congenital and neonatal infection · pdf fileclinical features of congenital infection general...
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Perinatal infections
Mike Starr
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Congenital Infections
ToxoplasmosisOther (syphilis)RubellaCMVHerpesviridae– Herpes simplex– Varicella zoster
ParvovirusHepatitis B virus
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Neonatal Infections
Streptococcus agalactiae (GBS)
Escherichia coli
Listeria monocytogenes
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TORCHUseful acronym but not a name for a test
SerologyIgG can be maternalIgM often insensitive
Despite reported incidence, in practice veryunusual to see full blown disease
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Clinical features of congenitalinfection
General - SGACVS - myocarditis; congenital heart diseaseResp - pneumonitisGIT - hepatosplenomegaly; conjugated jaundiceHaematological - haemolytic anaemiaSkin - petechiae; purpura
CNS - microcephaly; hydrocephaly; intracranialcalcification; meningoencephalitis
Eye - chorioretinitis; keratoconjunctivitis;cataracts; glaucoma
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Skinlesions
• Petechiae
•Intradermal erythropoeisis (blueberry muffin) - toxoplasmosis
•Granuloma
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Utility of TORCH screeningRarely diagnostic
Routine TORCH screening of all SGA infants(mostly preterm)– 71 infants investigated
– 1 case of ‘CMV-uria’
J Peds 1979;94:779-86
TORCH screen requested in 603 patients– No evidence of infection with toxoplasmosis,
rubella, CMV, herpes
Pediatrics 1983;72:41-3
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Utility of TORCH screening
Audit of screening of SGA babies forTORCH infection– Standard practice was to investigate all infants
<3rd centile for weight
– 66 of 1347 infants admitted were <3rd centile
– 2 had congenital rubella (both had clinical signs)
Clin Peds 1982;7:417-20
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Case 1
• 7 day old girl
• normal pregnancy
• NVD
• jaundice day 1
• increased head
circumference
• chorioretinitis
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Chorioretinitis
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ToxoplasmosisToxoplasma gondii – a protozoan parasite
Zoonosis: domestic animals esp. cats.• Eat oocysts in cat faeces or infected meat
Incidence: ~1:200 pregnancies• Usually not recognised
Most women asymptomatic• Can have flu-like illness or lymphadenopathy
Risk of fetal damage greatest in 1st
trimester
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Toxoplasmosis
Risks
Fetal infection Fetal damage
1st trimester 5-15% 60-80%
2nd trimester 25-40% 15-25%
3rd trimester 30-75% 2-10%
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ToxoplasmosisClassic tetrad– Chorioretinitis, hydrocephalus or microcephaly,
convulsions, intracranial calcification– ‘Blueberry muffin’ – cutaneous erythropoeisis
Main presentation– Hydrocephalus or vision abnormalities at birth or
later
Diagnosis - serology– IgM +ve, or IgG rise (or IgA +ve or low IgG avidity)
Treatment– pyrimethamine + sulfadoxine +/- spiramycin
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Case 2 •9 day old boy
•Snuffles
•Peeling skin
•Rash on soles
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Xray showingperiostitis
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SyphilisTreponema pallidum - spirochaete
Incidence: rare in Australia,though incidenceincreasing in gay men +outbreaks in Kimberley
Untreated maternalinfection in 1st trimestermore likely to produce fetaldamage
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SyphilisTransplacental spread– Abortion/fetal death,
hydrops fetalis, preterm labour, IUGR
Extrauterine manifestations– Wide spectrum, including fulminant sepsis
– Maculopapular rash on back, legs, palms, soles
– Bullous/desquamating rash
– Rhinitis - ‘snuffles’ - 1/52 - 3/12
– HSM, jaundice, osteitis, pancytopenia, oedema,keratitis, deafness, Hutchinsons teeth,neurosyphilis with handicap
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SyphilisDiagnosis: antenatal– Non-treponemal tests for screening (VDRL, RPR)
• high titre suggests active infection• low titre suggests false +ve or previously treated syphilis
– Specific treponemal tests for confirmation (TPHA,FTA-Abs)
• positive TPHA indicates current or past syphilis
Diagnosis: neonatal– clinical picture– IgM, IgG (RPR)– CSF
Treatment: Penicillin
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Case 3
• Baby girl, day 1
• ‘Bluish’ palpable rash
• No red reflex
• HSM
• Slight jaundice
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Rubella
Incidence– less since MMR - up to 10% of women susceptible
Fever, rash, lymphadenopathy in mother– hard to diagnose clinically; 50% asymptomatic
Screen for IgG in pregnant women
Congenital Rubella– Deafness, heart defects, mental retardation,
cataracts / retinopathy
– Main risk is in 1st trimester (~ 90%)
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Rubella - management
Prevent by immunisation!
Test maternal IgG and IgM– even if previously IgG positive
– reinfection can occur without detectableIgM - rare - ↓ risk of fetal damage ~ 5%
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CMV
Most common cause of congenitalinfection and non-hereditary deafness– 0.3 - 2% live births
Primary CMV infection occurs in 6/1000pregnancies
50% risk of transmission to fetus
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CMV - sequelae
Symptomatic congenital CMV (10%)– risk of sequelae 90%
• mortality 10-30%• microcephaly 35-50%• mental retardation up to 70%• SNHL 25-50%
Asymptomatic congenital CMV (90%)– risk of sequelae 10%
• SNHL 5%
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CMVFeatures
• thrombocytopenia• microcephaly and intracranial calcification
– periventricular
• jaundice• deafness - can be progressive
Diagnosis• culture/PCR of urine in first week of life• IgM (IgG reflects maternal antibody)
Management• ?role for ganciclovir
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Case 4
•5 day old baby girl
•low grade fever
•tachypnoea
•lethargic
•blistering lesionsnoted from day 2
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Herpes Simplex Virus
Incidence: 2/100 000 live births– most HSV-2
Risk to baby– if mother seropositive
= 0.04% risk of transmission to baby
– if shedding from reactivation during delivery
= 3% transmission
– if maternal primary infection
= 30-50% transmission
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Herpes simplex virus
Increased risk– prems
– fetal scalp monitoring
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Perinatal herpes infection
Congenital - rare
Postnatal - 3 clinical categories– Localised skin, eye, mouth (SEM): D5-6
– CNS: D9-12
– Disseminated
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• EM, PCR, IF, culture of vesicular fluid or tissuescraping microscopy (multinucleate giant cells andintranuclear inclusions )
• Serology: babies get IgG from mum!
HSV diagnosis
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Herpes simplex virus
Treatment– prompt treatment is essential
– hi-dose aciclovir (20 mg/kg iv 8H)
Outcome– even with early treatment of
meningoencephalitis, 85% major handicap
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Case 5
7 day old male infant
NVD at term
2 year old sibling has chickenpox
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Perinatal VZV infection
Congenital varicella syndrome– 2% if maternal infection at 13-20/40
– 0.4% if <13/40
Neonatal chickenpox– high risk if perinatal exposure (5 days
before to 2 days after delivery)
→ full IV dose virus with no maternal Ab
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Perinatal VZV infection
Outcome– Congenital - cicatricial skin lesions and
hypoplastic limbs; CNS; eyes– Neonatal - up to 30% mortality from
pneumonitis
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Perinatal VZV infection
Maternal chickenpox– >5 (7) d before delivery: no Rx to infant
– 5 (7) d before – 2 (28) d after delivery: ZIG
If baby develops chickenpox, giveaciclovir if:– prem
– severe disease
– ZIG given late
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Case 6
25 yo school teacher is pregnant
Child in class has slapped cheekdisease
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Parvovirus B19 infection inpregnancy
60% of adults are immune
Risk of infection if susceptible:– Exposure at home: 50%– Exposure at school/child care: 20-30%– Exposure in community: <20%
Exclusion of teachers/child care workersNOT recommended
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Parvovirus B19 infection inpregnancy - risks
50% risk of transmission from infectedmother to fetus
10 excess fetal loss in 1st 20/40 i.e.15%)
3% risk of hydrops
<1% congenital anomalies (no excess)
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Parvovirus B19 infection inpregnancy – overall risks
0.6%0.05 – 0.1%Death fromhydrops or itstreatment
5%0.4 – 1%Excess fetalloss in 1st
20/40
Pregnantwoman withproven recentinfection
Any pregnantwomanexposed toparvovirus
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Hepatitis B in infants
Risk of chronic infection and subsequent liverdisease is inversely proportional to age attime of infection
– 90-95% of hep B infections <1yo result inchronic liver disease
– 25 - 50% of infections in 1 - 5 yo
– 6 - 10% in adults
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Hepatitis B - vertical transmission
Risk depends on maternal status– sAg +ve = carrier (5-20% vertical transmission)– eAg +ve = high risk carrier (90% transmission)
Hepatitis B vaccine prevents ~ 85% infection
Hepatitis B immunoglobulin and vaccine prevents~95% - given if mother eAg +ve
If vertical transmission doesn't occur, there's stilla high risk of horizontal transmission till ~ 5yo ifunimmunised
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Neonatal Infections:Early Onset Sepsis
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Case 728 week gestation baby
Premature rupture of membranes 60 hourspreviously
Maternal fever
Baby born in immediate respiratory distressrequiring ventilation
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Group B StreptococcusStreptococcus agalactiae/GBS
Incidence• ~20% women colonised in pregnancy
• 40 - 70% babies colonised
• 1% of these get disease
• approximately 1-2/1000 live births in Australia
Features• serotypes Ia, Ib, and II-VIII cause EOS (2/3)
– pneumonia and septicaemia
• serotype III predominantly causes LOS (1/3)– bacteraemia and meningitis
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GBS infection
Early onset disease
< 7 days
Obstet Cx common
30% prems
Bacteraemia, pneumonia
Fulminant
Mortality 5-20%
Late onset disease
7 days – 3 months
Obstet Cx uncommon
Term babies
Bacteraemia, meningitis
Slowly progressive
Mortality 2-6%
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Management of pregnancy
Screening– low vaginal + anorectal swabs
– 35-37/40
Obstetric risk factors– Previous infant with GBS
– GBS bacteriuria
– Labour < 37/40
– ROM > 18/24
– Intrapartum fever
Intrapartum
penicillin
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Management of neonate
Surface swabs unhelpful
FBE; blood, urine and CSF cultures;CXR
Penicillin + gentamicin
Outcome– Mortality <10% overall
– Neurological sequelae in survivors of meningitis
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Escherichia coli
Early onset sepsis, but continued risk upto 3 mths of age
Risk factors same as for GBS– PROM, chorioamnionitis, maternal fever
UTI, bacteraemia, meningitis
Gentamicin for sepsis, cefotaxime ifmeningitis
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Neonatal Infections:Late Onset Sepsis
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Late Onset Sepsis (LOS)
LOS >48 hours– EOS bugs (GBS, E coli, Listeria)
– Plus nosocomial
– +/- Coagulase negative staphylococci
Other nosocomial pathogens– Enterococci, Candida, Pseudomonas….
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Antibiotics for neonatal sepsis
EOS - benzylpenicillin + gentamicin
LOS - flucloxacillin + gentamicin– vancomycin and gentamicin where CONS
suspected
Meningitis: add cefotaxime
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Acknowledgements
Jim Buttery
Australasian Society for InfectiousDiseases (ASID)