ATYPICAL INFECTIONS

DR. ATUL KULKARNI(MD)DR. MANDAR HAVAL(DCH DNB FELLOW

in NEONATOLOGY)

Definitions

• congenital – contracted in utero

• perinatal– from completion of 28 weeks gestation until 1-4

weeks after birth• postnatal

Common Infecting Agents

• Bacteria

• Viruses

• Protozoa

• Chlamydiae/Mycoplasma/Rickettsia

• Fungi

CASE 1

• 10 day FTND with fever, respiratory distress with cynosis.

• Had a history of conjuntivitis on day 5 and is on topical treatment

• Examination – tacypnea, cynosis • RS- bilat –crepts no wheese• Investigation –CBC – Eosinophilia• Xray –pnemonia

Chlamydia trachomatis

• Acquisition occurs in some 50% of infants born vaginally

to infected mothers and in some delivered by CS with

intact membranes

• The nasopharynx is the common site of primary

multiplication in the infant

– conjunctivitis in 15-50%

– pneumonia in 5 - 20%

Chlamydia trachomatis

• Pneumonia occurs between 1-3 months of the age and is

always insidious with persistent cough, tachypnea and

absence of fever

• Absence of fever and wheezing helps to distinguish

Chlamydia trachomatis from RSV.

DIAGNOSIS TREATMENT• Isolation of Chlamydia

in conjunctival and Nasopharynx

• Direct fluorescent antibody

• PCR

• Oral erethromycin 40mg/kg/day divided into 4 divided dose for 14 days

CASE 2

• 30wks Preterm on ventilator 10 days O2 dependent even

after 3wk x-ray bilat opacities

• Vaginal delivery

• Mother had history of chorioamniotis

• Baby required reintubation

• ?BPD

• CBC –N / BLOOD C/S Serile

Ureaplasma Urealyticum

• M.hominis and Ureaplasma Urealyticum have also been described to cause

- neonatal conjunctivitis

- lymphadenitis

- pharyngitis

- pneumonitis

- osteomyelitis

- brain abcess

- intraventricular hemorrhage and hydrocephalus

Ureaplasma Urealyticum

• Ureaplasma urealyticum has been recoverd from the

cervical culture of the pregnant women and implicated as

a possible cause of chorioamniotis, preterm, BPD

• PCR is diagnostic

• ERETHROMYCIN to prevent BPD

CASE 3

• 1 day preterm child had genaralised swelling, pale,

tacypnea

• Examination – generalized edema , pallor, tachycardia,

hypotension,hepatomegaly.

• Investigation –Hb 6.2 g/dl , Retic – 0.8%

USG – ascitis & pleural effusion

HYDROPS FETALIS

Parvovirus B19

• When acquired by a non-immune pregnant woman the transmission rate to the foetus is about 33%

• Anaemia , cardiomyopathy, hepatic dysfunction, hydrops foetalis - foetal death may occur

• Diagnosis by specific IgM

• Exchange transfusion in utero is appropriate therapy in severe cases

• IVIG (limited success)

CASE 4

• 3 days old IUGR came with a complain of jaundice , and convulsion.

• Mother having an 1 abortion history.

• On examination - icteric , hepatosplenomegaly, macrocephaly. Chorioretinitis

• Investigation – TLC – 3800 (E – 14% ) PLAT- 102000/cumm CRP – neg Blood culture – negative

CT HEAD- calcifications

INTRACRANIAL CALCIFICATION

Chorioretinitis of congenital toxo

Toxoplasmosis Clinical Manifestations

• Most (70-90%) are asymptomatic at birth• 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

Diagnosis Treatment• Maternal IgG testing• Culture from placenta,

umbilical cord, infant serum

• PCR testing on WBC, CSF, placenta– Not standardized

• Newborn serologies with IgM/IgA

• Symptomatic infants– Pyrimethamine

and sulfadiazine Treatment for 12 months total

CASE 5

• 7th day preterm baby came with rash, jaundice, abdominal distention , pallor ,the child had convulsion next day

• On examination- 2kg ictric , hepatosplenomegaly, purpura over face and abdomen.

• Investigation – CBC (HB 9.2gm/dl; PLAT- 89000) SGPT – 486; Bilirubin 17.6 D- 8.4 CRP – NEG BLOOD CUL – NO GROWTH CSF – few lymoho

CMV Clinical Manifestations• Early Congenital Acute fulminant infection involving multiple organ

system - petechiae and purpura(79%) - HSM (74%) - jaundice(63%) & prematurity

• Early onset symptomatic without life threatening - IUGR or disproportionate microcephaly(48%) - Intracranial calcification - ventricular dilatation, cortical atrophy,

lissencephaly, pachygyria (RARE)

• Asymptomatic Congenital (commonest)

• Perinatally Acquired

• Cmv Pneumonitis

• Transfusion Acquired Cmv Infection

Ventriculomegaly and calcifications of congenital CMV

Diagnosis

• CMV PCR from urine or saliva in 1st 3weeks of life– Afterwards may

represent post-natal infection

• Cmv IgG IgM – limited success

• Ganciclovir x6wks in symptomatic infants

• Treatment currently not recommended in asymptomatic infants due to side effects

• Valgancyclovir

CASE 6

• 8TH day IUGR had rash, refusal to feed

• Examination – , Pale, purpuric spots all over, cataract ,

continuous murmur in pul. Area

• Investigation – Hb – 10.5gm/dl, PLAT – 55000/cumm,

2D echo – PDA , CRP/BLOOD CULTURE - WNL

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

Rash Cataracts CHD (PDA) Blindness Neurosensory

deafness Microcephaly &

mental retardation

CONGENITAL RUBELLA

“Blueberry muffin” spots representing

extramedullary hematopoesis

Diagnosis Treatment• 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

• Prevention…immunize, immunize, immunize!

• Supportive care only with parent education

CASE 7

• 21 days old newborn – not moving both LL.• H/O 2 SB ,1 Neonatal death• Home delivery.• O/E - 2.5 KG ,Pallor ++,hepatospleenomegaly,• LL –Swelling of both knee joints• CBC -HB 8gm ,CRP –neg ,Blood c/s –sterile,• X –ray - periostitis• Diagnosis -

Periostitis

Clinical Manifestations

• Fetal:– Stillbirth– Neonatal death– Hydrops fetalis

• Intrauterine death in 25%

• Perinatal mortality in 25-30% if untreated

Clinical Manifestations

• Early congenital (typically 1st 5 weeks):

– Cutaneous lesions (palms/soles)

– HSM

– Jaundice

– Anemia

– Snuffles

– Periostitis and metaphysial dystrophy

– Funisitis (umbilical cord vasculitis)

Clinical Manifestations

• Late congenital:– Frontal bossing– Short maxilla– High palatal arch– Hutchinson teeth– 8th nerve deafness– Saddle nose – Perioral fissures

• Can be prevented with appropriate treatment

CASE 8

• 25 days baby had presented with severe respiratory distress with cyanosis

• h/o contact with family member with resp infection.

• Examination –febrile, resp.ditress, cyanosis

R/S –bilat crepts &wheese• Investigation – CBC(lymphocytosis)

CRP/BC- Wnl

X-ray- B/l infiltrate• Baby required intubation.

RSV Bronchiolitis

• DIAGNOSIS – Immunoflorocence Antigen testing of resp secretion.

• Viral Culture (3-5)

• Prevention avoid crowds and handling!!

• Treatment • RIBAVIRIN

nebulisation• RSV IG

CASE 9

• 9th day full term home delivery had rash started from

presenting part face and trunk with tachypnea and refusal

of feed, this baby later had temperature instability and

seizure

• Examination- vesicular rash,

• Investigation – thrombocytopenia and nutropenia.

SGPT/CSF/ CRP/ BC all are WNL

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

Presentations of congenital HSV

Diagnosis

• Culture of maternal lesions if present at delivery

• Cultures in infant:– Skin lesions,

oro/nasopharynx, eyes, urine, blood, rectum/stool, CSF

• CSF PCR

• High dose acyclovir 60mg/kg/day divided q8hrs– X21days for

disseminated, CNS disease

– X14days for SEM– Ocular involvement

requires topical therapy as well

CASE 10

• 7 days FTND had fever, rash all over body, respiratory

distress

• Mother had a history of chickenpox 3 days before delivery

• Examination – Febrile , Vesicular pleomorphic rash all over

body, tachepnea

• Investigation – TLC – 15,000,

Crp/Bc/Csf –Wnl,

X RAY – Pneumonia

Varicella / Chickenpox

Complications

Congénital infection (2%, 18-22 w of

gestation) Small size, cutaneous scarring,

limb hyplasia, microcephaly,

cortical atrophy, chorioretinitis, cataracts

Perinatal infection

5 days before to 2 days after birth

(high mortality without treatment 30%)

Treatment

• VZIG -125 U as soon as possible

• Isolation

• Iv acyclovir 20mg/kg/day 8hry for 7-10

days

CASE 11

• 16 days old baby had fever, restlessness, pallor, poor

feeding.

• Mother had fever before delivery

• Examination - pallor, jaundice and hepatosplenomegaly

• Investigation – cbc -Hb -5gm, Plt 40,000/cumm

• P/S falciparam

• Congenital malaria is acquired from the mother prenatally or perinatally and is a serious problem in endemic area

• In endemic areas, congenital malaria is an important cause of abortions, miscarriages, stillbirths, premature births, intrauterine growth retardation, and neonatal deaths

Treatment

• Chloroquin is the drug of choice for treatment. Primaquin

is not required for congenital malaria, because there is no

persistent liver phase in congenitally acquired infections.This

case highlights the fact that even in endemic regions malaria

can afflict the neonates with its varied presentation.

• Prompt treatment should be instituted to avoid associated

morbidity and mortality

Which TORCH Infection Presents With…• Snuffles?

– syphilis• Chorioretinitis, hydrocephalus, and intracranial

calcifications? – toxo

• Blueberry muffin lesions?– rubella

• Periventricular calcifications?– CMV

• No symptoms?– All of them

CASE 12

• 10 days baby – high fever, refusal to feed, excessive irritablity, rash

• Examination – Febrile 103 F, tacycardia (180)

flushing, CRT>3sec,

• Investigation – Hb-11.7g/dL, TLC-4,800/mm3

platelet 89,000/cumm

Neonatal Chikungunya

• The clinical features noticed in the chikungunya

confirmed infants were having foetal death,high fever,

seizures, loose stools, peripheral cyanosis and

dermatological manifestations like generalized

erythema,maculopapular rash, vesiculobullous lesions

and skin peeling.pigmentation over nose ,face ,limb.

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