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Congenital TORCH infections

Last updated: April 23, 2021

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Congenital infections are caused by pathogens transmitted from mother to child during pregnancy (transplacentally) or delivery (peripartum). They can have a substantial negative impact on fetal and neonatal health. The acronym TORCH stands for the causative pathogens of congenital infections: Toxoplasma gondii, others (including Treponema pallidum, Listeria, varicella zoster virus, and parvovirus B19), rubella virus, cytomegalovirus (CMV), and herpes simplex virus (HSV). TORCH infections can cause spontaneous abortion, premature birth, and intrauterine growth restriction (IUGR). These infections can also cause abnormalities in the CNS, the skeletal and endocrine systems, and the complex organs (e.g., cardiac defects, vision and hearing loss). Prophylaxis is of great importance during pregnancy. Primary prevention includes vaccination for varicella and rubella (prior to pregnancy), hygiene measures (washing hands and avoiding certain foods), and screening for syphilis during pregnancy. Affected infants require regular follow-ups to monitor for hearing loss, ophthalmological abnormalities, and developmental delays.

Several other pathogens can also be vertically transmitted during pregnancy and have detrimental effects on the fetus and/or newborn. These include HIV in pregnancy, perinatal hepatitis B, group B streptococci, E. coli, gonococcal infections and chlamydial infections, West Nile virus, Zika virus, measles virus, enterovirus, and adenovirus. The pathogens are discussed in more detail in their respective articles.

Infection Clinical features Diagnosis Treatment Prevention
Toxoplasmosis
  • Avoidance of uncooked meat
  • Avoidance of handling cat feces
  • Immediate administration of spiramycin to prevent of fetal toxoplasmosis
Syphilis
Listeriosis
  • Avoidance of unpasteurized dairy products
  • Avoidance of cold deli meats
Varicella zoster virus (VZV)
Parvovirus B19
  • Frequent hand washing
  • Avoid potentially contaminated workplaces (e.g., schools, pediatric clinics)
Rubella
  • Supportive care
Cytomegaly virus (CMV)
  • Frequent hand washing
  • Avoid potentially contaminated workplaces (e.g., schools, pediatric clinics)
Herpes simplex virus (HSV)
  • Viral culture
  • PCR for HSV DNA

Transplacental transmission occurs following primary infection of a seronegative mother during pregnancy. Maternal IgM antibodies, which are unable to cross the placenta, form first. Protective IgG antibodies, which are able to cross the placenta, have not yet been formed, so the infant is not protected from infection via the placenta.

In general, the earlier in pregnancy a TORCH infection occurs, the more severe the complications.

Attenuated live vaccines (measles, mumps, rubella, and varicella) are contraindicated in pregnancy. Conception should be avoided for 1 month after immunization with live vaccines.

Epidemiology

∼ 0.5–1:10,000 live births per year in the US [2]

Pathogen

Toxoplasma gondii

Transmission

  • Mother
    • Cat feces
    • Raw or insufficiently cooked meat
    • Unpasteurized milk (especially goat milk)
    • See “Etiology” in “Toxoplasmosis.”
  • Fetus

Clinical features [3]

Diagnostics [4]

Treatment [4]

Prevention [3]

  • Avoid raw, undercooked, and cured meats.
  • Wash hands frequently, especially after touching soil (e.g., during gardening).
  • Avoid contact with cat litter.

The 4 Cs of congenital toxoplasmosis: Cerebral calcifications, Chorioretinitis, hydroCephalus, and Convulsions.

Epidemiology

∼ 23:100,000 live births per year in the US [6]

Pathogen

Treponema pallidum

Transmission [6]

  • Mother
    • Sexual contact (contact with infectious lesion)
    • See “Etiology” in “Syphilis.”
  • Fetus: transplacental transmission from infected mother
    • Increased risk of transmission with recent syphilis infection
    • Risk of transmission increases with gestational age
  • Neonate: perinatal transmission during birth

Clinical features [7]

Diagnosis [9]

Treatment

Prevention [6]

Hutchinson triad: interstitial keratitis, sensorineural hearing loss, Hutchinson teeth

Epidemiology

∼ 3:100,000 live births per year in the US [10]

Pathogen

Listeria monocytogenes

Transmission [11]

  • Mother
    • Contaminated food: especially raw milk products
    • Other possible sources: fish, meat, and industrially processed vegetables (e.g., ready-made salads)
    • See “Etiology” in “Listeriosis.”
  • Fetus
    • Transplacental transmission from an infected mother
    • Direct contact with infected vaginal secretions and/or blood during delivery

Clinical features [12]

Diagnosis

Culture from blood or CSF samples (pleocytosis) [13]

Treatment

IV ampicillin and gentamicin (for both mother and newborn) [13]

Prevention [11]

  • Avoidance of soft cheeses
  • Avoidance of potentially contaminated water and food
  • Nationally notifiable condition: Listeriosis must be reported to the local or state health department.
  • See “Food and water safety.”

Epidemiology

  • Seroprevalence in the general population is ∼ 95%. [14]
  • Most mothers have been vaccinated, so congenital infection is rare (< 2%). [14]

Pathogen

Varicella-zoster virus (VZV)

Transmission [15]

  • Mother
  • Fetus: transplacental transmission from an infected mother

Clinical features [15]

Diagnosis [15]

Treatment [15]

Prevention

  • Immunization of seronegative women before pregnancy
  • VZIG in pregnant women without immunity within 10 days of exposure
  • Nationally notifiable condition: Varicella must be reported to the local or state health department.

Epidemiology [18]

  • ∼ 5% incidence in pregnant women per year in the US
  • Higher prevalence in daycare workers and elementary school teachers

Pathogen

Transmission

  • Mother
    • Mainly via aerosols
    • Rarely hematogenous transmission
    • See “Fifth disease.”
  • Fetus: transplacental transmission from infected mother

Clinical features [18]

  • Severe anemia and possibly fetal hydrops
  • Fetal demise and miscarriage/stillbirth in approximately 10% of cases (Risk is highest in the first and second trimesters.)
  • Most intrauterine infections do not result in fetal developmental defects.

Diagnosis

Serologic assay analysis for parvovirus B19
Results Positive IgM Negative IgM
Positive IgG
  • Acute infection
  • Refer to specialist
Negative IgG
  • Very recent infection
  • Refer to specialist

Treatment

Prevention

  • Hand hygiene (frequent hand washing)
  • Pregnant women with risk factors for TORCH infection should avoid potentially contaminated workplaces (e.g., schools, pediatric clinics).

Epidemiology

Most mothers have been vaccinated, so congenital infection is very rare. [19]

Pathogen

Rubella virus

Transmission

Clinical features [21]

Diagnosis [22]

Treatment

  • Intrauterine rubella infection [22]
    • < 16 weeks: Counsel to terminate pregnancy.
    • > 16 weeks: reassurance
  • Congenital rubella syndrome: supportive care (based on individual disease manifestations) and surveillance (including monitoring for late-term complications)

Prevention [23]

CCC-Triad of congenital rubella syndrome: Cataracts, Cochlear defects, Cardiac abnormality

Epidemiology

∼ 0.5–1% of live births per year in the US [24]

Pathogen

Cytomegalovirus

Transmission

Clinical features [25]

Diagnosis [27][28]

Differential diagnosis [27]

Treatment

Prevention

  • Frequent hand washing, especially after contact with bodily secretions of small children (e.g., diaper changing)
  • Avoidance of food sharing with children
  • Avoidance of kissing small children on the mouth

Congenital toxoplasmosis may manifest with symptoms resembling congenital CMV infection.

Epidemiology

∼ 1:3,000–10,000 live births per year [30]

Pathogen

Mainly herpes simplex virus 2 (HSV-2); in rare cases HSV-1

Transmission [30]

Clinical features [31]

Diagnosis

Treatment [32]

Prevention

HSV should be considered in infants up to 6 weeks of age with vesicular skin lesions, persistent fever with negative cultures, and/or symptoms of meningitis, encephalitis or sepsis.

Skin, eye, and mouth disease caused by HSV has a good prognosis if detected and treated early.

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