Module 10: MMRR

Roseola

Etiology: Common viral exanthem infection in children Serotype: Human Herpesvirus 6 (HHV-6) Two subtypes: HHV-6A and HHV-6B HHV-6B causes the majority of infections Epidemiology: most commonly affects children of all races by age 2, however may occur in adulthood (rare), infection with HHV-6 is nearly universal, with 40% having infection by 12 months and 77% by 24 months, peak age of infection is 9-21 months Pathophysiology: Viral replication occurs in leukocytes and in the salivary glands (HHV-6 is present in the saliva) in primary infection, following primary infection, HHV-6 is latent within the lymphocytes and monocytes, virus growth is supported by CD4+ T lymphocytes, the virus further weakens immune response via mechanisms that involve production of functional chemokines and chemokine receptors Transmission: Transmission mainly saliva from aerosolized droplets Prenatal transmission possible through placenta in cases of maternal reactivation of primary infection Incubation: Incubation period is 5-15 days; 9 days on average Presentation: Rash usually occurs after incubation period and can last up to a few days or even only a few hours Classic presentation: A 9-12 month old infant with sudden onset high fever (104 degrees F) that lasts for 3-5 days followed by an abrupt loss of fever and development of a rash 15% have febrile seizure The rash: Develops only after fever resolves Rose-pink maculopapular and blanchable Starts on the trunk and spreads to the face Nagayama spots- characteristic; erythematous papules on the soft palate and base of uvula Patient may have other nonspecific symptoms, such as rhinorrhea or fussiness, but is otherwise alert; may also occur just with acute fever without the characteristic rash Dx: Diagnosis is typically determined on a clinical basis, laboratory testing is usually not necessary, however in cases where the patient is immunocompromised or has severe illness, identification of HHV-6 may be necessary This is complicated when the individual is older than 3 years old, as there is high seroprevalence by the time a child reaches this age There are many ways to identify HHV-6, but PCR is the most useful Complications: Febrile seizures, meningoencephalitis, medial temporal lobe epilepsy, mononucleosis-like syndrome, hepatitis Tx: Patients with pregnancy or immune compromise may need antiretroviral therapy, any patient with CNS complications usually require hospitalization, treatment otherwise supportive

Roseola

Etiology: HHV-6 MC, can be caused by HHV-7, enteroviruses, adenovirus, and parainfluenza type 1 Epidemiology: MC in young kids 7-13 months, occurs throughout the year, most cases occur sporadically without known exposure The modes of transmission, duration of shedding, and incubation periods vary depending upon the etiologic agent. Human herpesvirus 6 (HHV-6) most likely is transmitted by asymptomatic shedding of virus in secretions of close contacts. The duration of shedding for HHV-6 is not known but is thought to be lifelong. The mean incubation period for HHV-6 is 9 to 10 days Presentation: 3-5 days of fever that may exceed 104, blanching or maculopapular rash on the neck and trunk that spreads to the face and extremities Dx: clinically (fever for 3-5 days followed by abrupt defervescence and rash development in young child), can see relative neutropenia and mild atypical lymphocytosis, thrombocytopenia, sterile pyuria Tx: usually benign and self limited, tx is supportive Complications: seizures, aseptic meningitis, encephalitis, thrombocytopenic purpura Prevention: standard hygiene, handwashing

Measles (Rubeola)

Etiology: Of the family paramyxoviruses, single stranded rna virus Pathophysiology: Hemagglutinin (HA) protein attaches to host cell usually mucous membranes Serologically only one type, isolates are all genetically similar Epidemiology: Seen all over the world, recent epidemic outbreaks in us due to under-vaccination, with vaccination, infections most commonly in teens and pre-teens, pre-vaccination usually infection of kids 5-9 years, mortality up to 10%, most in children <2yrs, or in adults There was documented eradication from the us in 2000 Since then, there are outbreaks in the us (cases are reportable to the cdc!), usually in the unvaccinated 2014: 384 cases in an ohio unvaccinated Amish community, rest brought into US from travelers from Philippines where an outbreak was happening Still common in Africa, Asia, Europe and South Pacific Transmission aerosol Causes common viral exanthem in children, but has serious possible sequelae making it potentially lethal Incubation: 10 - 11 days Presentation: Prodromal stage: fever, malaise, sneezing, rhinitis, congestion, conjunctivitis and cough. Koplik's spots, which are pathognomonic, appear on the buccal and lower labial mucosa opposite the lower molars Distinctive maculopapular rash appears 4 days after exposure, starts behind the ears and on the forehead, spreads to entire body Tx: Most cases are self-limiting and need no treatment Can be very serious in immunocompromised, undernourished, and those with chronic diseases Vaccination of those exposed within 72 hours mainstay of management Live vaccine: 99% efficacy, 10 year immunity, possibly lifelong Inactive vaccine: now discontinued, not nearly as effective as live vaccine Immunoglobulin: injection for pregnant women, immunocompromised, infants who have been exposed within 6 days of exposure Cases reportable to cdc Treatment is supportive: fever reduction, fluid support, hospitalization if signs of complications, immunoglobulin for infants, immunocompromised or pregnant women Antibiotics limited to pneumonia or ear infections that are secondary infections Vitamin A shown to help limit disease severity and length in those deficient in vitamin a (20,0000 IU injections x 2 days) Dx: ___________-Specific IgM diagnostic from ELISA on serum or saliva samples, only necessary if clinical diagnosis cannot be established It can be tricky to remember ____________ is also known as rubeola, especially since there is a roseola! I remember this by telling myself "_________ has a ruby red rash like Rubeola"

Mumps

Etiology: Paramyxovirus infection causing a viral exanthem, can be found, after infection, in most all bodily fluids but most exposures are aerosolized, virus usually just one serotype causing disease Epidemiology: Occurs worldwide, and incidence decreased by >99% after vaccine introduced in 1967, outbreaks occur in the US and other developed countries today Close contact a risk: NHL outbreak in 2014, sports teams, schools, prisons, colleges >3,000 cases in Arkansas in 2014 most in colleges Disease is highly contagious Along with measles and rubella, the vaccines are live, attenuated viruses Presentation: Incubation usually 16-18 days, and most people are infectious spreaders of disease 7 days before onset of symptoms, 2-3 weeks to manifestation of symptoms usually prodromal with fever up to 103F, anorexia, malaise, myalgias, 30% of infections are mild and subclinical, virus exposure leads to infection in upper or lower respiratory tract, gets into lymph tissue and disseminates viremia, 40% get classic parotitis from salivary gland infection, Can be unilateral or bilateral, most common manifestation. Lasts 10-14 days, may be painful to chew, Viral meningitis (15%) with stiff neck, headache, usually resolves in 10 days, Orchitis 50% of men with infection. 70% unilateral, usually with parotitis. Results in testicular scarring and atrophy, but is usually not a cause of infertility Complications: Rare complications include deafness, myocarditis, arthritis, nephritis, pancreatitis Dx: Diagnosis usually clinical, but there are serologic tests which can confirm Suspected: Parotitis, acute salivary gland swelling, orchitis, or oophoritis unexplained by another more likely diagnosis, OR A positive lab result with no __________ clinical symptoms (with or without epidemiological-linkage to a confirmed or probable case). Probable: Acute parotitis or other salivary gland swelling lasting at least 2 days, or orchitis or oophoritis unexplained by another more likely diagnosis, in: A person with a positive test for serum anti-________ immunoglobulin M (IgM) antibody, OR A person with epidemiologic linkage to another probable or confirmed case or linkage to a group/community defined by public health during an outbreak. Confirmed: A positive laboratory confirmation for _________ virus with reverse transcription polymerase chain reaction (RT-PCR) or culture in a patient with an acute illness characterized by any of the following: Acute parotitis or other salivary gland swelling, lasting at least 2 days Aseptic meningitis Encephalitis Hearing loss Orchitis Oophoritis Mastitis Pancreatitis In suspected clinical infection, laboratory confirmation by 2 diagnostic specimens: (+) serum IgM antibody RT-PCR Culture (buccal or oral swab) *ASAP after onset of parotitis* Should swab for 30 seconds Tx: No treatment other than supportive Outbreaks still happen (like in the nhl) in vaccinated people

Mumps

Etiology: caused by a paramyxovirus, a member of the Rubulavirus family. The average incubation period is 16 to 18 days, with a range of 12 to 25 days Presentation: pain, tenderness, and swelling in one or both parotid salivary glands (cheek and jaw area) that usually peaks in 1 to 3 days and then subsides during the next week. The swollen tissue pushes the angle of the ear up and out. As swelling worsens, the angle of the jawbone below the ear is no longer visible. Often, the jawbone cannot be felt because of swelling of the parotid. One parotid may swell before the other, and in 25% of patients, only one side swells. Other salivary glands (submandibular and sublingual) under the floor of the mouth also may swell but do so less frequently (10%), nonspecific prodromal symptoms including low-grade fever which may last 3 to 4 days, myalgia, anorexia, malaise, and headache, parotitis usually lasts at least 2 days, but may persist longer than 10 days. May also present only with nonspecific or primarily respiratory symptoms, or may be asymptomatic. Recurrent parotitis, when parotitis on one side resolves but is followed days to weeks later by parotitis on the other side, vaccinated cases are less likely to present severe symptoms or complications than under- or unvaccinated cases, lymphadenopathy with well-defined borders of the lymph nodes, their location behind the angle of the jawbone, and lack of the ear protrusion or obscuring of the angle of the jaw Background: Before the U.S. vaccination program started in 1967, about 186,000 cases were reported each year, and many more unreported cases occurred. The disease caused complications, such as permanent deafness in children, and occasionally, encephalitis, which could rarely result in death. Since the pre-vaccine era, there has been a more than 99% decrease in mumps cases in the United States. From year to year, the number of cases can range from roughly a couple hundred to a couple thousand. However, outbreaks still occur, even among highly vaccinated populations. Transmission: The virus replicates in the upper respiratory tract and is transmitted person to person through direct contact with saliva or respiratory droplets of a person infected. The risk of spreading the virus increases the longer and the closer the contact a person has with someone who has it. The infectious period is considered from 2 days before to 5 days after parotitis onset, although the virus has been isolated from saliva as early as 7 days prior to and up to 9 days after parotitis onset. Virus has also been isolated up to 14 days in urine and semen. When a person is ill, they should avoid contact with others from the time of diagnosis until 5 days after the onset of parotitis by staying home from work or school and staying in a separate room if possible. Complications: orchitis, oophoritis, mastitis, meningitis, encephalitis, pancreatitis, hearing loss Pregnancy: generally benign, theoretical risk of complications in early months of pregnancy (possible spontaneous abortion, intrauterine fetal death, congenital malformations) Vaccination: People who previously had one or two doses of MMR vaccine can still get and transmit the disease. During outbreaks in highly vaccinated communities, the proportion of cases that occur among people who have been vaccinated may be high. This does not mean that the vaccine is ineffective. The effectiveness of the vaccine is assessed by comparing the attack rate in people who are vaccinated with the attack rate in those who have not been vaccinated. In outbreaks of highly vaccinated populations, people who have not been vaccinated usually have a much greater attack rate than those who have been fully vaccinated. Disease symptoms are generally milder and complications are less frequent in vaccinated people. Vaccination is the best way to prevent disease and complications. This vaccine is included in the combination measles-mumps-rubella (MMR) and measles-mumps-rubella-varicella (MMRV) vaccines. Two doses of _______ vaccine are 88% (range 31% to 95%) effective at preventing the disease; one dose is 78% (range 49% to 91%) effective. In October 2017, the Advisory Committee on Immunization Practices (ACIP) recommended that people identified by public health authorities as being part of a group at increased risk for acquiring because of an outbreak should receive a third dose of MMR vaccine. The purpose of the recommendation is to improve protection of people in outbreak settings against disease and related complications. Dx: RT-PCR and viral culture (buccal swabs, may also use CSF or urine), negative result does not rule out Report to local health department

Rubella (German Measles)

Pathophysiology: The virus attaches to the cell surface, the receptor is thought to be phospholipids & glycolipids due to its wide tissue response, replication occurs in the cytoplasm of the host cell and the virus is then released from the cell, primary cytopathic effect is induction of apoptosis, infection causes IgG antibody production, protective immunity Epidemiology: Prior to vaccination, over 220,000 cases annually in US, after vaccination, very rare infection, have been cases both ________ and congenital __________ infection (CRI) since CDC declared it eradicated in 2004, most US infections caused by travelers to developing world countries and brought into country Vaccine: Live, attenuated virus like measles and mumps given with measles and mumps, usually Presentation: Symptoms typically mild, up to 50% are asymptomatic, maculopapular rash pink, pinpoint maculopapules starting on the face then spread to trunk & extremities within 24 hours, typically lasts 3 days hence the name "three-day measles", rash is not as red as that of measles, but pretty hard to distinguish! Usually affects children, but can affect adults, lymphadenopathy, malaise, or conjunctivitis. Arthralgia and arthritis can occur in <70% of infected adult and adolescent females. Arthritis rare in adults and men Congenital: triad→ cataracts, cardiac abnormalities, deafness Complications: rare complications are thrombocytopenic purpura, encephalitis, neuritis, and orchitis, congenital infection most risky in first trimester when organogenesis is occurring→ miscarriage, stillbirth, abortion, combinations of birth defects, or asymptomatic infection can occur. Dx: Although serologic testing remains the most available laboratory method for confirmation, CRI also can be confirmed by reverse transcriptase polymerase chain reaction (RT-PCR) assays, which detect virus If infection is suspected, confirm diagnosis with serology and diagnostic testing ALL 50 states require reporting of all cases of CRI and ________ Cases reported as: Suspected, Probable , Or confirmed Laboratory confirmation is required for case confirmation. Laboratory testing should be conducted for all suspected cases. IgM antibodies might not be detectable before 4--5 days after rash onset. If negative __________ IgM and IgG results are obtained from specimens taken before 4--5 days, repeat serologic testing Tx: Cases should be isolated for a week as soon as diagnosis is suspected! Report cases to CDC, CDC has list of questions all suspected cases should be asked (Risk factors, sick contacts, travel history, pregnancy history, workup and results of testing, vaccination history, close contacts)

e

People who have been exposed to cases of measles should be managed how? What about infants, pregnant women, and those previously vaccinated- how should they be managed after exposure? a. Post-exposure prophylaxis should be administered, or they should be excluded from the setting involved (school, hospital, childcare). Either administration of the MMR vaccine within 72 hours of initial exposure, or IG within 6 days of exposure is acceptable. b. Infants as young as 6 months may receive the MMR vaccine as prophylaxis c. Infants younger than 12 months of age, as well as pregnant women without immunity and the immunocompromised should receive IGIM. d. Healthcare providers should receive MMR within 72 hour of IGIM within 6 days of exposure and wait to return to healthcare settings from day 5 after 1st exposure to day 21 after last exposure, regardless of post-exposure prophylaxis. e. All of the above

Measles (Rubeola)

Presentation: acute viral respiratory illness, prodromal fever, malaise, cough, coryza, conjunctivitis, Koplik spots, maculopapular rash (14 days after exposure) spreads from head to trunk to lower extremities, considered to be contagious from 4 days before to 4 days after rash appears, sometimes rash does not develop in immunocompromised patients Etiology: single-stranded, enveloped RNA virus with 1 serotype. It is classified as a member of the genus Morbillivirus in the Paramyxoviridae family. Humans are the only natural hosts of virus. Background: In the decade before the live vaccine was licensed in 1963, an average of 549,000 cases and 495 deaths were reported annually in the United States. However, it is likely that, on average, 3 to 4 million people were infected annually; most cases were not reported. Of the reported cases, approximately 48,000 people were hospitalized and 1,000 people developed chronic disability from acute encephalitis caused by ___________ annually. In 2000, ____________ was declared eliminated from the United States. Elimination is defined as the absence of endemic virus transmission in a defined geographic area, such as a region or country, for 12 months or longer in the presence of a well-performing surveillance system. However cases and outbreaks still occur every year in the United States because measles is still commonly transmitted in many parts of the world, including countries in Europe, the Middle East, Asia, the Americas, and Africa. Worldwide, an estimated 10 million cases and 110,000 deaths are reported each year. Since 2000, when _______________ was declared eliminated from the U.S., the annual number of cases has ranged from a low of 37 in 2004 to a high of 667 in 2014. The 2019 case count exceeded 2014 levels as of April 26, 2019, and continues to climb. The majority of cases have been among people who are not vaccinated. Cases in the United States occur as a result of importations by people who were infected while in other countries and from transmission that may occur from those importations. Measles is more likely to spread and cause outbreaks in U.S. communities where groups of people are unvaccinated. Outbreaks in countries to which Americans often travel can directly contribute to an increase in cases in the United States. In recent years, importations have come from frequently visited countries, including, but not limited to, the Philippines, Ukraine, Israel, Thailand, Vietnam, England, France, Germany, and India, where large outbreaks were reported. Complications: otitis media, bronchopneumonia, laryngotracheobronchitis, diarrhea, acute encephalitis, death due to neurological or respiratory complications, subacute sclerosing panencephalitis (SSPE) People at high risk for severe illness and complications from __________ include: Infants and children aged <5 years Adults aged >20 years Pregnant women People with compromised immune systems, such as from leukemia and HIV infection Transmission: one of the most contagious of all infectious diseases; up to 9 out of 10 susceptible persons with close contact to a patient will develop. The virus is transmitted by direct contact with infectious droplets or by airborne spread when an infected person breathes, coughs, or sneezes. Virus can remain infectious in the air for up to two hours after an infected person leaves an area. Dx: clinical (febrile rash illness, recent travel, exposure, report to local health dept within 24 hours), confirmation via IgM Ab and RT-PCR in a respiratory specimen via serum & throat swab, urine sample, genotyping (only way to distinguish between wild-type and rash caused by recent vaccination) Evidence of Immunity: Acceptable presumptive evidence of immunity against ____________ includes at least one of the following: written documentation of adequate vaccination: one or more doses of a __________-containing vaccine administered on or after the first birthday for preschool-age children and adults not at high risk two doses of _________-containing vaccine for school-age children and adults at high risk, including college students, healthcare personnel, and international travelers laboratory evidence of immunity* (*People who have negative or equivocal results for ___________ IgG should be vaccinated or re-vaccinated. In some cases it is not possible to vaccinate a patient, and you may need to test them with a second line diagnostic assay to determine whether they are immune. Because the sensitivity and specificity of commercial measles IgG assays vary, state public health departments can provide information on appropriate second line assays.) laboratory confirmation birth before 1957 Vaccination: can be prevented with __________-containing vaccine, which is primarily administered as the combination measles-mumps-rubella (MMR) vaccine. The combination measles-mumps-rubella-varicella (MMRV) vaccine can be used for children aged 12 months through 12 years for protection against measles, mumps, rubella and varicella. Single-antigen measles vaccine is not available. One dose of MMR vaccine is approximately 93% effective at preventing; two doses are approximately 97% effective. Almost everyone who does not respond to the __________ component of the first dose of MMR vaccine at age 12 months or older will respond to the second dose. Therefore, the second dose of MMR is administered to address primary vaccine failure Recommendations: Kids: routine MMR; 1st dose 12-15 months, 2nd dose at 4-6 years or at least 28 days following the first dose Also available to kids 12 months-12 years, minimum interval between doses is 3 months Students at post-high school educational institutions without evidence of immunity: 2 doses of MMr, 2nd dose administered no earlier than 28 days after 1st dose Adults: at least 1 dose if born during or after 1957 International travelers: Infants 6 through 11 months of age should receive one dose of MMR vaccine† Children 12 months of age or older should have documentation of two doses of MMR vaccine (the first dose of MMR vaccine should be administered at age 12 months or older; the second dose no earlier than 28 days after the first dose)* Teenagers and adults born during or after 1957 without evidence of immunity against ____________ should have documentation of two doses of MMR vaccine, with the second dose administered no earlier than 28 days after the first dose Post-exposure Prophylaxis: either administer MMR vaccine within 72 hours of initial exposure, or immunoglobulin (IG) within six days of exposure. Do not administer MMR vaccine and IG simultaneously, as this practice invalidates the vaccine. Isolation: Infected people should be isolated for four days after they develop a rash; airborne precautions should be followed in healthcare settings. Regardless of presumptive immunity status, all healthcare staff entering the room should use respiratory protection consistent with airborne infection control precautions (use of an N95 respirator or a respirator with similar effectiveness in preventing airborne transmission). Because of the possibility, albeit low, of MMR vaccine failure in healthcare providers exposed to infected patients, they should all observe airborne precautions in caring for patients. The preferred placement for patients who require airborne precautions is in a single-patient airborne infection isolation room (AIIR). People without evidence of immunity who have been exempted from vaccination for medical, religious, or other reasons and who do not receive appropriate PEP within the appropriate time frame should be excluded from affected institutions in the outbreak area until 21 days after the onset of rash in the last case of measles. Tx: there is no specific antiviral therapy. Medical care is supportive and to help relieve symptoms and address complications such as bacterial infections. Severe cases among children, such as those who are hospitalized, should be treated with vitamin A. Vitamin A should be administered immediately on diagnosis and repeated the next day. The recommended age-specific daily doses are: 50,000 IU for infants younger than 6 months of age 100,000 IU for infants 6-11 months of age 200,000 IU for children 12 months of age and older

Rubella (German Measles)

Presentation: mild maculopapular rash starts on face and becomes generalized in 24 hours lasting about 3 days, lymphadenopathy of posterior auricular or suboccipital lymph nodes lasting 5-8 days, slight fever, can be asymptomatic Etiology: enveloped, positive-stranded RNA virus classified as a Rubivirus in the Togaviridae family Background: Before the vaccine was licensed in the United States in 1969, __________ was a common disease that occurred primarily among young children. Epidemics occurred every 6 to 9 years, with the highest number of cases during the spring. Was declared eliminated (the absence of endemic transmission for 12 months or more) from the United States in 2004. However, it is still commonly transmitted in many parts of the world. As a result, less than 10 cases (primarily import-related) have been reported annually in the United States since elimination was declared. Incidence in the United States has decreased by more than 99% from the pre-vaccine era. Because it continues to circulate in other parts of the world, an estimated 100,000 infants are born with congenital ___________ syndrome (CRS) annually worldwide. Complications: arthralgia, thrombocytopenic purpura, encephalitis, complications in pregnancy (esp 1st trimester→ miscarriages, fetal deaths/stillbirths, severe birth defects known as CRS) Congenital complications: cataracts, heart defects, hearing impairment Transmission: transmitted primarily through direct or droplet contact from nasopharyngeal secretions. Humans are the only natural hosts. In temperate climates, infections usually occur during late winter and early spring. The average incubation period of virus is 17 days, with a range of 12 to 23 days. People infected are most contagious when the rash is erupting, but they can be contagious from 7 days before to 7 days after the rash appears. Dx: consider in unvaccinated patients with febrile rash illness & other sx, esp if international travel or exposure, collect throat (best source), nasal, or urine specimens for PCR and molecular typing, and blood for serology Tx: no specific antiviral therapy, isolate and report to local health dept Evidence of Immunity: Acceptable presumptive evidence of immunity against includes at least one of the following: written documentation of vaccination with one dose of live virus-containing vaccine administered on or after the first birthday, laboratory evidence of immunity, laboratory confirmation of disease, or birth before 1957 Vaccination: routine MMR, about 97% effective Recommendations: Children: MMR at 12-15 months, and then 2nd dose at 4-6 years or at least 28 days after 1st dose Adults: students attending colleges or other post high school educational institutions, healthcare personnel, international travelers, non-pregnant women of childbearing age, and/or adults born during or after 1957 should receive at least one dose, pregnancy should be vaccinated immediately after birth, Isolation: Patients should be isolated for 7 days after they develop rash. In settings where pregnant women may be exposed, outbreak control measures should begin as soon is suspected and should not be postponed until laboratory confirmation of cases. People at risk who cannot readily provide acceptable evidence of immunity should be considered susceptible and should be vaccinated. People without evidence of immunity who are exempt from vaccination for medical, religious, or other reasons should be excluded from affected institutions in the outbreak area until 23 days after the onset of rash in the last case. Unvaccinated people who receive MMR vaccine as part of outbreak control may immediately return to school provided all people without documentation of immunity have been excluded.

Congenital Zika

TORCH Associated with severe congenital anomalies, greatest risk in 1st trimester Presentation: microcephaly, facial disproportion, hypertonia/spasticity, hyperreflexia, seizures, irritability, arthrogryposis, ocular abnormalities, sensorineural hearing loss, and neuroradiologic abnormalities (eg, intracranial calcifications, ventriculomegaly)

Congenital Toxoplasmosis

TORCH Classic triad- chorioretinitis, hydrocephalus, intracranial calcifications Etiology: toxoplasma gondii (protozoan parasite) Presentation: fever, maculopapular rash, HSM, microcephaly, seizures, jaundice, thrombocytopenia, generalized lymphadenopathy, many are asymptomatic Complications: vision loss, intellectual disability, deafness, seizures, spasticity

Congenital CMV

TORCH Mostly asymptomatic at birth, MC congenital viral infection Presentation: petechiae, jaundice, hepatosplenomegaly, chorioretinitis, and neurologic involvement (eg, microcephaly, motor disability, sensorineural hearing loss, cerebral calcifications, lethargy, seizures) Both asymptomatic & symptomatic infants are at risk for developing late complications including hearing loss (MC), visual impairment, intellectual disability, and delay in psychomotor development Dx: failed newborn hearing screen

Congenital Syphilis

TORCH Mostly asymptomatic at birth, clinical manifestation after birth are divided into early (<2 yo) and late (>2 yo) Etiology: treponema pallidum (spirochete) Complications: stillbirth, hydrops fetalis, prematurity and associated long-term morbidity

Neonatal HSV

TORCH Mostly perinatally acquired Presentation: usually appear normal at birth, although many are born prematurely. Can develop as 1 of 3 patterns: Localized to skin, eyes, and mouth Localized CNS disease: nonspecific, can include temp instability, respiratory distress, poor feeding, and lethargy, can quickly progress to hypotension, jaundice, DIC, apnea, and shock Disseminated disease

Congenital Rubella Syndrome (CRS)

TORCH No longer endemic in US, average 5-6 cases reported each year, usually in infants whose mothers emigrated from countries without immunization programs Presentation: sensorineural deafness, cataracts, cardiac malformations (eg, patent ductus arteriosus, pulmonary artery hypoplasia), and neurologic and endocrinologic sequelae. Neonatal manifestations may include growth retardation, radiolucent bone disease (not pathognomonic of congenital ________), hepatosplenomegaly, thrombocytopenia, purpuric skin lesions (classically described as "blueberry muffin" lesions that represent extramedullary hematopoiesis), and hyperbilirubinemia.

Congenital VZV

TORCH Presentation: scars, cataracts, chorioretinitis, microphthalmos, nystagmus, hypoplastic limbs, cortical atrophy, and seizures

TORCH

Toxoplasmosis, Other (Syphilis), Rubella, CMV, HSV Group of perinatal infections that may have similar presentations, including rash and ocular findings. Other important causes include enteroviruses, VZV, Zika virus, and parvovirus B19. Significant cause of fetal and neonatal mortality and an important contributor to childhood mortality Dx: Timely diagnosis of perinatally acquired infections is crucial to the initiation of appropriate therapy. In the absence of maternal laboratory results compatible with intrauterine infection, intrauterine infection may be suspected in newborns with certain clinical manifestations or combinations of clinical manifestations, including hydrops fetalis, microcephaly, seizures, cataract, hearing loss, congenital heart disease, hepatosplenomegaly, jaundice, and/or rash Screening: Pregnant women screened for rubella and syphilis at 1st prenatal visit, may also be screened for toxoplasmosis in countries other than US Newborns usually not screened if asymptomatic except: Toxoplasmosis: some countries and few select states in US CMV: some screening for infants who fail newborn hearing test, not universal Preferred approach for dx and screening is based on clinical presentation