TORCH Infections B&B

Question 1

what are the TORCH infections?

Answer 1

Toxoplasmosis
Other (syphilis, VZV, parvovirus B19)
Rubella
Cytomegalovirus (CMV)
Herpes

Question 2

how can pregnant women become infected with toxoplasmosis? what is the causative agent?

Answer 2

Toxoplasma gondii: protozoa, commonly lives in cats and oocysts shed in stool, TORCH infection

pregnant women can ingest oocysts from soil, contaminated food, etc

Question 3

what is the classic triad of a fetus exposed to toxoplasma gondii? (TORCH infection - toxoplasmosis)

Answer 3

1. hydrocephalus
2. chorioretinitis (inflammation of eye choroid)
3. intracranial calcifications (can be seen on prenatal ultrasound)

most newborns actually appear normal, but still at high risk of blindness, seizures, etc developing

Question 4

A baby is evaluated shortly after birth. Hydrocephalus and chorioretinitis are noted. The mother reports feeling well throughout the pregnancy. Of note, she owns multiple cats. What are you most concerned about?

Answer 4

Toxoplasma gondii: protozoa, commonly lives in cats and oocysts shed in stool, TORCH infection

pregnant women can ingest oocysts from soil, contaminated food, etc - most are asymptomatic

Question 5

A pregnant women is receiving a prenatal ultrasound. She reports feeling well. Intracranial calcifications are seen on imaging. The women owns multiple cats. What are you most concerned about?

Answer 5

Toxoplasma gondii: protozoa, commonly lives in cats and oocysts shed in stool, TORCH infection

pregnant women can ingest oocysts - most are asymptomatic

classic triad of fetus: hydrocephalus, chorioretinitis, intracranial calcifications

Question 6

what are the early vs late findings of congenital syphilis (TORCH infection)?

Answer 6

early: maculopapular rash, runny nose, abnormal long bones (legs)

late (not common anymore): saddle nose (no nasal bridge), hearing loss, Hutchinson teeth (notched), “mulberry” molars, Saber shins (bowed legs)

Question 7

A baby is evaluated one month after birth. A diffuse maculopapular rash is noted, as well as a profuse runny nose. The mother also had a maculopapular rash on her palms and soles during pregnancy, before receiving treatment. What is the likely cause of these shared symptoms?

Answer 7

Treponema pallidum, aka syphillis: spirochete transmitted via sexual contact, TORCH infection

maternal symptoms - chancre (primary), maculopapular rash (secondary)

child’s symptoms (early, <2yo) - maculopapular rash, runny nose, abnormal long bones (late symptoms uncommon in modern era)

Question 8

when during pregnancy can fetuses contract VZV infection from the mother? (TORCH infection)

Answer 8

primary infection during first trimester

recall primary = chickenpox (Varicella Zoster), secondary = shingles (Herpes Zoster)

Question 9

what are the newborn/long term signs and symptoms of VZV (TORCH infection)?

Answer 9

newborn - scars in dermatomal pattern (like chickenpox), microcephaly, hydrocephalus, seizures, ocular abnormalities (cataracts, nystagmus), limb atrophy/hypoplasia

long term - mental retardation, learning disabilities

Question 10

A newborn is evaluated shortly after birth. Scars are noted in a dermatomal pattern, as well as cataracts. There is microcephaly and hypoplasia of the limbs. What TORCH infection is your biggest concern? What is your long-term concern?

Answer 10

Varicella Zoster

long term - mental retardation

Question 11

How does parvovirus B19 infection present in children vs adults? Which patients are at particular risk?

Answer 11

children - fifth disease (“slapped cheek”)

adults - arthritis

patients with chronic anemia OR fetuses (TORCH infection) - aplastic crisis

Question 12

what kind of virus is parvovirus B19, which cells does it infect, and how does it spread?

Answer 12

naked, ssDNA virus found in respiratory secretions, infects RBC progenitors

Question 13

how does gestational infection with parvovirus B19 affect the fetus?

Answer 13

fetuses vulnerable to aplastic crisis due to immature immune system and shortened RBC half-life —> miscarriage or fetal death

hydrops fetalis may also occur - diffuse fluid accumulation (ascites, pleural, etc) due to severe anemia

(TORCH infection)

Question 14

how does rubella infection present in mothers vs their infected babies?

Answer 14

mothers - mild/self limited maculopapular rash, lymphadenopathy, joint pain

congenital rubella syndrome (TORCH infection) - sensorineural deafness, cataracts, patent ductus arteriosus (PDA), “blueberry muffin baby” (extra-medullary hematopoiesis)

Question 15

what are the classic clinical features of congenital rubella syndrome? (4)

Answer 15

1. sensorineural deafness
2. cataracts
3. patent ductus arteriosus (PDA)
4. “blueberry muffin baby” purpuric skin lesions (due to extra-medullary hematopoiesis)

Question 16

what is the classic cause of “blueberry muffin baby”?

Answer 16

[purpuric skin lesions]

congenital rubella syndrome (TORCH infection) - sensorineural deafness, cataracts, patent ductus arteriosus (PDA), “blueberry muffin baby” (extra-medullary hematopoiesis)

note that congenital toxoplasmosis and CMV may also cause blueberry muffin baby

Question 17

A baby is evaluated shortly after birth and is noted to have sensorineural deafness and cataracts. There is also a machine-like murmur best heard at the pulmonic position. Purpuric skin lesion are seen covering the baby. Of note, the mother reports having a self-limited maculopapular rash and mild joint pain during pregnancy which she attributed to her fatigue and allergies. What is your biggest concern?

Answer 17

congenital rubella syndrome (TORCH infection) - sensorineural deafness, cataracts, patent ductus arteriosus (PDA), “blueberry muffin baby” (extra-medullary hematopoiesis)

Question 18

what causes the “blueberry muffin” purpuric skin lesion seen in congenital rubella syndrome?

Answer 18

due to extra-medullary hematopoiesis, which normally stops prior to birth but persists in rubella infection

congenital rubella syndrome (TORCH infection) - sensorineural deafness, cataracts, patent ductus arteriosus (PDA), “blueberry muffin baby”

Question 19

how can mothers become infected with CMV and what type of illness does it cause (to the mother)?

Answer 19

most commonly via contact of infected individual (another child at daycare, family member), also sexual contact or blood/tissue exposure (transfusion, organ transplant)

usually asymptomatic, may cause “mono-like” infection (nonspecific, febrile)

(TORCH infection)

Question 20

what is the most common/major consequence of congenital CMV infection (to the baby)?

Answer 20

sensorineural hearing loss - most common infectious disease cause

Question 21

besides sensorineural hearing loss, how else might a prenatal CMV infection present in a newborn?

Answer 21

cytomegalovirus, DNA virus and TORCH infection

sensorineural hearing loss, microcephaly, “blueberry muffin baby,” most common cause of febrile seizures in newborns

[usually babies are asymptomatic + risk of hearing loss]

Question 22

A newborn baby is notably small for their gestational age and has purpuric “blueberry baby” skin lesions. Shortly after birth, they have a febrile seizure, prompting neuroimaging which reveals intracranial periventricular calcifications. The mother had a healthy pregnancy besides a mild “mono-like” febrile illness she developed after taking her first child to daycare. What is your long-term concern for the child?

Answer 22

cytomegalovirus (herpes DNA) infection (TORCH) - mother likely was infected from a child at the daycare

most common cause of febrile seizures in newborns, and most common infectious disease cause of sensorineural hearing loss

Question 23

which TORCH infection is NOT transplacental?

Answer 23

herpes simplex 2: DNA virus, genital HSV causes vesicles around vagina which may infect fetus during birth via genital tract lesions

may spread to CNS and disseminate to multiple organs

mothers are offered C-sections