What are the management guidelines for a neonate born to a mother with reactive Toxoplasmosis (TORCH), Other (TORCH), Rubella (TORCH), Cytomegalovirus (TORCH), Herpes simplex virus (HSV) infections?

Management of Neonates Born to Mothers with TORCH and HSV Infections

All neonates born to mothers with reactive TORCH or HSV serology require immediate comprehensive evaluation including serologic testing, ophthalmologic examination, neurologic assessment, and cranial imaging, with empiric IV acyclovir initiated immediately for suspected HSV while awaiting confirmatory testing.

Immediate Neonatal Evaluation

For Suspected HSV Exposure

Obtain cultures from multiple sites immediately: blood, skin vesicles (if present), mouth/nasopharynx, eyes, urine, and stool/rectum, as cultures obtained >48 hours after birth indicate viral replication 1, 2, 3.

Perform lumbar puncture for CSF HSV PCR unless contraindicated (moderate-to-severe impaired consciousness, focal neurologic signs, papilledema, systemic shock, coagulation abnormalities, or local infection at LP site) 2. CSF HSV PCR is the gold standard for diagnosing neonatal HSV encephalitis 2.

Critical pitfall: Only 60% of neonates with CNS or disseminated HSV disease present with vesicular rash—absence of skin lesions should not delay evaluation or treatment 2.

For Suspected Toxoplasmosis Exposure

Complete neonatal evaluation must include 4:

• Toxoplasma-specific IgM, IgA, or IgE testing (IgA may be more sensitive than IgM or IgE, though 20-30% of infected infants will be missed by neonatal IgA/IgM assays)
• Ophthalmologic examination for chorioretinitis
• Auditory examination
• Neurologic examination
• Lumbar puncture for CSF analysis
• Head imaging (CT or MRI) to evaluate for hydrocephalus or intracranial calcifications
• PCR testing on blood, CSF, or other body fluids at specialized reference laboratory

Use specialized reference laboratories capable of performing serology, organism isolation, and PCR with expert interpretation assistance 4.

Treatment Protocols

HSV Treatment (Start Empirically While Awaiting Results)

For CNS or disseminated disease: IV acyclovir 20 mg/kg/dose three times daily for 21 days 1, 3, 5.

• Do not discontinue therapy until repeat CSF HSV DNA PCR is negative at days 19-21 1, 2, 3
• This is mandatory—treatment cannot be stopped based on clinical improvement alone

For skin, eye, and mouth disease only: IV acyclovir 20 mg/kg/dose three times daily for 14 days 1, 3, 5.

• Monitor for cutaneous recurrences during the first 6 months after treatment 1, 3

Toxoplasmosis Treatment

For confirmed congenital toxoplasmosis: Pyrimethamine with sulfadiazine or trisulfapyrimidine 6.

Clinical Presentations to Recognize

HSV Disease Classification

Disseminated disease (25% of cases): Typically presents days 9-11, involves visceral organs (hepatitis, pneumonitis) with or without CNS involvement 1.

CNS disease (35% of cases): Typically presents days 10-11, may have focal or diffuse neurologic findings 1.

Skin, eye, and mouth disease (40% of cases): Vesicular rash present in 80% of localized disease 1.

Toxoplasmosis Presentations

70-90% of infected infants are asymptomatic at birth but majority develop late sequelae (retinitis, visual impairment, intellectual or neurologic impairment) months to years later 4.

Symptomatic presentations include 4:

• Generalized disease: maculopapular rash, lymphadenopathy, hepatosplenomegaly, jaundice, hematologic abnormalities (anemia, thrombocytopenia, neutropenia)
• Neurologic disease: hydrocephalus, intracerebral calcification, microcephaly, chorioretinitis, seizures

Monitoring and Safety

For acyclovir therapy, monitor for 3:

• Neutropenia
• Phlebitis
• Renal toxicity (dose adjustment required based on creatinine clearance)
• Nausea, vomiting, rash

Acyclovir pharmacokinetics in neonates (birth to 3 months): Clearance 4.46 ± 1.61 mL/min/kg, elimination half-life 3.80 ± 1.19 hours 5.

Critical Management Principles

Start empiric IV acyclovir immediately for any suspected neonatal HSV given the catastrophic consequences of untreated infection—do not wait for culture results 2.

Maternal primary HSV infection carries 30-50% transmission risk versus 0-5% for reactivation infection, but HIV-coinfected mothers have approximately 10% cervical HSV shedding at delivery regardless 4, 1.

For asymptomatic neonates born to mothers with documented TORCH infections during pregnancy: Complete the full diagnostic evaluation outlined above, as most infected infants are initially asymptomatic but develop severe sequelae later 4, 7.