Professional Documents
Culture Documents
TORCH Maranich
TORCH Maranich
TORCH Maranich
Introduction
You are taking care of a term newborn male with birth weight/length <10th %ile. Physical exam is normal except for a slightly enlarged liver span. A CBC is significant for low platelets. What, if anything, do you worry about? How do you proceed with a work-up?
Index of Suspicion
When do you think of TORCH infections?
IUGR infants Thrombocytopenia Unusual rash Concerning maternal history Classic findings of any specific infection
Shotgun screening approach NOT cost effective nor particularly useful Diagnostic work-up should be logical and directed by history/exam findings
Khan, NA, Kazzi, SN. Yield and costs of screening growth-retarded infants for torch
Toxoplasmosis
Caused by protozoan Toxoplasma gondii Domestic cat is the definitive host with infections via:
Ingestion of cysts (meats, garden products) Contact with oocysts in feces
Much higher prevalence of infection in European countries (ie France, Greece) Acute infection usually asymptomatic 1/3 risk of fetal infection with primary maternal infection in pregnancy
Infection rate higher with infxn in 3rd trimester Fetal death higher with infxn in 1st trimester
Clinical Manifestations
Most (70-90%) are asymptomatic at birth Classic triad of symptoms:
Chorioretinitis Hydrocephalus Intracranial calcifications
Other symptoms include fever, rash, HSM, microcephaly, seizures, jaundice, thrombocytopenia, lymphadenopathy Initially asymptomatic infants are still at high risk of developing abnormalities, especially chorioretinitis
Diagnosis
Maternal IgG testing indicates past infection (but when?) Can be isolated in culture from placenta, umbilical cord, infant serum PCR testing on WBC, CSF, placenta
Not standardized
Toxo Screening
Prenatal testing with varied sensitivity not useful for screening Neonatal screening with IgM testing implemented in some areas
Identifies infected asymptomatic infants who may benefit from therapy
Small studies have shown this reduces likelihood of congenital transmission (up to 50%)
Symptomatic infants
Pyrimethamine (with leucovorin rescue) and sulfadiazine Treatment for 12 months total
Asymptomatic infants
Course of same medications Improved neurologic and developmental outcomes demonstrated (compared to untreated pts or those treated for only one month)
Syphilis
Treponema pallidum (spirochete) Transmitted via sexual contact Placental transmission as early as 6wks gestation
Typically occurs during second half Mom with primary or secondary syphilis more likely to transmit than latent disease
Congenital Syphilis
2/3 of affected live-born infants are asymptomatic at birth Clinical symptoms split into early or late (2 years is cutoff) 3 major classifications:
Fetal effects Early effects Late effects
Clinical Manifestations
Fetal:
Stillbirth Neonatal death Hydrops fetalis
Clinical Manifestations
Early congenital (typically 1st 5 weeks):
Cutaneous lesions (palms/soles) HSM Jaundice Anemia Snuffles Periostitis and metaphysial dystrophy Funisitis (umbilical cord vasculitis)
Clinical Manifestations
Late congenital:
Frontal bossing Short maxilla High palatal arch Hutchinson teeth 8th nerve deafness Saddle nose Perioral fissures
Diagnosing Syphilis
(Not in Newborns)
Available serologic testing
RPR/VDRL: nontreponemal test
Sensitive but NOT specific Quantitative, so can follow to determine disease activity and treatment response
RPR/VDRL screen in ALL pregnant women early in pregnancy and at time of birth
This is easily treated!!
Treatment
Penicillin G is THE drug of choice for ALL syphilis infections Maternal treatment during pregnancy very effective (overall 98% success) Treat newborn if:
They meet CDC diagnostic criteria Mom was treated <4wks before delivery Mom treated with non-PCN med Maternal titers do not show adequate response (less than 4-fold decline)
Rubella
Single-stranded RNA virus Vaccine-preventable disease
No longer considered endemic in the U.S.
Mild, self-limiting illness Infection earlier in pregnancy has a higher probability of affected infant
Clinical Manifestations
Sensorineural hearing loss (50-75%) Cataracts and glaucoma (20-50%) Cardiac malformations (20-50%) Neurologic (10-20%) Others to include growth retardation, bone disease, HSM, thrombocytopenia, blueberry muffin lesions
Diagnosis
Maternal IgG may represent immunization or past infection - Useless! Can isolate virus from nasal secretions
Less frequently from throat, blood, urine, CSF
Serologic testing
IgM = recent postnatal or congenital infection Rising monthly IgG titers suggest congenital infection
Treatment
Preventionimmunize, immunize, immunize! Supportive care only with parent education
Cytomegalovirus (CMV)
Most common congenital viral infection
~40,000 infants per year in the U.S.
Mild, self limiting illness Transmission can occur with primary infection or reactivation of virus
40% risk of transmission in primary infxn
Clinical Manifestations
90% are asymptomatic at birth!
Up to 15% develop symptoms later, notably sensorineural hearing loss
Symptomatic infection
SGA, HSM, petechiae, jaundice, chorioretinitis, periventricular calcifications, neurological deficits >80% develop long term complications
Hearing loss, vision impairment, developmental delay
Diagnosis
Maternal IgG shows only past infection
Infection common this is useless
Treatment
Ganciclovir x6wks in symptomatic infants
Studies show improvement or no progression of hearing loss at 6mos No other outcomes evaluated (development, etc.) Neutropenia often leads to cessation of therapy
Treatment currently not recommended in asymptomatic infants due to side effects Area of active research to include use of valgancyclovir, treating asx patients, etc.
Clinical Manifestations
Most are asymptomatic at birth 3 patterns of ~ equal frequency with symptoms between birth and 4wks:
Skin, eyes, mouth (SEM) CNS disease Disseminated disease (present earliest)
Initial manifestations very nonspecific with skin lesions NOT necessarily present
Diagnosis
Culture of maternal lesions if present at delivery Cultures in infant:
Skin lesions, oro/nasopharynx, eyes, urine, blood, rectum/stool, CSF
CSF PCR Serologies again not helpful given high prevalence of HSV antibodies in population
Treatment
High dose acyclovir 60mg/kg/day divided q8hrs
X21days for disseminated, CNS disease X14days for SEM
Periventricular calcifications?
CMV
No symptoms?
All of them
Questions?