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CMV

CMV. Patricia Wang, R1 11/15/13. Cytomegalovirus. Most common perinatal viral infection in developed countries Infects nearly 1% of all newborns Leading cause of mental retardation and sensorineural hearing loss and an important cause of cerebral palsy and retinal damage

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CMV

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  1. CMV Patricia Wang, R1 11/15/13

  2. Cytomegalovirus • Most common perinatal viral infection in developed countries • Infects nearly 1% of all newborns • Leading cause of mental retardation and sensorineural hearing loss and an important cause of cerebral palsy and retinal damage • Member of human herpesvirus family • Large, linear, double-stranded DNA • Infects many cell types • fibroblasts, epithelial cells, endothelial cells, macrophages, myocytes • Incubation 1-2 m

  3. Epidemiology • CMV seroprevalence is ∼50% • CMVs shed in urine for 6-40 months in younger children vs several weeks in healthy adults

  4. Risk factors • Shedding of CMV in toddlers in child care centers can be as high as 70% • Lower economic status • Immunocompromised individuals or transplant recipients with immunosuppressive therapy

  5. Transmission • Via body fluids • Ie urine, tears, saliva, genital secretions, transplanted organs • Transplacental • Infected leukocytes cross placenta in maternal viremia • Higher risk in primary maternal CMV infection (40%) • In utero transmission via genital secretions • Shedding in child care centers by toddlers with CMV (70%) • Exposure to human-infected milk, blood products, or transplanted organs • Reduce risk with pasteurized human milk, leuko-reduced blood products, and blood from CMV-negative donors

  6. Signs and symptoms of congenital CMV • 90% asymptomatic at birth • 10% symptomatic • Jaundice, heptosplenomegaly, prematurity, microcephaly, thrombocytopenia, intrauterine growth restriction, skin manifestations, poly- or oligohydramnios, pereiventricular calcifications, seizures, spasticity, developmental delay, progressive sensorineural hearling loss (30%), eye manifestations like chorioretinitis, microphthalmia, strabismus, optic nerve atrophy, and cortical visual impairment

  7. Diagnosis of mother • Symptoms • Resemble flu-like illness • Fever, pharyngitis • CDC doesn’t recommend routine maternal screening for CMV infection • No single test can rule out primary CMV infection during pregnancy

  8. Mother with primary infection • No treatment is recommended in healthy pregnant women • Vaccines for preventing CMV infection still in the research and development stage

  9. Screening • Routine testing during pregnancy not indicated • Most transplacental infections don’t result in symptomatic CMV • Most common complication (SNHL)- in infants born to mother with secondary CMV

  10. Prevention of transmission of CMV • Contact with the saliva or urine of young children- major cause of CMV infection among pregnant women. • Wash hands often with soap and water for 15-20 seconds • Follow standard handwashing procedures after contact with body fluids, such as urine and saliva, that could contain CMV • Clean surfaces that come into contact with children’s urine or saliva

  11. Diagnosis of infant • Via PCR or viral culture of CMV from urine, throat swab, or saliva • Detection within first 3 weeks for congenital CMV • Antibody titers • IgM- can be detectable when newly infected, infected in past but recent re-exposed to CMV, undergoing reactivation of CMV infection that was acquired in the past, or false-positive test • Cannot be used to diagnose congenital CMV • IgG avidity • Low-avidity IgGvs high-avidity • Not available commercially widely in US yet

  12. Evaluation and treatment of infant • No antiviral treatment approved • Phase II randomized trial with ganciclovir vs no treatment suggest benefit • Randomized to 6 weeks of IV ganciclovir or no treatment, checked hearing outcome • Toxicity of ganciclovir • Neutropenia in 65% • Evaluate ears, eyes, CNS

  13. Treatment

  14. References • CDC • Cytomegalovirus Infection Erin J. Plosa,, Jennifer C. Esbenshade, M. Paige Fuller, Joörn-Hendrik Weitkamp. Pediatrics in Review 2012; 33:156-163; doi:10.1542/pir.33-4-156 • Cytomegalovirus Infection Robert F. Pass. Pediatrics in Review 2002; 23:163-170; doi:10.1542/pir.23-5-163 • EFFECT OF GANCICLOVIR THERAPY ON HEARING IN SYMPTOMATIC CONGENITAL CYTOMEGALOVIRUS DISEASE INVOLVING THE CENTRAL NERVOUS SYSTEM: A RANDOMIZED, CONTROLLED TRIAL. J PEDIATR. 2003 JUL;143(1):16-25.

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