Congenital Infections

Transcription

1 Congenital Infections Dr. Jane McDonald Pediatric Infectious Diseases Montreal Children s Hospital

2 Objectives Key characteristics of different congenital infections Pregnancy screening and work up of a child with a suspected congenital infection Treatment options in pregnancy and for the newborn

3 Disclosures Nothing to disclose

4 Case Baby girl born to 17 yr. P1G1 at term BW: 1.8 kg. Head Circumference: 31 cm. Length: 47 cm. Seizures at 16 hours of age Mother reports no illness during pregnancy

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6 Toxo transmission by trimester st 2nd 3rd rate of transmission severely affected

7 Toxoplasmosis Protozoan: Toxoplasma gondii Clinical: Microcephaly, hydrocephalus, intracranial calcifications Acute disease: fever, thrombocytopenia, hepatosplenomegaly, hepatitis, choreoretinitis

8 Management of Toxoplasmosis during pregnancy If seronegative repeat serology throughout pregnancy If IgM and IgG positive: refer to ID, will need Toxo IgG avidity If seroconversion recognized: Begin Spiramycin Amniocentesis for Toxoplasma PCR If evidence of fetal infection, change to pyramethamine, sulfadiazine

9 Avoiding Toxo in pregnancy Avoid under-cooked meat, raw shellfish Freeze meat for 48 hours Don t change cat litter (or if unavoidable, change every 24 hours) Avoid gardening and wash fruit and vegetables well Wash hands and clean all kitchen surfaces well

10 Cytomegalovirus DNA virus, Herpes Group 50% of pregnant women seropositive Severely affected babies result from primary infection in pregnancy Primary CMV occurs in % of pregnancies 50% transmission rate to fetus 10% of infected newborns symptomatic

11 Congenital CMV Hepatosplenomegaly, jaundice, thrombocytopenia, microcephaly, periventricular cerebral calcifications, choreoretinits, IUGR Pneunmonitis deafness

12 Choreoretinitis Toxoplasmosis CMV

13 Congenital CMV: diagnosis ***Isolation of virus in first 2 weks of life Viral culture of Urine CMV viral load LP with CMV viral load Serology (only useful if negative)

14 CMV during pregnancy Most infections asymptomatic Screening often difficult to interpret IgG and IgM testing available IgM may remain positive for >1 year Follow IgG titers Serial ultrasounds Amnio with CMV viral load available No treatment available

15 Congenital CMV: Treatment Oral ganciclovir for 6 months Improved audiologic and neurodevelopmental outcomes Potential toxicity of long term gancyclovir (neutropenia) IV ganciclovir if unable to tolerate PO

16 Case You are called by a daycare worker who is 26 weeks pregnant. There is an outbreak of Fifth disease in the daycare and she is worried about how this may affect her. What do you tell her?.

17 Parvovirus B19 Erythema infectiousum (5 th Disease) Aplastic crisis (Hemoglobinopathies) Arthropathy Fetal Anemia and hydrops

18 Parvovirus B19 DNA virus Replicates and is lytic for erythroid precursor cells in marrow 60% of adults immune Risk of fetal death 2-6% 50% household transmission 20% school or child care transmission Diagnosis by serology (IgM, IgG)

19 Case A woman who is pregnant in her first trimester is exposed to a child with chicken pox. She doesn t know whether she has ever had varicella and she is in a panic. What do you tell her?

20 Things to consider History of chicken pox or vaccination with Varicella vaccine Exposure history (contagious 1-2 days before rash and until lesions crusted) Certainty of diagnosis exposure Severity of VZV in pregnancy (consider VZIG)

21 VZV Embryopathy Limb scarring and atrophy Bony defects CNS (microceph., cortical atrophy) Eye (choreoretinitis)

22 VZV Embryopathy Development of Zoster early in life Maternal 1 st trimester infection: risk 2.3% Not known if VZIG is protective for malformations

23 Perinatal VZV Maternal varicella shortly before delivery may result in severe varicella in newborn. ( 5 days before to 2 days after delivery) Mortality in newborn 5% VZIG for newborn

24 Case 24 year old female travelled to N. E Brazil early in pregnancy Reports illness while there Fever, headache, rash lasting 3 days, mild conjunctivitis Worried about Zika virus.

25 Zika Virus Mosquito-borne flavivirus, transmitted by Aedes aegypti (Aedes albopictus) Identified in Brazil 2015 Outbreaks have occurred in Africa (named for Ugandan forest), SE Asia, Pacific Island, Easter Island (2014), South America 2015 Currently: Caribbean, Central America, South America, Florida (Miami)

26 Zika Virus Incubation 2-14 days Mild illness, 20-25% symptomatic Intrauterine infection associated with microcephaly, ventricular calcifications, and fetal loss esp. if infection is in first trimester. Sexual transmission

27 Zika recommendations Avoid becoming pregnant during travel and for 2 months after return from a risk area After male partner returns from an area of risk, delay trying to become pregnant for 6 months If travel cannot be avoided, use personal protection measures against mosquitos

28 Zika Virus diagnosis Serology IgM and IgG (need information about travel, date of symptoms etc.) Cross-reaction with Dengue, yellow fever (vaccine) Specific IgG test (neutralization, PRNT) very labour-intensive (NML) Final results may take between 3-6 weeks RT-PCR available on blood, placenta, CSF, amniotic fluid

29 Screening in the context of pregnancy Ask travel history! Screening discussed on case by case basis Actual risk currently unclear Testing (including blood PCR) should be offered to pregnant women with acute symptoms or history of compatible symptoms and travel to affected areas. Consider testing in asymptomatic pregnant women if compatible travel history (caveat; false + IgM, test delays) Serial ultrasounds do not pick up microcephaly until late 2 nd trimester

30 Case Baby boy born to a 18 year with no prenatal care. The mother has a history of cocaine ingestion and the father is an IV drug abuser. On questioning the mother reports a flu-like illness about 6 months ago but otherwise no problems. She thinks she may have had a rash with this illness. The baby is slightly SGA with a normal head circumference. The baby has anemia, jaundice, a heart murmur and a diffuse erythematous macular-papular rash..

31 Rubella RNA virus Congenital defects: 85% if infection < 4 wks. gestation 20-30% during 2 nd month 5% during the 3 rd or 4 th month

32 Congenital Rubella Transient Manifestation: Hepatitis, thrombocytopenia, dermal erythropoiesis, hemolysis, myocarditis, meningoencephalitis, bone radiolucencies Permanent Manifestations: cataracts, retinopathy deafness (sensoineural hearing loss) Cardiac (PDA, PS) Late Manifestations endocrinopathies (DM, thyroid)

33 Congenital Rubella

34 Congenital Rubella: Diagnosis Congenital defects Rubella virus isolated at birth (NPA, urine, CSF, eye) Rubella PCR Rubella IgM Rubella IgG antibody persists

35 Syphilis Transmission to fetus (if untreated) 1 0 syphilis: % 2 0 syphilis: 90% 3 0 syphilis: 30% Infection before 4 th month of gestation rare

36 Congenital Syphilis: Clinical signs Early Osteochondritis Snuffles Rash Anemia Hepatitis CNS Lymphadenopathy jaundice Late Frontal bossing Saddle nose Keratitis 8 th nerve deafness Hutchinson s incisors Mulberry molars Cluttons joints Saber shins

37 Syphilis : Diagnosis Spirochetes in skin lesions T. pallidum by IFA in mucosal lesions -ELISA screen (specific) -VDRL or RPR (non-treponemal test) titer -Specific serology: FTA-abs, TPHA, MHA-TP, TPI

38 Syphilis: Treatment Treat baby if mother inadequately treated: No Rx, non-penicillin Rx. or undocumented Rx Rx. 4 weeks or less before delivery maternal evidence of re-infection VDRL on mother should become negative (specific tests remain positive)

39 Case 7 day old baby presents with apnea, poor feeding and fever. The baby was born at 35 weeks after 24 hours of ruptured membranes. A scalp electrode was placed for the final 2 hours of labour because of decelerations. Apgars were 7 and 9. The baby seemed to do well in the immediate neonatal period until 7 days of life.

40 Herpes Simplex Virus DNA virus HSV 1 HSV 2 Vertical transmission: 75% HSV 2 Routes: transplacental (rare), ascending intrauterine, natal (80%), postnatal

41 Herpes Simplex Virus Highest risk of transmission if: 1 st episode vs. recurrent (50% vs 0-5%) Cervical lesion, multiple ROM > 6 hr. Instrumentation, scalp electrodes premature

42 HSV Neonatal infection-- Diagnosis Clinical: Disseminated disease (liver, lung, CNS) Localized CNS disease +/- skin involvement Disease localized to skin, eyes and/or mouth Diagnosis *** 20% have no skin lesions PCR of Blood and CSF Skin lesion and mucous membrane cultures LFT

43 Other congenital infections Candidiasis Chlamydia trachomatis Lymphocytic Choriomeningitis virus Respiratory papillomatosis TB Hepatitis B and C HIV

44 Conclusions Assess routine serology testing in pregnancy in view of risks, etc. Additions to routine testing Tailor investigation of newborn to fit possible diagnoses Consider treatment where indicated