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'''TORCH Complex''' (aka TORCHES or the TORCH infections) is a medical [[acronym]] for a set of 5 [[congenital infection]]s (i.e. that are passed from an infected mother to her fetus). 
__NOTOC__
{{TORCH complex}}
{{CMG}} {{AE}} {{AKI}}


==Conditions==
{{SK}} TORCHES; TORCH infections
The diseases present similarly, involving the heart, skin, eye, and CNSThey all cause [[chorioretinitis]], [[microcephaly]], and focal cerebral [[calcification]].
==Overview==
TORCH group of infections include: [[toxoplasmosis]], [[Treponema pallidum]] , [[rubella]], [[cytomegalovirus]], [[herpesvirus]], [[hepatitis viruses]], [[Human immunodeficiency virus]], and other infections such as [[varicella]], [[parvovirus B19]], and [[enteroviruses]]. All of these infections affect the [[fetus]] and can cause significant [[morbidity]] and [[mortality]]. Most of the infections reach the [[fetus]] via the [[transplacental route]] or by ascending infection. The timing of infection varies with individual infections to cause severe damage. Most of the infections can result in [[misscarriage]] or [[fetal demise]] or severe clinical manifestations in the [[newborn]]. The infections can compromise normal development during [[infancy]] and have [[poor development]]. Therefore, early diagnosis and treatment plays an important role in the management of these infections to improve outcomes in the [[newborn]].<ref name="pmid25677998">{{cite journal| author=Neu N, Duchon J, Zachariah P| title=TORCH infections. | journal=Clin Perinatol | year= 2015 | volume= 42 | issue= 1 | pages= 77-103, viii | pmid=25677998 | doi=10.1016/j.clp.2014.11.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25677998  }} </ref>


It is possible for genetic conditions (Aicardi-Goutieres syndrome) to present in a similar manner.<ref name="pmid12833411">{{cite journal |author=Knoblauch H, Tennstedt C, Brueck W, ''et al'' |title=Two brothers with findings resembling congenital intrauterine infection-like syndrome (pseudo-TORCH syndrome) |journal=Am. J. Med. Genet. A |volume=120A |issue=2 |pages=261–5 |year=2003 |month=July |pmid=12833411 |doi=10.1002/ajmg.a.20138 |url=http://dx.doi.org/10.1002/ajmg.a.20138}}</ref><ref name="pmid11226724">{{cite journal |author=Vivarelli R, Grosso S, Cioni M, ''et al'' |title=Pseudo-TORCH syndrome or Baraitser-Reardon syndrome: diagnostic criteria |journal=Brain Dev. |volume=23 |issue=1 |pages=18–23 |year=2001 |month=March |pmid=11226724 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0387760400001881}}</ref>
==Causes==
The TORCH group of infections include bacteria, parasites and viruses:
*[[Congenital Toxoplasmosis]] is caused by coccidian parasite [[Toxoplasma gondii]]
*[[Congenital syphliis]] is caused by [[Treponema pallidum]]
*[[Congenital Varicella syndrome]] is caused by [[Varicella zoster virus]]
*[[Congenital rubella syndrome]] is caused by [[Rubella virus]]
*[[Congenital CMV]] is caused by [[Cytomegalovirus]]
*[[Neonatal herpes simplex]] is caused by [[HSV-1]] and [[HSV-2]]


'''TORCH''' or '''TORCHES infections''' are a group of [[infection]]s that in a pregnant woman can lead to severe fetal anomalies or even fetal loss. They are a group of viral, and rarely bacterial infections, which gain access to the fetal bloodstream transplacentally via the chorionic villi.  Hematogenous transmission may occur any time during gestation or occasionally -as with HIV and Hep B- at the time of delivery via maternal-to-fetal transfusion.<ref>Robbins and Cotran Pathological Basis of Disease, pg 480</ref>  The mother often has a mild infection with few or no symptoms. ''TORCH'' is an acronym.
==Classification==
The TORCH group of infections can be classified based on the causative pathogen into the following :
*'''Viral causes:''' [[Cytomegalovirus]], [[Hepatitis B]], [[Hepatitis C]], [[Human immunodeficiency virus]], [[parvovirus B19|Rarvovirus B19]], [[Herpes virus]], [[Varicella zoster virus]], [[Rubella virus]]
*'''Bacterial causes :''' [[Treponema pallidum]]  
*'''Parasite causes:''' [[Toxoplasma gondii]]


===Initial four===
==Differential Diagnosis==
The infections are:
{|
|-style="background: #4479BA; color: #FFFFFF; text-align: center;"
! rowspan="1" |Diseases
! colspan="1" |Causative Organism
! colspan="1" |Transmission
! colspan="1" |Timing of Infection
! rowspan="1" |Symptoms in the Mother
! rowspan="1" |Clinical features in the newborn
! rowspan="1" |Classification
! rowspan="1" |Diagnosis
! rowspan="1" |Treatment
|-style="background: #4479BA; color: #FFFFFF; text-align: center;"
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" | [[Congenital syphilis]]
|style="background: #F5F5F5; padding: 5px;" |[[Treponema Pallidum]]
|style="background: #F5F5F5; padding: 5px;" |Vertical
|style="background: #F5F5F5; padding: 5px;" |16th to 28th week
|style="background: #F5F5F5; padding: 5px;" |Based on the stage of [[Syphilis]] infection
|style="background: #F5F5F5; padding: 5px;" |
*[[Low birth weight]]
*Non-immune [[Hydrops]]
*[[Maculopapular]] or [[Vesicobullous]] [[rash]] on the palms and soles
*Interstitial [[Keratitis]]
*[[Rhinitis]]
|style="background: #F5F5F5; padding: 5px;" |
*Early congenital syphilis
*Late congnenital syphilis
*Stigmata
|style="background: #F5F5F5; padding: 5px;" |
*Detection of [[IgM]] aganist [[T.pallidum]] in [[blood]] collected in [[chordocentesis]]
*[[Amniotic fluid]] [[PCR]] for [[T. pallidum]] [[DNA]]
*Antenatal [[Ultrasound]]
|style="background: #F5F5F5; padding: 5px;" |
*Aqueous crystalline [[penicillin G]]
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Congenital Toxoplasmosis]]
|style="background: #F5F5F5; padding: 5px;" |[[ Toxoplasma gondii | Toxoplasma gondii]]
|style="background: #F5F5F5; padding: 5px;" |Vertical
|style="background: #F5F5F5; padding: 5px;" |[[Third Trimester]]
|style="background: #F5F5F5; padding: 5px;" |
*Majority : Asymptomatic
*Few patients can have [[flu]] like symptoms
|style="background: #F5F5F5; padding: 5px;" |
*[[Low birth weight]]
*[[Chorioretinitis]]
*[[Microcephaly]]
*[[Intracranial calcification]]
*Spasticities and Paresis
*[[Sensorineural hearing loss]]
|style="background: #F5F5F5; padding: 5px;" | None
|style="background: #F5F5F5; padding: 5px;" |
*[[Amniotic fluid]] [[PCR]] for [[T.gondii]] [[DNA]]
*Detection of [[parasite]] in [[amniotic fluid]]
*[[Serology]]
|style="background: #F5F5F5; padding: 5px;" |
*Infected mothers without [[fetal]] infection : [[Spiramycin]]
*Infected mothers with established [[fetal]] infection : [[Pyrimethamine]], [[sulfadiazine]], and [[folinic acid]]
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Congenital varicella syndrome]]
|style="background: #F5F5F5; padding: 5px;" |[[Varicella zoster virus]]
|style="background: #F5F5F5; padding: 5px;" |Vertical
|style="background: #F5F5F5; padding: 5px;" |13 to 20th week
|style="background: #F5F5F5; padding: 5px;" |
*Vesicular skin rash
*[[Fever]]
|style="background: #F5F5F5; padding: 5px;" |
*Cicatrical skin lesions
*Limb hypoplasia
*[[Microcephaly]]
*[[Autonomic instability]]
*[[Chorioretinitis]]
*[[Microphalmia]] and [[anisocoria]]
|style="background: #F5F5F5; padding: 5px;" |None
|style="background: #F5F5F5; padding: 5px;" |
*[[Antenatal Ultrasound]]
*Fetal [[MRI]]
*[[Amniotic fluid]] [[PCR]] for [[VZV]] [[DNA]]
|style="background: #F5F5F5; padding: 5px;" |
*Termination of [[pregnancy]] with severe defects
*No definitive treatment
*Preconceptional [[vaccination]]
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Congenital CMV]]
|style="background: #F5F5F5; padding: 5px;" |[[Cytomegalovirus]]
|style="background: #F5F5F5; padding: 5px;" |Vertical
|style="background: #F5F5F5; padding: 5px;" |[[First trimester]]
|style="background: #F5F5F5; padding: 5px;" |
*[[Fever]]
*[[Cervical lymphadenopathy]]
|style="background: #F5F5F5; padding: 5px;" |
*[[Small for gestational age|SGA]]
*[[Microcephaly]]
*[[Sensorineural hearing loss]]
*[[Cataracts]]
*[[Petechiae]] and [[purpura]]
*[[Jaundice]]
*Poor sucking when feeding
*[[Hypotonia]]
|style="background: #F5F5F5; padding: 5px;" |
*Symptomatic
*Asymptomatic
|style="background: #F5F5F5; padding: 5px;" |
*[[Antenatal Ultrasound]]
*[[Amniotic Fluid]] [[PCR]] for [[CMV]] [[DNA]]
*[[CT]] [[brain]]
|style="background: #F5F5F5; padding: 5px;" |
*IV [[Ganciclovir]]
*Oral [[Valganciclovir]]
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Congenital rubella syndrome]]
|style="background: #F5F5F5; padding: 5px;" |[[Rubella]] Virus
|style="background: #F5F5F5; padding: 5px;" |Vertical
|style="background: #F5F5F5; padding: 5px;" |8 to 10th week
|style="background: #F5F5F5; padding: 5px;" |
*Asymptomatic
*[[Maculopapular rash]] starting on the [[face]] and spreads caudally
*[[Polyarthalgia]]
|style="background: #F5F5F5; padding: 5px;" |
*[[Low birth weight]]
*[[VSD]] and [[PDA]]
*[[Cataracts]], [[glacoma]], [[retinopathy]]
*[[Sensorineural hearing loss]]
*[[Microcephaly]]
*[[Encephalitis]]
|style="background: #F5F5F5; padding: 5px;" |None
|style="background: #F5F5F5; padding: 5px;" |
* Direct isolation of the [[virus]]
* [[Viral]] [[nucleic acid]] quantification
* Detection of [[IgM]]/ [[IgA]] [[antibodies]] in [[fetal]] [[blood]]
*[[Serological Testing]]
|style="background: #F5F5F5; padding: 5px;" |
*Termination of pregnancy: If infection diagnosed before 18 weeks of [[pregnancy]]
*No definitive Treatment
|-
|style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Neonatal herpes simplex]]
|style="background: #F5F5F5; padding: 5px;" |[[HSV-1]] and [[HSV-2]]
|style="background: #F5F5F5; padding: 5px;" |
*Direct Contact / Ascending infection from genital lesions
*Contact with infected people
*Vertical
|style="background: #F5F5F5; padding: 5px;" |At [[term]]
|style="background: #F5F5F5; padding: 5px;" |
*[[Genital herpes]] or [[Orolabial herpes]]
|style="background: #F5F5F5; padding: 5px;" |
*Vesicular skin lesions
*[[Oral ulcers]]
*[[Chorioretinitis]] and [[conjunctival erythema]]
*[[Encephalitis]]
*[[DIC]]
*[[Pneumonitis]]
|style="background: #F5F5F5; padding: 5px;" |
*Skin, eye, mouth disease (SEM)
*[[CNS]] Disease
*Disseminated Disease
|style="background: #F5F5F5; padding: 5px;" |
*Surface Cultures
*[[CSF]] analysis
*Elevated [[Alanine Transaminase]]
|style="background: #F5F5F5; padding: 5px;" |
*SEM : IV [[Acyclovir]] for 10 days
*Disseminated and [[CNS]] disease: IV [[Acyclovir]] for 14 to 21 days
|}


# '''T''' &ndash; [[Toxoplasmosis|'''T'''oxoplasmosis]] / [[Toxoplasma gondii]]
The list of clinical manifestations in TORCH group of infections include the following:<ref name="pmid25677998">{{cite journal |vauthors=Neu N, Duchon J, Zachariah P |title=TORCH infections |journal=Clin Perinatol |volume=42 |issue=1 |pages=77–103, viii |year=2015 |pmid=25677998 |doi=10.1016/j.clp.2014.11.001 |url=}}</ref><ref name="pmid25654000">{{cite journal |vauthors=Ajij M, Nangia S, Dubey BS |title=Congenital rubella syndrome with blueberry muffin lesions and extensive metaphysitis |journal=J Clin Diagn Res |volume=8 |issue=12 |pages=PD03–4 |year=2014 |pmid=25654000 |pmc=4316306 |doi=10.7860/JCDR/2014/10271.5293 |url=}}</ref>
# '''O''' &ndash; Other infections (see below)
<small>
# '''R''' &ndash; [[Rubella|'''R'''ubella]]
{| class="wikitable"
# '''C''' &ndash; [[Cytomegalovirus|'''C'''ytomegalovirus]]
!Congenital Infection
# '''H''' &ndash; [[Herpes simplex virus|'''HE'''rpes simplex virus]]
!Cardiac Findings
 
!Skin Findings
===Other===
!Ocular Findings
The "O" can stand for "other agents", namely [[Hepatitis B]], [[Syphilis]], [[Varicella zoster virus|Varicella-Zoster Virus]], [[HIV]], and [[Parvovirus B19]].
!Hepatosplenomegaly
 
!Hydrocephalus
[[Listeria]], [[E. coli]] and [[group B streptococci]] can also be acquired after membrane rupture and are the 3 most common causes of meningitis of the newborn.
!Microcephaly
 
!Intracranial Calcifications
The acronym has also been listed as '''TORCHES''', for '''To'''xoplasmosis, '''R'''ubella, '''C'''MV, '''He'''rpes simplex, '''S'''yphilis.
!Hearing deficits
 
|-
==History==
!Congenital Varicella Syndrome
There were originally four conditions,<ref name="pmid2850128">{{cite journal |author=Kinney JS, Kumar ML |title=Should we expand the TORCH complex? A description of clinical and diagnostic aspects of selected old and new agents |journal=Clin Perinatol |volume=15 |issue=4 |pages=727–44 |year=1988 |month=December |pmid=2850128 |doi= |url=}}</ref> with the "TO" referring to "Toxoplasma". The four-term form is still used in many modern references.<ref name="pmid16231309">{{cite journal |author=Abdel-Fattah SA, Bhat A, Illanes S, Bartha JL, Carrington D |title=TORCH test for fetal medicine indications: only CMV is necessary in the United Kingdom |journal=Prenat. Diagn. |volume=25 |issue=11 |pages=1028–31 |year=2005 |month=November |pmid=16231309 |doi=10.1002/pd.1242 |url=http://dx.doi.org/10.1002/pd.1242}}</ref> The capitalization "ToRCH" is sometimes used in these contexts.<ref name="pmid16791006">{{cite journal |author=Li D, Yang H, Zhang WH, ''et al'' |title=A simple parallel analytical method of prenatal screening |journal=Gynecol. Obstet. Invest. |volume=62 |issue=4 |pages=220–5 |year=2006 |pmid=16791006 |doi=10.1159/000094092 |url=http://content.karger.com/produktedb/produkte.asp?typ=fulltext&file=GOI2006062004220}}</ref>
| -
 
| -
Some uses of the term redefine the "O" as "other", and include other conditions under the "O", such as [[syphillis]].<ref name="pmid15552342">{{cite journal |author=França CM, Mugayar LR |title=Intrauterine infections: a literature review |journal=Spec Care Dentist |volume=24 |issue=5 |pages=250–3 |year=2004 |pmid=15552342 |doi= |url=}}</ref>
*Cicatrical Skin Lesions
 
*Skin Edema
==Features==
| -
Symptoms of a TORCH infection may include fever and poor feeding. The newborn is often [[Birth weight|small for gestational age]]. A [[petechia]]l rash on the skin may be present, with small reddish or purplish spots due to bleeding from capillaries under the skin. An enlarged liver and spleen ([[hepatosplenomegaly]]) is common, as is the yellowish discoloration of the skin and eyes called [[jaundice]]. [[Hearing impairment]], eye problems, [[mental retardation]], [[autism]], and death can be caused by TORCH infections.
*Micropthalmus
 
*Cataracts
==Diagnosis==
|
When physical examination of the newborn shows signs of the TORCH syndrome, the examiner may test blood, urine, and spinal fluid for evidence of the infections listed above. Diagnosis can be confirmed by culture of one of the specific pathogens or by increased levels of [[IgM]] against the pathogen.
| -
 
|
==Treatment and prevention==
|
Some of the TORCH infections, such as toxoplasmosis and syphilis, can be effectively treated with antibiotics if the mother is diagnosed early in her pregnancy. Many of the viral TORCH infections have no effective treatment, but some, notably rubella and varicella-zoster, can be prevented by [[Vaccination|vaccinating]] the mother prior to pregnancy. If the mother has active herpes simplex, delivery by [[Caesarean section]] can prevent the newborn from contact, and consequent infection, with this virus.
| -
 
|-
==Prognosis==
![[Toxoplasmosis congenital|Toxoplasmosis]]
Each type of TORCH infection has a different prognosis. The stage of the pregnancy at the time of infection also can change the effect on the newborn.
|  -
 
| -
[[Category:Infectious diseases]]
* [[Petechiae]]
[[Category:Pediatrics]]
* [[Purpura]]
[[Category:Obstetrics]]
* [[Maculopapular rash]]
 
| -
[[de:STORCH]]
* [[Chorioretinitis]]
[[it:TORCH]]
|
[[ja:TORCH症候群]]
|
[[pl:Zespół TORCH]]
|
|Diffuse intracranial calcifications
| -
|-
![[Congenital Syphils]]
| -
| -
* [[Petechiae]]
* [[Purpura]]
* [[Maculopapular rash]]
| -
* [[Chorioretinitis]]
* [[Glaucoma]]
|✔
|  -
|  -
|  -
|  -
|-
![[Rubella, congenital|Rubella]]
|
* [[Patent ductus arteriosus (PDA)]]
* [[Pulmonary artery stenosis]]
* [[Coarctation of the aorta]]
* [[Myocarditis]]
| -
* [[Petechiae]]
* [[Purpura]]
|  -
* [[Chorioretinitis]]
* [[Cataracts]]
* [[Glaucoma]]
* [[Microphthalmia]]  
|✔
|✔
|✔
|  -
|✔
|-
![[Cytomegalovirus (CMV)]]
|✔
-
* [[Petechiae]]
* [[Purpura]]
|
* [[Chorioretinitis]]
|✔
|  -
|✔
|Periventricular calcifications
|✔
|-
![[Herpes simplex virus (HSV)]]
|  -
* [[Myocarditis]]
|  -
* [[Petechiae]]
* [[Purpura]]
* [[Vesicles]]
|  -
* [[Chorioretinitis]]
|✔
|✔
|✔
|  -
|✔
|-
![[Parvovirus B19]]
|  -
* [[Myocarditis]]
|  -
* [[Petechiae]]
* [[Subcutaneous]] [[edema]]
|  -
* [[Chorioretinitis]]
* [[Cataracts]]
|✔
|  -
|  -
|  -
|  -
|}
</small>


==References==
==References==
{{reflist|2}}
{{Reflist|2}}
 
{{Diseases of maternal transmission}}

Latest revision as of 18:57, 18 September 2017

Congenital infections Main Page

Overview

Causes

Classification

Congenital Toxoplasmosis
Congenital syphilis
Congenital varicella syndrome
Congenital rubella syndrome
Congenital CMV
Neonatal herpes simplex

Differential Diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Aravind Kuchkuntla, M.B.B.S[2]

Synonyms and keywords: TORCHES; TORCH infections

Overview

TORCH group of infections include: toxoplasmosis, Treponema pallidum , rubella, cytomegalovirus, herpesvirus, hepatitis viruses, Human immunodeficiency virus, and other infections such as varicella, parvovirus B19, and enteroviruses. All of these infections affect the fetus and can cause significant morbidity and mortality. Most of the infections reach the fetus via the transplacental route or by ascending infection. The timing of infection varies with individual infections to cause severe damage. Most of the infections can result in misscarriage or fetal demise or severe clinical manifestations in the newborn. The infections can compromise normal development during infancy and have poor development. Therefore, early diagnosis and treatment plays an important role in the management of these infections to improve outcomes in the newborn.[1]

Causes

The TORCH group of infections include bacteria, parasites and viruses:

Classification

The TORCH group of infections can be classified based on the causative pathogen into the following :

Differential Diagnosis

Diseases Causative Organism Transmission Timing of Infection Symptoms in the Mother Clinical features in the newborn Classification Diagnosis Treatment
Congenital syphilis Treponema Pallidum Vertical 16th to 28th week Based on the stage of Syphilis infection
  • Early congenital syphilis
  • Late congnenital syphilis
  • Stigmata
Congenital Toxoplasmosis Toxoplasma gondii Vertical Third Trimester
  • Majority : Asymptomatic
  • Few patients can have flu like symptoms
None
Congenital varicella syndrome Varicella zoster virus Vertical 13 to 20th week
  • Vesicular skin rash
  • Fever
None
Congenital CMV Cytomegalovirus Vertical First trimester
  • Symptomatic
  • Asymptomatic
Congenital rubella syndrome Rubella Virus Vertical 8 to 10th week None
  • Termination of pregnancy: If infection diagnosed before 18 weeks of pregnancy
  • No definitive Treatment
Neonatal herpes simplex HSV-1 and HSV-2
  • Direct Contact / Ascending infection from genital lesions
  • Contact with infected people
  • Vertical
At term
  • Skin, eye, mouth disease (SEM)
  • CNS Disease
  • Disseminated Disease

The list of clinical manifestations in TORCH group of infections include the following:[1][2]

Congenital Infection Cardiac Findings Skin Findings Ocular Findings Hepatosplenomegaly Hydrocephalus Microcephaly Intracranial Calcifications Hearing deficits
Congenital Varicella Syndrome - -
  • Cicatrical Skin Lesions
  • Skin Edema
-
  • Micropthalmus
  • Cataracts
- -
Toxoplasmosis - - - Diffuse intracranial calcifications -
Congenital Syphils - - - - - - -
Rubella - - -
Cytomegalovirus (CMV) - - Periventricular calcifications
Herpes simplex virus (HSV) - - - -
Parvovirus B19 - - - - - - -

References

  1. 1.0 1.1 Neu N, Duchon J, Zachariah P (2015). "TORCH infections". Clin Perinatol. 42 (1): 77–103, viii. doi:10.1016/j.clp.2014.11.001. PMID 25677998.
  2. Ajij M, Nangia S, Dubey BS (2014). "Congenital rubella syndrome with blueberry muffin lesions and extensive metaphysitis". J Clin Diagn Res. 8 (12): PD03–4. doi:10.7860/JCDR/2014/10271.5293. PMC 4316306. PMID 25654000.