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TORCH
1. You are taking care of a term newborn male with birth
weight/length <10th %ile. Physical exam is normal
except for a slightly enlarged liver span. A CBC is
significant for low platelets
What, if anything, do I worry about?
3. 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)
Also described as STORCH
4. VIRUSES
Varicella, Parvovirus B19,
Hep B and C, HIV
Enteroviruses (coxackie)
BACTERIA
Listeria, Neisseria
Mycobacterium tuberculosis, salmonella, campylobater
PARASITES
Trepenoma pallidum, plasmodium
FUNGAL
Candida
6. Fetus may get infected
In utero
During delivery
Severity of manifestation depends on gestational age
Less the age more the morbidity
May lead to fetal loss or congenital malformations
Neonate may be even asymptomatic at birth and may
manifest symptoms later anytime during infancy or
even upto first decade of life
Therefore it is very important to recognize and manage
the neonate at the earliest
8. COMMON PRESENTATION
1. Premature delivery
2. IUGR or intrauterine death
3. Jaundice, petechia or purpura
4. Hepatosplenomegaly,
anemia,thrombocytopenia
5. Hydrocephaly,
microcephaly,intracranial calcification
6. Chorioretinitis
7. Myocarditis & cardiac abnormalities
But each infection have its peculiar
presentation and management
So, very important to differentiate
and identify the particular
infection
9. DNA virus and a member of the “herpesvirus group”.
Most common congenital infection
Severe sequalae are more common with infection in
the 1st trimester, while the overall risk of infection is
greatest in the 3rd trimester
Congenital CMV affects about 0.2-2.5% of babies
worldwide
Of these, only 1-10% of the babies born with the CMV
infection will have symptoms at birth and another 10-
15% may not show any symptoms at birth, but still may
have long term affects such as hearing loss and
learning disabilities
10. Secreted in all body fluids
Close contact through saliva, blood, genital secretions,
urine
Neonatal infection
Intrauterine or transplacental
Intrapartum – 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.
11. Postpartum period – Breast Feeding
9% to 88% of seropositive women shed CMV into their milk
50% to 60% of infants become infected
Blood Transfusions
2 -20% from unscreened or unfiltered blood
Especially preterms are more prone
Source - Stehel EK and Sanchez PJ. Cytomegalovirus
Infection in the Fetus and Neonate. NeoReviews
2005;6;e38-e45
15. COTTAGE CHEESE WITH KETCHUP TYPE OF
CHORIORETINITIS
NORMAL ABNORMAL
16. SENSINEURAL DEAFNESS
Most commonly seen if infection occurs in first or
second trimester
Usually progressive, unilateral or bilateral and may even
manifest later in life
17. ANTIBODY TITRE
IgG and IgM by ELISA
Not reliable
VIRAL DETECTION (GOLD STANDARD)
Neonatal body fluids – urine, blood, saliva by PCR or
culture within first 3 weeks of life
NEUROIMAGING
Cranial Ultrasound or MRI
OTHERS
Ophthalmology and audiological evaluation
18. PREVENTION IS BETTER THAN CURE
Mother should wash hands before and after handling
the baby
No donor breast milk
High chances of transmission through breast milk especially
in preterms
Mother can continue breast feeding
Avoid unnecessary blood transfusion
19. WHEN TO GIVE
Specific indication
Chorioretinitis
Relative indication
Hepatitis, menigioencephalitis,
Rx
Ganciclovir
Induction - 5mg/kg/dose 12 hourly for 2-3 weeks
Maintainence – 5mg/kg/dose once daily for 8-10 weeks
Very toxic – Daily monitoring of blood counts and platelets
Should be stopped if Neutrophils < 500/mm3 or platelets <
25000/mm3
May lead to testicular atrophy
20. Also known as German Measles
Single stranded RNA virus, member of family
Togavirus, and the genus, Rubivirus
Vaccine preventable disease
Effect on fetus
1st trimester- 80% infection, 90% malformation
2nd trimester- 25% infection, 30% malformation
3rd trimester- 100% infection, 10% malformation
Spontaneous abortions occur in upto 20% of cases if
infection occur within 20 wks of gestation.
21. MAY BE ASMPTOMATIC
May present as acute viral illness
Low grade fever, headache, swollen lymph nodes, joint
pain runny nose and rash
Contagious one week before and after the rash
22. Congenital rubella syndrome presents a classic triad
EYE
Cataract
Glaucoma
Chorioretinitis
Microphthalmia
EAR
Sensorineural hearing loss is the most frequent sequelae -80% of
infected children
Bilateral and progressive
HEART
Congenital malformation in ~ 50% of children infected in first 8
wks of gestation and consist of PDA, Pulmonary artery stenosis
25. ANTIBODY TITRE
IgG and IgM by ELISA
Reliable
VIRAL DETECTION
Pharyngeal secretions, urine, stool, eye discharge, blood
and CSF upto 1 year of age
26. PRE-PREGNANCY
Childhood vaccination – MMR
Vaccination programs for girls in their teens
PRE-NATAL
Routine checkup of rubella immunity status at first visit
Accidental vaccination in early pregnancy not an
indication of termination
27. No specific treatment available
Supportive management can be provided
Self limiting disease
Should be nursed in isolation
Heart defects and cataracts can be corrected surgically,
but damage to CNS is permanent
Long term follow up important, as some
abnormalities may develop beyond the first decade of
life
28. Caused by Toxoplasma gondii –
an obligate intracellular
protozoan parasite
Oocyst, excreted in cat feces –
source of infection to humans
In patients with an existing HIV
infection, toxoplasmosis is an
important opportunistic
infection with considerable
morbidity and mortality
especially in the pregnant
women
29.
30. In most immunocompetent individuals, including children
and pregnant women, the infection goes unnoticed
•In approximately 10% of the patients it causes a self-
limiting illness, most commonly in the 25-35 years age
group
Painless lymphadenopathy(Local or Generalised) is the
most common presenting feature. Cervical lymph nodes
are involved in particular. The mesenteric, mediastinal or
the retroperitoneal nodes may also be involved
•Other features include - Malaise, Fever, Fatigue, Muscle
pain, Sore throat and headache
31. Clinical features vary widely and can manifest at
different times before and after birth
Most infected(70-90%) infants are asymptomatic at
birth but up to 80% may develop learning and visual
disabilities later
Classic triad is found in < 10%
Chorioretinitis
Intrcranial calcification
Hydrocephalus
OTHERS
Srabismus, nystagmus and visual impairment
35. SEROLOGY BY ELISA (Enzyme linked immunosorbent
essay) or ISAGA (Immunoglobulin M immunosorbent
agglutination assay)
Positive toxoplasma IgG in infant at 12 months of age –
diagnostic (GOLD STANDARD)
Positive IgM or IgA at 5-10 days of life
ISAGA more sensitive than ELISA
CSF analysis
Positive T.Gondii specific IgM in CSF fluid diagnostic
Can produce CSF eosinophilia or extremely high proteins
level (> 1000mg/dl)
PCR
Positive in CSF, blood, or urine is diagnostic
36. MOTHER
SPIRAMYCIN
2gm/day throughout pregnancy
After 20 weeks gestation add sulfadiazine and pyrimethamine
INFANT
FIRST 6 MONTHS
Sulfadiazine 100 mg/kg/day in 2 divided doses
Pyrimethamine 1 mg/kg/day single dose
NEXT 6 MONTHS
Same therapy for 1 month alternated with spiramycin for 1 month(100
mg/kg/day in 2 divided doses)
Precaution
Sulfadiazine not to be used during 1st week
Folinic acid (5mg twice weekly) to be given along with
pyrimethamine
37. CORTICOSTEROIDS
When toxoplasmosis associated with acute
inflammatory response ( chorioretinitis, raised CSF
proteins etc)
Given for 8-12 weeks
Eyes to be examined every 3 months till the age of 18
months and then yearly
NEITHER MOTHER NOR INFANT IS INFECTIOUS
AND CAN BE HANDLED NORMALLY
38. Endemic in cat friendly countries unlike INDIA
Cats should be handled with gloves, kept indoors and
hand washed after their handling
Meat should be eat after thorough cooking
Hands should be washed before and after eating
39. • DNA Virus
• Two type
– HSV 1
– HSV 2
• Type 1 is responsible for most non-genital 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.
40. HSV infection of the neonate can be acquired
intrauterine, intrapartum, or postnatal
Most infections are acquired in intrapartum (85%)
period as ascending infections with rupture
membranes or by delivery through an infected
cervix or vagina
RISK OF DEVELOPING INFECTION
25 % with HSV1
2% with HSV2
41. MAY BE ASMPTOMATIC
Most infected women shed virus intermittently, and
most HSV transmission to a partner occurs during
periods of asymptomatic viral shedding
Vesicles on genitilia, labia majora, introitus
Both partners should be treated
42. Most asymptomatic at birth
IUGR – Not common
Peculiar presentation
If In utero infection
SKIN
Scarring, vesicular lesions
EYES
Keratitis, Microophtalmia, conjuctivitis, chorioretinitis
CNS
Microcephaly, Menigio-encephalitis, intracranial
calcification(rarely)
43. If Intrapartum or Postpartum
DISSEMINATED DISEASE
Involves multiple organs – liver, lungs, skin, eye, brain etc
Poor feeding, lethargy, fever, apnea etc
CNS
Seizures, lethargy, bulging anterior fontanelle
DISEASE LIMITED TO SKIN, EYES, OR MOUTH
Vesicles, or zoster like eruptions
46. Viral cultures
Cultures obtained from conjunctiva, throat, faeces, urine, nasal
pharynx, and CSF. The virus grows readily, with preliminary results
available in 24-72 h
Immunologic assays
To detect HSV antigen in lesion scrapings, usually using monoclonal
anti-HSV antibodies in either an ELISA or fluorescent microscopy
assay, are very specific and 80-90% sensitive
Tzanck smear
Cytological examination of the base of skin vesicles, looking for
characteristic but nonspecific giant cells is only about 50% sensitive
Serologic tests
Are not helpful in diagnosis of neonatal infection
Lumbar puncture
Should be performed in all suspected cases. Evidence of hemorrhagic
CSF with increased white blood cells and protein may be found
47. PREVENTION
If active genital HSV lesions or prodromal symptoms at
the time of delivery
Cesarean section should be performed
Preferably within < 4 hours of rupture of membranes
Breast feeding not contraindicated
Unless active lesions present on breast
Mother should wash hands before touching the baby
and should avoid kissing the baby
48. TREATMENT
ACYCLOVIR – Drug of choice
Dose – 20 mg/kg/dose 8 hourly
Disease localized to eyes, skin and mouth
For 14 days
Disseminated disease or CNS involvement
For 21 days
No serious side effects
VIDARABINE – Alternative but more side effects
Prevention and management of complications
49. Sexually transmitted disease caused by the spirochete,
Treponema pallidum
Early congenital syphilis is when clinical manifestation
occurs before 2 years of age, late congenital syphilis is
when manifestation occurs at more than 2 years of life
As per WHO, in 2009
2.6 million stillbirths and 3.1 million neonatal deaths
due to congenital syphilis
Syphilis can cause:
Preterm delivery
Stillbirth
Congenital infection
Neonatal death
50. Mostly intrauterine during 16th to 28th weeks but may
occur as early as 9th weeks
If mother has untreated primary or secondary syphilis
Risk of fetal infection 100%
In late maternal syphilis of more than 2 years
Risk of infection minimal
After infection, it takes 10-45 days for blood tests to
become positive
So initial negative test does not rule out infection
51. If adequate treatment taken
Mostly asymptomatic at birth
If untreated may lead to
Stillbirths
Hydrops fetalis
Premature delivery
May develop symptoms between 3 weeks and 14 weeks
after birth
Early congenital syphilis – first 2 years
Late congenital syphilis – after 2 years
52. MUCOCUTANEOUS
Snuffles - Blood tinged nasal discharge
Maculopapular rash involving palms and soles
SKELETAL
Symmetrical long bone lesions
Osteochondritis – within 5 weeks of infection
Periostitis - after 16 weeks of infection
RETICUOENDOTHELIAL
Generalized non tender lymphadenopathy
Anemia , leukopenia
55. MANIFESTATION OF LATE CONGENITAL SYPHILIS
HUTCHINSON INCISORS
INTERSTITIAL KERATITIS
EIGHTH NERVE DEAFNESS
56. TWO TYPES OF TESTS
TREPONEMAL
Fluoresent treponemal antobody absortion (FTA-ABS)
Traponema pallidum partcile agglutition (TP-PA)
NON-TREPONEMAL
Veneral disease research laboratory (VDRL)
Rapid plasma reagin (RPR)
Automated reagin test (ART)
VDRL is performed routinely in mothers during
antenatal visits
In high risk should be repeated at 28 weeks gestation
57. Any positive non-treponemal test in mother or infant
must be confirmed with a treponemal test
Blood, bones and CSF examination in all cases
A positive VDRL on CSF is diagnostic of neurosyphilis
To assess disease activity
Non-treponemal antibodies disappear in unaffected
infants by 6 months of age
Treponemal antibodies disappear by 15-18 months
58. Aqueous or crystalline penicillin G
Dose - 50000 IU/kg/dose
Duration
Without evidence of CNS infection – 10-14 days
With evidence of CNS infection – 21 days
Dosing
< 1 week age – 12 hourly
> 1 week age – 8 hourly
Patient become non infectious after 24 hours of
therapy
59. Non Treponemal antibody titer should decline by 3
months and become negative by 6 months
If raised at 3 months or positive at 6 months –
Retreatment
Infant with neurosyphilis should be followed with CSF
examination every 6 months for 3 years or until cell
count is normal
If CSF count still elevated at 6 months or VDRL in CSF is
positive – Retreatment
60. Cause chicken pox – usually a mild disease
If occurs in pregnancy may cause severe disease in mother
and baby
Congenital Varicella Syndrome
Skin scarring, malformed extremities, cataracts and brain
abnormalities
If disease occurs in mother 5 days before or 2 days after
delivery severe fatal neonatal disease may occur
Management
Vaccination of the neonate with varicella vaccine
Varicella IVIG (25 IU/kg) for passive immunity within 96
hours
Inj Acyclovir in affected neonates (doubtful utility)
61. Caused by Plasmodium
Defined as presence of malarial parasites (ring forms)
in the peripheral smear of the newborn within 7 days
of life
May be aquired
In utero or during delivery
Incidence is low due to
Placenta acts as barrier to the parasite
IgG antibodies transfer from immune mother
Resistance of RBC’s containing fetal Hb to parasite
62. Effect on fetus
Abortion, still birth, prematurity, low birth weight
Clinical features in neonate
Anemia, hepatosplenomegaly, jaundice, refusal to feed
Treatment
Oral Chloroquine phosphate
10 mg/kg loading
5 mg/kg at 6, 24 and 48 hours
Intravenous chloroquine unsafe
Radical therapy with primaquine unnecessary
In chloroquine resistant oral quinine sulfate
recommended
63. Tuberculosis continues to be a major health problem
Congenital tuberculosis is fortunately rare (340 cases)
Route of transmission
Pulomonary tuberculosis not a threat to fetus
Tubercular endometriosis, miliary Tb and genital Tb
Post natal exposure from infected mother
Clinical features
Poor feeding, lethargy, skin papules, jaundice
Hepatosplenomegaly, lymphadenopathy, tachypnea
Meningitis or sudden death
64. Diagnosis
Mantaux test is usually negative
Chest X ray may show evidence of miliary Tb
CSF should be examined for CNS involvement
Acid fast stains and cultures of gastric aspirate
65. Treatment
Rifampicin (10mg/kg/day), pyrizinimide (30mg/kg/day),
isoniazid(INH) (5mg/kg/day)
Pyrizinimide for first 2 months and rifampicin and
isoniazid for 9- 12 months
INH should be supplemented with pyridoxine
Corticosteroids if CNS involvement
Aminoglycosides for 2 months in HIV infected
newborns
INH for 3 months in asmptomatic infants of mother
with active Tb
66. 25-35%risk of mother to child transmission(MTCT)
during perinatal period
30% occur during pregnancy and 70% during labor and
delivery
Risk of infection through breast milk is 10-15%
Risk factors
Advanced disease, high viral load, low CD4 count
Vaginal delivery, PROM, chorioamnionitis
Breast feeding
67. Diagnosis
ELISA AND WESTERN BLOT MAY BE FALSE POSITIVE
Because of presence of maternal IgG antibodies
Persistence beyond 15 months indicate infection
Early detection can be done by
HIV specific IgM antibodies
Viral culture, p24 core anigen
HIV DNA by PCR
68. Vertical transmission can be reduced to <2% by
administration of antiretroviral therapy (ART) to
mother
NEWBORN BABY (NVP prophylaxis)
<2kg – 2mg/kg
2-2.5kg – 10mg once daily
> 2.5 kg – 15mg once daily
Nevirapine – each ml = 10 mg
Duration – 6 weeks
After 6 weeks – Start Clotrimazole prophylactic
therapy
69. Breastfeeding
Should be avoided if formula feeding is acceptable,
feasible, affordable, sustainable and safe (AFASS)
70. SCREENING
MATERNAL HISTORY
NEONATAL PRESENTATION
WHICH CLINICAL INVESTIGATIONS
WHICH MICROBILOGICAL TESTING
71. If suspected exposure in women or with clinical manifestations
Confirm presence of TORCH specific IgG
Confirm failure of appearance of IgM
Reassure patient
If maternal infection confirmed serologically
Early Pregnancy
Termination should be discussed
Late Pregnancy
Confirmation of fetal infection by invasive procedures
Fetal growth and well being monitored if infection suspected or confirmed
Labour, Delivery, and Postnatal
If fetal infection suspected
Blood for serologic investigation
If fetal infection confirmed
Careful pediatric assessment and follow up
SOURCE- Dk james , infection in pregnancy in High Risk Pregnancy Management Option, 4th edition,
elsevier , uk , 2011, pp-556.
72. ROUTINE SCREENING IN EVERY WOMAN NOT
RECOMMENED
Cost of the investigations
Difficult to differentiate between primary infection and
reinfection
Sensitivity and specificity of the serological test variable
Create unnecessary confusion and treatment
73. HISTORY INFECTION
EXPOSURE
1. Handling or ingestion of raw meat
2. Contact with diapered children
3. Travel to certain regions
4.Kitten or cat at home
5. No of sexual partners, illicit drug use
6. Unimmunized
Toxoplasmosis
Cytomegalovirus
Tuberculosis, malaria
Toxoplasmosis
Syphilis, herpes simplex, HepB, HIV
Rubella
ILLNESS
1. Rash
2. Arthritis
Syphilis, rubella, parvovirus B19
Rubella
Mononucleosis like fatigue,
lymphadenopathy
Toxoplasmosis, HIV
Screening in pregnancy or previous
history
HBV, rubella, syphilis, HIV
Fetal ultrasonography Variable
74. GENERAL FEATURES
1. Premature delivery
2. IUGR or intrauterine death
3. Jaundice, petechia or purpura
4. Hepatosplenomegaly, anemia,thrombocytopenia
5. Hydrocephaly, microcephaly,intracranial calcification
6. Chorioretinitis
7. Myocarditis & cardiac abnormalities
With suggestive maternal history
SUSPECT TORCH
80. PHYSICAL EXAMINATION
Gestational age, height, weight, head circumference
Liver/spleen size
Skin lesions (petechie, purpura, rash etc)
Ophthalmologic examination (pediatric expert)
LABORATORY
Complete blood count and smear with platelet count
Liver function tests and bilirubin (direct and indirect)
CSF examination ( as relevant)
Maternal and infant sera for microbiological testing (
not cord blood)
Hold pretransfusion blood for additional tests
81. OTHER INVESTIGATIONS
Cranial ultrasound, Computed Tomographic (CT) scan
or Magnetic resonance imaging (MRI) as relevant
Long bone X-rays (if suspecting syphilis or rubella)
Placenta pathology
FOLLOW UP
Audiology assessment
Serology
Prevention and management of complications
82. SPECIMEN TESTS INTERPRETATION
Urine Viral culture or detection
(CMV, HSV, Rubella)
For CMV within 3 weeks
should be done. If
positive, diagnostic
Throat swab Viral detection
(CMV, HSV, Rubella)
If positive, diagnostic
Blood Viral detection If positive, diagnostic
Serology of baby and
mother
IgG and IgM antibody
detection
Diffrentiates past and
recent infection
CSF Culture or detection
(CMV, HSV,
toxoplasmosis)
Rubella sepcific IgM
antibody
VDRL
If positive, diagnostic
Nasopharngeal secretions Dark field for T pallidum If positive, diagnostic
83. Skin lesions Culture or detection of
herpes, varicella zoster or
dark field for T pallidum
If positive, diagnostic
Stool Culture for enterovirus If positve, diagnostic
Placenta Patholgy Variable
DETECTION REFERS TO CULTURE OR POLYMERASE CHAIN REACTION
84. The TORCH test is used to screen pregnant women and
newborns for antibodies to the infectious diseases included
in the panel, if either the mother or new born has
symptoms
The blood test can determine if the person has had a recent
infection, a past infection, or has never been exposed.
The test is ordered when a pregnant woman is suspected of
having any of the TORCH infections
These infections can be serious if they occur during
pregnancy because they can cross the placenta from the
mother to the developing fetus and can cause congenital
defects in the newborn
85. TEST DONE - ELISA
Results are usually given as positive or negative, indicating
the presence or absence of IgG and IgM antibodies for each
of the infectious agents tested for with the panel
A "normal“ result is negative (undetectable) IgM antibody in
the blood of the mother or newborn
IgM antibodies produced in the mother cannot cross the
placenta, so presence of this type of antibody strongly
suggests an active infection in the infant
Presence of IgG and absence of IgM antibody in an infant may
reflect passive transfer of maternal antibody to the baby and
does not indicate active infection in that infant
86. If IgG positive in neonate
Compare with mother’s IgG titer
> 4 times indicates recent infection
Repeat after 3 months
Same or rising titer indicates recent infection
Presence of IgM and absence of IgG indicates false
positive
87. Likewise, the presence of IgM antibody in a pregnant
woman suggests a new infection with the virus or parasite
Further testing must be done to confirm these results since
IgM antibody may be present for other reasons
IgG antibody in the pregnant woman may be a sign of past
infection with one of these infectious agents. By testing a
second blood sample drawn two weeks later, the level of
antibody can be compared
If the second blood draw shows an increase in IgG
antibody, it may indicate a recent infection with the
infectious agent
88. Acute maternal infection doesn’t imply fetal infection
Early diagnosis and treatment can make a difference
TORCH doesn’t cause recurrent abortion
ELISA is not the only diagnostic test
All infected neonates should be followed up closely for
delayed sequalae
Reconfirmation of the positive test must be done from
a reference laboratory
Counselling is important
89. PIYUSH GUPTA
CARE OF THE NEWBORN – MEHERBAN SINGH
O P GHAI
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