Torch Diseases Web Ce

8/12/2019 Torch Diseases Web Ce

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Every attempt has been made to provide the most up-to-date and accurateinformation available, but this podcast should not be used as medical advice.

If you are a patient, seek the care of a licensed professional.

Forward questions or comments about this presentation to :

James Kundart, OD, MEd, FAAO ([email protected])

I hope that you find this presentation educational!
mailto:[email protected]:[email protected]


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Shedding Light on

TORCH DiseasesWeb-Based Continuing Education

Pacific University College of OptometryJames Kundart OD MEd FAAO

http://www.health-res.com/herpes-simplex-virus-encephalitis/


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Focus Questions

1. Which congenital infectious diseases can affect mental health, andcan cause serious mental health disorders, like schizophrenia?

2. What are six characteristics of autism? Which of the infectiousdisorders raise the risk of children acquiring it?

3. How common is congenital cytomegalovirus? What are the effectsof CMV, both ocular and systemic?

4. Which of the infectious disorders cause encephalitis and affectmostly patients of presbyopic age?

5. Which can cause meningitis, affecting mostly children?


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What Are the TORCH Diseases?

TORCH diseases can cause birth defects in the unborn child ifthe mother contracts them during pregnancy.

TORCH stands for:

1. Toxoplasmosis

2. Other

3. Rubella

4. Cytomegalovirus

5. Herpes Simplex

Ill cover Other last when we talk about Varicella


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1. What You Dont Know

About Toxoplasmosis

The most common form of posterior uveitis in children and adults istoxoplasmosis

Long known to be congenital, Toxo- has increasing evidence for

acquired forms as well According to the Wikipedia, Toxoplasma infection also causes

damage to astrocytes in the brain

There is evidence that the toxoplasmosis protzoan makes infectedrodents lose their fear of predators!

Typically, we worry about the effects in the eyes and brain of theunborn child and can cause coordination, learning, andperceptual disabilities


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Toxoplasmosis Life Cycle:

Cats or Meat Consumption?

Did you know that its notcats, but ingestion ofundercooked meat that

usually causes toxo-? I have personally seen it

also effect the expectantmothers retina, as well asthe unborn child

Toxo- is not harmless tocats either, and can affecttheir eyes and cerebellum

http://www.healthtree.com/articles/childhood-

diseases/rare/toxoplasmosis-symptoms/


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Toxoplasmosis: Objective Symptoms

Blurred vision

Photophobia

Watering eyes

Blind spots (?)

Except for transientlymphadenopathy, evenpatients with acquired Toxo-may be asymptomatic

http://emedicine.medscape.com/article/1204441-media


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Toxoplasmosis: Subjective Signs

These occur in 70-90% ofcongenital and up to 21% ofacquired cases of Toxo-

Focal Necrotic RetinalLesions

Glaucoma

Loss of vision

The patient shown has BCVA20/400 OS secondary tocongenital Toxoplasmosisretinochoroiditishttp://emedicine.medscape.com/

article/1204441-media


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Effects of Congenital Toxoplasmosis

Approximately 10% of

Toxo- infected infants have

clinical manifestations at

birth

Hydrocephalus, jaundice,

hepatosphenomegaly, and

papillitis are seen in severe

cases treat immediately!

Look for elevated blood

titers of IgA, IgE, and IgM http://emedicine.medscape.com/article/1204441-media


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Treatment of Acute Toxoplasmosis

Controversially, reductionin BCVA by 2 or more linescaused by maculitis would

call for systemic (oral or IV)treatment:

Pyrimathamine

Sulfanomides or otherantibiotics

Folic Acid Pyri-methamine

Steroids?



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Toxoplasmosis and Mental Health

Toxo- affects dopaminelevels, which are involved inmood, sociability, attention,motivation and sleep

patterns (Wikipedia)

Schizophrenia has long beenlinked to dopaminedysregulation

Toxo- antibodies were foundat significantly higher levelsin blood tests ofschizophrenics



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Toxoplasmosis and Behavior

Controversial correlationshave been found betweenlatent Toxoplasma infectionsand various characteristics:

Decreased novelty-seekingbehavior

Slower reaction time

Lower rule-consciousness

and greater jealousy (in men)

Promiscuity and greaterconscientiousness (in women)



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2. What You Dont Know About

Congenital Rubella Syndrome

Other features:

Retinopathy

Growth retardation Developmental

Delay

Autism Spectrum

DevelopmentalDisorders

Diabetes

The classic triad:

Eye abnormalities,

especially cataract(30% of patients)

Sensorineural deafness

(58% of patients)

Congenital heart

disease

(50% of patients)


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Congenital Rubella and Cataracts

30% of patients have

them, and are bilateral,

as seen here

These cataracts have been

described as pearly and

dense, but may have a

clear ring around them

Rubella causes liquefaction

of the lens cortex and may

have live virus inside (!)http://en.wikipedia.org/wiki/Congenital_rubella_syndrome


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Congenital Rubella and Retinopathy

About 45% will be expectedto have this salt-and-pepper fundus

Expect no foveal light reflexbecause of RPE hyperplasia

Vision is usually not affected

A mild microphalmos may beevident in short axial lengthand hyperopic refractiveerror

http://www.kellogg.umich.edu/theeyeshaveit/congenital/retinopathy.html


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Congenital Rubella and

Stunted Growth

All these children fromMadhya Pradesh in India arethe same age, but 6/10 sufferfrom malnutrition, but show

similar growth retardation

This can include not reachingproper milestones (sitting upat 6 months, walking at 1year, talking at 2 years, etc.)

Sometimes, milestones liketalking are delayed bysensorineural hearing loss

http://www.flickr.com/photos/dfid/4420550101/


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Congenital Rubella and

Developmental Delays

One possible cause of thesedelays is hearing loss, whichis part of the triad

Unilateral or bilateralsensorineural hearing loss,seen in over half of congenitalrubella patients

Those with underformed orabsent cristae (hair cells) in

the inner ear often havetrouble with learning,specifically speech-languagedevelopment

http://www.thedeafblog.co.uk/2009/04/hair_cells_could_restore_heari.html


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Congenital Rubella and Autism

Autism is characterized by:

1. Repetitive movements

2. Compulsive behavior

3. Resistance to change

4. Daily rituals

5. Special interests

6. Self-injury http://en.wikipedia.org/wiki/Autism


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Congenital Rubella, Autism

and Developmental Disorders

Is it normal for a child to

compulsively stack cans?

If the child also hasrestricted social

interaction and

communication, it may be

Look for restricted andrepetitive behavior in

autism and other pervasive

developmental disorders

http://en.wikipedia.org/wiki/Autism


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Congenital Rubella and Heart Disease

Part of the congenital rubellatriad is patent ductusarteriosus, or PDA

Children with congenitalRubella can later developprogressive endocrinecomplications, including:

IDDM

Hypothyroidism

Hyperthyroidism

http://en.wikipedia.org/wiki/Patent_ductus_arteriosus


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Congenital Rubella and Schizophrenia

While family history is far

and away the most serious

risk factor, others are (in

order of likelihood):1. CNS damage

2. Bereavement

3. Rubella

4. CNS infection(meningitis)

5. Birth hypoxiahttp://www.schizophrenia.com/newsletter/buckets/hypo.html


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3. What You Dont Know

About Cytomegalovirus (CMV)

According to the NY Times:

Cytomegalovirus is a largeherpes-type virus most have

It can cause serious infections inpeople with impaired immunity,including newborns

CMV infection may result in

pneumonia, gastroenteritis,retinitis or encephalitis

Antiviral medications may stopthe replication of the virus butwill not destroy it

http://www.nytimes.com/imagepages/2007/08/01/health/adam/17110CMVcytomegalovirus.html


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Subjective Symptoms of CMV

Blurred Vision (decreasedBCVA)

Photophobia

Redness

Loss of peripheral vision(blind spots)

Lots of floaters

Learning disabilities andperceptual problemshttp://eyecaremanual.com/eye-diseases/cmv-

retinitis/cmv-retinitis-symptoms-causes-treatment-surgery.html


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Objective Signs of CMV

Though >80% of adultshave antibodies to CMV,retinitis is rarely seen inhealthy adult patients

Look for a brushfireretinitis pattern inimmunocompromisedpatients, as seen here

Dont forget that unbornchildren are as vulnerableas those with HIV/AIDS

http://depts.washington.edu/hivaids/oit/case7/fig4d.html


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CMV in Immunocompromised Adults

36 year-old patient withHIV/AIDS, not on the cocktail,low CD4 count of only 9cells/mm3

Had a large subfoveal irregularpatch of retinal necrosis ODonly

Appears as a white, fluffy lesionwith overlying retinalhemorrhages and scatterednecrotic spots perifoveally

HIV retinopathy has all butdisappeared in the US, butcongenital CMV has not

http://webeye.ophth.uiowa.edu/eyeforum/cases/61-CMV-Cytomegalovirus-Retinitis-HIV.htm


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Congenital CMV Awareness

According to the Centers

for Disease Control and

Prevention, expectant

mothers are less aware ofCMV of all diseases,

including:

Fetal Alcohol

Congenital Rubella

Toxoplasmosis, etc.

Yet CMV is more commonthan all of these!

http://www.cdc.gov/Features/dsCytomegalovirus/


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Congenital CMV Incidence

Take a look at how many

cases of congenital Rubella

occur annually in the U.S.

Conditions for which

vaccines are given, like H

flu, are also much less

common than CMV

Unfortunately, there is no

vaccine, but natural

immunity is the norm



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Bottom Lines on Congenital CMV

http://www.cdc.gov/cmv/trends-stats.html#affected

About 3000 children are bornwith congenital CMVinfection each year (thats1:150 live births)

About 1 in 750 children in theU.S. is born with (or develops)permanent problems due tocongenital CMV infection

In the U.S., more than 5,000children each year sufferpermanent problems causedby CMV infection


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Congenital CMV Prevention


Since most adults haveimmunity, the greatestconcern is not to spread CMVfrom other children topregnant women

Hygiene measures withhandwashing not sharingcups, plates, washcloths,even pacifiers should make adifference

In a real sense, children are amore serious reservoir forCMV than cats are for Toxo-!!!


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4. What You Dont Know About the

Herpes Simplex Virus Encephalitis

This 33 year-old female patientpresented with agitation,confusion, mutism, and fever

A brain biopsy was performed

and the histology wasconsistent with HSV-Iencephalitis

HSV-1 causes 95% of all(septic?) herpetic encephalitis

Mortality ranges from 50-70%,and treatment is withintravenous antivirals

http://www.radpod.org/2007/03/24/herpes-simplex-encephalitis/


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What HSV Encephalitis Affects

The most common cause offatal sporadic viralencephalitis is HSV

HSV encephalitischaracteristic imagingfindings:

Asymmetric temporallobe involvement, and

Involvement of the insularcortex

http://radiopaedia.org/images/546349


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Profile of HSV Encephalitis Patients

According to Wikipedia:

2 in 3 cases occur inseropositive persons, few ofwhom have history ofrecurrent orofacial herpes

Approximately 50% ofindividuals that develop HSVencephalitis are over 50

It is estimated to affect atleast 1 in 500,000 individualsper year in the U.S. (thatsabout 6000 cases annually) http://www.health-

res.com/herpes-simplex-virus-encephalitis/


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HSV Encephalitis and CN I

The olfactory nerve (CN I)

may also be involved in

HSV encephalitis

This may explain its

predilection for the

temporal lobes, as CN I

sends branches there

The virus also lies dormant

in the trigeminal nerve,

which explains HSKhttp://www.health-res.com/herpes-simplex-virus-encephalitis/


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HSV Encephalitis Symptoms

Patients typically have a

fever, and may have

seizures

Most individuals with HSE

show:

Decreased consciousness

An altered mental state

Changes in personality

Confusion, or evendementia



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HSV Encephalitis and Alzheimer Disease

Researchers at BrownUniversity and the MarineBiological Laboratory atWoods Hole, Mass., have

found a connection betweenthe herpes simplex virus andamyloid precursor protein

This protein that breaks downto form a major component

of the amyloid plaques thatare consistently present inthe brains of people withAlzheimer disease

http://trendsupdates.com/link-between-the-herpes-virus-and-alzheimer/

http://www.sciencedaily.com/releases/2003/11/031107055048.htm


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Occurrence of HSV

Without treatment, HSVencephalitis results in rapiddeath in approximately 70%of cases

Survivors suffer severeneurological damage

Treatment is with high-doseintravenous Acyclovir

When treated, HSVencephalitis is still fatal inone-third of cases

http://www.textmed.com/disease/herpes-simplex.htm


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Treatment for HSV Encephalitis

There are serious long-termneurological damage in overhalf of survivors, includingvisual-perceptual problems

A 20% minority of treatedpatients recover HSVencephalitis with minor (butpermanent) brain damage

Only a small population ofsurvivors (2.5%) regaincompletely normal brainfunction



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5. What You Dont Know About

Neonatal Varicella-Zoster

Infection late in gestation

or immediately following

birth is referred to as

"neonatal varicella

Maternal infection is

associated with premature

delivery and miscarriage

Newborns who develop

symptoms are at a high

risk of pneumonia

http://en.wikipedia.org/wiki/Varicella


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Ocular Damage from


More severe than HZO, Varicellacan congenitally cause:

Microphthalmia

Cataracts/ lens vesicles

Chorioretinitis

Optic atrophy

Anisocoria

Horners Syndrome

http://cid.oxfordjournals.org/content/35/5/625.full


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CNS Damage from


Much like HSV, if Varicella

crosses the blood-brain

barrier in utero, it can

cause the following:

Encephalitis

Hydrocephaly

Microcephaly

Cerebral Aplasia

http://www.lookfordiagnosis.com/mesh_info.php?term=Encephalitis%2C+Varicella+Zoster&lang=1


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Other Neurological Effects

of Neonatal Varicella-Zoster

Besides encephalitis, viralinfection of the CNS can alsocause meningitis and affectspinal nerves thusly:

Spinal cord damage

Motor ataxia

Absent deep tendon reflexes

Compare HSV and Varicella-Zoster Virus (VZV) in eachcase

http://www.medscape.com/features/slideshow/varicella-zoster


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Systemic Effects of


How do you know if a patientonce had shingles, congenitalor otherwise? Look for:

Scars and other skin lesionsfollowing a dermatome(C8/T1 shown in this child)

Hypopigmentation where thevessicles once appeared

In cases of congenitalexposure, you may seestunted growth (hypoplasia)of the arms and legs

http://en.wikipedia.org/wiki/Herpes_zoster


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Otitis Media, Learning Disabilities

and Neonatal Varicella-Zoster

Chicken pox can invade theear canal where it isextremely uncomfortable

More importantly, due toscarring, Varicella caninterfere with long-termfunction of the eardrum

There is a high (>50%)correlation betweenrecurrent otitis media andlearning disabilities

http://www.umm.edu/patiented/articles/who_gets_chickenpox_shingles_000082_3.htm


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The Case for (and Against)

the Varicella Vaccine

Available since 1995, theVaricella vaccine aims toprevent severe infections

Why is this necessary? 80% of

children obtain naturalimmunity for life bycontracting chicken pox

In the U.S., there are 9300hospitalizations annually dueto severe infections

The vaccine doe cause fever in10% and localized rash in up to5%, and immunity may not last

http://www.justsharethis.com/wp-content/uploads/2009/07/chickenpoxmain_Full.jpg


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Bottom Lines on


For pregnant women,antibodies produced as aresult of previous infectionor immunization are

transferred via theplacenta to the fetus

Women who are immuneto chickenpox cannot

become infected, and donot need to be concernedabout their unborn infantduring pregnancyhttp://www.justsharethis.com/wp-

content/uploads/2009/07/ChickenPoxBabyCartoon.jpg


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Bottom Lines on Infectious Diseases

and Visual-Perceptual Problems


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Review Capsule

1. Which neonatal infectious diseases can cause retinalscarring, leading to scotomas?

2. Which can scar the middle ear, or cause sensorineural

hearing loss, leading to learning disabilities?

3. Which neonatal infectious diseases can cause dementia andmental confusion?

4. Which commonly leads to congenital cataracts?

5. Which can reside in CN V and cause anisocoria and HornersSyndrome?


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Readings and References

For further information on infectious disorders and the eye,

see chapter 9 in Wrights Handbook of Eye and Systemic

Disease

The author welcomes your questions or comments:

James Kundart OD MEd FAAO

Pacific University College of Optometry

2043 College Way

Forest Grove, OR 97116

503-352-2759

[email protected]

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