A 1-day-old boy is admitted to the neonatal intensive care unit due to microcephaly. Microcephaly and ventriculomegaly were first seen during an antenatal sonogram at 20 weeks gestation. Follow-up ultrasounds revealed progressive fetal growth restriction for which a cesarean delivery was performed at 35 weeks gestation. The mother is a 28-year-old woman, gravida 3 para 3, who is healthy and took prenatal vitamins. The infant's 2 siblings, age 18 months and 4 years, are healthy. Weight and length are at the 5th percentile, and head circumference is

Question

A 1-day-old boy is admitted to the neonatal intensive care unit due to microcephaly. Microcephaly and ventriculomegaly were first seen during an antenatal sonogram at 20 weeks gestation. Follow-up ultrasounds revealed progressive fetal growth restriction for which a cesarean delivery was performed at 35 weeks gestation. The mother is a 28-year-old woman, gravida 3 para 3, who is healthy and took prenatal vitamins. The infant's 2 siblings, age 18 months and 4 years, are healthy. Weight and length are at the 5th percentile, and head circumference is <3rd percentile. Temperature is 37.2 C (99 F), and the remaining vital signs are normal. Physical examination shows a jaundiced infant who is small for gestational age. The lungs are clear to auscultation, and no murmurs are audible. The liver edge is palpable at the level of the umbilicus. Platelet count is 25,000/mm³. CT scan of the head is shown below. The most likely source of congenital infection is maternal exposure to which of the following?

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11ec25c8_d6b6_be86_bc81_217e4afbc753_MD0003_00 This infant has microcephaly with periventricular calcifications on CT scan, features suggestive of congenital cytomegalovirus (CMV). CMV infection is common in children age 1-4 (particularly those who attend day care), and pregnant women typically acquire CMV through contact with body fluids (eg, urine, saliva) of infected children. Maternal infection is often asymptomatic but may present as a nonspecific, mild viral illness. CMV is then transmitted vertically from mother to fetus via placental transfer. Early (ie, first trimester) primary maternal infection is associated with higher infant morbidity as compared with recurrent maternal infection or infection late in pregnancy. Although most infected neonates are asymptomatic at birth, microcephaly with periventricular calcifications and ventriculomegaly (as seen in this patient) is highly suspicious for congenital CMV. Other clinical features include intrauterine growth restriction, hepatosplenomegaly, jaundice, and thrombocytopenia. In addition, sensorineural hearing loss is a common sequela that can occur in the presence or absence of other symptoms. Diagnosis is typically confirmed with PCR by detection of CMV in the urine or saliva. periventricular calcifications (Choices A and D) Toxoplasmosis can be transmitted via exposure to cat feces, either directly (eg, kitty litter) or indirectly (eg, unwashed, soil-contaminated fruits and vegetables). Transmission can also occur via consumption of undercooked meat from infected animals. Congenital toxoplasmosis commonly presents with hydrocephalus and diffuse parenchymal calcifications rather than periventricular calcifications. (Choice B) Congenital syphilis results from maternal Treponema pallidum infection, which is most commonly transmitted via sexual contact with a genital lesion of an infected individual. Infants with congenital syphilis can have bone lesions, growth restriction, petechiae, and jaundice but do not have microcephaly or calcifications. (Choice C) Zika virus is transmitted through the bite of an infected mosquito. Congenital infection can cause microcephaly and intracerebral (not periventricular) calcifications. Hepatosplenomegaly is not associated with congenital Zika virus infection. Educational objective: Characteristic features of congenital cytomegalovirus (CMV) infection include microcephaly and periventricular calcifications. Pregnant women most commonly acquire CMV through contact with infected body fluids (eg, saliva) and transmit the infection vertically to the fetus via placental transfer. References: Cytomegalovirus infection. (http://www.ncbi.nlm.nih.gov/pubmed/22474112) Prevention of maternal and congenital cytomegalovirus infection. (http://www.ncbi.nlm.nih.gov/pubmed/22510635)

A 1-Day-Old Boy Is Admitted to the Neonatal Intensive Care