Common neonatal skin rashes and TORCH infections

Overview

Newborn skin is thin, less hairy and less well attached between layers than adult skin, so it reacts in its own ways. Most spots and marks seen in the first weeks are harmless and self-limiting; the doctor's job is to reassure the parents and to recognise the few rashes that mean infection.

TORCH infections are acquired before or during birth. They cause similar features, so the clue to the organism lies in a few characteristic signs.

Part 1: Common neonatal skin conditions

Harmless rashes and marks

Rashes and skin signs that suggest disease

Part 2: TORCH(S) infections

What TORCH stands for

Toxoplasmosis, Others (syphilis, varicella, hepatitis B, HIV, parvovirus, TB), Rubella, Cytomegalovirus, Herpes simplex. The S in TORCHS stresses syphilis.

Shared features

• IUGR / low birth weight (often symmetrical)
• Hepatosplenomegaly, jaundice (often conjugated)
• Thrombocytopenia, petechiae, purpura, anaemia
• Rash (including blueberry muffin)
• Microcephaly, seizures, intracranial calcification
• Eye disease: chorioretinitis, cataract
• Many are normal at birth but later develop deafness, intellectual disability and eye problems.

Diagnosis rests on IgM antibody in the baby (IgM does not cross the placenta), rising or persisting IgG over months (maternal IgG in an uninfected baby is usually gone by 4-9 months), culture and PCR.

Comparison table

Toxoplasmosis

• Toxoplasma gondii, a protozoan; infection comes from cat faeces (soil, litter) and undercooked meat or unpasteurised milk.
• Mostly from a primary maternal infection in pregnancy. Infection later in pregnancy is transmitted more often, but infection earlier causes more severe fetal damage.
• 70-90% of infected babies have no signs at birth but may later develop visual loss and learning problems.
• Diagnosis: toxoplasma IgM (and IgA) in the baby, PCR of fluids, eye examination for chorioretinitis, CT for calcification, CSF (raised protein, mononuclear cells).
• Treatment: pyrimethamine and sulfadiazine with folinic acid; steroids for active eye or CNS disease.
• Prevention: avoid raw meat and contact with cat litter in pregnancy.

Rubella (congenital rubella syndrome)

• Spread by respiratory droplets; maternal infection in the first trimester infects the fetus in more than 90% of cases. Previous immunity (infection or vaccine) protects the fetus.
• Features: IUGR, microcephaly, cataract, glaucoma, microphthalmia, chorioretinitis ("salt and pepper" retinopathy), PDA and peripheral pulmonary artery stenosis, sensorineural deafness (the commonest late defect), blueberry muffin rash, hepatosplenomegaly, thrombocytopenia, metaphyseal lucencies on long-bone X-ray.
• Diagnosis: rubella-specific IgM in the newborn, persisting IgG, virus from throat, urine or CSF.
• Affected babies shed virus for up to a year; keep them away from non-immune pregnant women.
• Prevention: rubella vaccine (MMR/MR) for girls and non-immune women; it is a live vaccine and must not be given in pregnancy.

Cytomegalovirus (CMV)

• A DNA herpes virus; the commonest congenital (vertically transmitted) infection. It passes across the placenta, during birth and in breast milk.
• Both primary and recurrent maternal infection can infect the fetus; symptomatic babies are usually born after a primary infection. Greatest risk to the brain is in the first 22 weeks of pregnancy.
• Most infected babies are asymptomatic, but some develop progressive sensorineural deafness later; CMV is the leading infective cause of deafness in children.
• Symptomatic disease: IUGR, microcephaly, periventricular calcification, chorioretinitis, hepatosplenomegaly, jaundice, petechiae, pneumonitis.
• Diagnosis: virus in urine or saliva (culture or PCR) within the first 3 weeks of life (Nelson; later samples cannot separate congenital from acquired infection).
• Treatment: valganciclovir for symptomatic CNS or organ disease; hearing follow-up for all.
• Prevention: CMV-negative blood products for preterm babies; hand hygiene in pregnancy.

Neonatal herpes simplex

• About three quarters are HSV-2; about 80% are caught during delivery from the mother's genital tract; some are intrauterine or postnatal.
• Risk is much higher with a primary maternal infection (about 30-50%) than with a recurrent one (about 3-5%).
• Three patterns:

1. Skin, eye and mouth disease (vesicles, keratoconjunctivitis) 2. CNS disease (encephalitis with seizures and lethargy) 3. Disseminated disease (sepsis-like, liver failure, pneumonitis, DIC; highest mortality)

• Many babies have no skin lesions at first, so suspect HSV in any newborn with sepsis-like illness, seizures or raised liver enzymes.
• Diagnosis: PCR of CSF, blood and vesicle fluid; Tzanck smear shows giant cells; CSF shows red and white cells.
• Treatment: IV acyclovir at once.
• Prevention: caesarean section for women with active genital lesions (especially primary infection) in labour.

Congenital syphilis

• Early (under 2 years): snuffles (bloody nasal discharge), copper-red rash on palms and soles that peels, periostitis and osteochondritis (painful limbs, pseudoparalysis), hepatosplenomegaly, jaundice, condylomata lata, nephrotic syndrome.
• Late (over 2 years): Hutchinson teeth (notched incisors), saddle nose, bowing of the shins (sabre shins), frontal bossing, mulberry molars, rhagades (scars at the mouth corners), Clutton joints, interstitial keratitis, eighth nerve deafness. Hutchinson triad = interstitial keratitis + eighth nerve deafness + Hutchinson teeth.
• Diagnosis: treponemes in lesion scrapings; serology (non-treponemal and treponemal tests, IgM).
• Treatment: penicillin. Prevention: screen and treat mothers in pregnancy.

Hepatitis B

• Mainly caught at delivery from maternal blood; risk is highest when the mother has acute infection late in pregnancy (Akbar: 50-75% transmission) or is HBeAg positive.
• Screen all pregnant women for HBsAg.
• Babies of HBsAg-positive mothers: HBIG 0.5 mL IM plus hepatitis B vaccine 0.5 mL IM at a separate site, ideally within 12 hours of birth, then complete the vaccine course.
• Breastfeeding is allowed.

Tuberculosis and the newborn

• Congenital TB is rare; features are fever, failure to thrive, hepatosplenomegaly and respiratory distress.
• Mother with active pulmonary TB: treat the mother; give the baby isoniazid prophylaxis until the mother has been sputum-culture negative for about 3 months, then do a Mantoux test: if negative, stop isoniazid and give BCG; if positive, give full treatment.
• Breastfeeding continues.

Other "O" infections in brief

• Varicella: maternal infection early in pregnancy causes limb hypoplasia, skin scarring and eye defects; around delivery it can cause severe neonatal chickenpox (give zoster immunoglobulin).
• HIV: transmission reduced by maternal antiretroviral therapy and infant prophylaxis; follow the national programme.
• Parvovirus B19: fetal anaemia and hydrops fetalis.

Quick revision

• Erythema toxicum: well baby, day 1-3, eosinophils, gone in a week.
• Milia: white spots on the nose; miliaria: sweat duct block from overheating.
• Mongolian spots: lumbosacral, fade by about 7 years; not bruises.
• Sclerema = severe illness; SSSS = Nikolsky positive, cloxacillin, no steroids.
• TORCH common: IUGR, hepatosplenomegaly, jaundice, low platelets, microcephaly, eye disease.
• Toxo: hydrocephalus + chorioretinitis + diffuse calcification; pyrimethamine + sulfadiazine.
• Rubella: cataract + PDA + deafness; first trimester; live vaccine not in pregnancy.
• CMV: commonest; microcephaly + periventricular calcification + deafness; valganciclovir.
• HSV: HSV-2 at delivery; vesicles, encephalitis; IV acyclovir.
• Syphilis: snuffles, palm/sole rash, periostitis; later Hutchinson teeth; penicillin.
• Hep B: HBIG + vaccine within 12 h; breastfeed.

Written by The House Job from standard references (Basis of Paediatrics by Pervez Akbar; Nelson Essentials of Paediatrics).

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