1. TORCH infections and HIV/AIDS in newborn - diagnostic, treatment and prophylaxis.
Prof. Pavlyshyn H.A.

2. 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
Index of Suspicion

4. 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

6. 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

9. Treatment Symptomatic infants Asymptomatic 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)

10. 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

12. 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)

13. 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

14. “Blueberry muffin” spots representing extramedullary hematopoesis

16. Treatment Diagnosis Prevention…immunize, immunize, immunize!
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

17. 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

19. Ventriculomegaly and calcifications of congenital CMV

21. 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

22. PCR diagnostic

23. PCR diagnostic

24. 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.

25. Clinical Manifestations
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

27. Diagnosis Treatment High dose acyclovir 60mg/kg/day divided q8hrs
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

29. 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. 29

30. 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)

31. 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