Chapter 149: Congenital and Perinatal Infections

TORCH pathogens · CMV · Rubella · Toxoplasmosis · Syphilis · HSV · Zika · Parvovirus B19 · Chlamydia · GBS · HIV · Prevention · Diagnosis · Treatment
🩺 Key fact: Congenital CMV is the most common congenital viral infection (0.5-1% of births), leading cause of sensorineural hearing loss.

🦠 Congenital & Perinatal Infections: Core Concepts

🧬 Congenital (transplacental)
CMV, Rubella, Toxoplasma, Syphilis, Parvovirus B19, Zika, HIV, HSV (rare). Timing determines outcome (1st trimester → anomalies, later → active infection).
🩺 Perinatal (birth canal)
GBS, Chlamydia trachomatis, Neisseria gonorrhoeae, HSV, HIV, CMV (postnatal via breast milk).
📊 CMV – most common
0.5-1% live births. 10-15% symptomatic at birth. Sensorineural hearing loss (even asymptomatic). Ganciclovir/valganciclovir improves hearing outcomes.
😮 Rubella (congenital rubella syndrome)
Classic triad: sensorineural hearing loss, congenital heart disease (PDA, PA stenosis), cataracts. "Blueberry muffin" rash, microcephaly.
🦟 Toxoplasmosis
Chorioretinitis, intracranial calcifications, hydrocephalus. Treat with pyrimethamine + sulfadiazine + leucovorin.
📈 Syphilis (Treponema pallidum)
Early: rash (palms/soles), rhinitis ("snuffles"), osteochondritis. Late: Hutchinson teeth, interstitial keratitis, deafness. Penicillin G (10-14 days).
⚡ Zika virus: Microcephaly, intracranial calcifications, ocular findings, arthrogryposis. Diagnosis: RT-PCR (urine, serum) within 2 weeks of birth.

🔍 Approach to newborn with suspected congenital infection

1
Recognize clinical clues – IUGR, microcephaly, hepatosplenomegaly, jaundice (direct), petechiae, rash, chorioretinitis, hydrops, intracranial calcifications.
2
Maternal history – Fever, rash, lymphadenopathy, arthropathy during pregnancy; travel to endemic areas (Zika); sick contacts; cat exposure (toxo); sexual history (syphilis, HIV).
3
Initial laboratory workup – CBC (thrombocytopenia, anemia), LFTs (elevated transaminases, direct bilirubin), cranial US (intracranial calcifications).
4
Specific diagnostic testing (within 1-2 weeks) – CMV PCR (urine, saliva), Toxoplasma serology (IgG/IgM), Rubella IgM, RPR/VDRL, Zika PCR (urine, serum), HSV PCR if vesicles.
5
Referrals – Ophthalmology (chorioretinitis), Audiology (hearing screen), Infectious disease, Neurology.

📋 Stepwise management of congenital/perinatal infections

1
Congenital CMV – Ganciclovir (6 mg/kg IV q12h) or valganciclovir (16 mg/kg PO q12h) for 6 months for symptomatic disease (improves hearing). Monitor neutropenia.
2
Congenital toxoplasmosis – Pyrimethamine + sulfadiazine + leucovorin for 12 months. Spiramycin for maternal infection to prevent vertical transmission.
3
Congenital syphilis – Aqueous crystalline penicillin G 50,000 U/kg/dose IV q12h (first week) then q8h for 10-14 days. Evaluate CSF for neurosyphilis.
4
Neonatal HSV – Acyclovir 20 mg/kg IV q8h for 14 days (skin/eye/mouth) or 21 days (CNS or disseminated disease).
5
Congenital rubella – No specific antiviral; supportive care, isolation (contagious for 1 year).
6
Chlamydia conjunctivitis/pneumonia – Oral erythromycin (50 mg/kg/day divided q6h) or azithromycin (20 mg/kg/day x 3 days).
📌 Prevention: Rubella vaccine preconception, syphilis screening in pregnancy, HSV C-section if active lesions at delivery, toxoplasma avoid cat litter/undercooked meat.

🧠 Rapid reflex prompts – Congenital/perinatal infections

📌 Most common congenital infection?
Cytomegalovirus (CMV).
📌 Classic triad of congenital rubella?
Hearing loss, congenital heart disease (PDA/PA stenosis), cataracts.
📌 Toxoplasmosis: typical brain finding?
Intracranial calcifications (diffuse, periventricular).
📌 Congenital syphilis: early rash?
Palms/soles maculopapular or bullous, "snuffles" (rhinitis).
📌 HSV in newborn: 3 presentations?
Skin/eye/mouth (SEM), CNS disease (encephalitis), disseminated (multiorgan, DIC).
📌 Treatment for congenital CMV?
Ganciclovir or valganciclovir x 6 months.
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