TORCH Infections

5,452 views
5,295 views

Published on

0 Comments
10 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
5,452
On SlideShare
0
From Embeds
0
Number of Embeds
12
Actions
Shares
0
Downloads
321
Comments
0
Likes
10
Embeds 0
No embeds

No notes for slide

TORCH Infections

  1. 1. TORCH Infections Ashley M. Maranich, MD CPT/USA/MC Pediatric Infectious Disease Fellow
  2. 2. TORCH Infections <ul><li>T=toxoplasmosis </li></ul><ul><li>O=other (syphilis) </li></ul><ul><li>R=rubella </li></ul><ul><li>C=cytomegalovirus (CMV) </li></ul><ul><li>H=herpes simplex (HSV) </li></ul>
  3. 3. <ul><li>You are taking care of a term newborn male with birth weight/length <10 th %ile. Physical exam is normal except for a slightly enlarged liver span. A CBC is significant for low platelets. </li></ul><ul><li>What, if anything, do you worry about? </li></ul><ul><li>How do you proceed with a work-up? </li></ul>
  4. 4. Index of Suspicion <ul><li>When do you think of TORCH infections? </li></ul><ul><ul><li>IUGR infants </li></ul></ul><ul><ul><li>HSM </li></ul></ul><ul><ul><li>Thrombocytopenia </li></ul></ul><ul><ul><li>Unusual rash </li></ul></ul><ul><ul><li>Concerning maternal history </li></ul></ul><ul><ul><li>“Classic” findings of any specific infection </li></ul></ul>
  5. 5. Diagnosing TORCH Infection <ul><li>!!!!!!DO NOT USE TORCH TITERS!!!!!! </li></ul>
  6. 6. Diagnosing TORCH Infection <ul><li>Good maternal/prenatal history </li></ul><ul><ul><li>Remember most infections of concern are mild illnesses often unrecognized </li></ul></ul><ul><li>Thorough exam of infant </li></ul><ul><li>Directed labs/studies based on most likely diagnosis… </li></ul><ul><ul><li>Again, DO NOT USE TORCH TITERS! </li></ul></ul>
  7. 7. Screening TORCH Infections <ul><li>Retrospective study of 75/182 infants with IUGR who were screened for TORCH infections </li></ul><ul><li>1/75 with clinical findings, 11/75 with abnl lab findings </li></ul><ul><li>All patients screened: </li></ul><ul><ul><li>TORCH titers, urine CMV culture, head US </li></ul></ul><ul><ul><li>Only 3 diagnosed with infection </li></ul></ul><ul><ul><ul><li>NONE by TORCH titer!! </li></ul></ul></ul><ul><ul><li>Overall cost of all tests = $51,715 </li></ul></ul><ul><li>“ Shotgun” screening approach NOT cost effective nor particularly useful </li></ul><ul><li>Diagnostic work-up should be logical and directed by history/exam findings </li></ul>Khan, NA, Kazzi, SN. Yield and costs of screening growth-retarded infants for torch infections. Am J Perinatol 2000; 17:131.
  8. 8. Toxoplasmosis <ul><li>Caused by protozoan – Toxoplasma gondii </li></ul><ul><li>Domestic cat is the definitive host with infections via: </li></ul><ul><ul><li>Ingestion of cysts (meats, garden products) </li></ul></ul><ul><ul><li>Contact with oocysts in feces </li></ul></ul><ul><li>Much higher prevalence of infection in European countries (ie France, Greece) </li></ul><ul><li>Acute infection usually asymptomatic </li></ul><ul><li>1/3 risk of fetal infection with primary maternal infection in pregnancy </li></ul><ul><ul><li>Infection rate higher with infxn in 3 rd trimester </li></ul></ul><ul><ul><li>Fetal death higher with infxn in 1 st trimester </li></ul></ul>
  9. 9. Clinical Manifestations <ul><li>Most (70-90%) are asymptomatic at birth </li></ul><ul><li>Classic triad of symptoms: </li></ul><ul><ul><li>Chorioretinitis </li></ul></ul><ul><ul><li>Hydrocephalus </li></ul></ul><ul><ul><li>Intracranial calcifications </li></ul></ul><ul><li>Other symptoms include fever, rash, HSM, microcephaly, seizures, jaundice, thrombocytopenia, lymphadenopathy </li></ul><ul><li>Initially asymptomatic infants are still at high risk of developing abnormalities, especially chorioretinitis </li></ul>
  10. 10. <ul><li>Chorioretinitis of congenital toxo </li></ul>
  11. 11. Diagnosis <ul><li>Maternal IgG testing indicates past infection (but when…?) </li></ul><ul><li>Can be isolated in culture from placenta, umbilical cord, infant serum </li></ul><ul><li>PCR testing on WBC, CSF, placenta </li></ul><ul><ul><li>Not standardized </li></ul></ul><ul><li>Newborn serologies with IgM/IgA </li></ul>
  12. 12. Toxo Screening <ul><li>Prenatal testing with varied sensitivity not useful for screening </li></ul><ul><li>Neonatal screening with IgM testing implemented in some areas </li></ul><ul><ul><li>Identifies infected asymptomatic infants who may benefit from therapy </li></ul></ul>
  13. 13. Prevention and Treatment <ul><li>Treatment for pregnant mothers diagnosed with acute toxo </li></ul><ul><ul><li>Spiramycin daily </li></ul></ul><ul><ul><ul><li>Macrolide antibiotic </li></ul></ul></ul><ul><ul><li>Small studies have shown this reduces likelihood of congenital transmission (up to 50%) </li></ul></ul><ul><li>If infant diagnosed prenatally, treat mom </li></ul><ul><ul><li>Spiramycin, pyrimethamine (anti-malarial, dihydrofolate reductase inhib), and sulfadiazine (sulfa antibiotic) </li></ul></ul><ul><ul><li>Leucovorin rescue with pyrimethamine </li></ul></ul><ul><li>Symptomatic infants </li></ul><ul><ul><li>Pyrimethamine (with leucovorin rescue) and sulfadiazine </li></ul></ul><ul><ul><li>Treatment for 12 months total </li></ul></ul><ul><li>Asymptomatic infants </li></ul><ul><ul><li>Course of same medications </li></ul></ul><ul><ul><li>Improved neurologic and developmental outcomes demonstrated (compared to untreated pts or those treated for only one month) </li></ul></ul>
  14. 14. Syphilis <ul><li>Treponema pallidum (spirochete) </li></ul><ul><li>Transmitted via sexual contact </li></ul><ul><li>Placental transmission as early as 6wks gestation </li></ul><ul><ul><li>Typically occurs during second half </li></ul></ul><ul><ul><li>Mom with primary or secondary syphilis more likely to transmit than latent disease </li></ul></ul><ul><li>Large decrease in congenital syphilis since late 1990s </li></ul><ul><ul><li>In 2002, only 11.2 cases/100,000 live births reported </li></ul></ul>
  15. 15. From MMWR – Aug 2004
  16. 16. From MMWR – Aug 2004
  17. 17. Congenital Syphilis <ul><li>2/3 of affected live-born infants are asymptomatic at birth </li></ul><ul><li>Clinical symptoms split into early or late (2 years is cutoff) </li></ul><ul><li>3 major classifications: </li></ul><ul><ul><li>Fetal effects </li></ul></ul><ul><ul><li>Early effects </li></ul></ul><ul><ul><li>Late effects </li></ul></ul>
  18. 18. Clinical Manifestations <ul><li>Fetal: </li></ul><ul><ul><li>Stillbirth </li></ul></ul><ul><ul><li>Neonatal death </li></ul></ul><ul><ul><li>Hydrops fetalis </li></ul></ul><ul><li>Intrauterine death in 25% </li></ul><ul><li>Perinatal mortality in 25-30% if untreated </li></ul>
  19. 19. Clinical Manifestations <ul><li>Early congenital (typically 1 st 5 weeks): </li></ul><ul><ul><li>Cutaneous lesions (palms/soles) </li></ul></ul><ul><ul><li>HSM </li></ul></ul><ul><ul><li>Jaundice </li></ul></ul><ul><ul><li>Anemia </li></ul></ul><ul><ul><li>Snuffles </li></ul></ul><ul><ul><li>Periostitis and metaphysial dystrophy </li></ul></ul><ul><ul><li>Funisitis (umbilical cord vasculitis) </li></ul></ul>
  20. 20. <ul><li>Periostitis of long bones seen in neonatal syphilis </li></ul>
  21. 21. Clinical Manifestations <ul><li>Late congenital: </li></ul><ul><ul><li>Frontal bossing </li></ul></ul><ul><ul><li>Short maxilla </li></ul></ul><ul><ul><li>High palatal arch </li></ul></ul><ul><ul><li>Hutchinson teeth </li></ul></ul><ul><ul><li>8 th nerve deafness </li></ul></ul><ul><ul><li>Saddle nose </li></ul></ul><ul><ul><li>Perioral fissures </li></ul></ul><ul><li>Can be prevented with appropriate treatment </li></ul>
  22. 22. <ul><li>Hutchinson teeth – late result of congenital syphilis </li></ul>
  23. 23. Diagnosing Syphilis (Not in Newborns) <ul><li>Available serologic testing </li></ul><ul><ul><li>RPR/VDRL: nontreponemal test </li></ul></ul><ul><ul><ul><li>Sensitive but NOT specific </li></ul></ul></ul><ul><ul><ul><li>Quantitative, so can follow to determine disease activity and treatment response </li></ul></ul></ul><ul><ul><li>MHA-TP/FTA-ABS: specific treponemal test </li></ul></ul><ul><ul><ul><li>Used for confirmatory testing </li></ul></ul></ul><ul><ul><ul><li>Qualitative, once positive always positive </li></ul></ul></ul><ul><li>RPR/VDRL screen in ALL pregnant women early in pregnancy and at time of birth </li></ul><ul><ul><li>This is easily treated!! </li></ul></ul>
  24. 24. CDC Definition of Congenital Syphilis <ul><li>Confirmed if T. pallidum identified in skin lesions, placenta, umbilical cord, or at autopsy </li></ul><ul><li>Presumptive diagnosis if any of: </li></ul><ul><ul><li>Physical exam findings </li></ul></ul><ul><ul><li>CSF findings (positive VDRL) </li></ul></ul><ul><ul><li>Osteitis on long bone x-rays </li></ul></ul><ul><ul><li>Funisitis (“barber shop pole” umbilical cord) </li></ul></ul><ul><ul><li>RPR/VDRL >4 times maternal test </li></ul></ul><ul><ul><li>Positive IgM antibody </li></ul></ul>
  25. 25. Diagnosing Congenital Syphilis <ul><li>IgG can represent maternal antibody, not infant infection </li></ul><ul><li>This is VERY intricate and often confusing </li></ul><ul><ul><li>Consult your RedBook (or peds ID folks) when faced with this situation </li></ul></ul>
  26. 26. Treatment <ul><li>Penicillin G is THE drug of choice for ALL syphilis infections </li></ul><ul><li>Maternal treatment during pregnancy very effective (overall 98% success) </li></ul><ul><li>Treat newborn if: </li></ul><ul><ul><li>They meet CDC diagnostic criteria </li></ul></ul><ul><ul><li>Mom was treated <4wks before delivery </li></ul></ul><ul><ul><li>Mom treated with non-PCN med </li></ul></ul><ul><ul><li>Maternal titers do not show adequate response (less than 4-fold decline) </li></ul></ul>
  27. 27. Rubella <ul><li>Single-stranded RNA virus </li></ul><ul><li>Vaccine-preventable disease </li></ul><ul><ul><li>No longer considered endemic in the U.S. </li></ul></ul><ul><li>Mild, self-limiting illness </li></ul><ul><li>Infection earlier in pregnancy has a higher probability of affected infant </li></ul>
  28. 28. Copyright ©2006 American Academy of Pediatrics Meissner, H. C. et al. Pediatrics 2006;117:933-935 Reported rubella and CRS: United States, 1966-2004
  29. 29. Clinical Manifestations <ul><li>Sensorineural hearing loss (50-75%) </li></ul><ul><li>Cataracts and glaucoma (20-50%) </li></ul><ul><li>Cardiac malformations (20-50%) </li></ul><ul><li>Neurologic (10-20%) </li></ul><ul><li>Others to include growth retardation, bone disease, HSM, thrombocytopenia, “blueberry muffin” lesions </li></ul>
  30. 30. <ul><li>“ Blueberry muffin” spots representing </li></ul><ul><li>extramedullary hematopoesis </li></ul>
  31. 31. Diagnosis <ul><li>Maternal IgG may represent immunization or past infection - Useless! </li></ul><ul><li>Can isolate virus from nasal secretions </li></ul><ul><ul><li>Less frequently from throat, blood, urine, CSF </li></ul></ul><ul><li>Serologic testing </li></ul><ul><ul><li>IgM = recent postnatal or congenital infection </li></ul></ul><ul><ul><li>Rising monthly IgG titers suggest congenital infection </li></ul></ul><ul><li>Diagnosis after 1 year of age difficult to establish </li></ul>
  32. 32. Treatment <ul><li>Prevention…immunize, immunize, immunize! </li></ul><ul><li>Supportive care only with parent education </li></ul>
  33. 33. Cytomegalovirus (CMV) <ul><li>Most common congenital viral infection </li></ul><ul><ul><li>~40,000 infants per year in the U.S. </li></ul></ul><ul><li>Mild, self limiting illness </li></ul><ul><li>Transmission can occur with primary infection or reactivation of virus </li></ul><ul><ul><li>40% risk of transmission in primary infxn </li></ul></ul><ul><li>Studies suggest increased risk of transmission later in pregnancy </li></ul><ul><ul><li>However, more severe sequalae associated with earlier acquisition </li></ul></ul>
  34. 34. Clinical Manifestations <ul><li>90% are asymptomatic at birth! </li></ul><ul><ul><li>Up to 15% develop symptoms later, notably sensorineural hearing loss </li></ul></ul><ul><li>Symptomatic infection </li></ul><ul><ul><li>SGA, HSM, petechiae, jaundice, chorioretinitis, periventricular calcifications , neurological deficits </li></ul></ul><ul><ul><li>>80% develop long term complications </li></ul></ul><ul><ul><ul><li>Hearing loss, vision impairment, developmental delay </li></ul></ul></ul>
  35. 35. <ul><li>Ventriculomegaly and calcifications of congenital CMV </li></ul>
  36. 36. Diagnosis <ul><li>Maternal IgG shows only past infection </li></ul><ul><ul><li>Infection common – this is useless </li></ul></ul><ul><li>Viral isolation from urine or saliva in 1 st 3weeks of life </li></ul><ul><ul><li>Afterwards may represent post-natal infection </li></ul></ul><ul><li>Viral load and DNA copies can be assessed by PCR </li></ul><ul><ul><li>Less useful for diagnosis, but helps in following viral activity in patient </li></ul></ul><ul><li>Serologies not helpful given high antibody in population </li></ul>
  37. 37. Treatment <ul><li>Ganciclovir x6wks in symptomatic infants </li></ul><ul><ul><li>Studies show improvement or no progression of hearing loss at 6mos </li></ul></ul><ul><ul><li>No other outcomes evaluated (development, etc.) </li></ul></ul><ul><ul><li>Neutropenia often leads to cessation of therapy </li></ul></ul><ul><li>Treatment currently not recommended in asymptomatic infants due to side effects </li></ul><ul><li>Area of active research to include use of valgancyclovir, treating asx patients, etc. </li></ul>
  38. 38. Herpes Simplex (HSV) <ul><li>HSV1 or HSV2 </li></ul><ul><li>Primarily transmitted through infected maternal genital tract </li></ul><ul><ul><li>Rationale for C-section delivery prior to membrane rupture </li></ul></ul><ul><li>Primary infection with greater transmission risk than reactivation </li></ul>
  39. 39. Clinical Manifestations <ul><li>Most are asymptomatic at birth </li></ul><ul><li>3 patterns of ~ equal frequency with symptoms between birth and 4wks: </li></ul><ul><ul><li>Skin, eyes, mouth (SEM) </li></ul></ul><ul><ul><li>CNS disease </li></ul></ul><ul><ul><li>Disseminated disease (present earliest) </li></ul></ul><ul><li>Initial manifestations very nonspecific with skin lesions NOT necessarily present </li></ul>
  40. 40. <ul><li>Presentations of congenital HSV </li></ul>
  41. 41. Diagnosis <ul><li>Culture of maternal lesions if present at delivery </li></ul><ul><li>Cultures in infant: </li></ul><ul><ul><li>Skin lesions, oro/nasopharynx, eyes, urine, blood, rectum/stool, CSF </li></ul></ul><ul><li>CSF PCR </li></ul><ul><li>Serologies again not helpful given high prevalence of HSV antibodies in population </li></ul>
  42. 42. Treatment <ul><li>High dose acyclovir 60mg/kg/day divided q8hrs </li></ul><ul><ul><li>X21days for disseminated, CNS disease </li></ul></ul><ul><ul><li>X14days for SEM </li></ul></ul><ul><li>Ocular involvement requires topical therapy as well </li></ul>
  43. 44. Which TORCH Infection Presents With… <ul><li>Snuffles? </li></ul><ul><ul><li>syphilis </li></ul></ul><ul><li>Chorioretinitis, hydrocephalus, and intracranial calcifications? </li></ul><ul><ul><li>toxo </li></ul></ul><ul><li>Blueberry muffin lesions? </li></ul><ul><ul><li>rubella </li></ul></ul><ul><li>Periventricular calcifications? </li></ul><ul><ul><li>CMV </li></ul></ul><ul><li>No symptoms? </li></ul><ul><ul><li>All of them </li></ul></ul>
  44. 45. Which TORCH Infections Can Absolutely Be Prevented? <ul><li>Rubella </li></ul><ul><li>Syphilis </li></ul>
  45. 46. When Are TORCH Titers Helpful in Diagnosing Congenital Infection? <ul><li>NEVER! </li></ul>
  46. 47. Questions?

×