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Transcript
TORCH infections and HIV/AIDS in newborn - diagnostic, treatment and prophylaxis. Prof. Pavlyshyn H.A. TORCH Infections T=toxoplasmosis O=other (syphilis) R=rubella • When do you think of TORCH infections? C=cytomegalovirus (CMV) • IUGR infants H=herpes simplex (HSV) • HSM • Thrombocytopenia Index of Suspicion • Unusual rash • Concerning maternal history • “Classic” findings of any specific infection Toxoplasmosis • Caused by protozoan – Toxoplasma gondii • Domestic cat is the definitive host with infections via: • Ingestion of cysts (meats, garden products) • Contact with oocysts in feces • Much higher prevalence of infection in European countries (ie France, Greece) • Acute infection usually asymptomatic • 1/3 risk of fetal infection with primary maternal infection in pregnancy • Infection rate higher with infxn in 3rd trimester • Fetal death higher with infxn in 1st trimester • Most (70-90%) are asymptomatic at birth Clinical Manifestations • Classic triad of symptoms: • Chorioretinitis • Hydrocephalus • Intracranial calcifications • Other symptoms include fever, rash, HSM, microcephaly, seizures, jaundice, thrombocytopenia, lymphadenopathy • Initially asymptomatic infants are still at high risk of developing abnormalities, especially chorioretinitis Treatment • Symptomatic infants • Pyrimethamine (with leucovorin rescue) and sulfadiazine • Treatment for 12 months total • Asymptomatic infants • Course of same medications • Improved neurologic and developmental outcomes demonstrated (compared to untreated pts or those treated for only one month) Syphilis Clinical Manifestations • • • • • • • • • • • • Early congenital (typically 1st 5 weeks): Cutaneous lesions (palms/soles) HSM Jaundice Anemia Snuffles Periostitis and metaphysial dystrophy Funisitis (umbilical cord vasculitis) Late congenital: Frontal bossing Short maxilla High palatal arch Hutchinson teeth 8th nerve deafness Treatment • Penicillin G is THE drug of choice for ALL syphilis infections • Maternal treatment during pregnancy very effective (overall 98% success) • Treat newborn if: • • • • They meet CDC diagnostic criteria Mom was treated <4wks before delivery Mom treated with non-PCN med Maternal titers do not show adequate response (less than 4-fold decline) Rubella 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 “Blueberry muffin” spots representing extramedullary hematopoesis Diagnosis • Maternal IgG may represent immunization or past infection - Useless! • Can isolate virus from nasal secretions • Less frequently from throat, blood, urine, CSF • Serologic testing • IgM = recent postnatal or congenital infection • Rising monthly IgG titers suggest congenital infection • Diagnosis after 1 year of age difficult to establish Treatment • Prevention…immunize, immunize, immunize! • Supportive care only with parent education • Cytomegalovirus (CMV) 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 PCR diagnostic PCR diagnostic 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 • Area of active research to include use of valgancyclovir, treating asx patients, etc. Herpes Simplex (HSV) 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 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 •High dose acyclovir 60mg/kg/day divided q8hrs X21days for disseminated, CNS disease X14days for SEM •Ocular involvement requires topical therapy as well What is HIV? • Human immunodeficiency virus is the virus that causes AIDS. • The human immunodeficiency virus (HIV) infects cells of the immune system - (CD4+) T cells, destroying or impairing their function. • Infection with the virus results in the progressive deterioration of the immune system, leading to "immune deficiency." • Infections associated with severe immunodeficiency are known as "opportunistic infections", because they take advantage of a weakened immune system. Symptoms of HIV/AIDS in Children CNS – microcephaly - progressive neurological deterioration or spastic encephalopathy - developmental delay/regression - predisposition to CNS infections Respiratory System - Recurrent infections (pneumonia, sinusitis, otitis media) - Tuberculosis - Pneumocystis carinii pneumonia (PCP) or lymphoid interstitial pneumonitis (LIP) Clinical Features • CVS – cardiomyopathy with congestive cardiac failure • GIT- AIDS enteropathy (malabsorption, infections with various pathogens) leads to chronic diarrhoea resulting in failure to thrive - Abdominal pains, dysphagia, chronic hepatitis, pancreatitis • Renal – AIDS nephropathy: the most common presentation being nephrotic syndrome • Skin – Eczema, seborrheic dermatitis, candida infections, molluscum contagiosum, anogenital warts