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Cytomegalovirus (CMV) infection in

newborn infants and immunocompromised


patients
Rozlia Pusztai M.D., Ph.D.
Department of Medical Microbiology and Immunobiology,
Faculty of Medicine, University of Szeged,
Szeged, Hungary

4th ESCMID School, Clin Microbiol Infect Dis, Szeged, Hungary, 2005

Human herpesviruses
Herpesviridae
Betaherpesvirinae
human cytomegalovirus (HCMV)
or human herpesvirus 5 (HHV5)
large number of genetic
variants

HCMV epidemiology, 1
Humans are the only reservoir for human CMV
Sources of infection: oropharyngeal secretions, urine,
cervical and vaginal secretions, semen, breast milk,
tears, feces and blood
Transmission occurs by
hand to mouth contact with infected body fluids
sexual contact
blood transfusion
organ or bone marrow transplants
from infected pregnant women to the fetus or newborn
breastfeeding

HCMV epidemiology, 2
Up to 60% of children become infected before the age
of 14 years
The prevalence in adults varies widely (40-100%) and
is dependent on the geography and the socioeconomic
status of the population
Intermittant shedding of CMV from many sites is
common in seropositive hosts
Virus excretion may last for years in congenital,
perinatal and early postnatally infected hosts

Seroepidemiology of HCMV

Seroprevalence of HCMV infection by age


and sexual orientation in San Francisco

Adapted from: consensus form on CMV prevention. Triclinica, 1995

Clinical findings
Normal host
Primary infection in the normal host usually results in
mononucleosis (about 8% of infectious mononucleosis cases)
Rare complications include pneumonia, hepatitis and
CNS disease
In children <7 years of age, CMV infection may result in
severe liver or respiratory disease
Infection induces both a humoral (IgM, IgG and IgA) and
a cell mediated immune (CMI) response
Recurrent infection is rare in the normal host, but common in
the immunocompromised

People at increased risk of active CMV


infection and serious complications
Babies born to women who have a first-time CMV
infection during pregnancy
Pregnant women who work with infants and children
Persons with weakened immune systems, including
organ or bone marrow transplant recipients
persons with HIV infection
cancer patients on chemotherapy

Clinical findings
Immunocompromised host
Both the morbidity and the mortality are increased for
primary and recurrent infections in the immunocompromised
Viral excretion is more intense and prolonged with
immunosuppression, and chronic viremia may occur
The antibody response is similar in primary infection and
reactivation, but the CMI is depressed
CMV infection predisposes to fatal bacterial, fungal and
parasitic infections

Vertical transmission of CMV infection


Route

Maternal situation

Transplacental Primary gestational infection

Intrapartum

Breast milk

Rate of CMV in infant


20-40%

Seropositive before conception

0.2-2.2%

Seropositive

5%

Virus in genital tract at term

50%

Seropositive mother

25%

Virolactia

65-70%

Fields Virology, 2001

CMV infection in newborn infants


Incidence
0.5-2.2%
10-15% symptomatic
at birth
20-30% die
90% of survivors
develop sequelae

(mean 1%)
85-90% asymptomatic
at birth

5-15% develop sequelae

85-95% are normal

10% of survivors
are normal
~ 3 out of 1000 newborns suffer
from a congenital CMV infection

Epidemiology and pathogenesis of


congenital CMV infection in the USA*
Live births: 4 000 000/year
CMV infection of newborns: 40 000 (1%)

symptomatic at birth:
2 800 (7%)
fatal
survivors with
disease:
sequelae::
sequelae
340
2 200
(10%)
(90%)

asymptomatic at birth:
37 200 (93%)
survivors with
sequelae::
sequelae
5 600
(15%)

healthy
survivors:
31 200
(85%)

Fatal outcome and /or sequelae of all live births: 8140 (0.2%)
*Rothe et al., 2000

Congenital CMV infection


The rate of congenital CMV infection may be higher
Author

Country

Year

Population
infected

Infection
(%)

Women
Doyle et al.

Texas-USA 1996

HIV
AIDS

6.5
21

Congenital CMV infection and maternal


immunity
Seropositive women

Congenital
CMV infection

1.2%
(22/1828)

Women who seroconverted


during pregnancy
12.9%
(15/116)

Preconceptional maternal immunity is protective against congenital CMV


infection, decreasing the risk of infection by 91%
Stagno, 1997

Congenital CMV infection


Exogenous infection
(primary or secondary)
every
secretion

Endogenous infection

Pregnant women

Fetus

Hypothetical routes of congenital CMV


infection
Placental infection
Local reactivation
(endometrium, cervix, ovary)
Transovarian infection
Ascending infection (vaginal tract)

Transmission of CMV via the placenta and


infection of the fetus
Infected mother

Viremia

Infection of placental trophoblasts

Infection of
oropharynx
Virus in
amniotic fluid

Infection of fetal
endothelial cells

Fetal viruria

Fetal viremia
Viral replication in
target organs (kidney)

Findings in the fetus that should alert the clinician to


the possibility of intrauterine infection
Oligohydramnios or polyhydramnios
Non-immune hydrops
Fetal ascites
Intrauterine growth retardation
Microcephaly
Cerebral ventriculomegaly or hydrocephalus
Intracranial calcifications
Pleural or pericardial effusion
Hepatosplenomegaly
Intrahepatic calcifications

Primary CMV infection in pregnant


women
Symptoms
clinically inapparent (in most cases)
persistent fever, myalgia, sore throat, cervical
adenopathy, extreme fatigue (frequently)
infectious mononucleosis (uncommon)

Laboratory findings
atypical lymphocytosis
elevated hepatic transaminases
negative heterophilic antibody response

Diagnosis of maternal CMV infection

CMV-specific laboratory diagnosis

Diagnostic algorithm for CMV serology in


pregnant women
Perform sensitive CMV
IgM and IgG screening assays

M-G-

M-G+

M+G+

M+G-

Follow-up test later


No further testing
(remote infection)

Recall patient 3 weeks


later and retest
CMV IgG avidity test
M+G+ M+/-GHigh avidity
Low avidity
(remote infection)
No further
testing

Primary CMV
infection

Prenatal diagnosis at
weeks 21-23 of gestation

Follow-up
test later

Advanced CMV diagnosis


Determination of IgG avidity index
Application of anti-glycoprotein B IgG serology
Application of microneutralization
IgM confirmation by Western blotting
Isolation of the virus from the urine, saliva or
blood

Congenital CMV infections


Low IgG avidity is linked to primary infection
70

Avidity index (%)

60
50
40
30
20
10
0
0

10

15

20

25

30

35

Weeks after beginning of symptoms


Landini, 1999

Diagnosis of primary CMV infection in pregnancy by additional use of


anti-CMV gB (CG3) IgG ELISA
Rothe et al., 2000

A confirmatory test for CMV-IgM


New immunoblot

Vp150

1) Contains both structural and


nonstructural proteins

Vp82
Vp65
Vp28

2) Agrees with consensus of


different ELISAs

rp150

3) Is easy to standardize

rp52
rp130
r

4) Is easy to interpret

rp38

Purified
native
viral
proteins

Recombinant
proteins

CKS
Landini, 2000

Detection of CMV and CMV


products in maternal blood
CMV
CMV antigen
CMV DNA
CMV IE mRNA

diagnostic at any level


(confirmation of serology)

Methods of CMV detection


culturing of virus
shell vial
(IE viral protein)
CMV antigenemia assay
(pp65 protein)
PCR - for

qualitative and quantitative detection of CMV DNA

RT-PCR or NASBA* - either IE or late mRNA may be detected


*nucleic acid sequence-based amplification

Prenatal diagnosis of congenital CMV


infection
Prevents unnecessary termination in
70% of the cases

Why?

Gives the possibility of termination in


30% of the cases
The newborn will be checked for CMV
infection and, if necessary, treated
with ganciclovir
Prenatal therapy (?)
Landini, 1999

Prenatal diagnosis of congenital CMV


infection

When?

1. False-negative results may be reported


before this age: the fetus excretes CMV via
the urine into the amniotic fluid, and fetal
diuresis becomes established only after 2021 weeks of gestation

At 21-23 weeks of
gestation

2. In most cases, at least 6-9 weeks pass


from the time of maternal infection before
the virus can be detected in the amniotic
fluid and it is known that CMV
transmission is correlated with severe fetal
diseases, mainly when it occurs during the
first 12 weeks of gestation
Landini, 1999

Prenatal diagnosis of congenital CMV


infection
PCR and/or virus isolation from amniotic fluid
Weeks 21-23 of gestation

Positive result
qPCR
Level of fetal risk
Low
<105 GE/ml

High
105 GE/ml

Conclusion
Congenital CMV infections prenatally can
be diagnosed

Question
Can the prenatal diagnosis identify fetuses at
high risk of CMV-related symptoms?

qPCR in 79 amniotic fluids:


relationship with pregnancy outcome
F

CMV-GE/ml

N= newborns
F= fetuses

N F
N N
FN
N N
F

106
105
N

104

F
F

103
F
N (n 56)
Uninfected

NN N
NN
Infected
asymptomatic

Infected
symptomatic

Pregnancy outcomes
Landini, 1999

Clinical manifestations of congenital CMV


infection
Neonatal evaluation
Symptomatic
(10-15 % of cases)

Asymptomatic

*Intrauterine growth retardation

Clinical findings (estimated %)


Hepatosplenomegaly
65-75
Petechiae or purpura
60-70
Jaundice
50-60
Microcephaly
40-50
IUGR*
40-50
Hypo- or hypertonia
20-30
Chorioretinitis
10-20
Normal (10-15% exhibit a developmental
delay or a sensoneural hearing loss is
detected in childhood)

CMV-infected newborns

Blueberry muffin lesions

Congenital CMV infection

The head CT scan demonstrates diffuse


calcifications in the basal ganglion and
subependymal regions of the brain.
The degree of involvement is more
extensive than suspected from US
examination.

Ceola and Angtuaco, 1999

Congenital CMV infection

Cerebellar dysplasia in a neonate with


congenital CMV infection. Note the
lissencephaly of the cerebrum with
large calcifications

Patel and Barkovich, 2002

Postnatal diagnosis of congenital CMV


infection
First week of life
PCR and/or virus iolation from urine
Antigenemia viremia
-

Second week of life

Neonatal follow-up

virus isolation
from urine
-

Neonatal follow-up

Prevention of congenital CMV infection


There is currrently no method of proven efficacy
that prevents maternal CMV infection during
pregnancy

CMV infection in immunocompromised


patients
CMV is a significant opportunistic pathogen in
Solid organ recipients
Bone marrow recipients
AIDS patients
Patients receiving immunosuppressive therapy
Subjects with congenital immunodeficiencies

Mechanisms of CMV infection in


transplant recipients

Transmission by donor organ


Blood products
Reactivation of latent virus in the recipient

Clinical syndromes associated with CMV


infection in mmunocompromised patients
Syndromes

AIDS

Solid organ Bone marrow


transplant

Esophagitis

Gastritis
Enterocolitis
Fever/hepatitis
Pancreatitis
Pneumonitis
Retinitis
Encephalopathy
Polyradiculopathy

+
+
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+

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++
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-

+
+
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+
-

CMV enterocolitis in AIDS patients

Cecal ulceration

CMV colitis
Mucosal inflammation with mucosal hemorrhage, edematous
fields and polypoid lesions. Biopsis demonstrated viral inclusions
with CMV

http://www.endoatlas.com/co_co_08.html

CMV retinitis

Normal retina

Retinas affected by CMV retinitis


http://strc.cc/pages/disease_cytomegalovirus.asp

CMV inclusions in organs

Characteristic inclusion
in liver
Inclusions in lung

Strategies to prevent CMV infection in solid


organ and bone marrow recipients
matching the donor-recipient pair by CMV
serologic status
use of CMV-negative blood products
antiviral agents to suppress viral replication
immunoglobulin preparations to provide
passive immunization
reconstitution of cellular immunity to CMV
in bone marrow recipients

Drugs currently available for treatment


Ganciclovir
Foscarnet
Cidofovir
Valganciclovir
Fomivirsen
All antiviral compounds suppress active
replication of the virus, but do not eliminate it

Therapeutic approaches

Antiviral prophylaxis
Pre-emptive treatment
Treatment of an established disease

Antiviral prophylaxis
An antiviral drug is administered before any active
CMV infection is detected, in order to prevent its
occurrence
This prophylaxis is recommended for renal transplant
recipients
when the donor or recipient is seropositive
if the recipient is subjected to an immunosuppressive regimen

Pre-emptive therapy
Antiviral treatment is initiated when CMV positivity*
is detected in the blood or bronchoalveolar lavage
fluid by using sensitive method in
bone marrow
liver or
lung recipients

* CMV antigenemia or DNAemia

Treatment of established CMV disease


In immunosuppressed subjects:
ganciclovir 5 mg/kg every 12 h

or

foscarnet 60 mg/kg every 8 h


iv for 2-3 weeks

Benefits of host immune response


to CMV
Maternal immunity ameliorates the effects of intrauterine infection
on the fetus
Premature neonates with maternal antibody are protected from
postnatal infection
Pretransplant immunity protects organ allograft recipients from
severe disease
Passively administered antibody protects organ allograft recipients
Protective efficacy has been demonstrated in murine and guinea pig
models of (homologous strain) CMV infection using attenuated strains
Plotkin, 2000

Experimental CMV vaccines


Live attenuated Towne strain
Recombinant of Towne with genes from virulent virus
Multiple genes in canarypox vector
Subunit gB glycoprotein/MF59 or gB/alum
Peptide fusion of A2 and pp65 with helper peptide
DNA plasmids
Dense bodies
Arvin et al., 2004