TORCH infection refers to infection of a developing foetus or newborn by any of a group of infectious agents. The signs and symptoms, diagnosis and management of TORCH infections are elucidated in this article.

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Signs and symptoms

Symptoms and signs in a newborn include:

• Small for gestational age baby
• Microcephaly
• Poor feeding
• Listlessness
• Fever
• Petechiae/bruises / bleeding tendency
• Enlargement of the liver and spleen (hepatosplenomegaly)
• Jaundice, which may be prolonged
• Severe and usually direct hyperbilirubinemia
• Hearing impairment
• Abnormalities of the eyes
• Heart murmur

Following is a more specific description of the TORCH agents;

1. Toxoplasmosis is an infectious disease caused by the microscopic parasitic organism called Toxoplasma gondii. This parasitic infection, found worldwide, may be acquired or transmitted to the developing fetus from an infected mother during pregnancy. In some severely affected newborns, Toxoplasmosis may be associated with microcephaly, chorioretinitis, intracranial calcifications, and/or other abnormalities.
2. Rubella is a viral infection characterised by fever, upper respiratory infection, swelling of the lymph nodes, skin rash, and joint pain. Severely affected newborns and infants may have visual and/or hearing impairment, heart defects, calcium deposits in the brain, and/or other abnormalities.
3. Cytomegalovirus (CMV) Infection is a viral infection that may occur during pregnancy, after birth, or at any age. In severely affected newborns, associated symptoms and findings may include growth retardation, microcephaly, hepatosplenomegaly, hepatitis, hemolytic anaemia, calcium deposits in the brain, and/or other abnormalities.
4. Neonatal Herpes is a rare disorder affecting newborns infected with the Herpes simplex virus (HSV). This disorder may vary from mild to severe. In most cases, the disorder is transmitted to an infant from an infected mother with active genital lesions at the time of delivery. In the event that a mother has a severe primary genital outbreak, it is possible that a mother may transmit the infection to the foetus. After delivery, direct contact with either genital or oral herpes sores may result in neonatal herpes. Severely affected newborns may develop cutaneous vesicles, lesions in the oral cavity, conjunctivitis, abnormally diminished muscle tone, hepatitis, difficulty breathing, and/or other symptoms and findings.

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Diagnosis

A history of maternal infections during pregnancy is key for the early detection of a TORCH infection. Imaging and tests can also be key to prenatal diagnosis. A prenatal ultrasound can indicate unusual foetal findings, such as the enlargement of the ventricles in the foetus’ brain (i.e., ventriculomegaly), intracranial calcifications, and foetal growth restriction or retardation.

Prenatal diagnosis of congenital toxoplasmosis, congenital syphilis, and parvovirus B19 infection can be confirmed through a polymerase chain reaction (PCR) test, which evaluates DNA samples usually obtained from the amniotic fluid surrounding the foetus during pregnancy. Congenital CMV can be diagnosed prenatally by viral culture, DNA detection on a PCR test, or CMV-specific immunoglobulin M (IgM) antibody measurement. Similarly, prenatal diagnosis of rubella is usually based on positive rubella-specific IgM testing. Finally, HSV infection can be detected prenatally through viral cultures or PCR testing.

Similar to prenatal diagnosis, specific diagnoses can be confirmed through viral cultures, PCR testing, and antibody measurement in a blood sample of the baby.

Additional tests that can be performed include;

1. Brain computed tomography (CT) scans to look for brain lesions.
2. Hydrocephalus
3. Intracranial calcifications.
4. Eye tests can reveal cataracts, chorioretinitis or other eye problems.
5. Hearing tests can identify hearing loss.
6. Echocardiography of the newborn can detect congenital heart disease like PDA.

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Long-term complications

The long-term complications of TORCH infections include:

• Developmental retardation / Seizures
• Learning Disabilities
• Hearing & Visual Impairment
• Congenital Heart disease

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Management

Toxoplasmosis

1. Observational studies have demonstrated an effective reduction in transplacental transmission and/or severity of clinical manifestations in symptomatic infants.
2. The two regimens often used are spiramycin (fetal prophylaxis preventing intrauterine infection) and combined pyrimethamine/sulfadiazine/ folinic acid (treatment of evolving fetal infection).

Congenital rubella

1. Once developed, it cannot be treated. But it is the most common vaccine-preventable neonatal disease.
2. A single dose of the rubella vaccine to the mother can produce lifelong immunity. Mothers should have their immunity checked at the beginning of a pregnancy.

Patients with neonatal HSV

1. Should be treated aggressively. Clinical trials have demonstrated that acute therapy requires high-dose intravenous acyclovir (60 mg/kg/day intravenously divided three times daily).
2. The length of this therapy varies from fourteen to twenty-one days depending on the severity of the disease (10 for SEM/21 for disseminated and CNS) followed by long-term oral acyclovir suppressive therapy (300 mg/m/dose, given orally three times daily for six months is best for the management of neonatal herpes infection.
3. This work has dramatically reduced morbidity and mortality from neonatal HSV. Complete blood counts and renal function should be monitored. Dosing should be adjusted as the infant grows.

Patients with symptomatic cytomegalovirus infections

1. These patients should be treated with ganciclovir and valganciclovir. The primary reason for this therapy is to preserve hearing.
2. Neonates with symptomatic congenital CMV disease with or without central nervous system (CNS) involvement show better outcomes at two years when treated with oral valganciclovir (16 mg/kg/dose, administered orally twice daily) for six months. Dosing should be adjusted as the infant grows.

The treatment of HIV to prevent mother-to-child transmission

1. This depends on whether the mother was treated with viral suppression during the pregnancy.
2. Therapy for children born to well-controlled mothers should include the treatment of the infant with zidovudine (4 mg/kg, twice daily) for the first 4 to 6 weeks of life for term children.
3. Multiple drug regimens are recommended for children whose mother was not on antiretroviral therapy during pregnancy.

Syphilis

1. It must be diagnosed and treated immediately. Expectant mothers should be tested during pregnancy and, if positive, treated. Treatment of the neonate will depend on whether the mother was treated appropriately during pregnancy.
2. Normal neonates born to mothers adequately treated during pregnancy and greater than four weeks before delivery or have a non-reactive RPR but were born to mothers not treated properly should receive a single intramuscular injection of benzathine penicillin G (50,000 U/kg), although no evaluation is required or recommended.
3. Infants with serologic tests that confirm congenital syphilis should receive aqueous penicillin g (200,000 to 300,000 units/kg/day IV, administered as 50,000 units/kg every 4 to 6 hours for ten days).
4. If the child has a negative evaluation for clinical and laboratory evidence of syphilis, treatment with up to 3 weekly doses of benzathine penicillin G (50,000 U/kg IM) can be considered.

Foetuses with parvovirus

B19 may need an intrauterine blood transfusion.

Treatment for Zika virus

It focuses on managing symptoms by getting plenty of rest, hydrating adequately, and using medications, like acetaminophen, to reduce pain and fever. Notably, nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen, should be avoided for individuals with the Zika virus.

Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.

About the author of this article: Dr Naveen Jain is a practising paediatrician from Delhi.