Flu-like symptoms and hyperechoic foetal bowel

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Intraperitoneal administration of cytomegalovirus hyperimmunoglobulin to the cytomegalovirus-infected fetus

Twenty-five percent of cytomegalovirus (CMV)-infected fetuses had sequelae and 8% of those in the recurrent-infected group had sequelae. There is no report yet on the fetal therapy for CMV infections. A Japanese pregnant woman with intrauterine fetal CMV infection diagnosed at 26 weeks of pregnancy is presented. CMV culture of amniotic fluid was positive. A CMV DNA assay using the polymerase chain reaction method of the cord blood and the amniotic fluid was positive during the pregnancy; however, testing for fetal serum CMV-specific IgM was negative. The CMV IgG titer of fetal serum at 27 weeks of pregnancy was a third of that of the maternal serum. CMV hyperimmunoglobulin was injected into the fetal abdominal cavity at 28 and 29 weeks of pregnancy. A second administration of CMV hyperimmunoglobulin increased the titer of CMV IgG in the fetal circulation. At birth, the urine culture was positive for CMV. However, CMV DNA of the ascites became negative. A brain CT scan performed 2 weeks after birth revealed some small calcifications beside the right ventricle. CMV hyperimmunoglobulin injection to the fetal abdominal cavity has been shown to increase the IgG in the fetal serum. This is the first report of fetal therapy of congenital CMV infection.

Clinical survey of congenital cytomegalovirus infection in Japan

BACKGROUND

The clinical features of congenital cytomegalovirus (CMV) infection in countries with a higher percentage of maternal seropositivity for CMV has rarely been reported. We conducted a national survey for the first time in Japan to investigate the prevalence of congenital CMV infection.

METHODS

Questionnaires were sent in 1994 to pediatricians and obstetricians of 3398 hospitals with either more than 100 beds or a neonatal intensive care unit (NICU). The questionnaire asked for the number of new cases in 1992 and 1993, maternal status of CMV infection, diagnostic methods, clinical manifestations at birth, sequelae and prognosis.

RESULTS

A total of 46 cases of CMV infection were reported for the years 1992 and 1993 by 1448 hospitals; of these 39 were symptomatic. The annual incidence of symptomatic disease was 1.6 cases/100,000 live births. Major clinical manifestations such as low birthweight, hepatosplenomegaly, petechiae and intracranial calcification were noted at birth in 38-50% of symptomatic neonates. Sequelae, such as hearing loss, mental retardation and motor disability developed in 71% of survivors. Thirty-five percent of the 49 infected infants had either died or had severe disability. Several clinical manifestations at birth, including petechiae/thrombocytopenia, were significantly associated with severe sequelae or a poor prognosis.

CONCLUSION

The lower frequency of clinical findings at birth may be attributed to the higher seroprevalence of pregnant women in Japan than in Europe and the United States.

Improved prenatal diagnosis of congenital human cytomegalovirus infection by a modified nested polymerase chain reaction

Two major variables may cause false-negative results in prenatal diagnosis of congenital human cytomegalovirus (HCMV) infection: sensitivity of the techniques(s) used; and time elapsed between maternal infection and antenatal testing. Previous results indicated that rapid HCMV isolation from amniotic fluid samples and viral DNA detection in amniotic fluid by nested polymerase chain reaction (nPCR) had comparable levels of sensitivity (69.2% and 76.9%, respectively). The nPCR protocol was reviewed following two additional false-negative antenatal diagnosis in a twin pregnancy during which two procedures were performed at 18 and 23 weeks of gestation, respectively. In the new assay, multiple (instead of single) and 100 (instead of 20) microliters amniotic fluid aliquots were individually amplified and tested by nPCR. By using this approach, low DNA levels (1-10 genome equivalents) were detected in 1-5/8 replicates of amniotic fluid samples taken from both twins during both procedures. In addition, viral DNA was detected in 5/6 replicates from two amniotic fluid samples still available from two previous false-negative cases. However, nPCR on multiple amniotic fluid replicates did not anticipate positive prenatal results in a retrospective case, which required two procedures for correct diagnosis and, when prospectively employed, did not avoid one additional false-negative prenatal diagnosis 8 weeks after maternal infection. Thus, delayed intrauterine transmission of the infection may be a potential cause of false-negative results. However, the combination of a very sensitive technique with appropriate timing of prenatal testing can substantially increase the reliability of prenatal diagnosis results.

Detection of cytokines and cytomegalovirus DNA in serum as test for congenital infection

Maternal serum samples at 10 and 22 weeks of gestational age and cord blood samples were available from six cases of asymptomatic congenital human cytomegalovirus (HCMV) infection. Meaningful rises of serum IgG-antibody titers by ELISA occurred in three cases. Serum interferon (IFN)-gamma activity was detected in all six cases. Serum cell free soluble interleukin-2 receptor (sIL-2R) activity rose above the normal range (145-519 U/ml) in one IgG and IgM antibody-positive and three IgG antibody-positive woman. Serum levels of sIL-2R and IFN-gamma were not elevated in anti-HCMV antibody-negative healthy pregnant women. No HCMV IE DNA was detected by PCR in the serum of any of the pregnant women. HCMV DNA was detected in the serum of one of six infants with asymptomatic congenital HCMV infection. Assessment of the changes of serum cytokines such as sIL-2R and IFN-gamma in HCMV antibody-positive pregnant women may be useful for the prenatal diagnosis of active HCMV infection during pregnancy.

Cytomegalovirus infection

Cytomegalovirus (CMV) infection is the most common perinatal infection and may result in severe injury to the fetus. Forty percent to 50% of infants delivered to mothers with primary CMV will have congenital infections. Of these, 5% to 18% will be overtly symptomatic at birth. The mortality rate in these children is almost 30%; approximately 80% of the survivors have severe neurological morbidity. The majority of congenitally infected infants will be asymptomatic at birth; 10% to 15% of these children subsequently have sequelae such as visual and auditory defects. If recurrent or reactivated CMV infection develops during pregnancy, the risk of serious fetal injury is very low. Similarly, neonatal infection acquired during delivery or from breast feeding also poses minimal risk to the child. Because antimicrobial therapy and immunoprophylaxis for CMV infection are unsatisfactory, pregnant women must be educated about preventive measures.

Intellectual assessment of children with asymptomatic congenital cytomegalovirus infection

The findings of previous studies examining the neurocognitive development of children with clinically inapparent (asymptomatic) cytomegalovirus (CMV) infection have demonstrated mixed results. These studies have generally depended on small sample sizes (i.e., < 50). We examined the intellectual development of children with asymptomatic congenital CMV infection using a sample larger than previous studies. Two hundred and four cases aged 5 to 200 months were compared with 177 uninfected siblings ranging in age from 6 to 203 months. Parents were administered the Developmental Profile, a measure of developmental achievement. Children who were older than 30 months were administered an objective intelligence measure. Results of this study showed that children with asymptomatic congenital CMV infection do not demonstrate intellectual impairment, and that they perform similarly to uninfected siblings. Parents tended to overestimate their child's level of functioning regardless of whether the child had CMV infection.

Schizencephaly and congenital cytomegalovirus infection

Congenital cytomegalovirus (CMV) infection is known to be associated with some of the disorders of neuronal migration and organization, including gray matter heterotopias, and polymicrogyria. We report a patient with schizencephaly and congenital CMV infection.

Epidemiology of congenital cytomegalovirus infection: maternal risk factors and molecular analysis of cytomegalovirus strains

To determine factors that influence the occurrence of congenital cytomegalovirus (CMV) infection, the authors surveyed prospectively 8,254 infants born in eastern Iowa between October 1989 and June 1994. The authors conducted a case-control study to identify maternal risk factors, matching each CMV-infected infant with three uninfected infants according to hospital and date of birth. CMV strains were compared by using the polymerase chain reaction (PCR) to identify common sources of infection. Of the 7,229 infants cultured successfully for CMV, 35 (0.48%) were congenitally infected. Mothers of CMV-infected infants were more likely to be single (odds ratio (OR) = 3.05, p = 0.016), to work in sales (OR = 4.93, p = 0.008), or to be students (OR = 5.01, p = 0.017). Conversely, women who worked in health-care professions were less likely to have a congenitally infected infant (OR = 0.14, p = 0.049). PCR analysis indicated 27 distinct strains of CMV, but two groups of infants (two infants per group) excreted strains with indistinguishable molecular patterns. One of these pairs of infants had older siblings who attended the same child-care center during their mothers' pregnancies. The authors concluded that demographic and occupational factors influenced the risk of giving birth to an infant with congenital CMV infection. Many distinct CMV strains were identified, suggesting that major point source outbreaks had not occurred. Nonetheless, point source acquisition of CMV from child-care environments did account for some cases of congenital CMV infection in eastern Iowa.

Essential and nonessential amino acids in appropriate and small for gestational age fetuses with congenital cytomegalovirus infection

The aim of the study was to evaluate the correlation between valine and glycine, representatives of essential and nonessential amino acids, in appropriate and small fetuses for gestational age with congenital cytomegalovirus (CMV) infection. Umbilical venous cord blood was obtained by cordocentesis at 22 to 29 weeks' gestation from 18 women (11 in appropriate for gestational age (AGA) -A, and 7 in small for gestational age (SGA) -B) fetuses with CMV infection. Plasma amino acids were measured with a Beckman M 121 amino acid analyzer. Maternal valine level was 136.0 mmol/l; fetal valine in AGA and SGA fetuses: 219 and 189 mmol/l, respectively. Fetomaternal valine ratio was significantly lower in the SGA group (1.39 mmol/l-SGA, 1.61 mmol/l AGA, t = 6.9 p < 0.001). The glycine level in maternal blood was 139.0 mmol/l; fetal in SGA and AGA fetuses 137 mmol/l, and 176 mmol/l, respectively. The fetomaternal glycine ratio was also significantly lower in the SGA group than in AGA. 1.01 and 1.27, respectively (t = -2.96, p < 0.001). Valine/glycine maternal and fetal ratio did not show any difference between groups. In the congenital CMV infected fetuses with intrauterine growth retardation there were decreased valine and glycine levels compared to the congenitally CMV infected fetuses with normal intrauterine growth. There was a lower fetal concentration of these amino acids compared to the maternal level in SGA fetuses. A decreased glycine level compared to the valine level has also been found in congenitally CMV infected fetuses with intrauterine growth retardation.

[Human cytomegalovirus infection and congenital malformation]

OBJECTIVE

To study the relationship between intrauterine cytomegalovirus (HCMV) infection and congenital malformation, and to determine the distribution of tissues infected.

METHODS

Autopsy samples of 41 infants with congenital malformation and 19 infants with normal appearances were studied. Using polymerase chain reaction (PCR) technique the paraffin embedded specimens of main organs were examined for HCMV infection. In-situ hybridization (ISH) was performed in some of the PCR positive tissues in order to define the distribution of HCMV DNA.

RESULTS

19 of the 41 infants (46.34%) with congenital defects were HCMV positive, while 1 in 19 (5.26%) were positive in the control group, and there was significant difference between the 2 groups (P < 0.05), 20.46% (35/171) of the fetal organ samples were HCMV DNA positive in the malformation group, but only 1 out of 78 samples (1.28%%) was positive in the pulmonary tissue of the control group. More malformations of the digestive system were presented in HCMV infected babies but no statistical significant difference when compared with other systems. Brain tissue had the highest HCMV infection rates (41.37%, 12/29), which was significantly higher than other organs. By ISH technique HCMV DNA was found only in 6 out of 17 PCR positive samples, and they were located at neurons, neurogliocytes, epithelium and interstitial cells of the kidney, and epithelial cells of pulmonary alveolar.

CONCLUSION

There are strong correlation between HCMV infection and congenital malformation, and brain is more susceptible to HCMV. By combining PCR and ISH, both sensitivity and distribution of HCMV could be obtained.

Bilateral deafness due to congenital CMV and not rubella reinfection

We report on an infant with bilateral deafness discovered at the age of 5 months caused by a retrospectively diagnosed primary maternal CMV infection after definitive exclusion of maternal rubella reinfection as a cause of fetal infection.

[The postnatal adaptation of infants born to women with cytomegalovirus persistence]

As many as 120 neonates and their mothers presenting with persistency of cytomegaly virus were studied for impact of maternal specific antibodies to cytomegaly virus on rhe pattern of clinical adaptation in children. 90% of children born of infected mothers display neurologic disturbances, 71.4% have jaundice accompanied by hyperbilirubinemia, 4.7% present with hemorrhagic syndrome. 11 neonates were diagnosed as having cytomegaloviral infection, four such diagnoses were made in a pathoanatomical setting. Thus, the studies made suggest that cytomegaly virus might be neurotrophic and that maternal specific antibodies have negative impact on postnatal adaptation of neonates.

Current use of the TORCH screen in the diagnosis of congenital infection

The aim of the study was to determine the number of congenital infections detected in Dublin with the current use of the TORCH screen. A review of all laboratory results was undertaken with subsequent review of relevant medical charts. A total of nine cases were documented in a 5-year period from January 1991 to December 1995. Six of these had already been suspected. There was a failure to follow up 47% of positive screens. TORCH screening in Ireland has an unacceptably low yield, and in the opinion of the authors should be abolished.

Ganciclovir therapy for cytomegalovirus-associated liver disease in immunocompetent or immunocompromised children

Ganciclovir therapy was given intravenously to 20 children with cytomegalovirus (CMV)-associated liver disease, of whom 6 were immunocompetent and 14 were immunocompromised (9 had AIDS and 5 had solid tumors). Immunocompetent children had isolated liver disease diagnosed at birth (4 children), or systemic congenital CMV infection including liver disease (2 children). Ganciclovir was used following two regimens: A) 5 mg/kg twice daily for 8 to 86 days (mean 21); B) 7.5 mg/kg twice daily for 14 days followed by 10 mg/kg three times weekly for three months. CMV infection was diagnosed by viral isolation, detection of viral antigens, and/or CMV DNA from blood and urine. All immunocompetent children had negative CMV culture and CMV DNA detection from blood and/or urine after 14 weeks of treatment. However, the three children who were treated with regimen B showed normal ALT levels at the end of the maintenance course, whereas the children who received ganciclovir with regimen A had normal ALT levels only after about 1 year. All children with tumors initiated regimen B, but only three, who had negative CMV detection and markedly decreased ALT levels, received full treatment; of the remaining two children, one recovered after only an initial course, and the other had therapy interrupted because of hepatic failure and died 9 days later. In contrast, the children with AIDS received several ganciclovir courses for different periods at the lower dosage: they generally improved during treatment but did not recover completely, and five children died with active CMV infections. Based on our study, CMV-associated liver disease can be efficiently treated with ganciclovir both in immunocompetent and immunodeficient children. However, a single ganciclovir course including a higher dosage and prolonged therapy appeared to be more effective than several courses with lower dosages.

Congenital and perinatal cytomegalovirus infection in infants born to mothers infected with human immunodeficiency virus

OBJECTIVES

To determine the rates of congenital and perinatal cytomegalovirus (CMV) infection among infants born to mothers infected with HIV compared with infants born to mothers not infected with HIV from a CMV-immune, low-income population.

STUDY DESIGN

A total of 325 newborns from CMV-seropositive mothers were enrolled and evaluated for congenital CMV infection (150 infants from HIV+ mothers and 175 infants from HIV- mothers. A total of 101 infants from HIV+ mothers and 33 infants from HIV- mothers were evaluated for perinatal CMV infection. The virus was isolated from urine by culture in human fibroblasts and was detected by polymerase chain reaction at birth and at 15 days and 12 weeks of age.

RESULTS

Only 13 of 150 HIV+ mothers (8.7%) had an AIDS-defining condition, and none had a late-stage HIV infection. Congenital CMV infection was detected in 4 of 150 (2.7%) infants from HIV+ mothers and in 5 of 175 (2.9%) infants from HIV- mothers (p = 1.00). Perinatal CMV infection was diagnosed in 8 of 101 (7.9%) infants from HIV+ mothers and in 13 of 33 (39.4%) infants from HIV- mothers (p < 0.00001). Most infants (93.9%) from HIV- mothers and only 5.9% of infants from HIV+ mothers were breastfed.

CONCLUSIONS

CMV coinfection in mothers without advanced HIV disease from a CMV-immune population does not enhance the likelihood of congenital CMV infection. Perinatal CMV transmission from HIV-infected mothers may be decreased by avoiding breastfeeding. Further studies on mothers with late-stage HIV infection are needed.

Retrospective diagnostics of congenital cytomegalovirus infection performed by polymerase chain reaction in blood stored on filter paper

Capillary blood samples from 63 infants collected 3-7 days after birth, and thereafter stored on filter papers for 12-18 y, were tested for the presence of CMV DNA by the polymerase chain reaction (PCR) method. Of 16 infants with proven congenital CMV infection (positive virus isolation test in urine sampled within 1 week of age), 13 (81%) had a positive CMV PCR test and 3 (19%) a negative PCR test. All blood samples from 16 control infants without congenital CMV infection (negative virus isolation test in urine sampled within 1 week of age) were CMV PCR-negative. When 31 samples on filter papers stored above or below the samples of the infected infants were tested, 6 (19%) had a weak reactivity. This suggests that CMV DNA can be transferred from one filter paper to another during storage. We conclude that PCR performed on dried blood stored on filter paper is a useful method in the retrospective diagnostics of congenital CMV infection. Consideration must be given, however, to the possibility of transfer of CMV DNA from blood samples stored nearby.

[Murine cytomegalovirus for the animal models of congenital cytomegalovirus infection in human]

Cytomegalovirus(CMV) is the most common infectious cause of congenital anomalies of the central nervous system(CNS) caused by intrauterine infection in humans. Since studies of human subjects have obvious limitation and CMV have strict species specificity, we have developed model systems for brain abnormalities induced by infection of mouse embryos with murine CMV (MCMV) which has similarities in structure and biology to human CMV (HCMV). We have previously reported that brain abnormalities, such as microphthalmia and brain atrophy, can be induced in mouse embryo by injection MCMV in to the conceptus at mid gestation. We have also showed that neurotropic feature of MCMV are prominent and that viral antigens in neuronal cells are also observed for a prolonged time following infection. We showed the evidences which suggest that MCMV may persistently infect in neuronal cells, whereas lytic infection may preferentially occur in glial cell in the developing brain. Disturbance of the neuronal migration and loss of neurons were reported to occur postnatally in the brains of MCMV-infected mice. Furthermore, MCMV infection induces apoptosis in uninfected neurons, and blocks and induction of apoptosis of primary neuronal cultures. These viral effect on the induction and blocking neuronal apoptosis, resulting in persistent infection, may be important for pathogenesis of morphological and functional brain disorders caused by congenital CMV infection in humans.

[Diagnosis of congenital and perinatal infection by cytomegalovirus using polymerase chain reaction]

The practical application of a polymerase chain reaction (PCR) amplification for the diagnosis of congenital and perinatal cytomegalovirus (CMV) infections was evaluated. Three hundred five urine samples were tested by PCR and conventional virus isolation in cell culture. Viruria was detected in 47 urine samples by PCR using a primer pair which amplifies part of the major immediate-early (MIE) CMV genome. The PCR compared to virus isolation showed 89.6% sensitivity, 98.5% specificity and 91.5% positive predictive value. PCR with primer pairs amplifying parts of the glycoprotein B and glycoprotein H genes of CMV were used for confirmation of the positivity of the 47 urine samples. We concluded that this CMV PCR assay in urine has a suitable sensitivity for the diagnosis of congenital and perinatal infections and its specificity is highly increased by use of more than one pair of primers among the ones we used.

[Epilepsy and disorders of cortical development in children with congenital cytomegalovirus infection]

INTRODUCTION

Neuroimaging and experimental studies have related cytomegalovirus (CMV) to certain neuronal migration disorders.

MATERIAL AND METHODS

To define the electroclinical picture of children with epilepsy associated with disorders of cortical development (DCD) and congenital CMV infection, we conducted a clinical, electroencephalographic and neuroradiological study of 10 children with this condition.

RESULTS

Eighty per cent of them had dismorphic traits, or malformations outside CNS. All showed other neuroradiological signs (cerebral calcification, white matter damage, porencephaly). Six patients with bihemispheric DCD (agyria-pachigyria, 2; 'poligyria', 1; schizencephaly, 1; bilateral opercular DCD, 2) showed: Tetraparesis, severe or profound mental deficiency, early onset epilepsy (mean age at onset: 11 months) with spasms, tonic seizures, partial seizures, and multifocal paroxysms or unusual diffuse sharp Alfa-Beta EEG activity. One child developed Epilepsia Partialis Continua. Children with bilateral opercular DCD evolved to a continuous spike and wave (SW) electrical status during wakefulness and sleep, linked to a worsening of psychomotor derangement. Four patients with unilateral hemispheric DCD (pachigyric or 'poligyric') showed: Congenital hemiparesis, mild intellectual deficiency, motor seizures (orofacial, hemiclonic, generalized) beginning in the third year of live, atypical absences with focal phenomena, frequent focal rhythmic SW discharges during wakefulness, and continuous SW status during sleep (CSWS).

CONCLUSIONS

A wide spectrum of DCD due to congenital CMV infection is documented. Characteristic electroclinical pictures related to the extent and topographical distribution of the DCD are recognized, which may lead to an appropriate diagnosis and prognosis.

[Progress in the management of cytomegalovirus(CMV) infection]

We described the clinical feature of cytomegalovirus(CMV) infection, its epidemiology, and prognosis of congenital CMV infection. Then, the anti-viral treatment with the ganciclovir against the congenital CMV infection was discussed. We showed that the presence of CMV-DNA in the plasma was useful to determine the indication of the therapy. We also showed our case of chronic active Epstein-Barr virus infection to introduce the adoptive immune therapy as a new strategy for the treatment of severe virus infections. Lastly, application of this therapy for the CMV infection in overseas and its future prospect were described.

Cytomegalovirus enteritis in a premature infant

BACKGROUND/PURPOSE

Up to 2.5% of newborn infants are cytomegalovirus (CMV) positive at birth. Five percent will be symptomatic at birth, including cytomegalic inclusion disease. Symptoms such as hearing loss and mental retardation will ultimately develop in 15%.

METHODS

The authors describe a case of CMV enteritis in a 2.2-kg newborn that presented as necrotizing enterocolitis (NEC) and subsequently developed a colonic stricture.

RESULTS

There are four reports of neonatal CMV enteritis in the nonEnglish-language literature. Cytomegalovirus enteritis has become prevalent among the immunosuppressed pediatric and adult patient population.

CONCLUSIONS

We propose the addition of CMV to the list of pathogens responsible for NEC. A review of neonatal CMV infection is provided.