Master the board step 3

Pediatrics
TORCH Infections Summary
Many of the TORCH infections have similar presentations. The following table
highlights the distinguishing features to look for in the exam. (Refer to section
6 on obstetrics for more details.)
Infection Classic Feature(s) Diagnostic Workup
General features
Toxoplasmosis
Rubella
CMV
Herpes
Syphilis
Varicella
Intrauterine growth retardation,
hepatosplenomegaly, jaundice, mental
retardation
Hydrocephalus with generalized intracranial
calcifications and chorioretinitis
Cataracts, deafness, and heart defects
Blueberry muffin spots (extramedullary
hematopoiesis)
Microcephaly with periventricular
calcifications
Petechiae with thrombocytopenia,
sensorineural hearing loss
First week: Pneumonia/shock
Second week: Skin vesicles,
keratoconjunctivitis
Third to fourth week: Acute
meningoencephalitis
Osteochondritis and periostitis; desquamating
skin rash of palms and soles, snuffles
(mucopurulent rhinitis)
Neonatal: Pneumonia
Congenital: Limb hypoplasia, cutaneous scars,
seizures, mental retardation
Elevated total cord blood IgM
IgM against toxoplasmosis
Maternal rubella immune status negative or
unknown—obtain IgM against rubella
Urine or saliva CMV culture—if negative,
excludes CMV
Serum CMV IgM antibody in newborn
suggests congenital CMV
Best initial test: Tzanck smear/culture (does
not exclude disease if negative)
Most specific test: HSV PCR
Best initial test: VDRL screening
Most specific test: IgM-FTA-ABS
Best initial test: IgM serology
Most specific test: PCR of amniotic fluid
Seizures
In the newborn intensive care unit, an infant is noted to be “jittery” and has repetitive
sucking movements, tongue thrusting, and brief apneic spells. Blood counts
and chemistries are within normal limits. What is the initial workup of this patient?
Answer: Seizures classically present with subtle repetitive movements, such as chewing,
tongue thrusting, apnea, staring, blinking, or desaturations. Classic tonic-clonic
movements are uncommon. Look for ocular deviation and failure of jitteriness to
subside with stimulus (e.g., passive movement of a limb). Complete diagnostic workup
for seizures is listed below.
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