TORCH Infections Ashley M. Maranich, MD CPT/USA/MC Pediatric Infectious Disease Fellow
TORCH Infections
T=toxoplasmosis O=other (syphilis) R=rubella C=cytomegalovirus C=cytom egalovirus (CMV) H=herpes simplex (HSV)
TORCH Infections
T=toxoplasmosis O=other (syphilis) R=rubella C=cytomegalovirus C=cytom egalovirus (CMV) H=herpes simplex (HSV)
You are taking care of a term newborn male with birth weight/length <10th %ile. Physical Phy sical 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 workwork -up? -up?
Index of Suspicion When do you think of TORCH infections?
IIUGR UGR infants infants in H HSM SM Thro Th Thrombocytopenia romb mboc ocy yto top pen enia ia U Unusual nusual rash rash ra Conc Co Concerning ncer erni ning ng maternal matern mate rnal al history histo his tory ry ³Classic ³Cla ³Classic´ ssic´´ findings finding find ings s of any specific specific speci fic infection infect inf ectio ion n
Diagnosing TORCH Infection
!!!!!!DO NOT USE TORCH TITERS!!!!!!
Diagnosing TORCH Infection Good maternal/prenatal history Remember most infections of concern are mild illnesses often unrecognized
Thorough exam of infant Directed labs/studies based on most likely diagnosis« Again, Again, DO NOT USE TORCH TITERS!
Screening TORCH Infections Retrospective study of 75/182 infants with IUGR who were screened for TORCH infections 1/75 with clinical findings, 11/75 with abnl lab findings All patients screened: TORCH titers, urine CMV culture, head US Only 3 diagnosed with infection NONE by TORCH titer!!
Overall cost of all tests = $51,715
³Shotgun´ screening approach NOT cost effective nor particularly useful Diagnostic workwork-up should be logical and directed by history/exam findings Khan, NA, Kazzi, SN. Yield and costs of screening growth-retarded infants for torch infections. Am J Perinatol 2000 17:131.
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 hi her with infxn in 1st trimester
Clinical Manifestations Most (70(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
Chorioretinitis of congenital toxo
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
Newborn serologies with IgM/IgA
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
Prevention and Treatment Treatment for pregnant mothers diagnosed with acute toxo Spiramycin daily Macrolide antibiotic
Small studies have shown this reduces likelihood of congenital transmission (up to 50%)
If infant diagnosed prenatally, treat mom Spiramycin, pyrimethamine (anti (anti--malarial, dihydrofolate reductase inhib), and sulfadiazine (sulfa antibiotic) Leucovorin rescue with pyrimethamine
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
Large decrease in congenital syphilis since late 1990s In 2002, only 11.2 cases/100,000 live births reported
From MMWR ± ± Aug 2004
From MMWR ± ± Aug 2004
Congenital Syphilis 2/3 of affected livelive-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
Intrauterine death in 25% Perinatal mortality in 2525-30% if untreated
Clinical Manifestations Early congenital (typically 1 st 5 weeks): Cutaneous lesions (palms/soles) HSM Jaundice Anemia Anemia S nuffles Periostitis and metaphysial dystrophy Funisitis (umbilical cord vasculitis)
Periostitis of long bones seen in neonatal syphilis
Clinical Manifestations Late congenital:
Frontal bossing Short maxilla High palatal arch Hutchinson teeth
8th nerve deafness Saddle nose Perioral fissures
Can be prevented with appropriate treatment
Hutchinson teeth ± ± late result of congenital syphilis
Diagnosing Syphilis (Not in Newborns) Available serologic testing RPR/VDRL: nontreponemal nontreponemal test Sensitive but NOT specific Quantitative, so can follow to determine disease activity and treatment response
MHAMHA-TP/FTATP/FTA- ABS: ABS: specific treponemal test Used for confirmatory testing Qualitative, once positive always positive
RPR/VDRL screen in ALL pregnant women early in pregnancy and at time of birth This is easily treated!!
CDC Definition of Congenital Syphilis Confirmed if T. pallidum identified in skin lesions, placenta, umbilical cord, or at autopsy Presumptive diagnosis if any of:
Physical exam findings CSF findings (positive VDRL) Osteitis on long bone xx-rays Funisitis (³barber shop pole´ umbilical cord) RPR/VDRL >4 times maternal test Positive IgM antibody
Diagnosing Congenital Syphilis IgG can represent maternal antibody, not infant infection This is VERY intricate and often confusing Consult your RedBook (or peds ID folks) when faced with this situation
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 nonnon-PCN med Maternal titers do not show adequate response (less than 44-fold decline)
Rubella SingleSingle-stranded RNA virus Vaccine Vaccine--preventable disease No longer considered endemic in the U.S.
Mild, self self--limiting illness Infection earlier in pregnancy has a higher probability of affected infant
Reported rubella and CRS: United States, 1966-2004
Meissner, H. C.Am et al. 2006;117:933-935 Co ri ht ©2006 ic Pediatrics Acad of Pediatri
Clinical Manifestations
Sensorineural hearing loss (50(50 -75%) Cataracts and glaucoma (20(20 -50%) Cardiac malformations (20(20-50%) Neurologic (10(10-20%) Others to include growth retardation, bone disease, HSM, thrombocytopenia, ³blueberry
muffin´ lesions
³Blueberry 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
Cytomegalovirus (CMV)
M ost
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
Studies suggest increased risk of transmission later in pregnancy However, more severe sequalae associated with earlier acquisition
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
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 1 st 3weeks of life Afterwards Afterwards may represent post 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
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) HSV1 or HSV2 Primarily transmitted through infected maternal genital tract Rationale for C C--section delivery prior to membrane rupture
Primary infection with greater transmission risk than reactivation
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
Presentations of congenital HSV
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
Which TORCH Infection Presents With« Snuffles? syphilis
Chorioretinitis, hydrocephalus, and intracranial calcifications? toxo
Blueberry muffin lesions? rubella
Periventricular calcifications? CMV
No symptoms? All All of them
Which TORCH Infections Can Absolutely Be Prevented? Rubella Syphilis
