INFEKSI TORCH Pada Neonatus

TORCH Infections
T=toxoplasmosis O=other (syphilis) R=rubella C=cytomegalovirus (CMV) H=herpes simplex (HSV)

Pathogenesis of hematogenous transplacental infections.

Kapan perlu curiga?

IUGR / BBLR KMK Hepatosplenomegali Trombositopenia Unusual rash Riwayat antepartum maternal Temuan klasik dari infeksi torch neonatal

Diagnosis
Anamnesis yang baik terkait riwayat maternal / prenatal
Sebagian besar memberikan gejala2 yang ringan pada ibu

Pemeriksaan fisik BBL Pemeriksaan penunjang spesifik

Screening mahal !!! DO NOT USE TORCH TITERS!

TORCH INFECTION OF PREGNANT WOMEN

Infeksi Abortus/L Prematur ahir, + Kecil M.Kh. Peny. Akut Cacat Ssd. Lhr Peny. Menetap SSd. Lhr

Toksoplasma
Rubella Cytomegalovirus Herpes simpleks Sifilis

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Kelainan yg Terjadi pd Janin/Bayi akibat Infeksi TORCH pd Ibu Hamil Infeksi Kelainan Utama Kelainan Lain

Toksoplasma Hidro/mikrosefalus, Hepatomegali, Ikterus, limfadenopati, korioretinitis, kalsifikasi retardasi psikomotor intrakranial Sifilis Kelainan tulang, gigi, saraf, keratis Hepatosplenomegali, ruam, limfadenopati

Rubella
CMV

Katarak, tuli, kelainan jantung bawaan

Mikrosefali, tuli

Hepatosplenomegali, trombositopeni, retardasi psikomotor

Kalsifikasi intrakranial, hepatosplenomegali, tombositopeni, purpura korioretinitis, retardasi psikomotor Korioretinitis, hepatitis, retardasi psikomotor, peny. akut infeksi intrapartum

Herpes simpleks

Mikrosefali

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

A. Hydrocephalus following first-trimester : Dilated lateral ventricles were found during a fetal ultrasonographic survey for a small fetal size for the estimatedgestational age of 26 weeks. B. At birth the infant had monocular micro-ophthalmia, chorioretinitis, and blindness, in addition to massive hydrocephalus.

C. Brain computed tomographic scan showing small, calcified lesions. D. Necrotic lesion adjacentto the lateral ventricle in an infant who died from causes unrelated to Toxoplasma infection. Toxoplasma tissue cysts wereidentified in microscopic sections through the lesion. E. Chorioretinal scar with macular involvement

B
Gambar :

Retina pada pasien Toksoplasmosis A&B masih baik C retinopati berat

Congenital Syphilis
2/3 yang terinfeksi asimtomatik saat lahir Klasifikasi:
Fetal effects Early effects (< 2thn) Late effects

Manifestasi Klinis
Fetal:
Stillbirth Neonatal death Hydrops fetalis

Intrauterine death : 25% Perinatal mortality in 25-30% : untreated

Manifestasi Klinis
Early congenital (typically 1st 5 weeks):
Cutaneous lesions (palms/soles) Hepatosplenomegaly Jaundice Anemia Snuffles Periostitis and metaphysial dystrophy Funisitis (umbilical cord vasculitis)

Periostitis of long bones seen in neonatal syphilis

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

Hutchinson teeth late result of congenital syphilis

CDC Definition of Congenital Syphilis

Confirmed if T. pallidum identified in skin lesions, placenta, umbilical cord, or at autopsy Presumptive diagnosis if any of:
Physical exam findings CSF findings (positive VDRL) Osteitis on long bone x-rays Funisitis (barber shop pole umbilical cord) RPR/VDRL >4 times maternal test Positive IgM antibody

IgG can represent maternal antibody, not infant infection

SINDROMA RUBELLA KONGENITAL

Sering pada infeksi intrauterin subklinis Bayi kadang nampak normal + pembawa virus

Infeksi Maternal Primer (IgM Antibodi Rubella) Viremia Maternal Abortus Spontan/ Lahir mati

Infeksi Maternal Primer (IgM Antibodi Rubella)

Viremia Sangat Jarang

Tidak ada Viremia Bayi lahir normal

Defek muncul dikemudian hari atau

INFEKSI JANIN

Normal
Malformasi Cacat & penyakit & BBL Penyakit yg timbul kemudian

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

 Bayi terinfeksi kongenital : mempertahankan kadar antibodi Ig G terhadap rubella yang tinggi, kadar Ig M total yang meningkat Diagnosis pasti : ditemukan antibodi Ig M yang spesifik untuk rubella

Cytomegalovirus (CMV)
Most common congenital viral infection
~40,000 infants per year in the U.S.

Mild, self limiting illness Transmission can occur with primary infection or reactivation of virus
40% risk of transmission in primary infxn

Studies suggest increased risk of transmission later in pregnancy

However, more severe sequalae associated with earlier acquisition

Clinical Manifestations
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

Ventriculomegaly and calcifications of congenital CMV

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

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

Infeksi HSV Kongenital

Herpes Simplex (HSV)

HSV1 or HSV2 Primarily transmitted through infected maternal genital tract
Rationale for C-section delivery prior to membrane rupture

Primary infection with greater transmission risk than reactivation

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

Presentations of congenital HSV

Infeksi HSV Neonatus

Diagnosis
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
acyclovir 60mg/kg/day

Summary ............?
Snuffles?
syphilis

Chorioretinitis, hydrocephalus, and intracranial calcifications?

toxo

Blueberry muffin lesions?

rubella

Periventricular calcifications?
CMV

No symptoms?
All of them