Torch Infection

TORCH INFECTION
PRESENTED BY : DR. HEM NATH SUBEDI
RESIDENT

CONTENTS
• INTRODUCTION
• SCREENING FOR TORCH INFECTION
• CLINICAL FEATURES OF TORCH INFECTION
• APPOROACH TO INFANT WITH SUSPECTED
INTRAUTERINE INFECTION
• SUMMARY OF MANAGEMENTS

INTRODUCTION
• The original concept of the TORCH perinatal
infections was to group five infections with
similar presentations, including rash and
ocular findings.
These five infections are:
●Toxoplasmosis
●Other (syphilis)
●Rubella
●Cytomegalovirus (CMV)
●Herpes simplex virus (HSV)
Epps RE, Pittelkow MR, Su WP. TORCH syndrome. Semin Dermatol 1995; 14:179.

Incidence
• World wide incidence of TORCH varies it is up to
10% of congenital infection.
• Incidence in india the specific IgM antibodies
were found to be positive 1
– 19.4% cases for toxoplasmosis
– 30.4% cases for the Rubella virus
– 34.7%cases for CMV
– 33.5%for the HSV-2 infections.
• Incidence in nepal the seropositivity for T.
gondii was 50%, rubella virus 50%, HSV-2 33.3%,
and CMV 8.3% in pregnancy.2
1.Sen MR, Shukla BN, Tuhina B. Prevalence of Serum Antibodies to TORCH Infection in and Around
Varanasi, Northern India. J Clin Diagn Res. 2012 Nov;6(9):1483-5

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.
• Congenital Toxoplasmosis
– United States – 1 in 1000 to 1 in 10000 Primary
maternal infection in pregnancy
– 1 in 3 risk of fetal infection
– Infection rate higher with infection in 3rd trimester
– Fetal death higher with infection in 1st trimester
American Academy of Pediatrics. Toxoplasma gondii Infections. In: The Red Book 2006, 27th
Ed. p.666

• The incidence of prenatal infection resulting in
birth of a newborn with congenital
toxoplasmosis
– United State -0.8 per 10,000 live births
– France -10 per 10,000 live births
– Globally 3rd
of population is affected.
Cunninghams , Infectious Disease in williams obstetrics 24th
edition, newyork , macgraw hill
publication, 2014 pp 1255.

Clinical features-Maternal
• maternal symptoms in immunocompetent
– Fatigue
– Fever
– Headache
– muscle pain
– maculopapular rash
– posterior cervical lymphadenopathy.
• In immunocompromised.
– Encephalitis
– Retinochoroiditis
– mass lesions
• Four fold increase in preterm delivery rate.

Clinical features
• estimated the risk to be 15 percent at 13
weeks,44 percent at 26 weeks, and 71
percent at 36 weeks. 1
• Asymptomatic at birth in 70% - 90%
• Symptoms become apparent later in life
• Classic Triad
– Chorioretinitis *
– Hydrocephalus
– Intracranial calcifications
• Consequences of intrauterine meningo-
encephalitis
• Initially asymptomatic infants are still at
high risk of developing abnormalities,
especially chorioretinitis

Screening
• Prenatal testing with varied sensitivity not
useful for screening
• Routine neonatal screening with IgM testing
implemented in some areas
• Identifies infected asymptomatic infants who
– may benefit from therapy
Guerina NG et al., Neonatal screening and early treatment for congenital Toxoplasma gondii
infection. The New England Regional Toxoplasma Working Group. NEJM 1994; 330:1858

diagnosis
• Serology
• DNA PCR sensitivity is 81-88%.
• Histology
• Isolation of toxoplasma gondii-91-94%.
• Usg finding of congenital infection
– Intracranial calcifications
– Hydrocephaly
– Liver calcifications
– Ascites
– Placental thickening
– Hyperechoic bowel
– Growth restriction
edition, newyork , macgraw hill publication,
2014 pp 1255.
Dk james , infection in pregnancy in High Risk Pregnancy Management Option, 4th
edition, elsevier , uk ,
2011, pp-556.

Management
edition, elsevier , uk , 2011, pp-556.

Syphilis
• Nickname “lues” came from the Latin lues venereum, which means
“disease,” “sickness,” or “pestilence,” and originally was loosely
applied to any venereal disease.
• Caused by – Treponema pallidium(spirochete)
• Incidence of syphilis
• Worldwide- 10.6 million cases of syphilis
• In Nepal - 2.5-19.3 % (STD/AIDS Conselling and Training Services, Family Health International, USAID. Kathmandu FSW Seroprevalence Study. 2000)
• In USA-
– 0.9 case per 100,000 persons in 2012
– 9-percent decrease from 2010
edition, newyork , macgraw hill publication, 2014 pp 1255.

• Transmitted via sexual contact.
• Placental transmission as early as 6wks gestation
– Typically occurs during second half
– Mother with primary or secondary syphilis more likely to
transmit than latent disease
• The incubation period averages 3 weeks—3 to 90 days—
depending on host factors and innoculum size.
• These are associated with the highest spirochete loads and
transmission rates of up to 30 to 50 percent.

Clinical manifestation
Primary Syphillis- Chancre, 2 to 8week period
Secondary syphilis develop after 4 to 10 week of infection
– dermatological abnormalities - 90 percent of women.
– A diffuse macular rash plantar and palmar target like lesions,
patchy alopecia, and mucous patches may be seen.
– Condylomata lata are flesh-colored papules and nodules
found on the perineum and perianal area.
– constitutional symptoms
– Up to 40 percent will have cerebrospinal fluid abnormalities,
although only 1 to 2 percent will develop clinically apparent
aseptic meningitis.
– Hepatitis, nephropathy, ocular changes, anterior uveitis,
and periostitis may also develop.

• Latent syphilis develops when primary or secondary syphilis is
not treated.
– reactive serological testing
– resolved clinical manifestations.
• Early latent syphilis is latent disease acquired within
the preceding 12 months.
• Disease diagnosed beyond 12 months is either late
latent syphilis or latent syphilis of unknown duration.
• Tertiary or late syphilis

Clinical features
• Fetal:
– Stillbirth
– Neonatal death
– Hydrops fetalis
• Intrauterine death in 25%
• Perinatal mortality in 25-30% if untreated

Diagnosis
• Direct microscopic examination.
• Usg features of congenital syphilis.
• Serological examination.
– VDRL
– RPR
– TPHA
– FTA-abs

Treatment

Rubella
• Another name: German
measles or third disease
• Caused by : RNA virus
• Rubella infection in the first
trimester, however, poses
significant risk for abortion and
severe congenital
malformations.
• The incubation period is 12 to
23 days.

Diagnosis
• Rubella may be isolated from the urine, blood, nasopharynx,
and cerebrospinal fluid for up to 2 weeks after rash onset.
• Serology
– Specific IgG, IgM
– If no confirmed IgG avidity test is to be done.

edition,
elsevier , uk , 2011, pp-556.

CMV
• CMV, a DNA virus, is a member of the herpes family of
viruses, which causes a number of infectious syndromes in
humans.
• Three disease states are particularly important:
– intrauterine
– neonatal infection
– immunocompromised patient.
• 0.2 to 2.5 percent of all neonates

• The virus is secreted into all body fluids, and person-
to-person contact with viral-laden saliva, semen,
urine, blood, and nasopharyngeal and cervical
secretions can transmit infection.

Spectrum of infection
• Intrapartum – From Cervical and Vaginal Secretions
– 2% to 28% of seropositive pregnant women shed CMV
– Approximately 50% of exposed infants become infected
– Develop clinical signs of CMV disease at about 4 to 6 weeks
of age.
• Postpartum period – Breast Feeding
– 9% to 88% of seropositive women shed CMV into their milk.
– 50% to 60% of infants become infected.
– Show no significant clinical signs (re-activation disease)
• Blood Transfusions
– 2 -20% from unscreened or unfiltered blood
Stehel EK and Sanchez PJ. Cytomegalovirus Infection in the Fetus and Neonate. NeoReviews
2005;6;e38-e45

Infant outcome following cytomegalovirus (CMV)
maternal infection in pregnancy.
edition,
elsevier , uk , 2011, pp-556.

diagnosis
• Serology
– CMV IgG, CMV IgM
– CMV IgM is not useful ?
– CMV IgG Avidity test should be done
• DNA PCR
• Neuclic Acid Amplification test
– Sensitivities range from 70 to 99 percent and depend on
amniocentesis timing
• Usg finding of congenital CMV infections
– Findings include microcephaly, ventriculomegaly, and cerebral
calcifications; ascites, hepatomegaly, splenomegaly, and
hyperechoic bowel; hydrops; and oligohydramnios

Clinical features
• Most infections are asymptomatic, but 10 to 15 percent of
infected adults have a mononucleosis-like syndrome
characterized by
– Fever
– Pharyngitis
– Lymphadenopathy
– polyarthritis.
• Immunocompromised women may develop
– Myocarditis
– Pneumonitis
– Hepatitis
– retinitis,
– Gastroenteritis
– meningoencephalitis.

• Recurrent maternal infection infects the fetus in only
0.15 to 1 percent of cases.
• A review of nine studies of CMV vertical transmission
rates reported
– first-trimester 36 percent
– second-trimester 40 percent
– third-trimester 65 percent

Munro SC et al., Diagnosis of and Screening for CMV infection in Pregnant Women. J. Clin Micro
2005; 43 (9); 4713-4718

Management
• The management of the immunocompetent
pregnant woman with primary or recurrent CMV
is limited to symptomatic treatment.
• Counseling for continuation or termination
– pregnancy termination may be an option for some.
• Ganciclovir
• No vaccine available till now.
• Avoid primary infection to mother.
• Encourage maintain personal hygiene.

Herpes Simplex Virus
• Genital herpes simplex virus infection is one of the most
common sexually transmitted diseases.
• DNA Virus
• Two type
– HSV 1
– HSV 2
• Type 1 is responsible for most nongenital infections.
However, more than half of new cases of genital herpes in
adolescents and young adults are caused by HSV-1
infection.
• Type 2 HSV is recovered almost exclusively from the genital
tract and is usually transmitted by sexual contact. Most
recurrences—greater than 90 percent—are secondary to
HSV-2.

• Neonatal transmission is by three routes:
– Intrauterine in 5 percent.
– Peripartum in 85 percent.
– Postnatal in 10 percent.
• The overall transmission rate is 1 in 3200 to 1 in
30,000 births depending on the population
studied.
• Infants born to women who acquire genital HSV
near the time of delivery have a 30- to 50-
percent risk of infection.

Clinical features
• First episode primary infection describes cases in which HSV-
1 or -2 is isolated from genital secretions in the absence of
HSV-1 or -2 antibodies.
• First episode nonprimary infection is diagnosed when HSV is
isolated in women who have only the other serum HSV-type
antibody present.
• Reactivation disease is characterized by isolation of HSV-1 or
-2 from the genital tract in women with the same serotype
antibodies.
• Asymptomatic viral shedding is defined by HSV as detected
by culture or PCR in the absence of clinical findings.
• Most infected women shed virus intermittently, and most
HSV transmission to a partner occurs during periods of
asymptomatic viral shedding.

First-episode primary genital herpes simplex virus
infection. On the left labium majora and mons, both
vesicles and ulcers are seen.

Fetal features
• 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
• Cell culture and PCR
• Serology- HSV glycoproteins G1 and G2

Varicella Zoster
• Herpes virus family, DNA virus.
• If infection occurs in first trimester 4.9% risk of congenital
varicella .
• Congenital Syndrome
-Limb hypoplasia
-Ocular abnormalities
-CNS abnormalities ( convulsive disorders ).
-Dermatomal scarring
• Serology (IgG and IgM).
• Screening: Routine screening generally not recommended.
• Prevention: If pregnant woman (with no history of previous
chickenpox) is exposed, perform STAT Varicella IgG.
• Exposed neonate should receive VZ IG prophylaxis.

Parvovirus
• Human parvovirus B19 (DNA virus)
- erythema infectiosum in childhood
- chronic arthropathy
- chronic bone marrow failure (immunodefic)
- aplastic crisis (Sickle disaease)
• Incubation 4-14 days
• Respiratory droplet spread
• High fever, “Slapped cheek syndrome’
non specific rash, no symptoms
Hydrops (anaemia, myocarditis)

Take home message
• Serology is not useful in TORCH infection
• Routine screening is not recommended in
every type of TORCH infection , screening
should recommended in endemic areas.
• In our context we routinely do VDRL for
syphilis.
• Prevention Is better than cure.

Torch Infection

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