CMV in Immunocompetent

Hosts
Internal Medicine
Morning Report August 2009
Lindsay A. Wilson
A Herpes Virus:

A double-stranded linear DNA virus with 162 hexagonal

protein capsomeres surrounded by a lipid membrane.

CMV has the largest genome of the herpes viruses, ranging

from 230-240 kilobase pairs. Most closely related to HHV-6
and 7.
CMV Mononucleosis:
• Most common presentation of symptomatic CMV infection in
immunocompetent adults.

• Systemic symptoms and fever predominate and signs of

enlarged cervical nodes, tonsillitis, and splenomegaly are
not as commonly seen as they are in EBV.

• Patients with CMV mononucleosis may be older and have a

longer duration of fever.

• Often see mild transaminitis, which can aid in diagnosis.

Transmission

• Via body fluids: CMV has been cultured from multiple

sites, including urine, blood, throat, cervix, semen, stool,
tears, and breast milk.

Typical owl's eye inclusion seen on HE stain.

 Prevalance of CMV Worldwide--Seroprevalence
rates ranging between 40 to 100 percent of the adult
population. Studies suggest that certain groups (ie
developing countries) have a higher prevalence.
Other Presentations:

Disease localized to a single organ has

been described in immunocompetent
hosts. Of course, this is much less
common.
GI:

COLITIS:
• Diarrhea, fever, and abdominal pain are the common
presenting symptoms.
• Can be bloody diarrhea (about half of the time) and mimic
ischemic colitis.

Can also have CMV hepatitis, gastroduodenititis, gastric

ulcers, cholangitis, pancreatitis.
CV:

Pericarditis and myocarditis have been described in

immunocompetent patients with acute CMV infection.

Thought to be under-diagnosed due to it's milder presentation.

When it is found, it is often an incidental finding on EKG or

ECHO.
Neuro:

• Guillain-Barré syndrome:
CMV-related GBS are generally younger and experience more
prominent sensory deficits, respiratory insufficiency, and cranial
nerve impairments.

• Encephalitis:
Symptoms can include: motor deficits (localized weakness,
paraplegia), sensory abnormalities (numbness, hypoaesthesia,
paraesthesia, dysaesthesia, anaesthesia), disorientation,
confusion.

• Transverse myelitis
Pulm:

Pneumonia: Occurs at a rate of approximately 0-6% in CMV

infections. Often see ground-glass appearance on CT scan.
Renal: Collapsing focal
glomerulosclerosis
Infections that Can Cause FSGS HIV, CMV, HTLV-1, parvovirus
B19, polyomavirus, pulmonary TB, leishmaniasis.
Ocular:

Anterior uveitis (also called iritis) is more commonly seen in

immunocompetent (versus the retinitis seen in AIDS patients).

Presenting symptoms include loss or blurring of vision, as well

as redness of the affected eyes.
Gancyclovir

• The drug of choice for treatment of cytomegalovirus (CMV)

disease is ganciclovir.

• Ganciclovir is a nucleoside analogue that inhibits DNA

synthesis in the same manner as acyclovir. The major
difference is that CMV does not contain a thymidine
kinase.

• Major adverse effects of ganciclovir therapy are

neutropenia and thrombocytopenia.
CMV: most common congenital
infection
A woman who contracts CMV for the first time during
pregnancy has about a 1-in-3 chance of passing the virus on
to her fetus.

A woman can pass CMV on to her baby at any stage of

pregnancy. However, studies suggest that babies are more
likely to develop serious complications when their mother is
infected in the first 20 weeks of pregnancy.

Only about 1 percent of fetuses become infected when their

mother has a recurrent infection. When these babies do
become infected, they rarely develop any serious CMV-related
problems.
Babies w/ CMV:

• About 10 percent show temporary symptoms like liver or

spleen problems that eventually resolve.

• A very small percentage of babies born do suffer severe

complications: seizures, loss of hearing and vision, mental
and physical disabilities, delayed development and even
death.

• Some infected children don't demonstrate any of these

symptoms for months or years after birth, or experience
worse symptoms later in life after showing initially mild
symptoms.
Tips for pregnant women:

Wash hands!!

Avoid secretions from small children.

Healthcare workers--may want to be tested to know status;

however, this is not a general recommendation.
Take home points...

Most common presentation of CMV in immunocompetent is

mononucleosis-like illness. It can have some features that may
help distinguish it from EBV.

CMV infection can also be localized to a single organ.

CMV is an important congenital infection that is under-

recognized.

Monitor CBC with diff in patients on ganciclovir.

It is spread via bodily fluids, so hand-washing is an important

way to avoid infection.
Works Cited

Petros I Rafailidis et al. Severe cytomegalovirus infection in apparently

immunocompetent patients: a systematic review. Virol J. 2008; 5: 47. 2008 March
27.

Fernandez-Ruiz M et al. Cytomegalovirus myopericarditis and hepatitis in an

immunocompetent adult: successful treatment with oral valganciclovir. Intern
Med. 2008;47(22):1963-6. Epub 2008 Nov 17.

Uptodate.