wks gest following postnatal exposure
- Active tx: Acyclovir 30mg/kd/d TID
- Breastfeeding encouraged!
BFeeding has antibodies in it i think to help
What are the alternative names to Parvo B19?
- Human Parvovirus B19
- Fifth’s disease
- Erythema infectiosum
Hand slap
Who is infection rate highest in for parvo B19?
- Teachers
- Daycare workers
What % of women are usually immune to parvovirus B19?
1/2
What are the S/S of Congenital Parvo B19?
- Fetal anemia (aplastic)
- Myocarditis
- Hydrops fetalis
- Rash (slapped cheeks)
- Arthropathy
a plastic parvo
Hydrops fetalis = abnormal accumulation of fluid in 2+ fetal compartments
How is Parvo B19 diagnosed?
- Serology
- Percutaneous umbilical cord blood sample
If a mother is diagnosed with Parvo B19, how is the fetus monitored?
US weekly for signs of hydrop fetalis
Drop the Parv
What causes syphilis?
Spirochetes, treponema pallidum
How is syphilis MC transmitted congenitally and what does it usually result in?
Transplacental infection, resulting in a 40% chance of spontaneous abortion
How do most infants present with congenital syphilis?
Asymptomatic at birth.
If congenital syphilis appears prior to age 2, how does it usually present?
- Nasal Snuffles (persistent, white)
- Rash
- Hepatomegaly
- Generalized LAN
- Skeletal abnormalities
If congenital syphilis appears after age 2, how does it usually appear?
- CNS Abnormalities
- Teeth abnormalities
What are the late S/S of congenital syphilis?
- Hutchinson’s triad: interstitial keratitis, 8th CN deafness, hutchinson’s teeth
- Rhagades
- Bowing shins
- Saddle nose
- Mulberry molars
- Clutton joints
How is syphilis diagnosed?
Direct visualization via dark field exam of bodily fluids
What is the treatment for congenital syphilis?
- IV Pen G for 10 days
- Procaine Pen G for 10 days
- Repeat antibody titers at 3/6/12 months to make sure its falling
What is the MCC of sexually transmitted genital infections in the US?
Chlamydia
Chlamydia is Common
How does congenital chlamydia usually present?
- Conjunctivitis (bilateral)
- Pneumonia
The main reason for erythromycin ointment at birth
How is chlamydia diagnosed?
- Suspected in any infant under 1 month with conjunctivitis
- Gold standard: Culture of conjunctival and NP
How is chlamydia treated in an infant?
- Oral erythromycin QID x2wk
- Screen all pregnant women at first visit
Cannot use topical if they are born with it?
What kind of organism is gonorrhea?
G- diplococci
How does congenital gonorrhea present?
- Bilateral purulent conjunctivitis
- Profuse exudate
Who is at increased risk for gonorrhea?
- Previous STD
- Multiple partners
- Inconsistent condom use
- Sex workers
- Drug use
- High endemic area
What is the prophylaxis for congenital gonorrhea?
Erythromycin ointment
Prevention of conjunctivitis
How is congenital gonorrhea diagnosed?
Gram stain of conjunctival exudate
How is congenital gonorrhea treated?
Single dose of Rocephin
Also treat asymptomatic infants if mother is untreated
GR
How is HIV transmitted to a baby?
Transplacental or breastfeeding
How is congenital HIV diagnosed?
HIV DNA PCR
How is congenital HIV treated?
Antiviral prophylaxis (Zidovudine) for 6 weeks
How is Congenital Hep C transmitted primarily?
Vertical
Breastfeeding is not CI.
How is congenital Hep C diagnosed?
Anti-HCV present in blood at 18 months of age, confirmed with HCV RNA, then HCV genotyping.
What are the primary treatment options for congenital Hep C and what determines it?
Interferon and ribavirin, determined by GI.
How does congenital HPV present?
Hoarseness (airway)
What kind of virus is zika virus and how is it transmitted?
Arthropod flavivirus from mosquitoes, with placental transmission.
How does congenital zika present?
- FGR
- Fetal demise
- Ventriculomegaly
- Microcephaly
- Ocular scarring
- Sensorineural deafness
- Arthrogryposis (weird limb formation)
- ASD/VSD/PFO
- Hypertonia/Spasticity/Hyperreflexia/seizures
- SGA
How is congenital zika evaluated?
- H&P (head circumference and development)
- Labs
- Cranial US (anterior fontanelle is still open)
- Hearing assessment
What two labs being negative make zika very unlikely?
- Serum Zika IgM
- CSF for RNA and IgM
What lab combination is definite for congenital zika?
Serum + Urine for Zika RNA via PCR
Both positive = definite
What is the primary imaging screening tool for congenital zika?
Cranial US
What referrals are indicated for congenital zika?
- Ophthalmology
- Hearing screen (ABR)
- Neurology, ID, genetics, development
ABR = auditory brainstem response test
What is the definition of a newborn/neonate?
First 28d of life
What are the 3 major routes of perinatal infection?
- Bloodborne transplacental (CMV)
- Ascending due to disruption of amniotic barrier
- Infection via birth canal (HSV, HIV, GBS)
What is the MC pathogen to cause bacterial sepsis in a newborn?
Group B strep
How does early-onset newborn sepsis present?
- Respiratory distress
- Hypotension
- Acidemia
- Neutropenia
- Temperature instability
- Poor feeding
- Irritability
- Lethargy
Within 24 hrs
What temperature is considered suspicious for newborn sepsis and requires full W/u?
Rectal temp of 100.4 for any infant younger than 60d = full workup.
Anything under 90d is just newborn sepsis.
What is in a newborn sepsis workup?
- CBC/BMP
- Urine cath and culture
- CXR
- CRP and procalcitonin
- Blood cultures
- NP swab
- LP cultures
What is the empiric prophylaxic ABX therapy for newborn sepsis?
- Ampicillin + cefotaxmine
- Ampicillin + gentamicin
- Acyclovir +/-
amp and tax the neonate
Summary of ToRCHeS VP
