1. Clamydia, Rubella, Herpes
and CMV
TORCH

2. TORCH tests Toxoplasmosis.
The five categories of organisms whose antibodies are measured by the  TORCH test are grouped together because they can cause abortion for pregnant woman and/or birth defects in newborns.
Toxoplasmosis.
Others e.g: Chlamydia, syphilis, hepatitis B, coxsackie virus, Epstein-Barr virus, varicella-zoster virus(chickenpox), and humanparvovirus.
Rubella.
Cytomegalovirus(CMV).
Herpes(HSV)

3. Other non-viral causative agents for abortion include:
There are several causes for abortion, some of them are related to viral infection from these viruses:
Cytomegalovirus ( CMV).
Rubella.
Herpes.
Other non-viral causative agents for abortion include:
Clamydia
Toxoplasma gondii (parasite)
The main routes of transmission are across:
 Placenta (transplacental)
 Birth canal.

4. Chlamydia Small obligate intracellular parasite.
Confusion occurred by the discovery of Chlamydia as it was classified as both bacteria and virus.
It is classified as virus for it’s:
Basophilic staining in the host cell to form the elementary body, which are small, dense and about 0.3u in diameter.
Intracellular microorganism, they can’t synthesize ATP, but use the host cell for this purpose.
Chlamydia may be found in the form of an elementary body and a reticulate body. The elementary body is the nonreplicating infectious particle that is released when infected cells rupture. It is responsible for the bacteria's ability to spread from person to person and is analogous to a spore. The elementary body may be 0.25 to 0.30 μm in diameter,

5. Causes for classification of chlamydia as bacteria:
They have both DNA and RNA.
Have their self-metabolic system.
They are able to grow and multiply by binary fission.
They are surrounded by a cell membrane.
Response to antibiotic therapy.

6. Species of chlamydia
C. psittsci, cause psittacosis.
C. lymphogranulomatis, cause lymphogranuloma venerum ( LGV).
C. trachomatis, cause conjuctival and cornea disease (Trachoma)
C. occulogenitalis, cause conjunctivitis.

7. Psittacosis:
Is a respiratory disease of man acquired from contact with infected birds, which excretes the organism in their stool.
It causes infection in the upper respiratory system and pneumonia.
Laboratory diagnosis:
Sputum and blood test.
Smear to show elementary bodies.
ELISA  PCR

8. isolation: by inoculation of the yolk sack of an embryonated egg or intracerebral, intranasal or intraperitonial injection into a mice.
Serological tests:
Complement fixation.
Agglutination test.
Neutralization test.

10. Lymphogranuloma venerum:
It is a venereal disease characterized by:
Enlargement of lymph regional lymph nodes, tend to form sinuses.
Infect the urethral parts and cause urethritis and is accompanied by systemic symptoms.
Laboratory diagnosis:
Smears (biopsy from the infected lymph node), pus cells can be seen in infected LN and stain (elementary bodies)
Culture: is not useful as it will give negative result and resist all antibiotics.

11. C. Trachomatis:
Causes Chlamydial infection which is a sexually transmitted disease (STD)
Causes Trachoma by it’s growth in the conjunctival and cornea cells of the eye causing kerato-conjunctivitis.
If passed to the baby during the passage through the birth canal, chlamydia can cause conjunctivitis and pneumonia.

12. Laboratory diagnosis:
Many women who are infected do not even realize it because they often have no symptoms. However, when untreated, chlamydia can cause a scarring infection of the woman's internal reproductive organs, increasing her risk of a potentially fatal tubal pregnancy.
Laboratory diagnosis:
Smear(eye swab).
ELISA (IgM, IgG or IgA).

13. Rubella
Rubella is a rather mild disease spread by the way of respiratory secretion, skin contact or congenitally.
Cause German measles, causing the following symptoms:
Firstly, catarrhal symptoms and mild fever.
Irregular rash.
Incubation period is (3-4) weeks.
The tragic aspect of Rubella may become evident of infection occurs during pregnancy.
MMR vaccine .(IgG pesist for life)
Measels mumps rubellaؤ
Catarrhal inflamation of nose and throat and increase production of mucus

14. symptoms
The virus can cross placental wall and infect the fetus, this may lead to fetal death or congenital defect which may be:
Hearing loss
Mental retardation
heart disease
 retarded growth
blood disorders
 vision problems
pneumonia

15. Laboratory Diagnosis Complement fixation. Neutralization test.
Heme agglutination inhibition (HAI).
ELISA IgM and IgG.
Heme agg inhibition:presence of Ab prevent the virus from agglutinating RBCs
Sample : saliva, blood

16. Herpes Human Viruses (HHV)
There are eight types of herpes viruses known to affect humans:
HSV1 (Herpes Simplex Virus 1 commonly known as oral herpes)
HSV2 (Herpes Simplex Virus 2 commonly known as genital herpes)
HHV3 - VZV (Varicella Zoster Virus commonly known as chickenpox or shingles)
HHV4 - EBV (Ebstein Barr Virus commonly known as infectious mononucleosis [mono or glandular fever])

17. HHV5 - CMV (Cytomegolo Virus is the most common virus transmitted to a pregnant woman's unborn child)
HHV6 - Roseolovirus more commonly known as the 6th disease or Roseola Infantum
HHV7 - Similar to HHV6 (not yet classified)
HHV8 - A type of rhadinovirus known as the Kaposi's sarcoma-associated herpesvirus (KSHV)

18. Herpes simplex virus There are two forms of the herpes simplex virus:
Herpes simplex virus 1 (HSV-1)
Herpes simplex virus 2 (HSV-2) .
HSV-2
HSV-1
Genital area
Oral cavity(mouth)
Area of infection
sexually
By contact
Transmission

19. HSV-1 also commonly referred to as fever blisters, oral herpes.
It is a viral infection of the skin that may occur once or return again and again.
 some factors that may trigger it to return:
Stress
Fever
Menstruation Cycle
Fatigue
Certain foods
Pregnancy
This happens when the virus is cleared from the skin by the immune system, it then hides in the nerves and is never completely removed from the body. Herpes outbreak infections are very common. It is estimated that nine out of ten people have been exposed to herpes outbreaks and many of these don't even know they have it. Those who carry herpes can spread the disease without even knowing it.

20. HSV-2
Genital herpes outbreaks are contagious viral infection that affects primarily the genitals of men and women.
It is characterized by recurrent clusters of lesions in the genital areas.
It is sexually transmitted (STD)

21. Varicella zoster
Infection with the varicell virus can cause chicken pox and shingles
It can be spread through contact with the sneezes or coughs of an infected person.
becoming infected during pregnancy can cause serious complications to newborn:
Scarring
malformed limbs
damage to the eyes and brain.
shingles (an infection that can cause a painful rash with blisters)
Because most adults had chicken pox as children, it is uncommon for a pregnant woman to become infected with the varicella virus. The American College of Obstetricians and Gynecologists estimates that a woman's risk of contracting varicella during pregnancy is less than 1 in 1,000. However, becoming infected during pregnancy can cause serious complications.

22. Diagnosis of HSV and herpes zoster
Viral culture. 
Tzanck smear.
Direct immunofluorescence study with monoclonal antibodies (DFA)
Type-specific serologic tests for HSV.
glycoprotein (gG) type-specific to distinguish b/w HSV1 and 2 according to glycoproteins on their surface.
 Viral culture. Isolation of HSV in cell culture is the preferred virologic test for patients who seek medical treatment for genital ulcers or other mucocutaneous lesions. However, the sensitivity of culture is low, especially for recurrent lesions, and declines rapidly as lesions begin to heal. Specimens are most likely to yield virus if they are taken from the early lesions within the first one or two days after their formation. Viral culture isolates should be typed to determine if HSV-1 or HSV-2 is the cause of the infection. Lack of HSV detection does not indicate a lack of HSV infection,
Tzanck smear. The smear is obtained by scraping the base of a vesicle with a scalpel. The material is then fixed in alcohol and stained with Wright or Giemsa stain. Multinucleated giant cells will be seen as with other herpesvirus infections. However, it is only positive in about 50% of cases.
 Direct immunofluorescence study with monoclonal antibodies (DFA) on samples obtained from active lesions, and PCR assay are useful tests. PCR assay for HSV DNA is a highly sensitive and specific. Detection of HSV DNA in CSF is particularly helpful in the early diagnosis of HSV encephalitis. However these tests may be limited by their cost and availability.
d) Type-specific serologic tests for HSV: Type-specific HSV serologic assays might be useful in the following scenarios: (1) recurrent genital symptoms or atypical symptoms with negative HSV cultures; (2) a clinical diagnosis of genital herpes without laboratory confirmation; and (3) a partner with genital herpes. Some specialists believe that HSV serologic testing should be included in a comprehensive evaluation for STDs among persons with multiple sex partners, HIV infection, and among MSM at increased risk for HIV acquisition. The sensitivities of the FDA-approved glycoprotein G type-specific tests for the detection of HSV-2 antibody vary from 80-98%, and false-negative results might be more frequent at early stages of infection. The specificities of these assays are >96%.

23. Cytomegalo virus (CMV)
CMV is also called salivary gland virus which may infect salivary glands or parotid gland.
An increase number of infections with the virus have reported in adults with neoplastic disease, leukemia or tissue transplation.
we can isolate this virus from all body fluids.

24. Symptoms of congenital CMV
90% of congenital CMV cases are asymptomatic at birth.
0.5 –15% of these are at risk for psychomotor, hearing, neurologic, ocular, or dental abnormalities within first few years of life. microcephaly, seizures, petechial rash also can be manifeted.
10% of cases may have sensorineural hearing loss.

25. Laboratory diagnosis
Histopathological studies, this virus leads to the formation of certain inclusion in the infected cells.
Virus isolation.
ELISA(IgM and IgG)
Note: when we measure IgG, it rarely negative and often positive, so we determine the titer, suppose it is 300 IU/ml, after 2-3 weeks we make follow up and do the CMV again:
The titer in the same level or less it is negative.
The titer is higher, it is positive.