TORCH infections and HIV/AIDS in newborn - diagnostic, treatment and prophylaxis.

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TORCH infections and HIV/AIDS in newborn -
diagnostic, treatment and prophylaxis.

• Prof. Pavlyshyn H.A.

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Index of Suspicion
TORCH Infections
Ttoxoplasmosis Oother (syphilis) Rrubella Ccyt
omegalovirus (CMV) Hherpes simplex (HSV)

• When do you think of TORCH infections?
• IUGR infants
• HSM
• Thrombocytopenia
• Unusual rash
• Concerning maternal
• history
• Classic findings of any specific infection

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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

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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

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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)

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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

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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 lt4wks before delivery
• Mom treated with non-PCN med
• Maternal titers do not show adequate response
  (less than 4-fold decline)

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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

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• Blueberry muffin spots representing
• extramedullary hematopoesis

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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

• Preventionimmunize, immunize, immunize!
• Supportive care only with parent education

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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
• gt80 develop long term
• complications
• Hearing loss,
• vision impairment,
• developmental delay

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• Ventriculomegaly and calcifications of congenital
  CMV

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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

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PCR diagnostic
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PCR diagnostic
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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.

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Clinical Manifestations
Herpes Simplex (HSV)

• 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

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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

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What is 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.

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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)

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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