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CONGENITAL INFECTION
BLOK 27 2017

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

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Introduction

Congenital infection
Acquired in utero and perinatally
Can be asymptomatic in the newborn period
Clincal symptoms complexes

Currently ToRCHES CLAP

To xoplasma gondii
Before TORCH R ubella
T oxoplsama gondii C ytomegalovirus
O thers H erpes simplex virus
R ubella S yphilis
C ytmogelavirus C hickenpox
H erpes simplex virus L yme disease
A ids
P arvovirus

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Pathogenesis of infection in the fetus and newborn

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

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Clinical Manifestation
Other clinical signs and
Classic Triad : symptoms :
Hydrocephalus Blueberry mun rash
Chorioretinitis Hepatosplenomegaly
Brain calcication Jaundice
Eryhtroblastosis
Hyrdops fetalis
Non sepcic sign : fever,
lymphadenopathy, vomiting,
diarrhea, pneumonitis
Microcephaly can be described

Diagnosis
Physical examination
Full neurologic examination
Funduscopy
CT-Scan Ultrasound scan
Denitive laboratory diagnosis :
PCR on CSF
T. gondii-specic IgM, IgA and IgE

CSF : xanthochromia, mononuclear cell pleocytosis, protein CSF

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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 ???

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Rubella

Rubella German measles

Classied 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%
2nd trimester : 39%

Defects :
< 11 weeks : severe congenital heart disease and deafness
13-16% : 35% deafness alone
> 16 weeks : no congenital defects

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Clinical features
Other :
Virus infection all tissue wide
range of congenital defects Microcephaly neurodevelopmental

aecting any organ delay

Most consistent : Commonest congenital heart disease :

Severe sensorineural deafness pulmonary artery hypoplasia and
Eye defect cataract & salt-and- patent ductus arteriosus
pepper retinopathy
IUGR
Late clincal features :
Diabetes mellitus

Autoimmune disease

Dental problems

Neruopyschiatirc problems
autisme

Panecephalitis similar to SSPE

Diagnosis
Rubella-specic IgM in infantserum

Maternal infection in pregnancy serologic

Therapy
None

Prevention
Immunization

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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 :
1st trimester : sensorineural loss and CNS sequele
Late pregnancy : still can cause sequele

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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 calcication
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

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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

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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)

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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 encephalitis
Present in second week of life
Seizures, fever, lethargy, poor feeding,
- HSV pneumonitis irritability, jitterness, and rigidity

3-14 days after birth LP : mononuclear cell pleocytosis,

micro- or macroscopic blood, glucose
Often misdiagnosed
low, protein initially low but rise with
Classic chest x-ray : illness progression
Hilar and central interstitial Brain imaging : parenchymal damage
inltrate on temporal, parietal, frontal, or sub-
cortical common temporal changes

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

Treatment
Diagnosis Intravenous acyclovir 20
Rapid virologic techniques mg/kg/dose 8 hourly
Nucleic acid amplication Localized 14 days
by PCR Disseminated and
antigen detection by Elisa encephalitis 21 days
Immunouorescence
Monitoring
HSV culture not timely Neutrophil count < 500/
mm3b decrease acyclovir
dose or give G-CSF

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Prevention
Prognosis
No eective vaccine
Prior antiviral
Antiviral prophylaxis
Mortality 85%
Caesarean section for
Encephalitis 50%
symptomatic mother
After antiviral
Reduce the use of invasive
Mortality 29%
monitor at the time of
Encephalitis 4%
labour

Syphilis

Etiology : spirochaeta Treponema pallidum

Aects the placenta focal villositis

stillbirth and neonatal death

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Clinical
Prematurity
IUGR
Classic rash :
Pink or copper coloured oval macular
eruption on buttock or trunk often
develop to vesicobullous
pemphiguissy
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

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Treatment
Diagnosis
Proven or probable :
Dicult
Penicillin G 50.000 units/kg/IV
Methods
12 hourly in the rst week 8
Serology hourly after 10 days
PCR Or
Microscopy Procain penicillin (50.000
Lumbar puncture is units/kg IM once daily)

recommended 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

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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

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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

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