[The prospective study of the influence of cytomegalovirus (CMV) infection of pregnant women to fetus]

Screening of CMV infection in 450 pregnant women in Shenyang was carried on by ELISA and PCR methods, and CMV infection was detected in 100 of their infants prospectively. The results were 97.11% of pregnant women with past infection, 0.89% with primary infection, 11.11% with recurrent infection, only 2% were susceptible. From 450 pregnant women, there were 3 infants with congenital defects and 3 abortions in active infective group, who were positive for IgM antibody, CMV DNA were positive in heparin peripheral blood, cervical secretion, placenta or amnionic fluid. The fetal infection rate and congenital defect rate in infective group were higher than that in inactive control group. Within 100 maternal-infant pair group, congenitally infected infants were 1.43 times higher in infective group than that in control group (RR = 1.43). Two infants with mental retardations (MDI<70) were born in infective group, but none in control group. In our study, primary infection of early pregnancy was most harmful to fetus, the intrauterine transmission rate was 33.3%. Among nine infected infants born from the infective group, two infants were with CID, and seven were symptomless. CMV screening is important for pregnant women in view of eugenic. When active CMV infection is found in early pregnancy, termination of pregnancy is better considered while CMV detection of amniotic fluid is also positive.

Ten-year clinical, developmental, and intellectual follow-up of children with congenital cytomegalovirus infection without neurologic symptoms at one year of age

OBJECTIVE

This study was undertaken to ascertain whether children with congenital cytomegalovirus (CMV) infection at birth, but without neurologic symptoms at 1 year of age, differed in somatic, neurologic, developmental, or intellectual status from matched control children at long-term follow-up.

MATERIAL AND METHODS

Congenital CMV infection, as demonstrated by isolation of the virus within the first week of life, was diagnosed in 44 (0.5%) of 9806 infants. From this basic CMV-infected population, children who developed neurologic disturbances including sensorineural deafness before 1 year of age were excluded (n = 7), as were those unwilling to participate (n = 2). Congenitally infected infants (n = 35) and matched control infants (n = 53) were followed up clinically and neurologically. At 21 months, development was assessed with the Griffiths' Developmental Scale and at 7 years of age neurologic status was assessed with the Stott test and intellectual development with the Wechsler Intelligence Scale for Children.

RESULTS

As reported previously, 18% (8/44) of the CMV-infected infants manifested symptoms at birth, as compared to 8% (4/53) in the control group. In the congenital CMV group 7% (2/30) children tested had abnormal Stott test results, as compared to 2% (1/43) in the control group. Thirty-two CMV-infected and 51 control group children were assessed with the Griffiths' scale at 21 months of age. The two groups did not differ significantly, either in mean scores (6.3 +/- 2.3 vs 6.1 +/- 1.9) or in the proportion of children with scores below normal (19% [6/32] vs 16% [8/51]). Twenty-five CMV-infected and 41 control group children were assessed with the Wechsler Intelligence Scale for Children at 7 years of age (median 86 months; range, 82 to 90 and 82 to 91, respectively). The two groups did not differ significantly, either in mean scores (5.8 +/- 2.0 vs 6.4 +/- 1.6) or in the proportion of children with scores below normal (12% [3/25] vs 5% [2/41]).

CONCLUSION

Children with congenital CMV infection are unlikely to be at an increased risk of subsequent neurodevelopmental or intellectual impairment if they show normal development at 12 months of age.

Congenital cytomegalovirus infection after recurrent infection in a mother with a renal transplant

A woman with a renal transplant developed a systemic cytomegalovirus infection. She recovered and 3 years later she became pregnant. She had 3 days of fever in the first trimester. She delivered an infant severely affected with congenital cytomegalovirus infection. The incidence of symptomatic congenital cytomegalovirus infection in infants born to immunosuppressed mothers who develop reactivated cytomegalovirus during their pregnancy seems high.

Cytomegalovirus infection in newborns and their family members: polymerase chain reaction analysis of isolates

Polymerase chain reaction (PCR) analysis with primers for the pp65, a-sequence, glycoprotein B, and major immediate early genes of human cytomegalovirus (CMV) was used to study five congenitally-infected infants and their CMV-infected family members. Family members excreting CMV included three mothers and two siblings. The PCR results indicated that the CMV strain excreted by each infant was indistinguishable from that excreted by the corresponding family member. By contrast, the molecular profiles of the CMV strains were distinct between families, indicating that the PCR algorithm described in this study is a useful method for analyzing CMV strains.

Prenatal diagnosis of fetal primary cytomegalovirus infection

OBJECTIVE

To evaluate the validity of prenatal diagnosis work-up for congenital cytomegalovirus (CMV) in women with primary infection.

METHODS

Sixty-three pregnant women with primary cytomegalovirus disease (including two with twin pregnancies), referred to three tertiary perinatal centers over 4 years, underwent evaluation for congenital cytomegalovirus. Fetal diagnosis was made after 21 weeks' gestation by amniocentesis and fetal blood sampling (40 subjects), or amniocentesis only (23 subjects).

RESULTS

Twenty-two (35%) pregnancies showed evidence of vertical transmission: 13 of them underwent funipuncture, but only ten (77%) of the 13 showed positive immunoglobulin (Ig)-M results in fetal blood. No cases of positive fetal serum Ig-M with negative amniotic fluid culture or polymerase chain reaction were observed. In nine (41%) of the 22 pregnancies with evidence of vertical transmission, abnormal ultrasonographic findings were recorded. Six (27%) women with evidence of vertical transmission continued their pregnancies and in only one (with prenatal ultrasonographic abnormalities) was an infant born with neurologic sequelae. In 41 (65%) pregnancies, no evidence of vertical transmission was found, and 37 continued to term. Only one newborn from this subgroup subsequently showed mild motor disability during a median of 23 months of follow-up.

CONCLUSION

Among pregnant patients with primary CMV infection, analysis of amniotic fluid detected all of the infected fetuses. Thus, this is a reliable tool for counseling pregnant women with primary infection. This may guide the patient as to whether or not pregnancy can be continued with a high level of confidence.

Ganciclovir treatment of symptomatic congenital cytomegalovirus infection: results of a phase II study. National Institute of Allergy and Infectious Diseases Collaborative Antiviral Study Group

Congenital cytomegalovirus (CMV) infection occurs in approximately 1% of newborns in the United States. A phase II evaluation was done of ganciclovir for the treatment of symptomatic congenital CMV infection. Daily doses of 8 or 12 mg/kg were administered in divided doses at 12-h intervals for 6 weeks. Clinical and laboratory evaluations sought evidence of toxicity, quantitative virologic responses in urine, plasma drug concentrations, and clinical outcome. A total of 14 and 28 babies received 8 and 12 mg/kg/day, respectively. Five additional babies received ganciclovir on a compassionate plea basis. Significant laboratory abnormalities included thrombocytopenia (< or = 50,000/mm3) in 37 babies and absolute neutropenia (< or = 500 mm3) in 29 babies. Quantitative excretion of CMV in the urine decreased; however, after cessation of therapy, viruria returned to near pretreatment levels. Hearing improvement or stabilization occurred in 5 (16%) of 30 babies at 6 months or later, indicating efficacy.

Progressive and fluctuating sensorineural hearing loss in children with asymptomatic congenital cytomegalovirus infection

OBJECTIVE

To determine the prevalence and temporal changes of sensorineural hearing loss (SNHL) among children with clinically inapparent (asymptomatic) congenital cytomegalovirus (CMV) infection identified from a cohort of newborn infants screened for congenital CMV infection.

METHODS

The study population consisted of 307 children with documented asymptomatic congenital CMV infection, 76 uninfected siblings of children with asymptomatic congenital CMV infection, and 201 children whose neonatal screen for congenital CMV infection showed negative results. Audiologic evaluations were completed for all children to determine their hearing status.

RESULTS

SNHL occurred only in children with congenital CMV infection. Of the children with asymptomatic congenital CMV infection, 22 (7.2%; 95% confidence interval, 4.5% to 10.6%) had SNHL. Among the children with hearing loss, further deterioration of hearing occurred in 50.0%, with the median age at first progression at 18 months (range, 2 to 70 months). Delayed-onset SNHL was observed in 18.2% of the children, with the median age of detection at 27 months (range, 25 to 62 months). Fluctuating SNHL was documented in 22.7% of the children with hearing loss.

CONCLUSIONS

Asymptomatic congenital CMV infection is likely a leading cause of SNHL in young children. The continued deterioration of hearing and delayed onset of SNHL in these children emphasizes the need for continued monitoring of their hearing status.

Neuroradiographic findings in the newborn period and long-term outcome in children with symptomatic congenital cytomegalovirus infection

OBJECTIVE

To determine whether newborn cranial computed tomographic (CT) scan abnormalities predict an adverse neurodevelopmental outcome in children with symptomatic congenital cytomegalovirus (CMV) infection and to examine the association between clinical findings at birth and imaging abnormalities.

METHODS

The data from 56 children with symptomatic congenital CMV infection who underwent cranial CT scans as newborns and were enrolled in a long-term follow-up study were analyzed. The incidence of sequelae was compared between the groups of children with normal and abnormal imaging studies. The relationship between CT scan results and other newborn findings was also examined.

RESULTS

Abnormal CT scans were noted in 70% of subjects; intracerebral calcification was the most frequent finding. Most of the children with an abnormal newborn CT scan (90%) developed at least one sequela, compared with 29% of those with a normal study. Only 1 child with a normal CT scan had an IQ < 70, in contrast to 59% of those with imaging abnormalities. In addition, almost half of the children with CT abnormalities had an IQ < 50 compared with none of those with a normal CT scan. Newborn CT abnormalities were also associated with an abnormal hearing screen at birth and hearing loss on follow-up. None of the neonatal neurologic findings were predictive of an abnormal CT scan.

CONCLUSION

In neonates with symptomatic congenital CMV infection, a cranial CT scan is a good predictor of an adverse neurodevelopmental outcome. In addition, newborn clinical and laboratory findings did not predict neuroradiographic abnormalities in neonates with symptomatic congenital CMV infection.

Diagnosis of congenital cytomegalovirus infection by examination of placenta: application of polymerase chain reaction and in situ hybridization

We examined the placentas of 12 patients in whom congenital cytomegalovirus (CMV) infection was suspected from serological and/or pathological evaluation. Seven patients died (including four intrauterine deaths) and five survived. On histological examination, the characteristic inclusion bodies were detected in only three placentas, and villitis with plasma cell infiltration was seen in eight placentas. Immunohistochemistry using a specific antibody against CMV improved the sensitivity of CMV deletion (10 cases were positive). With the polymerase chain reaction (PCR) following the extraction of DNA from formaldehyde-fixed placenta samples, CMV DNA was detected in seven cases. All 12 subjects were diagnosed with CMV infection by additional Southern blot analysis after the PCR. CMV DNA was also detected by an in situ hybridization method in all cases. With current molecular biological techniques the placenta can be reliably used for the diagnosis of congenital CMV infection.

Recent advances in the diagnosis of cytomegalovirus infection

Herpesviruses are highly disseminated in nature, and nearly 100 Herpesviruses have been at least partially characterized. Seven Herpesviruses have been isolated so far from humans and one has recently been detected by sequence analysis. Consequently, the diagnosis of human Herpesvirus infection is based on eight different viruses. The diagnosis of a Herpesvirus infection can be achieved through the direct demonstration of the presence of the virus or its components (mainly nucleic acids and antigens) in pathological materials or indirectly through serology. In recent years much progress has been made in both directions and thanks to the detailed study of the viral genomes and their antigenic gene products and by the determination of the immune reactivity against individual antigenic polypeptides in different clinical settings. Progress in the direct detection of the viruses in pathological materials mainly regards the production of specific probes and their use with or without DNA amplification for the detection of viral genomes. Serological advances are mainly linked to the production, characterization and use of specific viral antigens by DNA recombinant procedures and by the production and use of synthetic peptides acting as good antigenic epitopes.

Cytomegalovirus infection and Joubert's syndrome

A patient with serologically proven congenital cytomegalovirus (CMV) infection is described with periventricular calcifications on CT. The condition was associated with the typical cerebellar changes of clinicoradiologically proven Joubert's syndrome. Although this may be a chance association only, the condition raised the question if an early intrauterine CMV infection, which affects the cerebellum, may contribute to the occurrence of Joubert's syndrome.

Congenital lobar emphysema in congenital cytomegalovirus infection

We report a case of congenital lobar emphysema diagnosed antenatally in an infant of 32 weeks' gestation. Histology and serology confirmed infection with cytomegalovirus (CMV). CMV pneumonitis leading to inflammation and obstruction in the bronchial tree may have resulted in the development of congenital lobar emphysema.

Ileal perforation caused by congenital or perinatal cytomegalovirus infection

Enteritis developed in a 42-day-old female infant, and during hospitalization ileal perforation occurred unexpectedly. Serologic data, urinary viral culture, and pathologic studies of the resected ileal segment all suggested cytomegalovirus infection. Gastrointestinal involvement in congenital or perinatal infection with this virus may be relatively more common than previously recognized.

Congenital cytomegalovirus infection in infants infected with human immunodeficiency virus type 1

OBJECTIVES

To determine the rate of in utero transmission of cytomegalovirus (CMV) in perinatally HIV-exposed infants and to determine whether coinfection with CMV in early life affects outcome.

METHODS

Infants born to HIV-infected women between March, 1988, and March, 1995, were evaluated (n = 206). Congenital or in utero CMV infection was defined as a positive CMV culture or shell vial assay on urine obtained in the first 3 weeks of life. HIV-infected infants either had positive serology beyond 18 months of age or, for an infant younger than 18 months, had a positive HIV PCR or HIV culture on at least two separate occasions.

RESULTS

There were 30 HIV-infected and 171 uninfected infants (144 who seroreverted and 27 infants with at least 2 negative HIV PCR or culture results and normal immunologic studies during the first 6 months of age). Urine culture for CMV was obtained during the first 3 weeks of life on 154 infants: 24 of 30 (80%) HIV-infected infants; and 130 of 171 (76%) HIV-uninfected infants. Overall 10 of 154 (6.5%) infants were infected with CMV: 5 of 24 (21%) HIV-infected and 5 of 130 (3.8%) HIV-uninfected infants. The rate of in utero CMV infection was significantly higher in HIV-infected infants (P = 0.008). Dually infected infants were more immunosuppressed than their CMV-negative counterparts. At 3 months of age the percentage of CD4+ T lymphocytes (P = 0.0021) and CD4:CD8 ratios (P = 0.0018) were significantly lower in the CMV-infected infants than in the CMV-uninfected infants. At 6 months of age the absolute CD4+ T lymphocyte counts (P = 0.0038), percentage of CD4+ T lymphocytes (P = 0.044) and CD4:CD8 ratios (P = 0.037) were significantly lower in the CMV-infected infants. The mean survival of HIV-infected infants who were coinfected with CMV in early life (5 in utero and 1 perinatally infected infant identified at 7 weeks) was 24.77 months. Kaplan-Meier survival analysis indicated a trend toward decreased survival in the infants who were coinfected with CMV in early life (P = 0.088).

CONCLUSIONS

Congenital CMV infection is more common in HIV-infected infants than in HIV-uninfected infants. Infection with CMV in early life is associated with greater immunosuppression and may be associated with a more rapid progression of HIV infection in infants.

Immunization strategy for prevention of congenital cytomegalovirus infection

Women of childbearing age are a logical target for a vaccine aimed at prevention of congenital cytomegalovirus (CMV) infections. However, the impact of a CMV vaccine could likely be enhanced by considering the sources of maternal infection and characteristics of mothers of infected newborns. Contact with preschool-age children and sexual activity are important sources of CMV infection for young women. Approximately half of infants with congenital CMV infection in the U.S. are born to unmarried, adolescent mothers. To prevent CMV infection in those who are the sources of maternal infection as well as in young, unmarried mothers, universal immunization of toddlers and preteen children should be considered.

Detection of congenital cytomegalovirus infection in Chinese newborn infants using polymerase chain reaction

Polymerase chain reaction (PCR) amplification was used to detect cytomegalovirus (CMV) in 1000 urine specimens from Chinese newborns for defining the incidence of congenital CMV infection in the Chinese population. The major immediate-early and the late antigen genes of CMV were amplified and detected by gel electrophoresis. There were 18 congenitally infected infants found when tests were performed with one or both primer pairs. Comparing with tissue culture, PCR of both primer sets provided a sensitivity of 94%, a specificity of 100% and a predictive value of positive result of 100%.

Cytomegalovirus in peripheral blood leukocytes of infants with congenital or postnatal infection

BACKGROUND

Cytomegalovirus (CMV) is the most frequent agent of viral infection in the fetus; it causes varying damage, particularly neurologic, which becomes evident at birth or in infancy in about 20% of infected individuals. Postnatal acquisition is usually asymptomatic and without sequelae. Laboratory diagnosis of congenital and postnatal infection is based on the demonstration of virus in urine.

OBJECTIVES

To investigate the systemic spread of CMV in neonates with congenital or postnatal infection and to evaluate its significance in diagnosis and in monitoring anti-CMV treatments.

DESIGN

Quantitative determinations of infective CMV (viremia) and viral antigen pp65 (antigenemia) were performed on peripheral blood leukocytes (PBL) from the buffy coat of heparinized blood from children with a diagnosis of congenital (n = 19) or postnatal (n = 19) infection based on viral isolation from urine.

RESULTS

Antigen pp65 in PBL was detected particularly in children with symptomatic infection, both congenital (100%) and postnatal (79%; P > 0.05), and significantly less frequently (50%; P < 0.001) in those with asymptomatic infection. Viremia was observed less often but always in association with antigenemia. Both tests became negative within 6 months. Neither viral titer nor persistent positivity was related to clinical manifestations. In the nine infants given anti-CMV therapy (ganciclovir and/or hyperimmune gamma-globulins) an early suspension of treatment resulted in the appearance of antigenemia and/or viremia.

CONCLUSIONS

Cytomegalovirus was detected in PBL mainly in the most severely affected children. Monitoring antigenemia and viremia in CMV-infected infants is recommended to demonstrate persistent systemic infection and to evaluate virologic results of treatment.

Late intrauterine Cytomegalovirus infection: clinical and neuroimaging findings

Fetal Cytomegalovirus (CMV) infection in early pregnancy usually results in severe neurological handicap and sensorineural hearing loss with typical neuroradiological findings of calcification, migrational anomalies, disturbed myelination, and cerebellar hypoplasia. Infections acquired in late pregnancy have less prominent signs, such as microcephaly, hearing deficits, and minor neurological handicap. We report 7 children who presented with a similar clinical complex of signs: microcephaly, sensorineural hearing impairment, behavior problems with hyperactivity, reduced apprehension for pain in 5 of the 7, ataxia in 3, and hypotonia with clumsiness in 3 others. All manifested mild to severe developmental problems. Cranial CT revealed calcification in 4 of 6 patients. MRI in all 7 children showed patchy to confluent nonprogressive dysmyelination. Only 2 children had acute neonatal signs of congenital CMV infection. We assume that these children acquired CMV infection in the third trimester of gestation, leading to microcephaly, hearing loss, and neurological and developmental problems with typical neuroradiological signs.