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PHM Board Review > Newborn - TORCH > Flashcards

Newborn - TORCH Flashcards

1
Q

What is the most common complication of intrauterine CMV infection?

A

Sensorineural hearing loss.

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2
Q

What percentage of infants with congenital CMV infection have symptoms?

A

10%

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3
Q

What is the most common CNS imaging abnormality seen in infants with congenital CMV infection?

A

Calcifications. Also ventriculomegaly and periventricular leukomalacia

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4
Q

What is the treatment for infants with congenital CMV

A

Valgancyclovir (Gancyclovir if life threatening infection).

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5
Q

Which infants with congenital CMV require treatment?

A

Symptomatic infants (except, possibly, those with isolated hearing loss).

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6
Q

When does hearing loss become evident in children with congenital CMV?

A

It can be detected at birth, but many are not detected until later in childhood.

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7
Q

Bonus Round: What percentage of hearing loss at 4 years of age is due to congenital CMV?

A

25%

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8
Q

What is the initial workup of an infant with suspected congenital CMV?

A
  1. CBC
  2. CMP (screening for liver injury)
  3. Head US (CT or MRI if abnormal)
  4. Hearing screen
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9
Q

In addition to CMV, what other congenital infections are associated with sensorineural hearing loss?

A
  1. Rubella
  2. Zika virus
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10
Q

The TORCH acronym is becoming increasingly useless due to the large number of infectious organism included under “O” (other). What are they?

A
  1. Hepatitis B
  2. Parvovirus
  3. HIV
  4. Syphilis
  5. Varicella
  6. Zika
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11
Q

In addition to hearing loss, what are the most common complications of congenital CMV infection?

A

Hepatitis
Thrombocytopenia
Periventricular intracranial calcifications
Microcephaly

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12
Q

Intracranial calcifications are associated with what three congenital infections?

A

CMV
Toxoplasma
Zika virus

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13
Q

You are caring for a 4 month old infant, with no prior health concerns, who presents with irritability. The patient is sufficiently irritable that an LP is performed which shows pleocytosis with lymphocyte predominance. A UA is positive for protein. A CBC reveals a normal white count but Hgb of 8.4 and platelets of 60,000. The patient is not moving her left arm. Plain films of the arm demonstrate radiolucent lesions. There is diffuse infiltrate noted on the portion of of the chest caught on the shoulder films. This presentation is consistent with what congenital infection?

A

Syphilis

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14
Q

Radiolucent bone lesions are associated with which two congenital infections?

A

Syphilis
Rubella

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15
Q

You are caring for a newborn delivered at 36 weeks do a mother whose pregnancy was complicated by a febrile illness. The birthweight is 2900 grams. You note the infant is microcephalic. You are not able to elicit a red reflex on ocular exam. In addition, a persistent murmur prompts a cardiac echo which finds peripheral pulmonary stenosis and a PDA. The infant subsequently fails his hearing screen. What congenital infection would explain these findings?

A

Rubella

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16
Q

What long term sequelae should be monitored for in a patient with congenital rubella?

A
  1. Learning disabilities
  2. Endocrine disorders, particularly diabetes
  3. Immune system dysfunction
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17
Q

What is the treatment for congenital rubella?

A

Supportive care and addressing the sequelae of infection. Antiviral therapy is not indicated.

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18
Q

You are caring for a newborn whose mother had a toxoplasma infection during pregnancy that was treated by her obstetrician. The infant is asymptomatic. What testing is indicated?

A
  1. Toxoplasma serologies
  2. PCR by a reference laboratory if serology equivocal
    (Note: PCR should also be performed for a symptomatic infant with negative serologies if clinical suspicion remains high).
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19
Q

What infants with known or suspected congenital toxoplasma infection should be treated?

A

All of them, regardless of whether or not they have symptoms.

In the case of equivocal serology, begin treatment until repeat testing rules out toxoplasma (note that send out labs to a reference laboratory can take weeks or months).

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20
Q

What is the treatment duration for congenital toxoplasma?

A

1-2 years.

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21
Q

What is the treatment for congenital toxoplasma infection?

A

pyrimethamine, sulfadiazine, and folinic acid

22
Q

What follow up does an infant with congenital toxoplasma infection need?

A
  1. CBCs (to screen for treatment induced anemia or neutropenia)
  2. Neurodevelopmental monitoring and therapies
  3. Opthalmology follow up
  4. Serial titers for treatment response. (Note that titers often rise again after treatment–it is not clear what this means or what to do about it.)
23
Q

What is the treatment for congenital HSV?

A

IV acyclovir for 21 (14 if only SEM disease), followed by oral acyclovir for 6 months. Topical treatment is also indicated for eye involvement. Note that repeat LP with negative PCR is required to discontinue IV acyclovir.

24
Q

Erythromycin ointment prevents opthalmia neonatorium due to which sexually transmitted infection?

A

Gonorrhea, but not chlamydia.

25
Q

What is tthe treatment for opthalmia neonatorium secondary to N. gonorrhea?

A

A single dose of ceftriaxone

26
Q

What is the duration of treatment for congenitally acquired syphillis?

A

10 days. (Repeat LP with cell count and VDRL every 6 months until normalized if positive at initial evaluation. If CSF VDRL remains positive or WBC remains elevated, patient should be retreated.)

27
Q

What is the treatment for neonatal HIV?

A

Zidovudine

28
Q

What mothers should be counseled NOT to breast feed?

A
  1. Those with HIV.
  2. Those with Hepatitis B (or C?) and cracked or bleeding nipples.
  3. Those with active Tb until treated for two weeks and negative sputum test.

(We can’t think of any other population who should be advised not to breast feed. Those who smoke marijuana should be counseled to stop smoking marijuana, not counseled to stop breastfeeding.)

29
Q

How is congenital Hepatitis B managed?

A
  1. All infants born to surface ag positive mother should be treated with Hep B immunoglobin in addition to vaccine.
  2. The mother should received anti-viral therapy prior to delivery if high viral load (>200,000 IU/ml or 1 million CFU/ml)
  3. Do not test infant for 9 months.
30
Q

What is the management for congenital Tb?

A
  1. Latent Tb: Breastfeeding ok, no treatment, simply follow up.
  2. Primary/Active Tb: Tb skin test, interferon gamma release assay, culture of gastric aspirate, LP, CXR. Start isoniazid, rifamimpin, amikacin, pyrazinamide.
31
Q

What treatment should Hepatitis C positive mothers receive during pregnancy for their Hepatitis C infection?

A

None

32
Q

What is the recommended route of delivery for infants of Hepatitis C positive mothers?

A

The Hepatitis C status of the mother need not influence route of delivery. Prolonged rupture of membranes and instrumentation should be avoided if possible.

33
Q

What testing does an infant born to a Hepatitis C positive mother need?

A
  1. HepC RNA test at 2-4 months
  2. HCV antibody test at 18 months regardless of result of initial RNA test
34
Q

What treatment do infants with vertically acquired Hepatitis C require?

A

None until several years of age. These infections often spontaneously resolve.

35
Q

Can mothers with hepatitis C breast feed?

A

Yes unless nipples are cracked or bleeding.

36
Q

How can the probability of vertical transmission of chlamydia trachomatis be minimized?

A
  1. Treatment of mother (with Azithromycin, as doxycycline is contraindicated in pregnancy).
  2. C-section without rupture of membranes.
37
Q

When does chlamydial pneumonia typically occur in infants and what is the treatment?

A

2-19 weeks of life
Azithromycin x 3 days (same as for conjunctivitis)

38
Q

What is the prophylaxis for infants born to mothers with active gonorrhea infection?
Chlamydia infection?

A
  1. Ceftriaxone 25-50 mg/kg x 1
  2. Nothing (treat mother during pregnancy if possible, otherwise deliver via c-section).
39
Q

What is the treatment for neonatal gonorrhea?

A

Ceftriaxone or cefotaxime, 7 days (14 days for meningitis).

40
Q

When and how long should infants be treated for HSV in the context of mother with active lesions?

A

7 days (if culture positive, symptomatic, OR primary outbreak regardless of culture or symptoms)
14 days (if meningitis)
If not primary outbreak, cultures are negative, and patient is asymptomatic, can stop treatment

41
Q

What is the prophylaxis for infants born to HIV+ mothers?

A

Zidovudine (start within 12 hours of delivery).
Treat for 6 weeks.
Follow-up at 2-4 weeks for testing

42
Q

What prophylaxis should be given to infants born to mothers who are Hepatitis surface antigen positive?

A

HepB vaccine and HBIG within 12 hours of delivery.

43
Q

What prophylaxis should be given to a newborn born to a mother whose Hepatitis B surface antigen status is unknown?

A

The usual hepatitis B vaccine series (first dose within 12 hours of delivery) UNLESS the infant is preterm with a birthweight <2kg, in which case HBIG should also be given.

44
Q

Should pregnant women with hepatitis B infection receive antiviral therapy during pregancy?

A

Yes, during third trimester if viral load >200,000 IU/ml (> 1 million CFUs per ml). Note that this does not alter the requirement to give HBIG to the newborn at delivery.

45
Q

What is the relative risk of vertical transmission of Hepatitis A, B, and C?

A

B&raquo_space;> C > A

46
Q

Summarize the treatment of pregnant women with Hepatitis A, B, or C during pregnancy, and the treatment of their infants after birth

A

Hepatitis A: No treatment, possible immunoglobin after delivery.
Hepatitis B: Antiviral treatment in third trimester if high viral load, HBIG and vaccine after birth.
Hepatitis C: No treatment of mother, no treatment of infant.

Note that even if vertical transmission occurs, treatment of infants with Hepatitis is supportive and focused for monitoring of development of sequelae.

47
Q

When should newborns with suspected congenital CMV be tested?

A

Ideally immediately, but at a minimum within 3 weeks of delivery, both to distinguish between congenital and antenatal infection and to ensure treatment starts within 1 month of birth. Note that healthy, term infants and children generally do not require treatment for antenatal infections.

48
Q

Which infants are at high risk for hip dysplasia and what screening do they require?

A

Those with breech presentation or positive family history.
These infants should have frog leg xrays or hip ultrasound between 4 and 6 months of age regardless of exam findings.

49
Q

Which infants require a referral to orthopedics for hip dysplasia evaluation?

A
  1. ** Those with a positive Ortolani exam (hips abducted with anterior traction). **
  2. Those with abnormal imaging at 4-6 months of age (for those infants in whom imaging is indicated).
  3. Those with a persistently abnormal Barlow exam (downward traction of adducted legs) beyond about 2 weeks of age.
  4. Those with risk factors combined with practitioner or parental concerns regardless of exam or imaging findings.
50
Q

Which infants require imaging for hip dysplasia screening?

A

Those with abnormal exam (Ortolani or Barlow) persisting beyond the first few months of life.
Infants with risk factors (family history or breech presentation).

Note that imaging should be completed by 4-6 months to ensure maximum benefit from treatment.
Also, any infant with an abnormal Ortolani exam should be referred to ortho for follow up.

51
Q

What infants should be treated with varicella immunoglobin?

A

Those whose mothers develop varicella between 5 days before and 2 days after delivery. Also it may be considered if an infant less than 2 weeks old is exposed to varicella if the infants’ mother is not immune. (Maternal immunity would otherwise be passed to the infant).

52
Q

Can a mother with varicella breastfeed?

A

Yes unless their are active lesions near the nipple. Note that if the mother developed disease within 5 days of delivery, the infant and mother should be separated, but pumped breast milk may still be provided to the infant (again, provided the mother does not have active lesions near the nipple).

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