Congenital Infections

TORCH

T oxoplasmosis O ther (syphilis) R ubella C ytomegalovirus (CMV) H erpes simplex virus (HSV)

 Varicella zoster (the chickenpox virus).  Entroviruses  Hepatitis B.  Parvovirus.  HIV (human immune deficiency virus).  Chlamydia trachomatis.  Mycoplasma.  Group B streptococcus.  Malaria

COMMON CLINICAL FEATURES

 Low birth weight for gestational age  Prematurity  Seizures  Chorio-retinitis  Cataracts  Purpura  Cerebral calcification  Micro-ophthalmia  Jaundice  Anaemia  Hepatosplenomegaly  Pneumonitis

CONGENITAL CMV

 Caused by a DNA herpesvirus Cytomegalovirus (CMV)  Most common congenital viral infection  The majority of congenital infections are asymptomatic  severe neurologic morbidity occurs in 80 percent of survivors  sequelae appear to be more severe when infection is acquired earlier in pregnancy

PATHOGENESIS



Neonatal 1.

Antenatal (in utero) - 80-96% of cases

 

Primary Maternal Infection Recurrent Maternal Infection 2.

Perinatal 3.

Postnatal



Childhood 1. Horizontal Transmission

 CMV excreted in saliva, urine, stool, tears

2. Organ Transplantation

 kidney, marrow, heart, liver, blood (leukocytes)

CLINICAL FEATURES:

90% of infants with congenital CMV infection are clinically silent



CNS Manifestations



70% - microcephaly



60% - intellectual impairment



35% - sensorineural hearing loss



seizures



22% - chorioretinitis

CLINICAL FEATURES:



Systemic Manifestations



Reticuloendothelial (Liver) - 65-75%



70% - hepatomegaly/splenomegaly



68% - jaundice



65% - thrombocytopenia (with petechiae and purpura)



hepatitis



Others

65% -

low birth weight (< 2500 gm) 2-5% - pneumonitis

INVESTIGATIONS

  

Diagnostic

  

Virology

  gold standard of urine, saliva, blood, CSF, nasopharynx

Serology

  ELISA - CMV-specific IgM of neonatal blood specimens, cord sampling

Others

 PCR

Serum

 CBC - anemia, thrombocytopenia   conjugated , unconjugated hyperbilirubinemia elevated hepatic transaminases

CSF

 elevated protein content

INVESTIGATIONS:



Imaging Studies CT (Head)

 periventricular calcifications  can be identified in 25-50% of symptomatic infants

Prognosis

 Infants with signs of congenital CMV infection

80% have long-term sequelae:



sensorineural hearing loss



neuromuscular problems



motor and intellectual retardation



seizures



chorioretinitis with visual deficits



Infants with silent congenital CMV infection

have a more favourable outcome

®

Ganciclovir

CONGENITAL TOXOPLASMOSIS

 caused by the protozoan Toxoplasma gondii  ocular, central nervous system (CNS)  incidence: 0.3-1/1000 live births

Routes of Transmission

Neonatal (in utero) Primary Maternal Infection

 acquired by the ingestion of raw or undercooked meat ( cattle), or of infectious oocysts in feces (cats, birds)  1st trimester - 17% - spontaneous abortion  2nd trimester - 25% - spontaneous abortion or severe disease  3rd trimester - 65% - subclinical disease

CLINICAL FEATURES:

70% of infants with congenital toxoplasmosis infection are asymptomatic



Ocular Manifestations (76%)

 chorioretinitis  optic nerve atrophy  microphthalmias  blindness

CLINICAL FEATURES:



CNS Manifestations (52%)

 hydrocephaly  motor and intellectual retardation  seizures  sensorineuronal hearing loss  Systemic Manifestations 

classic triad of congenital toxoplasmosis :

chorioretinitis, hydrocephalus, and intracranial calcifications.

INVESTIGATIONS:

  Isolation of T. gondii from placenta or cord blood

Serology

 measures IgG T. gondii antibody  IgM fluorescent antibody test 

Imaging Studies



CT (Head)

 intracranial calcifications (33%)

MANAGEMENT

 combination of :  pyrimethamine  sulphadiazine  folinic acid is added  Spiramycin

Prevention

CONGENITAL RUBELLA

 caused by an RNA Togavirus  Vaccine-preventable disease

Routes of Transmission

Antenatal (in utero)



1st trimester - 75-90%



2nd trimester - 35-40%



3rd trimester - 25-50%

CLINICAL FEATURES:

 Neonatal Manifestations  IUGR low birth weight - prematurity  stillbirth - spontaneous abortion  Early Manifestations  cloudy corneas  Cataracts  microcephaly  hepatomegaly splenomegaly  jaundice  pulmonary valve stenosis  patent ductus arteriosus  thrombocytopenia purpura

INVESTIGATIONS:



Virology

 from urine, naspharynx, CSF 

Serology

 fetal rubella-specific IgM  persistence of rubella-specific IgG after 8-12 months of age