Pediatric Resident MGMCRI Pondicherry

1. TORCH INFECTION IN
NEONATES
DR. RAVI KUMAR S
PEDIATRIC RESIDENT
MGMCRI
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2. DISCUSSION
 Introduction
 Perinatal Infections
 Clinical features
 Diagnosis
 Treatment
 Prevention
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3. INTRODUCTION
CONGENITAL INFECTIONS
 “Infections acquired in utero or during the birth process”
 The infected newborn may show abnormal growth,
developmental anomalies, or multiple clinical and laboratory
abnormalities
 Severity depends on the gestational age of fetus at the time
of infection & virulence of the organism
 Timely diagnosis of perinatally acquired infections is crucial
the initiation of appropriate therapy.
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4. PERINATAL INFECTIONS
T = Toxoplasmosis
O = Others
R = Rubella
C = Cytomegalovirus
H = Herpes Simplex virus
The TORCH acronym has now become Obsolete, due to a
large basket of infections in “Others”
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5. TOXOPLASMOSIS
Causative Organism: Toxoplasma gondii
 Oocyst excreted in cats feces is the source of infection to
humans  Contaminates in soil, water & raw meat
Transmission: Vertical transmission can occur in utero or
during vaginal delivery & risk of fetal transmission is
 25% in 1st Trimester
 75% in 3rd Trimester
 90% during last few weeks prior delivery.
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6. CLINICAL FEATURES
Most infected newborns are asymptomatic at birth
Few develop
 IUGR
 Fever
 Maculopapular rash
 Anemia
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• Jaundice
• Seizure
• Hepatospleenomegaly
• Thrombocytopenic purpura

7. Contd.,
Classical Triad
1) Chorioretinitis
2) Diffuse Nodular Intracranial
calcifications
3) Hydrocephalus
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8. DIAGNOSIS
 Maternal history & Serology
 Clinical Examination
 Laboratory Evaluation - Serology/ CBC / LFT
 Fundus Examination - Chorioretinitis
 Neuroimaging – Intracranial Calcifications/ Hydrocephalus
 Lumbar Puncture – Elevated CSF Protein/ Mononuclear Pleocytosis
 Prenatal Diagnosis- PCR by Amniocentesis is the best method for
prenatal diagnosis of fetal infection.
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9. CONFIRMED CONGENITAL TOXOPLASMA
INFECTION
Any of the following:
1. Detection of toxoplasma specific IgM (after 5 days of life) or
IgA titres (after 10 days of life) is considered diagnostic of
congenital toxoplasmosis in infants with a positive
Toxoplasma IgG titre
2. Positive for Toxoplasma IgG beyond 12months of age
3. Positive CSF PCR
4. Increase in anti-Toxoplasma IgG titer during the first year of
life or increasing IgG titer compared with the mother's
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10. MANAGEMENT
WHO & CDC Recommends Combination Therapy for standard
treatment of congenital toxoplasmosis
 Pyrimethamine (1mg/kg/day daily for first 6months &
1mg/kg/day thrice a week for second 6 months)
 Sulfadiazine (100mg/kg/day in 2 divided doses for 1 year)
 Leucovorin (Folinic Acid; 5-10mg thrice a week)
Prevention
 Avoidance of Exposure- Food hygiene
 Maternal Screening
 Prenatal Treatment - Spiramycin
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11. RUBELLA
Also known as German Measles
Organism: RNA virus, a member of the Togavirus family
Transmission:
 Direct droplet contact from nasopharyngeal secretions 
virus replicates in the lymph tissue of the upper respiratory
tract  spreads hematogenously across the placenta  CRI
 Maternal infection rate is high, especially at the time of 1st
trimester & last 1 month
 Malformation occurs in 90% of infection during 2-10 weeks of
gestation.
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12. CLINICAL FEATURES
General: IUGR, Prematurity,
Stillbirth, Abortion
CVS: PDA, PAS, CoA
Eye: Cataracts, Microphthalmia,
Pigmentary Retinopathy
Ear: Sensory Neural Deafness
GIT: HepatoSpleenomegaly
CNS: Meningoencephalitis,
Microcephaly, Hypotonia, MR
Skin: Blueberry Muffin Rash,
Dermatoglyphic abnormalities
Blood: Thrombocytopenia
Skeletal: Radio-lucencies of
long bones
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13. Blueberry Muffin Rash
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14. DIAGNOSIS
HISTORY OF MATERNAL INFECTION
 Symptoms - Low-grade fever/Headache/mild coryza and
conjunctivitis occurring 1 to 5 days before the onset of rash.
 Maculopapular exanthem that begins on the face and
the ears and spreads downward over 1 to 2 days.
 The rash disappears in 5 to 7 days from onset,
 Posterior cervical lymphadenopathy is common.
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15. DIAGNOSIS
ANTENATAL DETECTION
 Specific IgM in Fetal blood obtained by percutaneous
umbilical cord blood sampling.
 Rubella antigen and RNA in a Chorionic villous biopsy
specimen.
POSTNATAL DETECTION OF CONFIRMED CRI
Serology: Detection of Rubella Specific
 IgM below 3months (or)
 IgG between 6months to 12 months.
Virus Isolation: pharyngeal secretions/urine sample upto 1 yr
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16. MANAGEMENT
 Supportive care
 Multi disciplinary approach
 Hearing loss - hearing aids and referral to an early
intervention program
 Structural cardiac defects – Surgical correction
 Ocular abnormalities – Referral to Ophthalmology expert
 CNS abnormalities - special education services, speech,
language, occupational, and/or physical therapy.
 Endocrine abnormalities – Expert Followup for Diabetes/
Hypothyroidism
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17. PREVENTION
 Girls should be vaccinated against rubella before entering the
childbearing years.
 Rubella vaccine is a live attenuated vaccine which is available
separately or as triple vaccine (MMR) that contain measles,
mumps and rubella.
 Principal goal of Rubella vaccination is Prevention of CRS.
 As per IAP recommendation – two doses of MMR vaccines -
1st at 15 months and the 2nd at 4–6 years
 Special care should be taken in reproductive females to avoid
pregnancy for 3 months after MMR vaccination.
 Avoidance of Exposure
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18. CMV
Causative Organism:
 Cytomegalovirus - member of herpes virus family
 It is the most common cause for Non-Hereditary cause of
SNHL worldwide.
Transmission:
 Close contact – young children attending daycare center
 Saliva/ Urine/ Blood & Breastmilk*
 Route – Transplacental/ Intrapartam/ Postnatal
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19. CLINICAL FEATURES
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At birth, most infants with
congenital CMV are asymptomatic.
Few Develop:
 SGA/Prematurity
 Hepatospleenomegaly
 Microcephaly/Periventricular
Calcifications/SNHL/Seizures
 Petechiae & Jaundice at Birth
 Thrombocytopenia
 Pneumonia

20. DIAGNOSIS
Diagnostic Testing of Urine/Saliva for CMV by
 PCR
 Viral Culture(Shell vial assay)
Detection of CMV IgG antibodies in blood
Post Natal Evaluation Include
 Physical & Neurological Examination
 Laboratory testing (CBC/Coagulation/LFT)
 Hearing assessment (ABR)
 Opthal assessment (Chorioretinitis)
 Neuroimaging (USG Cranium/CT Brain)
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21. MANAGEMENT
For symptomatic congenital CMV
 Ganciclovir* (12mg/kg/day iv infusion 2 div doses for 6
weeks)
 Valganciclovir
 Close monitoring & Followup of infected infants
Prevention
 Personal protective measures/ Avoidance of unnecessary
blood transfusion & use of leukocyte depleted blood.
 Prenatal diagnosis- By viral culture or CMV DNA detection in
amniotic fluid, or by CMV IgM antibody measurement in fetal
blood of the symptomatic fetus
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22. HSV
Organism:
 Herpes Simplex Virus(HSV) - DNA virus with two virologically
distinct types: 1 and 2
 The virus can cause localized disease of the infant's skin, eye,
or mouth (SEM) or may be Disseminated disease or CNS
disease.
Transmission:
 Contact with genital lesions during delivery: Common
 Transplacental : Rare.
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23. CLINICAL FEATURES
Inutero Infection:
Skin: Scarring, vesicles, hypo/hyperpigmenation
Eyes: Microphthalmia, retinal dysplasia
CNS: Microcephaly, encephalomalacia, hydranencephaly
Intrapartam/Postpartam Infection:
SEM disease : Vesicular lesions, Conjunctivitis, excessive tearing,
Ulcerative lesions of the mouth, palate & tongue
Disseminated disease : Sepsis, Fever, Respiratory distress, DIC,
Skin lesions, CNS involvement(60 to 75%)
CNS disease+/− Skin : Seizures, Lethargy, Irritability, Tremors,
Poor feeding, Skin lesions(60 to 70%)
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24. LESIONS OF NEONATE WITH
SEM DISEASE
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NECK VESICLES SCALP LESIONS

25. LESIONS OF NEONATE WITH
SEM DISEASE
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EYE VESICLES
HYPOPIGMENTED, SCALING, AND
CRUSTED EROSIONS OF THE
TRUNK AND EXTREMITIES

26. DIAGNOSIS
 For SEM disease - Viral Culture by Isolation – Newer vesicular
fluid, Urine & conjunctival smears.
 For Non SEM disease– PCR of CSF
 EEG and Imaging studies of brain also aids in the diagnosis of
HSV encephalitis
 Cytology of vesicular fluid – Presence of Tzanck cells
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27. MANAGEMENT
Acyclovir Therapy- 60 mg/kg/day 3 div doses
 SEM disease : Duration for 14 days
 CNS / Disseminated disease : Duration for at least 21 days, or
longer if the CSF PCR remains positive.
 Infants with ocular involvement : Ophthalmologic evaluation/
Topical ophthalmic antiviral agents in addition to parenteral
therapy.
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28. Contd.,
Recent evidence : Suggests to start on suppressive therapy
following parenteral treatment with oral acyclovir 300 mg/m2
per dose three times per day for six months as it reduces
cutaneous recurrences and is associated with improved
neurologic outcomes in infants with CNS disease.
Prevention :
 C-Section for mothers with genital lesions
 Acyclovir for pregnant mothers with primary HSV
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29. PERINATAL HIV INFECTION
Organism:
 Retrovirus
 80% of HIV Infections in children occur during perinatal
period
Transmission:
 35% Risk of Mother to child transmission(MTCT) of HIV
during perinatal period
 30% Vertical
 60% During labor & delivery
 10% Breastmilk
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30. RISK FACTORS
Maternal:
 High viral load/ Low CD4 count
 Primary infection during pregnancy/Vaginal delivery
 Pronlonged ROM
Fetoplacental:
 Chorioamnionitis
 Prematurity
Postnatal:
 Breastfeeding (viral load)/Cracked nipples/Mastitis
 EBF Infant having oral thrush at less than 6 months
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31. PREVENTION OF PERINATAL HIV
Risk of MTCT can be reduced by
 ARV Prophylaxis to the mother during pregnancy/ labor & to
the infant after birth.
 Elective C-Section(prior to onset of labor & ROM) &
 Complete avoidance of breastfeeding
 Membranes should not be artificially ruptured unless there is
fetal distress/delay in progress of labor
 Repeated vaginal examinations/instrumental delivery/
invasive procedure on fetus/ routine episiotomy must be
avoided
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32. ARV REGIME – PREGNANT WOMEN
 Recent WHO guidelines recommends an simplified, optimized
& fixed dose combination of ART
 HIV detected Pregnant women during antenatal period must
be initiated on ART regimen as below throughout the
pregnancy (regardless of clinical stage/CD4 count)
 Tenofovir(TDF) 300mg
 Lamivudine(3TC) 300mg
 Efavirez(EFV) 600mg
 Initiation shouldn’t be delayed for C4 count
 Lifelong ART is initiated as soon as possible
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Alternate Regimen
AZT+3TC+EFV
AZT+3TC+NVP
TDF+3TC+NVP

33. ARV REGIME – INFANTS BORN TO
HIV MOTHER
• If mother received ART adequately/regularly in antenatal
period: Daily NVP prophylaxis at birth till 6 weeks of life.
• If Infected Mother did not receive any ART earlier/ directly
presents in labor without adequate duration of ART(atleast 24
weeks): Daily NVP prophylaxis at birth till 12 weeks of life.
• First dose initiated within 6-12 hrs of delivery
• Dose can be increased to 20mg OD after 6-8 wks of age.
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B.WT NVP DAILY DOSE DAILY DOSE IN SUSP
<2kg 2mg/kg OD 0.2ml/kg
2-2.5kg 10mg OD 1ml OD
>2.5kg 15mg OD 1.5ml OD

34. POSTNATAL DIAGNOSIS OF HIV
INFECTION
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35. HEPATITIS B VIRUS
Organism:
 HBV- DNA Virus
 Most common cause of acute & chronic Hepatitis
Transmission:
 Exposure of Infected maternal blood via percutaneous or
permucosal routes during delivery.
 Amniocentesis
 Breastfeeding not contraindicated
Clinical Features:
 Affected neonates are mostly asymptomatic.
 Later Develop chronic antigenemia with mild and often
persistent liver enzyme elevations beginning at two to six
months of age
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36. INFANT BORN TO MOTHER WITH
HEPATITIS-B INFECTION
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37. Contd.,
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38. CONGENITAL TUBERCULOSIS
Organism:
Mycobacterium Tuberculosis
Risk factors:
 Tubercular endometriosis
 Miliary TB/Genital TB
Transmission:
 Transplacental spread
 Postnatal exposure from infected mother/healthcare worker
Clinical Features:
 Fever
 Lymphadenopathy
 Lethargy
 Poor feeding
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• HSM
• Tachypnea
• Jaundice

39. INFANT BORN TO MOTHER WITH
TUBERCULOSIS
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40. OTHER PERINATAL INFECTIONS
DISEASE TRANSMISSION SYMPTOMS DIAGNOSIS TREATMENT
Chickenpox
VZV
1st 20wks of
Pregnancy
• Cicatricial lesions
• Limb hypoplasia
• Microcephaly
• Cataract
PCR of
Vesicular fluid
• Acyclovir
• VZIG
Syphilis
T,Pallidum
Between 1st &
2nd Trimester of
Pregnancy
• Skeletal
abnormalities
• Pseudoparalysis
• Persistent rhinitis
• Maculopapular
rash
Specific IgM
fluorescent
antibody
• Benzathine
Penicillin G
Malaria
P.Vivax &
Falciparum
Infected blood
administration
• Stillbirth/IUGR
• Hemolytic Anemia
• Jaundice
Blood Smear • Chloroquine
Phosphate
Parvo Virus
B19
Within the first
20 weeks
• Abortion/ Anemia
• Hydrops
• Slapped Cheek
rash
PCR of Blood • Supportive
• IVIG
Coxsackie B Intrauterine
exposure
• Carditis
• Orofacial clefts
Cord serum for
specific IgM
Supportive
care
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41. DIAGNOSTIC TECHNIQUES FOR DIAGNOSIS
OF COMMON PERINATAL INFECTIONS
PATHOGEN TEST OF CHOICE
RUBELLA Isolation – Viral Culture of Urine/ Throat swab
Cord serum for IgM & specific IgM fluorescent
antibodies
HSV PCR of skin lesion, blood, or CSF
CMV PCR urine/saliva
Spin-enhanced urine culture (shell vial)
HIV DNA PCR – Blood if mother is HIV Infected
HBV HBsAg of blood
DNA PCR of blood
VZV PCR of skin lesion
TOXOPLASMA Specific IgM & IgA fluorescent antibody by ELISA/
ISAGA
PCR - CSF
SYPHILIS Specific IgM fluorescent antibody
Paired Maternal & Cord sera for RPR/VDRL 41

42. TAKE HOME MESSAGE
 CMV, Rubella, Toxoplasma are the most common cause of
chronic intrauterine infections in the newborn.
 Congenital TB should be suspected in newborns who have
Non-resolving pneumonia, persistent fever & HSM, in
absence of any of the bacterial pathogen isolated on culture.
 DNA PCR to detect HIV should be conducted in a neonate 6
weeks after cessation of breastfeeding.
 Timely diagnosis of perinatally acquired infections is crucial to
the initiation of appropriate therapy, development of care
plan, prognosis, and family counseling.
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43. THANK YOU
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