Neurosurgery notes/Infection/Cranial infection/TORCHES infection

TORCHES infection

View Details
logo
Parent item
Cranial infection

Mechanism

  • Hematogenous spread through the placenta (toxoplasma and viruses), or via delivery (especially HSV-2)
  • Ascending from the cervix (bacteria)
  • During passage through the birth canal (herpes, this mechanism causes neonatal rather than true congenital infection)
  • They may cause developmental changes or tissue destruction. Larger organisms such as bacteria, fungus, and protozoa are unable to enter the embryo before 3 to 4 months, but viruses may pass through the placenta.
  • The usual time frame for congenital infections is
    • First trimester (rubella),
    • 4 months (syphilis),
    • 5 months (toxoplasma),
    • Perinatal (bacteria, HIV),
    • During passage through birth canal (HSV-2, HIV).
  • Nonspecific signs
    • Hepatosplenomegaly
    • Jaundice
    • Thrombocytopenia
    • Growth retardation.
  • Infectious agents (all causes of meningitis in neonates)
    • Streptococcus agalactiae (group B streptococci)
    • E coli
    • Listeria monocytogenes
    • Parvovirus B19 causes hydrops fetalis.
  • Calcifications — caused mainly by CMV (periventricular) and toxoplasma (disseminated)
  • Cardiac malformations — caused by rubella
  • Deafness — caused by rubella, syphilis, and CMV

Cytomegalovirus (CMV)

  • Modes of maternal transmission
    • Sexual contact, organ transplants
  • Maternal manifestations
    • Usually asymptomatic; mononucleosis-like illness
  • Neonatal manifestations
      • Hearing loss, seizures, petechial rash, "blueberry muffin" rash, chorioretinitis, periventricular calcifications
       
      Periventricular calcifications
      Periventricular calcifications

Toxoplasma

  • Toxoplasma is the second most frequent congenital CNS infection.
  • It occurs in 1 in 1000 to 1 in 10,000 pregnancies and is acquired by hematogenous spread through the placenta. There may be giant cell granulomas with atrophy of the basal ganglia, periventricular white matter, and cortex.
  • Unlike CMV, there are no migrational disorders or periventricular calcifications. The infection is significant if acquired before 26 weeks gestation.
  • Findings include seizures, microcephaly, and spontaneous abortions. Deafness is the most common late manifestation.
  • Modes of maternal transmission
    • Cat feces or ingestion of undercooked meat
  • Maternal manifestations
    • Usually asymptomatic; lymphadenopathy (rarely)
  • Neonatal manifestations
      • Classic triad: bilateral chorioretinitis, hydrocephalus, and intracranial calcifications, +/- "blueberry muffin" rash
      “Blueberry muffin” rash
      “Blueberry muffin” rash
  • Treat with spiramycin if the mother seroconverts in 2–3 months. If the mother seroconverts after 4 months, use pyrimethamine and sulfadiazine.

Rubella

  • Mechanisms
    • Rubella is transmitted transplacentally.
    • The virus inhibits cell multiplication to cause an insufficient number of cells in the brain (less neurons, astrocytes, and oligodendrocytes) and also is teratogenic and destructive.
    • The infection may cause meningoencephalitis, vasculopathy with ischemia and necrosis, microcephaly, decreased myelin, and cortical and basal ganglia calcifications. If the infection occurs before 12 weeks, the effects are very severe and spontaneous abortion is likely. If it occurs after 12 weeks, the infection is less severe.
    • Congenital rubella syndrome occurs with infection in the first trimester
      • Abnormalities of eye
        • Chorioretinitis
        • Cataracts
        • Glaucoma
        • Microphthalmia
      • Microcephaly,
      • Mental retardation
      • Deafness
      • Congenital heart disease (PDA)
      • ± "blueberry muffin" rash
    • During infection, the CSF has increased mononuclear cells and IgM; prevent with maternal vaccination before pregnancy.
  • Modes of maternal transmission
    • Respiratory droplets
  • Maternal manifestations
    • Rash, lymphadenopathy, polyarthritis, polyarthralgia

Herpes simplex virus-2 (HSV-2)

  • Modes of maternal transmission
    • Skin or mucous membrane contact
  • Maternal manifestations
    • Usually asymptomatic; herpetic (vesicular) lesions
  • Neonatal manifestations
    • Meningoencephalitis, herpetic (vesicular) lesions

Human immunodeficciency virus (HIV)

  • HIV can be transmitted perinatally. 30% of HIV mothers transmit the virus to the children.
  • Pathologic examination demonstrates brain atrophy and basal ganglia calcifications.
  • Symptoms include weight loss, failure to thrive, diarrhea, and fever. Most die in 1 year.
  • Modes of maternal transmission
    • Sexual contact, needlestick
  • Maternal manifestations
    • Variable presentation depending on CD4+ cell count
  • Neonatal manifestations
    • Recurrent infections, chronic diarrhea

Syphilis

  • Syphilis has transplacental transmission at 4–7 months.
  • Hutchinson triad — dental disorders, bilateral deafness, and interstitial keratitis
  • The other symptoms of syphilis are the same as in adults, but occur much earlier at 9–15 years. Hydrocephalus and stroke may occur.
  • The child should be treated with penicillin until the CSF is acellular and has a normal protein.
  • Modes of maternal transmission
    • Sexual contact
  • Maternal manifestations
    • Chancre (1°) and disseminated rash (2°) are the two stages likely to result in fetal infection
  • Neonatal manifestations
    • Often results in stillbirth, hydrops fetalis; if child survives, presents with facial abnormalities (eg, notched teeth, saddle nose, short maxilla, saber shins, CN VIII deafness)

Listeria

  • Causes increased abortions and premature deliveries