Congenital cytomegalovirus infection

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Congenital cytomegalovirus infection
CMV placentitis1 mini.jpg
Micrograph of a cytomegalovirus (CMV) infection of the placenta (CMV placentitis). The characteristic large nucleus of a CMV infected cell is seen off-centre at the bottom-right of the image. H&E stain
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Congenital cytomegalovirus (cCMV) is cytomegalovirus (CMV) infection in a newborn baby. [1] Most have no symptoms. [1] Some affected babies are small. [1] Other signs and symptoms include a rash, jaundice, hepatomegaly, retinitis, and seizures. [1] [2] It may lead to loss of hearing or vision, developmental disability, or a small head. [1]

Contents

CMV is a member of the virus family herpesviridae and is the most common congenital intrauterine infection. [3] cCMV is caused when a mother is infected with CMV in pregnancy and passes it to her unborn baby. [1] The risk of severe disease is greatest if the mother is infected in early pregnancy; most have no symptoms. [2] Diagnosis is by tests in the first 3-weeks after birth; on preferably urine, although saliva and blood can be used. [1] [2] The chance of infection is reduced by hand washing, and avoiding touching saliva or urine of very young children. [1]

Worldwide the condition is common, and likely underreported. [4]

Presentation

For infants who are infected by their mothers before birth, two potential adverse scenarios exist:

These risks appear to be almost exclusively associated with women who previously have not been infected with CMV and who are having their first infection with the virus during pregnancy. There appears to be little risk of CMV-related complications for women who have been infected at least 6 months prior to conception. For this group, which makes up 50% to 80% of the women of child-bearing age, the rate of newborn CMV infection is 1%, and these infants appear to have no significant illness or abnormalities. [6]

The virus can also be transmitted to the infant at delivery from contact with genital secretions or later in infancy through breast milk. However, these infections usually result in little or no clinical illness in the infant. CMV can also be transferred through blood transfusions and close contact with large groups of children. [7]

To summarise, during a pregnancy when a woman who has never had CMV infection becomes infected with CMV, there is a risk that after birth the infant may have CMV-related complications, the most common of which are associated with hearing loss, visual impairment, or diminished mental and motor capabilities. On the other hand, healthy infants and children who acquire CMV after birth have few, if any, symptoms or complications. However, infants born preterm and infected with CMV after birth (especially via breastmilk [8] ) may experience cognitive and motor impairments later in life. [9] [10]

Symptoms associated with CMV, such as hearing loss, can result in further developmental delay. A delay in general speech and language development is more common in children with CMV. [11] Children with symptomatic CMV have been found to have a greater incidence of long-term neurological and neurodevelopmental complications than children with fetal alcohol syndrome or down syndrome. [7]

Congenital cytomegalovirus infection can be an important cause of intraventricular hemorrhage and neonatal encephalopathy. [12]

Diagnosis

CMV Testing

People infected with CMV develop antibodies to it, initially IgM later IgG indicating current infection and immunity respectively. The virus can be diagnosed through viral isolation, or using blood, urine, or saliva samples. [3]

When infected with CMV, most women have no symptoms, but some may have symptoms resembling mononucleosis. Women who develop a mononucleosis-like illness during pregnancy should consult their medical provider.[ citation needed ]

The Centers for Disease Control and Prevention (CDC) does not recommend routine maternal screening for CMV infection during pregnancy because there is no test that can definitively rule out primary CMV infection during pregnancy. Women who are concerned about CMV infection during pregnancy should practice CMV prevention measures. Considering that the CMV virus is present in saliva, urine, tears, blood, mucus, and other bodily fluids, frequent hand washing with soap and water is important after contact with diapers or oral secretions, especially with a child who is in daycare or interacting with other young children on a regular basis.[ citation needed ]

A diagnosis of congenital CMV infection can be made if the virus is found in an infant's urine, saliva, blood, or other body tissues during the first week after birth. Antibody tests cannot be used to diagnose congenital CMV; a diagnosis can only be made if the virus is detected during the first week of life. Congenital CMV cannot be diagnosed if the infant is tested more than one week after birth.[ citation needed ]

Visually healthy infants are not routinely tested for CMV infection although only 10–20% will show signs of infection at birth[ citation needed ] though up to 80% may go onto show signs of prenatal infection in later life. If a pregnant woman finds out that she has become infected with CMV for the first time during her pregnancy, she should have her infant tested for CMV as soon as possible after birth.[ citation needed ]

Treatment for CMV infection should start at 1 month of age and should occur for 6 months. The options for treatment are intravenous ganciclovir and oral valganciclovir. After diagnosis, it is important to further investigate any possible evidence of end-organ disease and symptoms through blood tests, imaging, ophthalmology tests, and hearing tests. [5]

Prevention

Recommendations for pregnant women with regard to CMV infection:[ citation needed ]

Treatment with hyperimmune globulin in mothers with primary CMV infection has been shown to be effective in preventing congenital disease in several studies. [13] [14] [15] [16] One study did not show significant decrease in the risk of congenital cytomegalovirus infection. [17]

Childcare

Most healthy people working with infants and children face no special risk from CMV infection. However, for women of child-bearing age who previously have not been infected with CMV, there is a potential risk to the developing unborn child (the risk is described above in the Pregnancy section). Contact with children who are in day care, where CMV infection is commonly transmitted among young children (particularly toddlers), may be a source of exposure to CMV. Since CMV is transmitted through contact with infected body fluids, including urine and saliva, child care providers (meaning day care workers, special education teachers, as well as mothers) should be educated about the risks of CMV infection and the precautions they can take. [18] Day care workers appear to be at a greater risk than hospital and other health care providers, and this may be due in part to the increased emphasis on personal hygiene in the health care setting.[ citation needed ]

Recommendations for individuals providing care for infants and children:

Epidemiology

Worldwide, approximately 1 in 100 to 500 babies are born with congenital CMV. Approximately 1 in 3000 will show symptoms and 1 in 7000 will die. [19] Congenital HCMV infection occurs when the mother has a primary infection (or reactivation) during pregnancy. Due to the lower seroprevalence of HCMV in industrialized countries and higher socioeconomic groups, congenital infections are actually less common in poorer communities, where more women of child-bearing age are already seropositive. In industrialized countries up to 8% of HCMV seronegative mothers contract primary HCMV infection during pregnancy, of which roughly 50% will transmit to the fetus. [20] Between 10 and 15% of infected fetuses are then born with symptoms, [5] which may include pneumonia, gastrointestinal, retinal and neurological disease. [21] [22] 10-15% of asymptomatic babies will develop long term neurological effects. SNHL is found in 35% of children with CMV, cognitive deficits have been found in 66% of children with CMV, and death occurs in 4% of children. [3] HCMV infection occurs in roughly 1% of all neonates with those who are not congenitally infected contracting the infection possibly through breast milk. [23] [24] [25] Other sources of neonatal infection are bodily fluids which are known to contain high titres in shedding individuals: saliva (<107copies/ml) and urine (<105copies/ml ) [26] [27] seem common routes of transmission.

The incidence of primary CMV infection in pregnant women in the United States varies from 1% to 3%. Healthy pregnant women are not at special risk for disease from CMV infection. When infected with CMV, most women have no symptoms and very few have a disease resembling infectious mononucleosis. It is their developing fetuses that may be at risk for congenital CMV disease. CMV remains the most important cause of congenital viral infection in the United States. HCMV is the most common cause of congenital infection in humans and intrauterine primary infections are more common than other well-known infections and syndromes, including Down Syndrome, Fetal Alcohol Syndrome, Spina Bifida, and Pediatric HIV/AIDS.[ citation needed ]

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References

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  3. 1 2 3 4 Dobbie, Allison M. (2017). "Evaluation and management of cytomegalovirus-associated congenital hearing loss". Current Opinion in Otolaryngology & Head and Neck Surgery. 25 (5): 390–395. doi:10.1097/moo.0000000000000401. ISSN   1068-9508. PMID   28857892.
  4. ↑ Ssentongo, P; Hehnly, C; Birungi, P; Roach, MA; Spady, J; Fronterre, C; Wang, M; Murray-Kolb, LE; Al-Shaar, L; Chinchilli, VM; Broach, JR; Ericson, JE; Schiff, SJ (2 August 2021). "Congenital Cytomegalovirus Infection Burden and Epidemiologic Risk Factors in Countries With Universal Screening: A Systematic Review and Meta-analysis". JAMA Network Open. 4 (8): e2120736. doi:10.1001/jamanetworkopen.2021.20736. PMC   8383138 . PMID   34424308.
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  8. ↑ Maschmann, J.; Hamprecht, K.; Dietz, K.; Jahn, G.; Speer, C. P. (2001). "Cytomegalovirus Infection of Extremely Low—Birth Weight Infants via Breast Milk". Clinical Infectious Diseases. 33 (12): 1998–2003. doi: 10.1086/324345 . PMID   11712092.
  9. ↑ Brecht, K; Goelz, R; Bevot, A; Krägeloh- Mann, I; Wilke, M; Lidzba, K (2015). "Postnatal Human Cytomegalovirus Infection in Preterm Infants Has Long-Term Neuropsychological Sequelae". The Journal of Pediatrics. 166 (4): 834–9.e1. doi:10.1016/j.jpeds.2014.11.002. PMID   25466679.
  10. ↑ Bevot, Andrea; Hamprecht, Klaus; Krägeloh-Mann, Ingeborg; Brosch, Sibylle; Goelz, Rangmar; Vollmer, Brigitte (1 April 2012). "Long-term outcome in preterm children with human cytomegalovirus infection transmitted via breast milk". Acta Paediatrica. 101 (4): e167–e172. doi:10.1111/j.1651-2227.2011.02538.x. PMID   22111513. S2CID   29018739.
  11. ↑ Korndewal, Marjolein J Oudesluys-Murphy, Anne Marie Kroes, Aloys C M Vossen, Ann C T M de Melker, Hester E (December 2017). "Congenital Cytomegalovirus Infection: Child Development, Quality of Life and Impact on Daily Life". The Pediatric Infectious Disease Journal. 36 (12): 1141–1147. doi:10.1097/INF.0000000000001663. OCLC   1018138960. PMID   28650934. S2CID   20122101.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  12. ↑ Suksumek, N; Scott, JN; Chadha, R; Yusuf, K (July 2013). "Intraventricular hemorrhage and multiple intracranial cysts associated with congenital cytomegalovirus infection". Journal of Clinical Microbiology. 51 (7): 2466–8. doi:10.1128/JCM.00842-13. PMC   3697656 . PMID   23678057.
  13. ↑ Nigro, G.; Adler, S.P.; La Torre, R.; Best, A.M. (2005). "Passive immunization during pregnancy for congenital cytomegalovirus infection". N. Engl. J. Med. 353 (13): 1350–1362. doi: 10.1056/nejmoa043337 . PMID   16192480.
  14. ↑ Visentin, S.; Manara, R.; Milanese, L.; Da Roit, A.; Salviato, E.; Citton, V.; Magno, F.M.; Morando, C. (2012). "Early primary cytomegalovirus infection in pregnancy: maternal hyperimmunoglobulin therapy improves outcomes among infants at 1 year of age". Clin Infect Dis. 55 (4): 497–503. doi: 10.1093/cid/cis423 . PMID   22539662.
  15. ↑ Nigro, G.; Adler, S.P.; Parruti, G.; Anceschi, M.M.; Coclite, E.; pezone, I.; Di Renzo, G.C. (2012). "Immunoglobulin therapy of fetal cytomegalovirus infection occurring in the first half of pregnancy--a case-control study of the outcome in children". J Infect Dis. 205 (2): 215–227. doi: 10.1093/infdis/jir718 . PMID   22140265.
  16. ↑ Buxmann, H.; Stackelberg, O.M.; Schlosser, R.L.; Enders, G.; Gonser, M.; Meyer-Wittkopf, M.; Hamprecht, K.; Enders, M. (2012). "Use of cytomegalovirus hyperimmunoglobulin for prevention of congenital cytomegalovirus disease: a retrospective analysis". J Perinat Med. 40 (4): 439–446. doi: 10.1515/jpm-2011-0257 . PMID   22752777.
  17. ↑ Revello, M. G.; Lazzarotto, T.; Guerra, B.; Spinillo, A.; Ferrazzi, E.; Kustermann, A.; Guaschino, S.; Vergani, P.; Todros, T.; Frusca, T.; Arossa, A.; Furione, M.; Rognoni, V.; Rizzo, Nicola; Gabrielli, Liliana; Klersy, Catherine; Gerna, G. (2014). "A Randomized Trial of Hyperimmune Globulin to Prevent Congenital Cytomegalovirus" (PDF). N Engl J Med. 370 (14): 1316–1326. doi:10.1056/NEJMoa1310214. hdl: 2434/262989 . ISSN   0028-4793. PMID   24693891.
  18. ↑ Pickering, Larry; Baker, Carol; Kimberlin, David; Long, Sarah (2012). 2012 Report of the Committee on Infectious Diseases (PDF) (29 ed.). Elk Grove Village, IL: American Academy of Pediatrics. p. 145. ISBN   978-1-58110-703-6 . Retrieved 20 November 2016.
  19. ↑ Butler, Declan (5 July 2016). "Zika raises profile of more common birth-defect virus". Nature . 535 (17): 17. Bibcode:2016Natur.535...17B. doi: 10.1038/535017a . PMID   27383962.
  20. ↑ Adler, Stuart P. (December 2005). "Congenital Cytomegalovirus Screening". The Pediatric Infectious Disease Journal. 24 (12): 1105–1106. doi:10.1097/00006454-200512000-00016. PMID   16371874.
  21. ↑ Barry Schoub; Zuckerman, Arie J.; Banatvala, Jangu E.; Griffiths, Paul E. (2004). "Chapter 2C Cytomegalovirus". Principles and Practice of Clinical Virology . Chichester: John Wiley & Sons. pp.  85–122. ISBN   978-0-470-84338-3.
  22. ↑ Vancíková Z, Dvorák P (2001). "Cytomegalovirus infection in immunocompetent and immunocompromised individuals--a review". Curr. Drug Targets Immune Endocr. Metabol. Disord. 1 (2): 179–87. doi:10.2174/1568008013341334. PMID   12476798.
  23. ↑ Kerrey BT, Morrow A, Geraghty S, Huey N, Sapsford A, Schleiss MR (2006). "Breast milk as a source for acquisition of cytomegalovirus (HCMV) in a premature infant with sepsis syndrome: detection by real-time PCR". J. Clin. Virol. 35 (3): 313–6. doi:10.1016/j.jcv.2005.09.013. PMID   16300992.
  24. ↑ Schleiss MR; Dror, Yigal (2006). "Role of breast milk in acquisition of cytomegalovirus infection: recent advances". Curr. Opin. Pediatr. 18 (1): 48–52. doi:10.1097/01.mop.0000192520.48411.fa. PMID   16470162. S2CID   37437573.
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  27. ↑ Yoshikawa T, Ihira M, Taguchi H, Yoshida S, Asano Y (2005). "Analysis of shedding of 3 beta-herpesviruses in saliva from patients with connective tissue diseases". J. Infect. Dis. 192 (9): 1530–6. doi: 10.1086/496890 . PMID   16206067.
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