Transcript TORCH Infections

TORCH infections and
HIV/AIDS in newborn
- diagnostic, treatment and prophylaxis.
Prof. Pavlyshyn H.A.
TORCH Infections
T=toxoplasmosis
O=other (syphilis)
R=rubella
• When do you think of TORCH infections?
C=cytomegalovirus (CMV)
• IUGR infants
H=herpes simplex (HSV)
• HSM
• Thrombocytopenia
Index of Suspicion
• Unusual rash
• Concerning maternal
history
• “Classic” findings of any specific infection
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
• Most (70-90%) are asymptomatic at birth
Clinical Manifestations
• 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
Treatment
• 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
Clinical Manifestations
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Early congenital (typically 1st 5 weeks):
Cutaneous lesions (palms/soles)
HSM
Jaundice
Anemia
Snuffles
Periostitis and metaphysial dystrophy
Funisitis (umbilical cord vasculitis)
Late congenital:
Frontal bossing
Short maxilla
High palatal arch
Hutchinson teeth
8th nerve deafness
Treatment
• Penicillin G is THE drug of choice for ALL
syphilis infections
• Maternal treatment during pregnancy very
effective (overall 98% success)
• Treat newborn if:
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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
Clinical Manifestations
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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
“Blueberry muffin” spots representing
extramedullary hematopoesis
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
• Diagnosis after 1 year of age difficult to establish
Treatment
• Prevention…immunize, immunize,
immunize!
• Supportive care only with parent
education
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Cytomegalovirus
(CMV)
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
Ventriculomegaly and
calcifications of
congenital CMV
Diagnosis
• Maternal IgG shows only past infection
• Infection common – this is useless
• Viral isolation from urine or saliva in 1st
3weeks of life
• Afterwards may represent post-natal infection
• Viral load and DNA copies can be assessed
by PCR
• Less useful for diagnosis, but helps in following
viral activity in patient
• Serologies not helpful given high antibody in
population
PCR diagnostic
PCR diagnostic
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.
Herpes Simplex (HSV)
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
•Ocular involvement requires topical therapy as
well
What is HIV?
• Human immunodeficiency virus is the virus that causes AIDS.
• The human immunodeficiency virus (HIV) infects cells of the immune
system - (CD4+) T cells, destroying or impairing their function.
• Infection with the virus results in the progressive deterioration of the
immune system, leading to "immune deficiency."
• Infections associated with severe immunodeficiency are known as
"opportunistic infections", because they take advantage of a
weakened immune system.
Symptoms of HIV/AIDS in
Children
CNS – microcephaly
- progressive neurological deterioration
or spastic encephalopathy
- developmental delay/regression
- predisposition to CNS infections
Respiratory System
- Recurrent infections (pneumonia, sinusitis, otitis
media)
- Tuberculosis
- Pneumocystis carinii pneumonia (PCP) or
lymphoid interstitial pneumonitis (LIP)
Clinical Features
• CVS – cardiomyopathy with congestive cardiac failure
• GIT- AIDS enteropathy (malabsorption, infections with
various pathogens) leads to chronic diarrhoea resulting in
failure to thrive
- Abdominal pains, dysphagia, chronic hepatitis, pancreatitis
• Renal – AIDS nephropathy: the most common presentation
being nephrotic syndrome
• Skin – Eczema, seborrheic dermatitis, candida infections,
molluscum contagiosum, anogenital warts