Congenital InfectionsCongenital Infections

TORCHTORCHToxoplasmosis Other (syphilis) Rubella Cytomegalovirus (CMV) Herpes simplex virus (HSV)

Varicella zoster (the chickenpox virus). Varicella zoster (the chickenpox virus). Entroviruses Entroviruses Hepatitis B. Hepatitis B. Parvovirus. Parvovirus. HIV (human immune deficiency virus). HIV (human immune deficiency virus). Chlamydia trachomatis. Chlamydia trachomatis. Mycoplasma. Mycoplasma. Group B streptococcus. Group B streptococcus. MalariaMalaria

COMMON CLINICAL FEATURESCOMMON CLINICAL FEATURES

Low birth weight for Low birth weight for gestational age gestational age

Prematurity Prematurity Seizures Seizures Chorio-retinitis Chorio-retinitis Cataracts Cataracts Purpura Purpura

Cerebral calcification Cerebral calcification Micro-ophthalmia Micro-ophthalmia Jaundice Jaundice Anaemia Anaemia Hepatosplenomegaly Hepatosplenomegaly Pneumonitis Pneumonitis

CONGENITAL CMVCONGENITAL CMV

Caused by a DNA herpesvirus Cytomegalovirus Caused by a DNA herpesvirus Cytomegalovirus (CMV)(CMV)

Most common congenital viral infectionMost common congenital viral infection The majority of congenital infections are The majority of congenital infections are

asymptomatic asymptomatic severe neurologic morbidity occurs in 80 percent of severe neurologic morbidity occurs in 80 percent of

survivors survivors sequelae appear to be more severe when infection sequelae appear to be more severe when infection

is acquired earlier in pregnancy is acquired earlier in pregnancy

PATHOGENESISPATHOGENESIS NeonatalNeonatal

1.1. Antenatal (in utero) - 80-96% of casesAntenatal (in utero) - 80-96% of cases Primary Maternal InfectionPrimary Maternal Infection Recurrent Maternal InfectionRecurrent Maternal Infection

2.2. PerinatalPerinatal3.3. PostnatalPostnatal

ChildhoodChildhood1. Horizontal Transmission1. Horizontal Transmission

CMV excreted in saliva, urine, stool, tears CMV excreted in saliva, urine, stool, tears

2. Organ Transplantation2. Organ Transplantation kidney, marrow, heart, liver, blood (leukocytes) kidney, marrow, heart, liver, blood (leukocytes)

CLINICAL FEATURESCLINICAL FEATURES : :90% of infants with congenital CMV infection are clinically silent 90% of infants with congenital CMV infection are clinically silent

CNS ManifestationsCNS Manifestations 70% - microcephaly 70% - microcephaly 60% - intellectual impairment 60% - intellectual impairment 35% - sensorineural hearing loss 35% - sensorineural hearing loss seizuresseizures 22% - chorioretinitis 22% - chorioretinitis

CLINICAL FEATURESCLINICAL FEATURES:: Systemic ManifestationsSystemic Manifestations

Reticuloendothelial (Liver) - 65-75%Reticuloendothelial (Liver) - 65-75% 70% - hepatomegaly/splenomegaly 70% - hepatomegaly/splenomegaly 68% - jaundice 68% - jaundice 65% - thrombocytopenia (with petechiae 65% - thrombocytopenia (with petechiae

and purpura) and purpura) hepatitis hepatitis

OthersOthers 65% - 65% - low birth weight (< 2500 gm) low birth weight (< 2500 gm) 2-5% - pneumonitis 2-5% - pneumonitis

INVESTIGATIONSINVESTIGATIONS DiagnosticDiagnostic

VirologyVirology gold standard gold standard of urine, saliva, blood, CSF, nasopharynx of urine, saliva, blood, CSF, nasopharynx

SerologySerology ELISA - CMV-specific IgM ELISA - CMV-specific IgM of neonatal blood specimens, cord sampling of neonatal blood specimens, cord sampling

OthersOthers PCR PCR

SerumSerum CBC - anemia, thrombocytopeniaCBC - anemia, thrombocytopenia conjugated , unconjugated hyperbilirubinemia conjugated , unconjugated hyperbilirubinemia elevated hepatic transaminases elevated hepatic transaminases

CSFCSF elevated protein content elevated protein content

INVESTIGATIONSINVESTIGATIONS::

Imaging StudiesImaging StudiesCT (Head)CT (Head)

periventricular periventricular calcifications calcifications

can be identified in can be identified in 25-50% of 25-50% of symptomatic infants symptomatic infants

PrognosisPrognosis Infants with signs of congenital CMV infectionInfants with signs of congenital CMV infection

80% have long-term sequelae:80% have long-term sequelae: sensorineural hearing loss sensorineural hearing loss neuromuscular problems neuromuscular problems motor and intellectual retardation motor and intellectual retardation seizures seizures chorioretinitis with visual deficits chorioretinitis with visual deficits

Infants with silent congenital CMV infectionInfants with silent congenital CMV infection have a more favourable outcomehave a more favourable outcome

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CONGENITAL TOXOPLASMOSISCONGENITAL TOXOPLASMOSIS

caused by the protozoan Toxoplasma caused by the protozoan Toxoplasma gondii gondii

ocular, central nervous system (CNS)ocular, central nervous system (CNS) incidence: 0.3-1/1000 live births incidence: 0.3-1/1000 live births

Routes of TransmissionRoutes of Transmission

Neonatal Neonatal (in utero)(in utero) Primary Maternal InfectionPrimary Maternal Infection

acquired by the ingestion of raw or undercooked acquired by the ingestion of raw or undercooked meat ( cattle), or of infectious oocysts in feces meat ( cattle), or of infectious oocysts in feces (cats, birds) (cats, birds)

1st trimester - 17% - spontaneous abortion 1st trimester - 17% - spontaneous abortion 2nd trimester - 25% - spontaneous abortion or severe 2nd trimester - 25% - spontaneous abortion or severe

disease disease 3rd trimester - 65% - subclinical disease 3rd trimester - 65% - subclinical disease

CLINICAL FEATURESCLINICAL FEATURES::

70% of infants with congenital toxoplasmosis infection are asymptomatic70% of infants with congenital toxoplasmosis infection are asymptomatic Ocular Manifestations (76%)Ocular Manifestations (76%)

chorioretinitis chorioretinitis optic nerve atrophy optic nerve atrophy microphthalmiasmicrophthalmiasblindness blindness

CLINICAL FEATURESCLINICAL FEATURES::

CNS Manifestations (52%)CNS Manifestations (52%) hydrocephaly hydrocephaly motor and intellectual retardation motor and intellectual retardation seizures seizures sensorineuronal hearing loss sensorineuronal hearing loss

Systemic ManifestationsSystemic Manifestationsclassic triad of congenital toxoplasmosis classic triad of congenital toxoplasmosis ::

chorioretinitis, hydrocephalus, and intracranial chorioretinitis, hydrocephalus, and intracranial calcifications.calcifications.

INVESTIGATIONSINVESTIGATIONS::

Isolation of T. gondii from placenta or cord blood Isolation of T. gondii from placenta or cord blood SerologySerology

measures IgG T. gondii antibody measures IgG T. gondii antibody IgM fluorescent antibody test IgM fluorescent antibody test

Imaging StudiesImaging Studies CT (Head)CT (Head)

intracranial calcifications (33%) intracranial calcifications (33%)

http://imaging.birjournals.org/cgi/content/full/16/2/174/F12

MANAGEMENTMANAGEMENTcombination of :combination of :

pyrimethamine pyrimethamine sulphadiazine sulphadiazine folinic acid is added folinic acid is added

Spiramycin

PreventionPrevention

CONGENITAL RUBELLACONGENITAL RUBELLA

caused by an RNA Togavirus caused by an RNA Togavirus Vaccine-preventable disease Vaccine-preventable disease

Routes of TransmissionRoutes of Transmission Antenatal (in utero)Antenatal (in utero)

1st trimester - 75-90% 1st trimester - 75-90% 2nd trimester - 35-40% 2nd trimester - 35-40% 3rd trimester - 25-50% 3rd trimester - 25-50%

CLINICAL FEATURESCLINICAL FEATURES::

Neonatal ManifestationsNeonatal Manifestations IUGR low birth weight - prematurityIUGR low birth weight - prematurity stillbirth - spontaneous abortionstillbirth - spontaneous abortion

Early ManifestationsEarly Manifestations cloudy corneas cloudy corneas CataractsCataracts microcephaly microcephaly hepatomegaly splenomegaly hepatomegaly splenomegaly jaundice jaundice pulmonary valve stenosis pulmonary valve stenosis patent ductus arteriosuspatent ductus arteriosus thrombocytopenia purpurathrombocytopenia purpura

INVESTIGATIONSINVESTIGATIONS::

VirologyVirologyfrom urine, naspharynx, CSFfrom urine, naspharynx, CSF

SerologySerology fetal rubella-specific IgM fetal rubella-specific IgM persistence of rubella-specific IgG after 8-12 months of age persistence of rubella-specific IgG after 8-12 months of age