Neonatal Infections Final PDF

‫بسم هللا الرحمن الرحيم‬ ‫‪1‬‬  Neonatal Infections Jaafar Ibrahim Mohamad Prof of Pediatrics Assiut University  ILOs By the end of this lecture the students can: o Define neonatal sepsis o Recognize early and late sepsis o Describe risk factors of sepsis o...

‫بسم هللا الرحمن الرحيم‬ ‫‪1‬‬  Neonatal Infections Jaafar Ibrahim Mohamad Prof of Pediatrics Assiut University  ILOs By the end of this lecture the students can: o Define neonatal sepsis o Recognize early and late sepsis o Describe risk factors of sepsis o Describe clinical presentation o Mention the work up of sepsis o Know lines of treatment of sepsis A 3-week-old infant presents with irritability, poor feeding, fever (T 38.9°C), and grunting. Physical examination reveals a bulging fontanel and delayed capillary refill. Few hours later the baby developed seizures  Risk factors Prematurity Chorioamnionitis Intrapartum fever Prolonged rupture of membranes Etiology Most common organisms: group B Streptococcus, E. coli, and Listeria monocytogenes.  Clinical presentation The initial diagnosis of sepsis is a clinical one because it is important to begin treatment before the results of cultures are available. Signs and symptoms are very nonspecific ▪ Irritability, lethargy, poor feeding ▪ Temperature changes (fever and hypothermia both possible) ▪ Tachypnea, apnea, hypotension, poor perfusion, and delayed capillary refill > 3 sec Specific symptoms Neonatal meningitis Often no signs of meningism Early phase: general symptoms (see above), vomiting Late phase: bulging fontanelles, shrill crying, seizures, stupor Neonatal pneumonia Tachypnea with intercostal/sternal retractions and nasal flaring Reduced oxygen saturation with cyanosis  Diagnosis Sepsis workup CBC, differential and platelets Blood culture, urine analysis and culture Chest x-ray Lumbar puncture only for neonates with severe signs (lethargy, hypothermia, hypotonia, poor perfusion, apnea, abnormal neurological findings, or clinical deterioration from birth) Neonatal pneumonia Lumbar puncture  Treatment ❖ If no evidence of meningitis: ampicillin and aminoglycoside until 48–72-hour cultures are negative ❖ If meningitis or diagnosis is possible: ampicillin and third-generation cephalosporin (not ceftriaxone) A 3-week-old infant presents with irritability, poor feeding, temperature of 38.9°C, and grunting. Physical examination reveals a bulging fontanel, delayed capillary refill, and grunting. Few hours later the baby developed seizures. Which of the following is the most appropriate next step for diagnosis? A. CBC B. Serum electrolytes C. CRP D. Lumbar puncture E. Chest X ray  TRANSPLACENTAL INTRAUTERINE INFECTIONS (TORCH) Toxoplasmosis Other (syphilis, varicella, HIV, and parvovirus B19) Rubella Cytomegalovirus (CMV) Herpes TORCH infections are typically acquired in first or second trimester. Most infants have IUGR.  Toxoplasmosis Toxoplasmosis is a maternal infection worldwide, due primarily to ingestion of undercooked or raw meat containing tissue cysts. Ingestion of water or food with oocytes that have been excreted by infected cats (fecal contamination) is the most common form of transmission. Advise pregnant women not to change/clean cat litter while pregnant. Findings : Jaundice, hepatosplenomegaly Thrombocytopenia, anemia Microcephaly Chorioretinitis Hydrocephalus Intracranial calcifications Seizures Multiple scattered intracranial calcifications of Toxoplasmosis Outcomes — Psychomotor retardation — Seizure disorder — Visual impairments Brain MRI of a 2-month-old boy A Girl with hydrocephalus due to congenital toxoplasmosis showing dilated ventricles (hydrocephalus) and intracranial calcifications (arrow) Chorioretinitis Triad of congenital Toxoplasmosis Hydrocephalus Intracranial calcifications Chorioretinitis  Treatment ❖ Maternal treatment during pregnancy reduces the likelihood of transmission significantly (spiramycin) ❖ Infants are treated with pyrimethamine, sulfadiazide, and leucovorin.  Congenital rubella ❑ Classic findings when maternal infection occurs in first 8 weeks’ gestation. ❑ Findings Blueberry muffin spots (extramedullary hematopoiesis), thrombocytopenia Cardiac: PDA, peripheral pulmonary artery stenosis Cataracts Congenital hearing loss Thrombocytopenia Hepatosplenomegaly Blueberry muffin spots are multiple blue/purple marks or nodules in the skin. These are due to the presence of clusters of blood- producing cells in the skin (extramedullary erythropoiesis) Outcomes of congenital rubella Hearing loss Persistent growth retardation Microcephaly Mental and motor retardation Hearing loss Triad of Rubella syndrome  Cytomegalovirus (CMV) Primary infection (higher risk of severe disease) or reactivation of CMV Findings Hepatosplenomegaly, jaundice Periventricular calcifications Intrauterine growth retardation Chorioretinitis Microcephaly Thrombocytopenia, hemolytic anemia Microcephaly Periventricular calcifications Intrauterine growth retardation Outcomes Sensorineural hearing loss Neuromuscular abnormalities Intellectual disability  Herpes simplex ❑ Keratojunctivitis, skin (5–14 days), CNS (3–4 weeks), disseminated (5–7 days) ❑ Best diagnosis: PCR, any body fluid ❑ Best treatment: IV acyclovir ASAP Outcomes Microcephaly, spasticity Deafness Blindness Seizure disorder Psychomotor retardation Death Skin lesions Keratojunctivitis Neonatal seizure due to herpetic meningoencephalitis Prevention Prevention is elective Cesarean section when active disease or visible lesions are identified; however, this is not 100% effective. Treatment: acyclovir  Congenital syphilis Transplacental transmission usually during second half of gestation At-risk infants must undergo serologic testing at the time of delivery. Findings Early (birth–2 yrs): snuffles, maculopapular rash (including palms of soles, desquamates), jaundice, periostitis, osteochondritis, chorioretinitis, congenital nephrosis Late (>2 years of age): Hutchinson teeth, Clutton joints (inflammation of synovial membranes of joints), saber shins (anterio bowing of tibia), saddle nose, osteochondritis, rhagades (thickening and fissures of corners of mouth) Rhinitis with mucopurulent nasal discharge Desquamating and maculopapular skin lesions Osteochondritis X-ray of bone abnormalities, syphilitic metaphysitis in an infant with diminished density in the ends of the shaft and destruction at the proximal end of the tibia (right).  Hutchinson teeth Central incisors are thin and notched Saddle nose due to loss of septal support Diagnosis —Treponema in scrapings (most accurate test) from any lesion or fluid, serologic tests Infant with positive VDRLplus pathognomonic signs; if not, perform serial determinations—increasing titer in infection Most helpful specific test is IgM-FTA-ABS (immunoglobin fluorescent treponemal antibody absorption); but it is not always positive immediately. Treatment: penicillin  Varicella Neonatal Seen when delivery occurs > 1 week before/after maternal infection Treat with VZIG (varicella zoster immune globulin), if mother develops varicella 5 days before to 2 days after delivery. Congenital Associated with limb malformations and deformations, cutaneous scars, microcephaly, chorioretinitis, cataracts, and cortical atrophy Associated with infection during 1 st or 2 nd — trimester Limb malformation and skin scars Important Note Many of the findings of the TORCH infections are very similar, so note the most likely presentations: Toxoplasmosis: hydrocephalus with generalized calcifications and chorioretinitis Rubella: the classic findings of cataracts, deafness, and heart defects CMV: microcephaly with periventricular calcifications; petechiae with thrombocytopenia; hepatosplenomegaly; sensorineural hearing loss Herpes: skin vesicles, keratoconjunctivitis, acute meningoencephalitis Syphilis: osteochondritis and periostitis; skin rash involving palms and soles and is desquamating; snuffles (mucopurulent rhinitis) Clinical Recall Which of the following TORCH infections is correctly matched to an associated finding? (A) Rubella: patent ductus arteriosus (B) CMV: maculopapular rash (C) Herpes simplex: chorioretinitis (D) Congenital syphilis: periventricular calcifications (E) Varicella: snuffle SUBSTANCE ABUSE AND NEONATAL WITHDRAWAL A 2-day-old infant is noticed to have coarse jitters and is very irritable with a high-pitched cry. A low-grade fever is reported, as well as diarrhea. Maternal history is positive for heroin use. Neonatal Features of Maternal Major Drug Use Diagnostic tests Good history and the clinical presentation usually are sufficient to make the diagnosis. Meconium toxicology can detect opioid and cocaine exposure after the first trimester. Urine drug screening provides maternal drug use data for only a few days prior to delivery. Cord blood sample has become the best test for diagnosis. Treatment Narcotics, sedatives, and hypnotics, as well as swaddling and reducing noxious stimulation Complications infants of addicted mothers are at higher risk for low birth weight, IUGR, congenital anomalies (alcohol, cocaine), and sudden infant death syndrome, as well as of mother’s complications, such as sexually transmitted diseases, toxemia, breech, abruption, and intraventricular hemorrhage (cocaine). A 2-day-old infant is noticed to have coarse jitters and is very irritable with a high-pitched cry. A low-grade fever is reported, as well as diarrhea. Maternal history is positive for heroin use. Which of the following is an expected neonatal feature? a) Late withdrawal symptoms b) Premature labor c) Multiple congenital anomalies d) Increased incidence of intracranial hemorrhage e) Increased incidence of stillbirth Thank you very much for your attention 40