1 00:00:08,189 --> 00:00:08,970 Sara Dong: Hi everyone. 2 00:00:09,000 --> 00:00:13,080 Welcome to Febrile, a cultured podcast about all things infectious disease. 3 00:00:13,500 --> 00:00:16,640 I'm Sara Dong, your host and a Med-Peds ID fellow. 4 00:00:16,770 --> 00:00:19,920 In today's Febrile Digest, I'm joined by Justin Penner. 5 00:00:19,980 --> 00:00:21,810 Can you tell the listeners a little about yourself? 6 00:00:22,020 --> 00:00:22,410 Justin Penner: Sure. 7 00:00:22,410 --> 00:00:23,700 Thanks Sara for having me on. 8 00:00:23,760 --> 00:00:32,590 I'm really excited about this series coming up and I hope everyone else gets as excited about it and enjoys it as much as we enjoyed doing it. 9 00:00:32,950 --> 00:00:34,400 I'm Justin Penner. 10 00:00:34,400 --> 00:00:42,290 I'm a pediatric infectious diseases consultant at the Children's Hospital of Eastern Ontario in Ottawa, Canada. 11 00:00:42,380 --> 00:00:51,030 And I also do some work in Europe, in the UK, as uh that's where I did my Paeds ID and my immunocompromised ID fellowship. 12 00:00:51,580 --> 00:00:52,150 Sara Dong: Awesome. 13 00:00:52,435 --> 00:00:52,915 Yeah. 14 00:00:53,545 --> 00:01:06,085 Uh, so this episode of Febrile digest is really here to announce and say how excited we are about our next, uh, what will be four case-based episodes that will run in April and May. 15 00:01:06,085 --> 00:01:09,115 And they're all related to congenital infections. 16 00:01:09,205 --> 00:01:17,634 And before we started recording, I was telling Justin how I am so thrilled with how these have turned out and, these episodes are absolutely brilliant. 17 00:01:17,634 --> 00:01:21,185 And it really is all thanks to Justin and our amazing guests. 18 00:01:21,565 --> 00:01:26,965 And I really can't wait for our listeners to meet everyone that came on the show and worked through these interesting cases. 19 00:01:27,144 --> 00:01:37,495 And so to kick off this series entitled Curious Congenital Conundrums, we're going to do a quick refresher about the classic congenital infections. 20 00:01:38,285 --> 00:01:42,695 So many of us were taught or learned the classic TORCH mnemonic. 21 00:01:42,695 --> 00:01:53,405 So T for toxoplasmosis, O as other, which is really kind of a catch all letter, R for rubella, C for CMV, and H for HSV. 22 00:01:53,555 --> 00:02:05,465 And there are some limitations to this, similar to really any other medical mnemonic or acronym, but there have been other pushes to try to propose different concepts that would be more broad than TORCH. 23 00:02:05,555 --> 00:02:16,300 And you, Justin, and some of your colleagues had put together a review suggesting the possible use of SCORTCH as an alternate acronym or a diagnostic framework instead. 24 00:02:16,630 --> 00:02:26,830 And so I'll link everyone to this paper, "Stop, think SCORTCH", uh, which also has some really awesome diagrams and, uh, graphics, which everyone knows we love here on Febrile. 25 00:02:26,860 --> 00:02:37,820 But I was wondering, Justin, if you could talk a little bit about how and why you were thinking about this modification and how we can use that to think about infections in these young babies. 26 00:02:38,305 --> 00:02:39,355 Justin Penner: Yeah, exactly. 27 00:02:39,355 --> 00:02:58,840 I think, um, the reason that we tried to rethink the traditional TORCH screen, as everyone kind of is taught in medical school, is that I think our, our understanding of congenital infections has become much more broad than, than just the classic kind of TORCH infections in namesake, but also in diagnostics as well. 28 00:02:59,200 --> 00:03:07,780 So we moved much further along, I think, diagnostically than just the serological tests that we think of when we think of the kind of classic TORCH screen. 29 00:03:08,380 --> 00:03:19,420 The second reason that we tried to kind of diversify this acronym was because the one main infection that that tends to get forgotten in the TORCH acronym is syphilis. 30 00:03:19,830 --> 00:03:24,275 And that's because it gets buried a bit in the O, which I think we'll talk about in a second. 31 00:03:24,365 --> 00:03:35,855 And, and I think the increasing rates of congenital syphilis that's really been seen around the world, but in, in particular parts of the world where we see it much more often than we did before. 32 00:03:36,185 --> 00:03:49,475 Uh, and that's, you know, secondary to many factors, but certainly we are seeing syphilis in the general population increase, in particular syphilis in populations we didn't typically see in the past, in particular women of childbearing age. 33 00:03:50,075 --> 00:03:53,825 So that's really where the new acronym came from. 34 00:03:54,215 --> 00:04:07,275 Uh, I think that the really the, the fetal placental interface is quite a interesting concept as a whole, and I think we're still learning about, uh, you know, how infections interplay with that interface. 35 00:04:07,745 --> 00:04:10,865 And we have new infections coming on all the time. 36 00:04:10,925 --> 00:04:19,525 And now that we live in a globalized society, uh, just thinking of the Zika virus epidemic in Brazil that we had not so long ago. 37 00:04:20,065 --> 00:04:27,820 And you know, how, how COVID perhaps may present with a certain features in a kind of congenital format. 38 00:04:27,820 --> 00:04:34,480 I think that the, the jury is still out, uh, and certainly I'm sure that there will be viruses and other infections in the future. 39 00:04:34,780 --> 00:04:39,780 So keeping the kind of traditional acronym dynamic, I think is a really important thing. 40 00:04:40,490 --> 00:04:40,920 Sara Dong: Yeah. 41 00:04:40,920 --> 00:04:47,465 As much as we'd love to have memories that didn't necessarily need these acronyms, I suspect we won't be able to get rid of them. 42 00:04:47,975 --> 00:04:52,325 Uh, so it is helpful to think of ways to modify them to fit a bit better. 43 00:04:52,865 --> 00:04:53,435 Justin Penner: Exactly. 44 00:04:53,595 --> 00:05:01,015 Sara Dong: So I thought what we could do is talk a little bit about the letters that have multiple things associated with them. 45 00:05:01,585 --> 00:05:04,995 Uh, so going through this or, or going from TORCH to SCORTCH. 46 00:05:05,195 --> 00:05:08,995 In SCORTCH, the S being syphilis, which you've mentioned briefly. 47 00:05:09,355 --> 00:05:11,335 C is still CMV. 48 00:05:11,555 --> 00:05:12,835 O is other. 49 00:05:13,265 --> 00:05:16,640 R is still rubella and T is still toxoplasmosis. 50 00:05:16,940 --> 00:05:21,350 The second C is chicken pox or varicella zoster virus. 51 00:05:21,620 --> 00:05:28,740 And then finally H which is really another catchall of more than just the HSV that is listed in TORCH. 52 00:05:29,180 --> 00:05:38,330 And so I was wondering if maybe you could tell everyone a little bit about what you put in this O bucket and H bucket within the SCORTCH acronym. 53 00:05:38,540 --> 00:05:39,240 Justin Penner: Yeah, of course. 54 00:05:39,600 --> 00:05:48,510 So as you mentioned Sara, the O is kind of a catch-all for things that exist currently that we know of, but also perhaps where we can put things that come in the future. 55 00:05:48,510 --> 00:05:52,865 So right now, what we've included in our O is malaria. 56 00:05:52,955 --> 00:06:05,665 Um, I know that again, talking about a globalized world, we see people traveling much more often now, and we do know that the malaria parasites have a predilection for the placenta and crossing the placenta. 57 00:06:06,175 --> 00:06:08,605 So it was something certainly we need to think of. 58 00:06:08,815 --> 00:06:19,344 Similarly in South America, Chagas disease or American trypanosomiasis is something that we need to think about, not just in that location itself, but in travelers or in migrants from those areas. 59 00:06:19,804 --> 00:06:27,944 And for example, where I did my pediatrics training in central Canada, in the prairies where, you know, you don't think of Chagas. 60 00:06:27,964 --> 00:06:31,834 Actually we had a, quite a large migrant population from South America. 61 00:06:32,284 --> 00:06:36,904 So it is something certainly that we need to keep in our heads in all locations. 62 00:06:37,764 --> 00:06:41,634 Other things in the O that we need to think about our arboviruses. 63 00:06:41,634 --> 00:06:46,734 So the most common one that we think of is the one that I mentioned already, which is Zika virus. 64 00:06:46,764 --> 00:06:51,324 But I think the jury is out whether or not some of the other arboviruses like dengue. 65 00:06:51,604 --> 00:07:01,464 There's certainly been case reports of dengue causing a, uh, kind of congenital syndrome, whether or not any of those will cause further issues from a congenital perspective in the future. 66 00:07:02,064 --> 00:07:06,264 Now there's other things that I didn't include in the O, but probably could have been. 67 00:07:06,264 --> 00:07:08,784 For example, congenital tuberculosis. 68 00:07:08,814 --> 00:07:19,989 I mean, it's not something that we think of terribly often, but it's certainly something that we see in, uh, particularly in, in hyper endemic areas. 69 00:07:20,049 --> 00:07:30,199 Um, so, you know, thinking broadly and thinking of that, especially in, in, in mums who have active tuberculosis or tuberculosis of the gynecological tract. 70 00:07:30,269 --> 00:07:45,734 The other one that we included, uh, here is parvovirus and, you know, parvovirus classically we think about with, you know, the very edematous uh, hydropic baby, which didn't really have its place in the traditional TORCH mnemonic. 71 00:07:46,184 --> 00:07:56,024 And lastly, and I think this is something that's probably been on our radar radar a little bit more lately, I think is enterovirus and kind of an enterovirus syndrome. 72 00:07:56,324 --> 00:08:14,624 We certainly see babies with kind of a traditional septic like picture or, uh, uh, hepatitis or, you know, even babies that present in kind of similar terms to a congenital HLH like picture, which is certainly something that enterovirus can present like. 73 00:08:14,894 --> 00:08:23,264 Which is very different than what we think of traditionally enterovirus presenting like in older children, uh, so just things to keep on our radar and I'm sure there'll be more to come. 74 00:08:23,534 --> 00:08:30,584 The other kind of catch all that we had in our mnemonic was the H, as you mentioned Sara. 75 00:08:30,604 --> 00:08:44,784 And, um, that was because we really didn't want to forget the viruses or the infections that didn't have the kind of traditional congenital syndrome, but either can come along with, uh, other infections. 76 00:08:44,784 --> 00:08:48,904 So in particular, the sexually transmitted infections, the blood-borne viruses. 77 00:08:48,904 --> 00:08:52,474 It's certainly something that we never want to forget about, co-infections. 78 00:08:53,284 --> 00:09:04,599 Now what we know in ID in general is that, um, certain behaviors or certain high-risk behaviors or certain exposures don't just predispose you to one thing, but certainly predispose you to more than one thing. 79 00:09:04,599 --> 00:09:10,420 And we do know that STIs travel in packs and bloodborne viruses tend to coincide with each other. 80 00:09:10,689 --> 00:09:18,069 And it would just be a shame to miss a concurrent infections, which is why we included those in our H part of the mnemonic. 81 00:09:18,069 --> 00:09:20,680 So the H stands for HIV. 82 00:09:20,800 --> 00:09:28,329 And certainly we now in this day and age have many tools available to us to prevent vertical transmission of HIV. 83 00:09:28,329 --> 00:09:30,339 So really in my mind, it's a never event. 84 00:09:30,339 --> 00:09:35,959 So it's something that I really wanted to stress in the, uh, SCORTCH mnemonic. 85 00:09:36,464 --> 00:09:39,254 And in similar terms, the viral hepatitises. 86 00:09:39,254 --> 00:09:55,830 So hepatitis B and hepatitis C, so unfortunately, we don't have any preventatives for hepatitis C, but certainly something that is important to know in mums for future pregnancies, because now we have eradication treatments that can be offered post-pregnancy and certainly for screening in the fetus. 87 00:09:56,250 --> 00:09:59,370 But hepatitis B, we do have, um, preventative measures that we can take. 88 00:09:59,370 --> 00:10:03,540 So we just felt, it was really important to, to bring people's attention to that. 89 00:10:03,720 --> 00:10:18,370 HSV is in the H as well, which is the classic TORCH infection, which I also wanted to kind of stress in our algorithms and our diagnostic algorithms that really HSV from a congenital perspective can manifest in several kind of different ways as well. 90 00:10:18,370 --> 00:10:20,440 So not to, to forget about that. 91 00:10:20,530 --> 00:10:31,180 And that is really dependent on when the mother and the fetus or baby is exposed to HSV, whether or not it's early in utero and you really have a congenital HSV syndrome. 92 00:10:31,510 --> 00:10:39,940 Or whether or not it's perinatally, and that's what we kind of traditionally think of with the septic baby or the baby with vesicular lesions or HSV meningitis. 93 00:10:40,030 --> 00:10:48,330 And last but not least, probably something that's not on most people's radar, but certainly is becoming more recognized is HTLV-1. 94 00:10:48,930 --> 00:10:57,280 And again, something that doesn't have a traditional congenital infection syndrome, but certainly is something that we would like to be aware of. 95 00:10:57,280 --> 00:11:05,140 So these are, you know, mums that perhaps have presented previously with a particular types of malignancies that we would want to screen for. 96 00:11:05,140 --> 00:11:14,665 And, and the reason for this, because we don't have any particular treatment for the children per se, but it would be one indication that we would not want the mum to breastfeed. 97 00:11:14,695 --> 00:11:16,465 So it's something that we should keep in mind. 98 00:11:17,215 --> 00:11:17,665 Sara Dong: Yeah. 99 00:11:17,695 --> 00:11:36,955 And what I think is also emphasized in the episodes that are coming up is, um, well I think the way that TORCH infections are generally taught to us suggests "here's this baby with this very clear syndrome", such as, you know, blueberry muffin rash, and then you'll check their serology and it will clearly say yes or no, this baby is infected. 100 00:11:36,985 --> 00:11:42,505 And I think we all know that it's so much more complicated and complex than that. 101 00:11:42,505 --> 00:11:49,090 And, or maybe often you're called that a neonate is asymptomatic, but their mom has some sort of incomplete blood work. 102 00:11:49,270 --> 00:11:58,450 And so in addition to these often difficult to interpret serologies when we have them, we also need to remember to incorporate all these other newer tools and modalities that we have. 103 00:11:58,660 --> 00:12:14,275 And so I hope that this series can emphasize, you know, thinking or, or moving out of that space of how we learned it, and considering these patients as we see them more broadly, um, you know, a lot of times it might just be that they have undifferentiated sepsis of some kind. 104 00:12:14,365 --> 00:12:17,335 But, that's actually all I had for today. 105 00:12:17,725 --> 00:12:21,925 Uh, Justin, are there any other thoughts or things you want to share before we wrap up? 106 00:12:22,135 --> 00:12:33,505 Justin Penner: Uh, yeah, just, I, like you said, Sara, the one really important thing I want everyone to take out of this series is that the congenital infections, when they present clinically, they don't always present like you read in textbooks. 107 00:12:33,565 --> 00:12:45,365 And although we think of, you know, the classic, for example, congenital toxoplasmosis child with large head and hydrocephalus and the CMV child with microcephaly and features associated with that. 108 00:12:45,605 --> 00:12:48,845 Actually there's a lot of overlap in a lot of them. 109 00:12:48,875 --> 00:12:56,315 And I think when we learn it in medical school, we think of, oh, if we have these certain features, we should test them for this one disease. 110 00:12:56,365 --> 00:12:56,535 Sara Dong: Yeah. 111 00:12:56,695 --> 00:13:01,275 Justin Penner: And really actually all the features tend to muddle together. 112 00:13:01,665 --> 00:13:05,415 And when we think of one, we should really be thinking of all of them. 113 00:13:05,745 --> 00:13:06,175 Sara Dong: Yeah. 114 00:13:06,385 --> 00:13:14,040 Justin Penner: And not pigeonholing ourselves into just testing for one thing, because that's when we risk missing other things. 115 00:13:14,640 --> 00:13:23,100 Secondly, from a diagnostic perspective, like I mentioned before, and like Sara had mentioned with, with serology, I think we've moved much past that. 116 00:13:23,130 --> 00:13:32,940 And what we need to remember with congenital infections is that really it's a multiorgan disease for the most part, for most of the congenital infections. 117 00:13:32,970 --> 00:13:37,410 And, and thinking just beyond serology and beyond blood tests as well. 118 00:13:37,410 --> 00:13:39,390 So thinking of all the organs that could be infected. 119 00:13:39,390 --> 00:14:05,090 So this includes thinking of involving our ophthalmology colleagues to look in the eye, involving our audiology colleagues to make sure that the children aren't deaf, uh, making sure that we are ordering appropriate head imaging to see if there are any changes in the brain, whether or not that's polymicrogyria, or inflammatory neuronal lesions, looking at, you know, musculoskeletal abnormalities with x-rays. 120 00:14:05,140 --> 00:14:08,955 All of these kinds of things are really important, in addition to the blood test that you're going to do. 121 00:14:09,395 --> 00:14:16,685 I think what we sometimes forget is the importance of the placenta itself and what sort of diagnostic value that has. 122 00:14:16,685 --> 00:14:22,775 I think too often, the placenta is just thrown out and I think there's a lot we can learn from that. 123 00:14:22,865 --> 00:14:32,380 And again, going back to that interesting dynamic between the fetal placental interface is I think not quite understood as much as it could be. 124 00:14:32,920 --> 00:14:36,950 And having those sort of specimens are very, very useful. 125 00:14:37,100 --> 00:14:45,470 Um, and then molecular diagnostics are also advancing so rapidly that we, we must consider that, uh, as well. 126 00:14:45,550 --> 00:14:56,645 And I guess last but not least, I really, really wanted to stress and I hope this, the series of episodes do that and stress this-- is the importance of real multidisciplinary collaboration. 127 00:14:57,305 --> 00:15:07,865 You know, involving people and colleagues from elsewhere that are really experts in their field and understanding things from other people and putting our brains together. 128 00:15:07,925 --> 00:15:29,840 And I'm hopeful that, you know, we've brought together some international colleagues who will exemplify that, but also from a research perspective, increasing those collaborations for larger databases and larger randomized controlled trials, because we truly don't understand these diseases as much as we could, or as much as we should. 129 00:15:30,140 --> 00:15:42,540 And, from a treatment perspective, could really learn a lot about both short, medium and long-term effects of the treatments that we currently have and how good they do work, uh, or don't work. 130 00:15:42,730 --> 00:15:46,630 But also, developmental outcomes and audiological outcomes. 131 00:15:46,630 --> 00:15:59,380 There's so much that we could learn if we all kind of put our expertise together and, uh, create kind of larger databases because these in, in essence are quite rare disease in isolation. 132 00:15:59,410 --> 00:15:59,650 Sara Dong: Yeah. 133 00:15:59,980 --> 00:16:03,400 Justin Penner: But, uh, certainly warrant further study, further discussion. 134 00:16:03,610 --> 00:16:05,380 Sara Dong: Well, thank you so much for coming. 135 00:16:05,500 --> 00:16:09,160 Uh, we'll have all the listeners tune in next week to get us started with the series. 136 00:16:09,375 --> 00:16:10,275 Justin Penner: Thanks so much, Sara. 137 00:16:10,995 --> 00:16:12,135 Sara Dong: All right, everyone. 138 00:16:12,135 --> 00:16:13,865 So next week I'll be joined by Dr. 139 00:16:13,865 --> 00:16:15,795 Nuria Sanchez-Clemente and Dr. 140 00:16:15,795 --> 00:16:18,855 Hermione Lyall from London with our very first case. 141 00:16:18,915 --> 00:16:22,955 As always, you can find Febrile on Twitter or the website febrilepodcast.com. 142 00:16:23,325 --> 00:16:27,945 You can find the link to Justin's SCORTCH paper we were discussing on the Consult Notes for this episode. 143 00:16:28,095 --> 00:16:28,905 Thanks for listening. 144 00:16:28,935 --> 00:16:30,705 Stay safe, and I'll see you next week.