CONGENITAL INFECTION

BLOK 26
Objectives
1. The common means of
transmission of these
infections
2. The major manifestations
of congenital and
perinatal infections
3. Diagnosis, management
and prevention these
infections

Introduction
Congenital infection
Acqurired in utero and perinatally
Can be asymptomatic in the newborn period
Clincal symptoms complexes
Before TORCH
T oxoplsama gondii
O thers
R ubella
C ytmogelavirus
H erpes simplex virus

Currently ToRCHES CLAP
To xoplasma gondii
R ubella
C ytomegalovirus
H erpes simplex virus
S yphilis
C hickenpox
L yme disease
A ids
P arvovirus

Toxoplasmosis
Potential devastating but preventable
Outcome can be improved with early diagnosis and treatment
Cat as the definitive host
Exposure to cat, particularly feses
Undrcooked meat
Clymatic condition
Infection risk :
1
st
trimester : 14 % congeital infection, 6 % infants severely infected, 5% perinatal deaths
2
nd
trimester : 29 % congenital infection, 2 % infants severely infecterd, 2 5 perinatal deaths
3
rd
trimester : 59 % congnetial infection, 6 % mildly affected

Clinical Manifestation
Classic Triad :
Hydrocephalus
Chorioretinitis
Brain calcification

Other clinical signs and symptoms :
Blueberry muffin rash
Hepatosplenomegaly
Jaundice
Eryhtroblastosis
Hyrdops fetalis
Non sepcific sign : fever,
lymphadenopathy, vomiting,
diarrhea, pneumonitis
Microcephaly can be described


Diagnosis
Physical examination
Full neurologic examination
Funduscopy
CT-Scan Ultrasound scan
Definitive laboratory diagnosis :
PCR on CSF
T. gondii-specific IgM, IgA and IgE
CSF : xanthochromia, mononuclear cell pleocytosis, protein CSF
Treatment (1 year)
Pyrimethamine :
Loadiing : 1 mg/kg /12 hourly for 2 days 1 mg/kg/day for 2-6
months 1 mg/kg three times a week to total 1 year
Sulfadizine :
50 mg/kg 12 hourly for 1 year
Folinic acid 10 mg three times daily
Asymptomatic infants are recommended to be treated

Prevention
Primary : education
Pregnant woman should avoid risk activities cat litter and eating
undercooked meat
Secondary : maternal screening and treatment
Flu-like illness or maternal screening
Termination or treatment
Tertiary : infant screening
Screening all infants ???

Rubella
Rubella German measles
Classified in Togaviridae genus Rubivirus
Epidemiology of rubella is closely linked with
congenital rubella syndrome related with
rubella and MMR vaccine

Foetal rubella infection
Maternal infection transmission to foetuses
< 11 weeks : 90%
11-12 weeks : 67%
13-14 weeks : 54%
2
nd
trimester : 39%
Defects :
< 11 weeks : severe congenital heart disease and deafness
13-16% : 35% deafness alone
> 16 weeks : no congenital defects
Clinical features
Virus infection all tissue wide
range of congenital defects affecting
any organ
Most consistent :
Severe sensorineural deafness
Eye defect cataract & salt-and-
pepper retinopathy
IUGR

Other :
Microcephaly neurodevelopmental
delay
Commonest congenital heart disease :
pulmonary artery hypoplasia and
patent ductus arteriosus
Late clincal features :
Diabetes mellitus
Autoimmune disease
Dental problems
Neruopyschiatirc problems
autisme
Panecephalitis similar to SSPE

Diagnosis
Rubella-specific IgM in infantserum
Maternal infection in pregnancy serologic
Therapy
None
Prevention
Immunization
Cytomegelovirus
Largest herpesvirus and most structurally
complex
Able to cause latent infection and to reactivate
with intermittent viral shedding
CMV cyto (cell), megalo (large) infection
results in large cells with inclusion owls eye
appearence


Congenital CMV infection :
Primary maternal infection
CMV reactivation
Reinfection in a seropositive mother
Timing of infection during pregnancy to neonatal
ouctome :
1
st
trimester : sensorineural loss and CNS sequele
Late pregnancy : still can cause sequele

Clinical manifestation
10-11% symptomatic
Clinical signs :
Most common (at birth or soon after
birth ) : petechial or purpuric rash,
jaundice, hepatomegaly
50% with microcephaly
intracranial calcification classically
periventricular
50% with IUGR
14% with chorioretinitis may
resemble toxoplasma retinitis


Sensorineural hearing loss
Commonest in symptomatic children
Asymptomatic infants develop progressive
hearing loss
Severity related to viral load
Treatment :
Antiviral prolonged, parenteral, and toxic
Recommended antiviral and dose :
Ganciclovir 6 mg/kg/dose IV 12 hourly
Valganciclovir 16 mg/kg/dose orally
Duration 6 weeks
Common adverse reaction neutropenia
Treatment decision made individually
Prevention :
Avoid transmission to pregnant women from
suspected CMV-infected childrens nasopharyngeal
secretion, urine, tears, or genital secretion
Hyperimmunoglobulin
Candidate recombinant vaccine

Herpes Simplex Virus
Herpes Simplex Virus (HSV)
Cause latent and reactivate viral shedding
Neurotropic
Two antigenic types (HSV-1 and HSV-2)
Infection of one type partial protection to the other type
Transmission
Classic transplasental infection
>> perinatally

Clinical presentation
Classical triad :
Skin involvement (vesicular or bullous skin lesion)
Eye (chorioretintitis and/or keratoconjuctivitis)
CNS (microcephaly)
Other :
Hepatomegaly
Cytopenia (two or more cell line)

Neonatal HSV infection
Skin, eye or mouth
infection
Individual punched-out
vesicles, diameter 0.5, often
rupture and coalesce
Anywhere on infants skin
common site scalp around
eye associated with
conjunctivitis


- HSV pneumonitis
3-14 days after birth
Often misdiagnosed
Classic chest x-ray :
Hilar and central interstitial infiltrate
HSV encephalitis
Present in second week of life
Seizures, fever, lethargy, poor feeding,
irritability, jitterness, and rigidity
LP : mononuclear cell pleocytosis,
micro- or macroscopic blood, glucose
low, protein initially low but rise with
illness progression
Brain imaging : parenchymal damage
on temporal, parietal, frontal, or sub-
cortical common temporal changes


Disseminated HSV infection
Overlapping with severe bacterial
sepsis
Hepatitis and features of DIC
Jaundice, iritability, seizure and
shock
Hemophaocytic
lymphoshistiocytosis
Hepato and/or splenomegaly
Fever
Lympadenopathy
Respiratory failure
Seizure
Cytopaenia of two or more cell line
Elevated ferritin
Difficult to prove biopsy from
bone marro, lymph node or spleen

Diagnosis
Rapid virologic techniques
Nucleic acid amplification
by PCR
antigen detection by Elisa
Immunofluorescence
HSV culture not timely

Treatment
Intravenous acyclovir 20
mg/kg/dose 8 hourly
Localized 14 days
Disseminated and
encephalitis 21 days
Monitoring
Neutrophil count <
500/mm
3
b decrease
acyclovir dose or give G-
CSF

Prognosis
Prior antiviral
Mortality 85%
Encephalitis 50%
After antiviral
Mortality 29%
Encephalitis 4%
Prevention
No effective vaccine
Antiviral prophylaxis
Caesarean section for
symptomatic mother
Reduce the use of invasive
monitor at the time of
labour
Syphilis
Etiology : spirochaeta Treponema pallidum
Affects the placenta focal villositis
stillbirth and neonatal death

Clinical
Prematurity
IUGR
Classic rash :
Pink or copper coloured oval macular eruption
on buttock or trunk often develop to
vesicobullous pemphiugs sy
Desquamated and red of soles and palm
Hepatosplenomegaly often associated with
ascites
Pot belly and withered skin
Generalized painless lympadenopathy
charactersiticcaly epitrocheal
lymphadenopathy
Rhinitis (second week of life)
Laryngitis and hoarse cry
Mocous patches in mouth
Nasal mucosal ulceration
destroy nasal cartilage saddle
nose
Osteitis pseudoparalysis of
Parrot
Eye involvement : salt-and-pepper
retinitis, cataract and glaucoma
Nephrotic syndrome (2-3 months)
leptomeningitis

Diagnosis
Difficult
Methods
Serology
PCR
Microscopy
Lumbar puncture is
recommended

Treatment
Proven or probable :
Penicillin G 50.000 units/kg/IV
12 hourly in the first week 8
hourly after 10 days
Or
Procain penicillin (50.000
units/kg IM once daily)
Prevention
Maternal screening
Varicella (Chickenpox)
Acute infection : varicella
Reactivation : zoster or herpes zoster
Etiology : varicella herpes zoster
Importancy
Maternal VZV primary infection
Life threatening
Cause congenital varicella syndrome
Neonatal VZV infection
Life-threatening

Congenital varicella syndrome
Cicatrical skin lession
Unilateral limb hypoplasia
Severe CNS disorder
(microcephaly, cortical atrophy,
seizure, developmental delay)
Ocular abnormalitites
(chorioretinitis, microphtalmia)
Recommendation :
VZIG to non-immune pregnant
women exposed to VZIG
Neonatal varicella
Mother developed chickenpox 4 days prior to delivery
until 2 days after delivery newborn pneumonitis
high mortalitiy
Management
VZIG shortly after birth
Alternative
IVIG
Still develop varicella acyclovir intravenously
Parvovirus B19
Common viral illness
Rash, fever, and athralgia or
arthritis
Maternal infection
Foetus severe anemia and non-
immune hydrops
Severe developmental delay
Diverse CNS abnormalities
No consistent syndrome
- Early detection
- Intrauterine tranfussion