Michael Nissen Director of Infectious Diseases & Clinical Microbiologist Royal Children s Hospital-Brisbane

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1 Michael Nissen Director of Infectious Diseases & Clinical Microbiologist Royal Children s Hospital-Brisbane

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3 Neonatal Herpes simplex Usually type 2 Vertical transmission2-5% if mother has active lesions Manifestation in neonate: Generalised infection Encephalitis Localized infection of the skin, eyes and mouth Prevention: Elective LSCS

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6 Gershon A. PREP:ID 1997

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8 Neonatal & Perinatal Varicella Maternal Varicella (3 w to 5d before delivery) VZV in infant 20% Usually mild Protected by maternal ab Maternal Varicella (5d before to 2d after) No maternal abs IP shorter Severe VZV (MR 17-30%) Post natal exposure D5-10 (MR 21%) Can be severe esp if mothers susceptible

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10 Case 1 Phone call from regional hospital Infant male 36 hrs old T+9 days by SVD 3.99 kg ROM 6 hrs Labour 5 hrs No resuscitation required Otherwise well & breastfeeding Maternal hx of genital herpes No lesions delivery but? lesion 4-5 days prenatally Now has obvious genital ulcer! What would you do? Repeat H2T exam CXR LP MCS/Biochemistry HSV PCR Urine collection HSV PCR Blood collection FBC HSV PCR? Skin Swabs HSV PCR Start Aciclovir 20mg/kg/q8hr IVI

11 Case 1 What are the risks to the baby?

12 Case 1 What should have happened?

13 Case 1 What could have been done?

14 Latest neonatal HSV recommendations

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16 Case 2 6 wk female from NGH Phone Consult 1/52 Acute onset abdominal distension Ascites? Small vesico-bullous lesions on extremities Peri-anal excoriation Poor weight gain (2.5kg at 6 weeks) O/E Afebrile, mild respiratory distress Moderate ascites, no organomegaly ANHx 37/40, IUGR, BWt. 2250g, no foetal ascites

17 On arrival : Afebrile, Alert ( no encephalopathy) Moderate tachypnea 64, Increase WOB Tachycardia 200/min, SaO2-94% room air Moderate ascites, no peritonism Distended abdominal wall veins Hepato-splenomegaly Poor muscle bulk Vesico-bullous skin lesions No obvious lower limb oedema No peripheral stigmata of chronic liver disease Summary Infant with rapid onset ascites, hepato-splenomegaly prominent anterior abdominal veins, mild abnormal transaminases /conjugated jaundice with no synthetic liver dysfunction (INR/BSL normal)/ encephalopathy

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24 FBE

25 ELFT

26 Clotting Profile

27 Ascitic Fluid

28 HSV CMV Serology

29 Syphilis Serology

30 Diagnosis?

31 Additional Tests CMV PCR Qualitative and quantitative Urine and blood Mother s CMV serology Note IgG non reactive

32 Urine

33 Blood

34 Foot CMV / HSV

35 Lesion on foot

36 Foot - TP

37 Syphilis or CMV? Any further investigations?

38 CSF

39 CSF - CMV

40 CSF - VDRL

41 CSF - TP

42 Ascitic Fluid - CMV

43 Ascitic Fluid - TP

44 Syphilis or CMV? Any further investigations? Treat both?

45 Newborn Screening Card Collected Day 5 of life Screen for:???? Hypothyroidism Galactosaemia Phenylketonuria Cystic fibrosis Stored for varying periods in different states of Australia and in New Zealand. Where are they stored in Qld.? allow for normal quality control practices may need to be used for approved research after identifying information has been removed used for further testing at the request of the parent or guardian, to provide new medical information of benefit to the family No further tests will be carried out on any identified stored blood sample by the newborn screening laboratory without written consent from either the parent(s)/guardian(s), the individual if they are old enough, or other lawful authority

46 Newborn Screening Card

47 Newborn Screening Card

48 Diagnosis Congenital Syphilis Acute CMV

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50 Case days gestation Absent foetal movements 1 day Last 36+5 days-nad Mother 26 yoa G1P0, A-, BMI 33 US confirmed IUFD Membranes intact, No PV bleed Stillborn by SVD, shoulder dystocia, BWt 4.14 kg Death certificate: IUFD Autopsy performed Maternal investigations: HbA1c 6.4% Kleihaurer <1.0 ml, fetal RBCs Lupus screen: ANA+ Anticardiolipin Ab: <3 CU CMV: Nonreactive G & M Rubella/Toxo: IgG reactive Syphilis: Nonreactive Parvovirus B19: IgG reactive Foetal lung: ParvoB19 PCR+

51 Case 3 Foetal autopsy Body Wt: kg (Mean kg) Marked maceration with skin loss Heart: Normal external appearance Pericardial cavity-3 ml serous fluid Wt-23.8 g (16.7 g) Lungs: Normal appearance Pleural fluid-17 ml serous fluid Histopathology: No viral inclusions seen Maternal Parvovirus serology Vital Diagnostics IgM : Nonreactive Absorbance: (Cu ) IgG: Strongly reactive 11.0 Units (Cu 1.1) Absorbance: (Cu-0.229) Do you still think this foetus died from Parvovirus? What is your DDx of IUFD?

52 Case 3 Differential diagnosis: 1. Early maternal Parvovirus infection with resolved intrauterine involvement. 2. Maternal DM 3. Maternal Obesity 4. Congenital chromosomal defect yet to be resolved Unanswered questions? 1. Placenta yet to be examined 2. No heart tissue PCR 3. Rexamination of autopsy material: 4. Photos-residual skin folds 5. Histology-viral inclusions 6. Maternal Parvo IgG avidity? 7. PCR contamination?

53 Parvovirus B19 infection