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TORCH infections and HIV/AIDS in newborn - d iagnostic, treatment and prophylaxis. Prof. Pavlyshyn H.A. TORCH Infections . Index of Suspicion . T=toxoplasmosis O=other (syphilis) R=rubella C=cytomegalovirus (CMV) H=herpes simplex (HSV). When do you think of TORCH infections?
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TORCH infections and HIV/AIDS in newborn - diagnostic, treatment and prophylaxis. Prof. Pavlyshyn H.A.
TORCH Infections Index of Suspicion T=toxoplasmosis O=other (syphilis) R=rubella C=cytomegalovirus (CMV) H=herpes simplex (HSV) • When do you think of TORCH infections? • IUGR infants • HSM • Thrombocytopenia • Unusual rash • Concerning maternal history • “Classic” findings of any specific infection
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 higher with infxn in 1st trimester
Clinical Manifestations • Most (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
Treatment • 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 Clinical Manifestations Early congenital (typically 1st 5 weeks): • Cutaneous lesions (palms/soles) • HSM • Jaundice • Anemia • Snuffles • Periostitis and metaphysial dystrophy • Funisitis (umbilical cord vasculitis) Late congenital: • Frontal bossing • Short maxilla • High palatal arch • Hutchinson teeth • 8th nerve deafness • Saddle nose • Perioral fissures • Can be prevented with appropriate treatment
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 non-PCN med • Maternal titers do not show adequate response (less than 4-fold decline)
Rubella Clinical Manifestations • Sensorineural hearing loss (50-75%) • Cataracts and glaucoma (20-50%) • Cardiac malformations (20-50%) • Neurologic (10-20%) • Others to include growth retardation, bone disease, HSM, thrombocytopenia, “blueberry muffin” lesions
“Blueberry 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) • 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
Diagnosis • Maternal IgG shows only past infection • Infection common – this is useless • Viral isolation from urine or saliva in 1st 3weeks of life • Afterwards may represent 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) 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
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
Whatis HIV? Human immunodeficiency virus is the virus that causes AIDS. The human immunodeficiency virus (HIV) infects cells of the immune system - (CD4+) T cells, destroying or impairing their function. Infection with the virus results in the progressive deterioration of the immune system, leading to "immune deficiency." Infections associated with severe immunodeficiency are known as "opportunistic infections", because they take advantage of a weakened immune system.
Symptoms of HIV/AIDS in Children CNS– microcephaly - progressive neurological deterioration or spastic encephalopathy - developmental delay/regression - predisposition to CNS infections Respiratory System - Recurrent infections (pneumonia, sinusitis, otitis media) - Tuberculosis - Pneumocystis carinii pneumonia (PCP) or lymphoid interstitial pneumonitis (LIP)
Clinical Features • CVS – cardiomyopathy with congestive cardiac failure • GIT- AIDS enteropathy (malabsorption, infections with various pathogens) leads to chronic diarrhoea resulting in failure to thrive - Abdominal pains, dysphagia, chronic hepatitis, pancreatitis • Renal – AIDS nephropathy: the most common presentation being nephrotic syndrome • Skin – Eczema, seborrheic dermatitis, candida infections, molluscum contagiosum, anogenital warts