DNB pediatric

1. ATYPICAL INFECTIONS
DR. ATUL KULKARNI(MD)
DR. MANDAR HAVAL(DCH DNB
FELLOW in NEONATOLOGY)

2. Definitions
• congenital
– contracted in utero
• perinatal
– from completion of 28 weeks gestation until 1-4
weeks after birth
• postnatal

3. Common Infecting Agents
• Bacteria
• Viruses
• Protozoa
• Chlamydiae/Mycoplasma/Rickettsia
• Fungi

4. CASE 1
• 10 day FTND with fever, respiratory distress with
cynosis.
• Had a history of conjuntivitis on day 5 and is on topical
treatment
• Examination – tacypnea, cynosis
• RS- bilat –crepts no wheese
• Investigation –CBC – Eosinophilia
• Xray –pnemonia

5. Chlamydia trachomatis
• Acquisition occurs in some 50% of infants born vaginally
to infected mothers and in some delivered by CS with
intact membranes
• The nasopharynx is the common site of primary
multiplication in the infant
– conjunctivitis in 15-50%
– pneumonia in 5 - 20%

6. Chlamydia trachomatis
• Pneumonia occurs between 1-3 months of the age and is
always insidious with persistent cough, tachypnea and
absence of fever
• Absence of fever and wheezing helps to distinguish
Chlamydia trachomatis from RSV.

7. DIAGNOSIS
TREATMENT
• Isolation of Chlamydia
in conjunctival and
Nasopharynx
• Direct fluorescent
antibody
• PCR
• Oral erethromycin
40mg/kg/day divided
into 4 divided dose for
14 days

8. CASE 2
• 30wks Preterm on ventilator 10 days O2 dependent even
after 3wk x-ray bilat opacities
• Vaginal delivery
• Mother had history of chorioamniotis
• Baby required reintubation
• ?BPD
• CBC –N / BLOOD C/S Serile

9. Ureaplasma Urealyticum
• M.hominis and Ureaplasma Urealyticum have also
been described to cause
- neonatal conjunctivitis
- lymphadenitis
- pharyngitis
- pneumonitis
- osteomyelitis
- brain abcess
- intraventricular hemorrhage and hydrocephalus

10. Ureaplasma Urealyticum
• Ureaplasma urealyticum has been recoverd from the
cervical culture of the pregnant women and implicated as
a possible cause of chorioamniotis, preterm, BPD
• PCR is diagnostic
• ERETHROMYCIN to prevent BPD

11. CASE 3
• 1 day preterm child had genaralised swelling, pale,
tacypnea
• Examination – generalized edema , pallor, tachycardia,
hypotension,hepatomegaly.
• Investigation –Hb 6.2 g/dl , Retic – 0.8%
USG – ascitis & pleural effusion

12. HYDROPS FETALIS

13. Parvovirus B19
• When acquired by a non-immune
pregnant woman
the transmission rate to the
foetus is about 33%
• Anaemia , cardiomyopathy,
hepatic dysfunction, hydrops
foetalis - foetal death may
occur
• Diagnosis by
specific IgM
• Exchange
transfusion in
utero is
appropriate
therapy in severe
cases
• IVIG (limited
success)

14. CASE 4
• 3 days old IUGR came with a complain of jaundice , and
convulsion.
• Mother having an 1 abortion history.
• On examination - icteric , hepatosplenomegaly, macrocephaly.
Chorioretinitis
• Investigation – TLC – 3800 (E – 14% ) PLAT- 102000/cumm
CRP – neg
Blood culture – negative
CT HEAD- calcifications

15. INTRACRANIAL
CALCIFICATION

16. Chorioretinitis of congenital
toxo

17. Toxoplasmosis
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

18. Diagnosis Treatment
• Maternal IgG testing
• Culture from placenta,
umbilical cord, infant
serum
• PCR testing on WBC,
CSF, placenta
– Not standardized
• Newborn serologies
with IgM/IgA
• Symptomatic infants
– Pyrimethamine
and sulfadiazine
Treatment for 12
months total

19. CASE 5
• 7th day preterm baby came with rash, jaundice, abdominal
distention , pallor ,the child had convulsion next day
• On examination- 2kg ictric , hepatosplenomegaly,
purpura over face and abdomen.
• Investigation – CBC (HB 9.2gm/dl; PLAT- 89000)
SGPT – 486; Bilirubin 17.6 D- 8.4
CRP – NEG
BLOOD CUL – NO GROWTH
CSF – few lymoho

20. CMV
Clinical Manifestations
• Early Congenital
Acute fulminant infection involving multiple organ
system
- petechiae and purpura(79%)
- HSM (74%)
- jaundice(63%) & prematurity
• Early onset symptomatic without life threatening
- IUGR or disproportionate microcephaly(48%)
- Intracranial calcification
- ventricular dilatation, cortical atrophy,
lissencephaly, pachygyria (RARE)

21. • Asymptomatic Congenital (commonest)
• Perinatally Acquired
• Cmv Pneumonitis
• Transfusion Acquired Cmv Infection

22. Ventriculomegaly and
calcifications of
congenital CMV

23. Diagnosis
• CMV PCR from urine
or saliva in 1st 3weeks
of life
– Afterwards may
represent post-natal
infection
• Cmv IgG IgM –
limited success
• Ganciclovir x6wks in
symptomatic infants
• Treatment currently not
recommended in
asymptomatic infants
due to side effects
• Valgancyclovir

24. CASE 6
• 8TH day IUGR had rash, refusal to feed
• Examination – , Pale, purpuric spots all over, cataract ,
continuous murmur in pul. Area
• Investigation – Hb – 10.5gm/dl, PLAT – 55000/cumm,
2D echo – PDA , CRP/BLOOD CULTURE - WNL

25. 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

26. CONGENITAL
RUBELLA
 Rash
 Cataracts
 CHD (PDA)
 Blindness
 Neurosensory
deafness
 Microcephaly &
mental retardation

27. “Blueberry muffin” spots representing
extramedullary hematopoesis

28. Diagnosis
Treatment
• 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
• Prevention…immunize,
immunize, immunize!
• Supportive care only with
parent education

29. CASE 7
• 21 days old newborn – not moving both LL.
• H/O 2 SB ,1 Neonatal death
• Home delivery.
• O/E - 2.5 KG ,Pallor ++,hepatospleenomegaly,
• LL –Swelling of both knee joints
• CBC -HB 8gm ,CRP –neg ,Blood c/s –sterile,
• X –ray - periostitis
• Diagnosis -

30. Periostitis

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

32. Clinical Manifestations
• Early congenital (typically 1st 5 weeks):
– Cutaneous lesions (palms/soles)
– HSM
– Jaundice
– Anemia
– Snuffles
– Periostitis and metaphysial dystrophy
– Funisitis (umbilical cord vasculitis)

33. Clinical Manifestations
• Late congenital:
– Frontal bossing
– Short maxilla
– High palatal arch
– Hutchinson teeth
– 8th nerve deafness
– Saddle nose
– Perioral fissures
• Can be prevented with appropriate treatment

34. CASE 8
• 25 days baby had presented with severe
respiratory distress with cyanosis
• h/o contact with family member with resp
infection.
• Examination –febrile, resp.ditress, cyanosis
R/S –bilat crepts &wheese
• Investigation – CBC(lymphocytosis)
CRP/BC- Wnl
X-ray- B/l infiltrate
• Baby required intubation.

35. RSV Bronchiolitis
• DIAGNOSIS –
Immunoflorocence
Antigen testing of resp
secretion.
• Viral Culture (3-5)
• Prevention avoid
crowds and handling!!
• Treatment
• RIBAVIRIN
nebulisation
• RSV IG

36. CASE 9
• 9th day full term home delivery had rash started from
presenting part face and trunk with tachypnea and refusal
of feed, this baby later had temperature instability and
seizure
• Examination- vesicular rash,
• Investigation – thrombocytopenia and nutropenia.
SGPT/CSF/ CRP/ BC all are WNL

37. 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

38. Presentations of congenital HSV

39. Diagnosis
• Culture of maternal
lesions if present at
delivery
• Cultures in infant:
– Skin lesions,
oro/nasopharynx, eyes,
urine, blood,
rectum/stool, CSF
• CSF PCR
• High dose acyclovir
60mg/kg/day divided
q8hrs
– X21days for
disseminated, CNS
disease
– X14days for SEM
– Ocular involvement
requires topical
therapy as well

40. CASE 10
• 7 days FTND had fever, rash all over body, respiratory distress
• Mother had a history of chickenpox 3 days before delivery
• Examination – Febrile , Vesicular pleomorphic rash all over
body, tachepnea
• Investigation – TLC – 15,000,
Crp/Bc/Csf –Wnl,
X RAY – Pneumonia

45. Varicella / Chickenpox
Complications
Congénital infection (2%, 18-22 w of
gestation) Small size, cutaneous scarring,
limb hyplasia, microcephaly,
cortical atrophy, chorioretinitis, cataracts
Perinatal infection
5 days before to 2 days after birth
(high mortality without treatment 30%)

46. Treatment
• VZIG -125 U as soon as possible
• Isolation
• Iv acyclovir 20mg/kg/day 8hry for 7-10
days

47. CASE 11
• 16 days old baby had fever, restlessness, pallor, poor
feeding.
• Mother had fever before delivery
• Examination - pallor, jaundice and hepatosplenomegaly
• Investigation – cbc -Hb -5gm, Plt 40,000/cumm
• P/S falciparam

48. • Congenital malaria is acquired from the
mother prenatally or perinatally and is a
serious problem in endemic area
• In endemic areas, congenital malaria is an
important cause of abortions,
miscarriages, stillbirths, premature
births, intrauterine growth
retardation, and neonatal deaths

49. Treatment
• Chloroquin is the drug of choice for treatment. Primaquin is
not required for congenital malaria, because there is no
persistent liver phase in congenitally acquired infections.This
case highlights the fact that even in endemic regions malaria
can afflict the neonates with its varied presentation.
• Prompt treatment should be instituted to avoid associated
morbidity and mortality

50. Which TORCH Infection
Presents With…
• Snuffles?
– syphilis
• Chorioretinitis, hydrocephalus, and intracranial
calcifications?
– toxo
• Blueberry muffin lesions?
– rubella
• Periventricular calcifications?
– CMV
• No symptoms?
– All of them

51. CASE 12
• 10 days baby – high fever, refusal to feed, excessive
irritablity, rash
• Examination – Febrile 103 F, tacycardia (180)
flushing, CRT>3sec,
• Investigation – Hb-11.7g/dL, TLC-4,800/mm3
platelet 89,000/cumm

63. Neonatal Chikungunya
• The clinical features noticed in the chikungunya
confirmed infants were having foetal death,high fever,
seizures, loose stools, peripheral cyanosis and
dermatological manifestations like generalized
erythema,maculopapular rash, vesiculobullous lesions and
skin peeling.pigmentation over nose ,face ,limb.

64. LOGO