[Music] hello everyone my name is Pooja upolo Patti and this is a presentation on

torch infections the goals and objectives of this presentation are to describe the various infectious

organisms that can cross the placenta and infect the fetus to outline the maternal presentation of the illness to

review the effects on the fetus and the resulting neonate and to briefly review treatment and prevention of torch

infections torch is an acronym that stands for the variety of most commonly seen and tested congenital infections

the first infection T is going to be Toxoplasma gondii I it's an intracellular parasite tissue

sis or oocysts are the main form and can be found in undercooked meat and cat feces or contaminated food or soil this

is a commonly tested board's question the image below are tacky so it's the tacky sites can replicate rapidly in

infected cells causing necrosis necrosis will eventually lead to tissue calcification congenital infection

through trans plus central transmission can happen after infection during pregnancy or reactivation of dormant

toxoplasmosis in pregnancy Toxoplasma can affect a fetus in a variety of ways usually they are

asymptomatic ever the classic triad that you see with congenital toxoplasmosis is Koryo retinitis hydrocephalus and

intracranial calcifications the images on your right show hydrocephalus increased fluid buildup and the spaces

in the brain and Coria retinas inflammation of the choroid and retina intracranial calcifications would also

be seen on this scan as bright white spots most commonly the symptoms of congenital toxoplasmosis are anemia

seizures jaundice splenomegaly and hepatomegaly which is enlargement of the spleen and liver thrombocytopenia a drop

in platelets and motor and cerebellar dysfunction microcephaly which is a small head an intellectual disability as

well as sensory neural hearing loss are also commonly seen you want to test the mother for

toxoplasmosis and also the child you can screen for the IgG or IgM antibodies as well as look for the parasite using PSR

PCR excuse me if the mother is diagnosed before 18 weeks you can treat the mother with spear Meissen if there is a

confirmed transmission to the fetus or the newborn infant regardless of symptoms at birth you would want to

treat the newborn with pyrimethamine and sulfadiazine as well as folic acid for 12 months folic acid is very important

for development and growth you'll want to repeat testing after therapy is given and monitor with neuro auditory and

ophthalmic exams as these are very common manifestations of congenital toxoplasmosis the image on the right is

a schematic of the life cycle of the Toxoplasma gondii eye and how it is transmitted the next T is Treponema

pallidum also commonly known as syphilis syphilis is a sexually transmitted infection caused by the spirochete

Treponema pallidum which leads to the disease usually it will present in the mother in a variety of stages the first

stage is usually a painless Shanker then there will be a rash that is often seen on the palms and soles in the second

stage the third stage is much later and will appear as granulomas affecting bones and joints syphilis is one of the

few fully treatable infections in this list so congenital infection is truly preventable the highest risk of

transmission to the child is seen with poor antenatal care high titers during pregnancy early stage of syphilis during

pregnancy and early stage of pregnancy as well as late treatment of the infection meaning it was caught too

close to delivery you can see in this chart below that there are a variety of symptoms from congenital syphilis it can

affect the reticulo-endothelial system mucocutaneous skeletal neurologic and ocular it can cause a

and thrombocytopenia like many of the other torch infections it can also cause a rash how are this rash is very

particular as it's on the palms and soles rhinitis in the newborn also known as snuffles is very commonly seen and

can be seen in the picture on the right snuffles contain high loads of the bacteria Treponema pallidum and are

therefore infectious and contagious skeletal manifestations of congenital syphilis are also very common symmetric

long bone lesions can be seen something called saber shins is a buzzword for syphilis you can also see other bone

abnormalities such as a saddle nose and dactyl itis neurological manifestations can include meningitis cranial nerve

deafness and there are also ocular manifestations Coria retinas and glaucoma the second

image on your right represents hutchinson teeth which are very characteristic of syphilis the

spirochetes can cross the placenta and cause congestion restricting blood flow to the fetus the infection causes an

inflammatory response that does not affect organ development but it can affect organ function that's why you

will not see organ development issues in congenital syphilis to test and treat you'll want to screen all pregnant women

at the first prenatal visit and repeat at the time of delivery you'll want to treat the mother with I am benzathine

penicillin and if they are allergic you must sensitize them this is the only medication that will work and it is

imperative that they are treated before delivery if there is a concern for congenital syphilis you'll want to test

the infant with VDRL RPR ER or fta abs tests the next organism is parvovirus b19 also known as v disease this comes

under the O category or other in torch infections parvovirus is a single-stranded DNA that's

transmitted via respiratory droplets or blood those with parvovirus infection can present with a distinct slapped

cheek facial rash and a macular rash that starts on the trunk and spreads outwards

there is usually a fever one week prior to this rash Aki a tional exposure either in a healthcare

setting or even in daycare setting can increase the risk of seroconversion which means that the person who's

infected can form antibodies the vertical transmission risk is relatively high around 35% this usually happens one

to three weeks after maternal infection and it is via transplant old transmission parvo virus attacks

erythroid progenitor cells and causes both direct toxic cell injury and the induction of apoptosis this often leads

to anemia and myocarditis if the fetus is affected the infection may spontaneously resolve however common

sequelae of fetal parvo virus are severe anemia non-immune hydrops fetalis caused by heart failure thrombocytopenia

maternal mirror syndrome maninjau encephalitis or fetal demise the picture on the right shows hydrops fetalis it is

a type of heart failure where fluid builds up in the fetus as you can see from the ascites or increased fluid in

the abdomen and skin edema to test and treat for parvo virus you will want to test for IgM antibodies and the mother

which are detectable seven to ten days after infection and peak around two weeks pcr is a more sensitive test

amniotic fluid can also be tested for fetal infection if there is a concern of fetal transmission you will want to

monitor with ultrasounds for 12 to 20 weeks after the possible exposure fetal treatment is to manage the anemia and

fetal hydrops with in utero fetal transfusions persistent congenital infection with parvovirus b19 can lead

to red cell aplasia and most of the care for these infants is supportive only the next infectious organism is

varicella-zoster also known as chickenpox varicella is a herpes virus and is often characterized

by a paretic blistering rash that is often seen in different stages of blistering after the primary infection

with a rash the virus remains dormant in the dorsal root ganglion which is why it can cause

sensory symptoms lead in life shingles is a later manifestation of chickenpox and can

present during pregnancy or any other form of immune suppression or stress chickenpox can be transmitted through

reactivation or active infection you will want to diagnose varicella by the appearance of a rash as ink smear from a

blister direct fluorescent antibody or through looking at IgM and IgG congenital varicella syndrome often

comprises a variety of symptoms you will see underdeveloped toes or fingers anal and bladder malformations encephalitis

microcephaly and aplasia mycroft Almia cataracts and Koryo retinitis spinal cord damage Horner syndrome to catriel

skin lesions hyperpigmentation and motor and sensory deficits encephalitis would be an inflammation in the brain microbe

thalya is when eyes are smaller than normal and Horner syndrome which is often seen when the classic triad of

meiosis a constricted people ptosis a drooping of the eyelid and sweating of one side of the face the skin findings

with congenital or varicella often appear like scars the image on your right is what the under development of

the limbs it can look like in condemned Allah varicella syndrome the likelihood of transmission to the fetus is higher

if the mother is infected in the first two trimesters another time where there is a high likelihood of transmission to

the fetus is when the mother is infected close to delivery this will instead be called neonatal varicella this also

carries a 30% mortality the antibodies as well as an active infection can be transferred through the placenta

maternal infection is associated with preterm delivery but not fetal demise if you are concerned about congenital

varicella ultrasounds are often done to look for intrauterine growth restriction microcephaly when tricky low megali

which is enlargement of the ventricles and the presence of echogenic foci in the fetal liver

as well as circular scarring and deformities of the limbs as we mentioned earlier pcr of the amniotic fluid can be

done to test for varicella-zoster DNA if the newborn is born with congenital varicella syndrome you can treat with

antiviral therapy as well as varicella immunoglobulins you will also want to treat pregnant women with

immunoglobulins if there is a high concern of transmission however you would not want to give the chickenpox

vaccine to a pregnant women the next organism is rubella also known as German measles this is now the are portion of

Torch rubella is a single-stranded positive-sense RNA virus that is transmitted through aerosolized

particles it presents with a mild flu-like illness with a rash that starts on the face and spreads towards the

hands and feet and fades in about three days the rash is less erythematosus and measles and it's often accompanied by

swollen lymph nodes there are two points where there's a highest risk of congenital infection the first is in the

first trimester of pregnancy and again a term rubella causes progressive necrotizing vasculitis and a focal

inflam inflammatory response congenital rubella syndrome presents with an infant that is often small for its age

deafness cataracts again microfauna which is common with other infections corneal opacity and glaucoma

there are many cardiac defects most notably PDA pulmonary artery stenosis & korek tation of the aorta PDA is patent

ductus arteriosus blueberry muffin rash is also seen in rubella however this is not specific for rubella as other torch

infections may also cause this rash hepatosplenomegaly is also seen later manifestations of congenital rubella

syndrome can also be hypertension and diabetes in the young child to test and treat for a rubella women of

childbearing age should be tested to see if they are immune to rubella from previous vaccinations if not they should

have window of bee-lieve MMR vaccine if a pregnant woman is found to be non-immune she

should be vaccinated after the pregnancy and avoid pregnancy for 28 days after the vaccination again because it is a

live vaccine infants with congenital rubella syndrome should be tested with a culture testing for IgG or with PCR if

any of these tests are positive consider the infant contagious with rubella until 1 year of age unless 2 cultures one

month apart are negative after 3 months of age there is no defined treatment for rubella the next disease is

cytomegalovirus also known as CMV Sammy is a type of herpes virus it is slow growing will give a lifelong infection

and often presents acutely with nonspecific viral symptoms it can be transmitted sexually through breast milk

through close contact with oropharyngeal secretions or through blood transfusions young children that have CMV often shed

the virus when they have high titers so women that are pregnant that are exposed to young children should be we aware of

their risk the risk of symptomatic in general CMV is highest when pregnant women acquire a primary infection during

pregnancy CMV is one of the major non-genetic causes of sensory hearing loss and neuro developmental delay CMV

for most people is a very mild illness however in periods of immune suppression or pregnancy it can have devastating

consequences congenital zme presents with hepatosplenomegaly jaundice conjugated hyperbilirubinemia

thrombocytopenia the t GI which is a rash with pinpoint red or purplish spots microcephaly seizures hypotonia and also

intracranial calcifications what separates this from Toxoplasma is that these calcifications are often

periventricular versus spread out in the brain CMV can also present with querier retinitis

intraventricular hemorrhages and periventricular leukomalacia neural stem cells are very susceptible to this virus

which also causes newer information which you can see with the neurological sequelae placental insufficiency can

also develop due to local infection with CMV in the placenta this can lead to intrauterine growth restriction to

diagnose the mother you will want to test our GT or IDM antibodies to CMV IgM can last up to eight months which

can be confusing depending on when you test to diagnose CMV in an infant you can isolate the virus from saliva or

urine specimens within two weeks of birth for viral culture you all want to do this within two weeks because you

cannot be sure if it was a maternal to child transmission to monitor for congenital CMV during pregnancy head

ultrasounds of a fetus can be done at regular intervals maternal infection is not diagnostic of fetal infection and

even the mother with low titers can still have a child with congenital CMV ganciclovir and val gancyclovir are the

two antivirals that are currently used for the treatment of symptomatic CMV infected infants infants diagnosed with

congenital CMV should continue to have close followup with developmental hearing and ophthalmologic assessments

the next organism HIV starts the last letter of rec room HIV is a retrovirus that affects dendritic cells lymphoid

tissue and causes cd4 cell depletion HIV can progress to AIDS HIV is spread through blood semen pre seminal fluids

rectal fluids vaginal fluids and breast milk maternal viral load cd4 count the stage of the disease

breastfeeding an active infection all affect the risk of transmission the table on your right has a nice setup of

the timing of transmission the rate of transmission the mechanism and how to prevent transmission the three main

modes of transmission are in utero intrapartum or through breastfeeding to test and

treat virtue in general HIV you'll want to test the mother early in pregnancy again in the third trimester and at the

time of delivery you'll also want to test postpartum as she may choose to breastfeed there are usually no clinical

signs of HIV infection at birth you will want to test HIV exposed infants within 48 hours of birth at two weeks at four

to six weeks and at four months with PCR or qualitative RNA testing early combined and try retroviral therapy for

infected infants reduces mortality and increases attainment of normal developmental milestones and gross motor

skills if untreated the infant often presents with the infant often presents with recurrent infections and chronic

diarrhea the next organism is herpes simplex herpes simplex virus has two types HSV one is more commonly seen to

cause infections around the mouth so this is your common cold sore and the HSV 2 most commonly causes general

infections similar pathophysiology is seen in HSV as the other herpes viruses mothers should be screened during

prenatal visits and a history of HSV should be documented as herpes is a lifelong infection and cannot be cured

neonatal herpes simplex infection is most often acquired in the peripartum period from maternal viremia so an

active infection an ace ending transp lentil infection which is from the outside in through the placenta or

retrograde spread through intact or ruptured amniotic membranes intrauterine transmission of HSV is rare about less

than one third of infants with congenital HSV exhibit the characteristic triad which is skin

vesicles eye damage and central nervous system manifestations the central nervous system manifestations have the

highest morbidity the SEM manifestation or skin eye and mucocutaneous is the most commonly seen

and does not have high mortality however SEM herpes can progress disseminated herpes which can also affect the liver

and this does have a high mortality infants can also present with placental invites hydrops fetalis or even in utero

demise a picture of the skin lesions of a newborn with HSV is seen on the right to test and treat for herpes simplex you

can test the mother if there are active lesions or you can test for titers during pregnancy with someone with

recurrent genital herpes so they continued to have lesions you will want to provide the mother with suppressive

therapy at 36 weeks if there are active lesions at Labor a c-section should be used as a delivery method to decrease

the risk of transmission infants are often asymptomatic at birth if a newborn has vesicular lesions evaluate for HSV

with PCR HSV can cause meningitis and encephalitis so watch for any neuro changes in the infant as well as any

skin changes newborns can be treated with IV acyclovir which is the antiviral of choice for herpes simplex hepatitis B

is the next age hepatitis B virus is double-stranded circular DNA that's enveloped it causes cellular injury from

host immune response which is cytotoxic to hepatocytes via cytotoxic T cell activation transmission is most often at

the time of delivery with mothers with an active infection usually later in pregnancy we need to talk about it so

different components of hepatitis B virus for our purposes you just need to know that there are antigens in the

envelope the core and on the surface so the maternal envelope antigen which can be seen an active infection is small

enough to pass through the placenta for someone who is vaccinated they will only have seen the surface antigen in the

vaccine so they will not have antibodies to the envelope perinatal infection has high chance of develop

both acute and chronic hepatitis B in infants you will want to screen all mothers for hepatitis B using the H B

surface antigen and again at delivery again this is the antigen not the antibody if the antigen for the surface

protein is positive newborns should receive prophylactic hepatitis B immunoglobulin at delivery

as well as the hepatitis B vaccine within 12 hours and completion of the series by 6 months with follow-up

testing this is only prophylactic we do not have a conformation of hepatitis B transmission to confirm you will want to

test newborns for hepatitis B antigen within one to two months the next virus is hepatitis C I'm try to see is a

single-stranded RNA that infects hepatocyte s' but it may not be directly toxic hepatitis C is the number one

cause of chronic liver disease in the world transmission occurs through pre or perinatal exposure to peripheral

mononuclear cells infected with hepatitis C in pregnancy in general it can be transmitted through blood other

factors that increase the risk of maternal to child transmission are HLA types female gender of the fetus and an

HIV co-infection and the mother the method of delivery and choosing to breastfeed are not associated with

maternal to child transmission as some of the other diseases have both infants are asymptomatic but may develop chronic

hepatitis C there is no proven transmission prevention method however if it is known that the mother has

hepatitis C invasive instrumentation or prolonged rupture of membranes during labor should be avoided if you're

concerned about transmission to a newborn you should test with RNA PCR after one to two months of life anti HCV

IgG should be tested after 18 months of age and if positive you should repeat testing after 12 months the infant may

have cleared the infection their own interferon base therapy ribavirin new antivirals for hepatitis C

an IVIG are all commonly used to treat adults with hepatitis C however these are not indicated in infants we have now

covered all of the organisms that in torch infections the last slide has a nice table with takeaways of the most

common findings in each infection as you can see many of these infections have similar sequelae the way that you'll

remember them are by the specific unique sequelae that usually occurs with that infection for example toxoplasmosis is

the only disease in this chart that presents with diffuse intracranial calcifications and again toxoplasmosis

causes local calcifications due to tissue necrosis so this would make sense Treponema pallidum can present with a

rash it can also have cornea retinas and glaucoma which is different you will also see the infant with snuffles or

Hutchinson teeth can be mentioned in a question stem rubella the most common sequelae that you will see on Tess as a

payton ductus arteriosus as well as pulmonary artery stenosis and myocarditis you'll also see cataracts

and microphthalmia as indicative of rubella infection the blueberry muffin rash is not specific to rubella so you

should not rely on that for the diagnosis CMV can cause deafness as well as rubella but I can also present with

calcifications in the brain to separate this from toxoplasmosis you have to remember that these calcifications are

periventricular meaning you'll see small white spots studying the borders of the ventricles for HSV which is herpes

simplex you will often see a vesicular rash on the newborn and if not you can see myocarditis and ophthalmic

manifestations such as cataracts and Koryo retinitis finally for parvovirus b19 hydrops fetalis

is the buzzword that is often associated you will want to look for Colonel risk factors as well as maternal

infection as well as the congenital syndrome which can have subcutaneous edema myocarditis and ophthalmologic

abnormalities thank you for listening to this lecture about torch infections and I hope you feel more comfortable in

identifying a variety of diseases that can be transferred from mother to child [Music]

you [Music]