TORCH Infections

• Core 1 (Pre-Clerkship)
  • Biomedical Science
    • Microbiology
      
      • Herpesvirus
  • Integrative Systems
    • Dermatology
      • HSV, VZV, enterovirus
      • Syphilis
      • Viral exanthems
• Core 2 (Clerkship)
  • Pediatrics Clerkship: Well baby nursery
  • Ob/Gyn: Obstetrics
• Core 3 (Post Clerkship) Electives that may further knowledge - NICU

Clinical Vignettes:

A 2-day old newborn with IUGR presents with differences in hearing detected on newborn hearing screen 

A 2-day-old newborn born to a mother with scant prenatal care presents with microcephaly and a rash 

History 

• Patient age, gestational age 
• Patient symptoms and signs (look for rash, hepatosplenomegaly, head circumference & overall size/percentiles, limb differences) 
• Pre-existing birthing parent medical conditions (history of HIV, HSV)? 
• Adequate prenatal care? 
• Birthing parent illnesses or symptoms during pregnancy, exposures (sick contacts, STI, animal exposures i.e. cat/litter box, undercooked foods) 
• Birthing parent immunization record and titers testing 
• Issues with pregnancy? Abnormal scans (hydrops, IUGR)? 

Physical Exam

• Vital signs (always important), including growth parameters  
• General: Symmetric or asymmetric growth percentiles? (also known as head-sparing if head circumference is normal but weight/length are low), SGA or LGA? 
• Cardiac and pulmonary exam (ABCs always important) - murmurs? Perfusion? Friction rubs? - some TORCHES infections can cause CHD; some can cause inflammation of myocardium/pericardium. 
• Skin exam: petechiae? Vesicles? Other rashes (i.e. blueberry muffin spots)? How is it distributed? Jaundice
• Neurologic status – could have intracranial involvement?  
• HEENT exam: abnormal fontanelle, body-head size discrepancy? Abnormal eye exam/red reflex (congenital cataracts?) 

Clinical syndromes for TORCH Syndromes overlap, findings can be non-specific! 

• Many clinical syndromes for those infections presenting in the immediate neonatal period overlap and include features such as:
  • low birth weight/IUGR
  • rashes (maculopapular, petechial or “blueberry muffin rash”, or purpuric)
  • microcephaly
  • jaundice
  • sensorineural hearing loss
  • chorioretinitis
  • hepatosplenomegaly
  • cardiac anomalies + thrombocytopenia + hyperbilirubinemia

Buzzwords for specific conditions (not always present in clinical practice): 

• Toxoplasmosis: diffuse intracerebral calcifications, diffuse chorioretinitis  
• Rubella: congenital cataracts  
• CMV: Periventricular calcifications  
• HSV: vesicles 
• Syphilis: rhinorrhea, desquamating or bullous rash, abnormal long bone radiographs 

Evaluation

• Labs: CBCd, LFTS and total bilirubin (direct and indirect), blood culture; more specific testing based on suspected infections (blood or lesion serologies, PCR testing, maternal labs if HSV or syphilis is expected, including RPR titer, lumbar puncture) 
• Imaging: head ultrasound (if suspected intracranial calcifications, other involvement), abdominal ultrasound, echocardiogram (if suspected CHD or open PDA), Xrays if concern for syphilis 
• Other: hearing screen, ophthalmology
• Consultants: Ophthalmology, ID, Radiology, Hematology

Management 

• Some TORCH infections should be treated for cure or to prevent further damage; some don’t have treatments available, and damage may be irreversible 

• In babies, infections are ALWAYS on the differential (including TORCH infections).  

• Birthing parent history is key! 

• Think about route/timing of transmission – prenatal, intrapartum/perinatal, postnatal? 

Answer:

Q1: (b) CMV is the leading non-genetic cause of sensorineural hearing loss (SNHL) in children. While meningitis is associated with hearing loss, it is a less common cause than congenital CMV. HSV has not been associated with hearing loss. AOM can cause hearing loss if repeated infections or persistent effusion, but uncommon in neonates.

Articles

• UpToDate: Overview of TORCH ifnections
• DermNet Torch Infections
• Red Book: Report of the Committee of Infectious Diseases (can access via Epic)

Video 

• Sketchy Micro Series
• Osmosis video - Congenital TORCH infections: Pathology Review  
• Review Key things about TORCH infections + Symptoms

Podcasts  

• The Cribsiders: The Great Imitator - Unmasking Congenital Syphilis
• Neonatal Resources, The Podcast: TORCH
• Mighty Littles Podcast Episode 23: NICU Education: Respiratory Distress Syndrome in the NICU
• Rx Bricks Podcast, Neonatal Respiratory Distress Syndrome