Diagnosis and medical care for congenital cytomegalovirus infection: An observational study using claims data in Japan, 2010 to 2017

Although early detection and intervention may improve the outcome of the congenital cytomegalovirus (cCMV) infection, few studies assessed the real-world clinical practice for cCMV patients. We analyzed medical claims data to assess the patterns of diagnoses and medical care for cCMV patients.We used a subset of medical claims database (JMDC Claims Database) in Japan, covering 207,547 newborns between April 2010 and March 2017 and observed for at least 6 months. The diagnosis of cCMV and related symptoms and sequelae and medical care, including essential examinations and antiviral treatment, were identified using standardized codes.Overall, we identified 53 (25.5 per 100,000 newborns) cCMV patients diagnosed within 6 months after birth; of these, 83% were diagnosed within 1 month and 68% had at least 1 cCMV-related symptom at birth. Objective hearing tests and fundus examinations were performed within 6 months in 60% and 30% of patients, respectively. Antivirals were prescribed in 26% of patients. During the observation period (median = 33 months), sensorineural hearing loss (49%) and developmental problems (28%) were commonly identified as cCMV-related sequelae. The proportions of the patients continuously followed up with objective hearing tests up to 36 months were 30% in total and 56% in antiviral-treated patients, respectively.The cCMV patients did not necessarily receive a timely diagnosis nor continuous follow-ups in usual clinical practice. Although the universal screening for cCMV may, if implemented, facilitate early diagnosis, it should be accompanied by strategic follow-up plans to support timely interventions.

[Congenital Toxoplasmosis and CMV in Switzerland in 2019]

Epidemiological trends in congenital toxoplasmosis and CMV are extremely divergent. While there were only 39 cases of congenital toxoplasmosis in Switzerland between 1982 and 2015, there was an equivalent number of cases of congenital CMV, 38 in total, in 2017 alone. Serological screening for toxoplasmosis was logically abandoned in Switzerland in 2008. Regarding CMV, there is no recommendation for serological screening or neonatal screening in Switzerland, whereas early diagnosis can improve prognosis through the rapid initiation of antiviral treatment. The epidemiological data generated by sentinel surveillance of congenital CMV infections in Switzerland may or may not justify such a measure in our country in the future.

Should You Follow the Better-Hearing Ear for Congenital Cytomegalovirus Infection and Isolated Sensorineural Hearing Loss?

OBJECTIVE

To describe the progression of sensorineural hearing loss (SNHL) in the better- and poorer-hearing ears in children with asymptomatic congenital cytomegalovirus (CMV) infection with isolated SNHL.

STUDY DESIGN

Longitudinal prospective cohort study.

SETTING

Tertiary medical center.

SUBJECTS AND METHODS

We analyzed hearing thresholds of the better- and poorer-hearing ears of 16 CMV-infected patients with isolated congenital/early-onset or delayed-onset SNHL identified through hospital-based CMV screening of >30,000 newborns from 1982 to 1992.

RESULTS

By 12 months of age, 4 of 7 patients with congenital/early-onset SNHL developed worsening thresholds in the poorer-hearing ear, and 1 had an improvement in the better-hearing ear. By 18 years of age, all 7 patients had worsening thresholds in the poorer-hearing ear and 3 patients had worsening thresholds in the better-hearing ear. Hearing loss first worsened at a mean age of 2 and 6 years in the poorer- and better-hearing ears, respectively. Nine patients were diagnosed with delayed-onset SNHL (mean age of 9 years vs 12 years for the poorer- and better-hearing ears), 6 of whom had worsening thresholds in the poorer-hearing ear and 1 in both ears.

CONCLUSION

In most children with congenital CMV infection and isolated SNHL, the poorer-hearing ear worsened earlier and more precipitously than the better-hearing ear. This study suggests that monitoring individual hearing thresholds in both ears is important for appropriate interventions and future evaluation of efficacy of antiviral treatment.

The MRI spectrum of congenital cytomegalovirus infection

Human cytomegalovirus (CMV) is an ubiquitous pathogen, with a high worldwide seroprevalence. When acquired in the prenatal period, congenital CMV (cCMV) is a major cause of neurodevelopmental sequelae and hearing loss. cCMV remains an underdiagnosed condition, with no systematic screening implemented in pregnancy or in the postnatal period. Therefore, imaging takes a prominent role in prenatal diagnosis of cCMV. With the prospect of new viable therapies, accurate and timely diagnosis becomes paramount, as well as identification of fetuses at risk for neurodevelopmental sequelae. Fetal magnetic resonance imaging (MRI) provides a complementary method to ultrasound (US) in fetal brain and body imaging. Anterior temporal lobe lesions are the most specific finding, and MRI is superior to US in their detection. Other findings such as ventriculomegaly, cortical malformations and calcifications, as well as hepatosplenomegaly, liver signal changes and abnormal effusions are unspecific. However, when seen in combination these should raise the suspicion of fetal infection, highlighting the need for a full fetal assessment. Still, some fetuses deemed normal on prenatal imaging are symptomatic at birth or develop delayed cCMV-associated symptoms, leaving room for improvement of diagnostic tools. Advanced MR sequences may help in this field and in determining prognosis, but further studies are needed.

Distribution of the CMV glycoprotein gH/gL/gO and gH/gL/pUL128/pUL130/pUL131A complex variants and associated clinical manifestations in infants infected congenitally or postnatally

Human cytomegalovirus (CMV) is a major cause of morbidity in fetuses following intrauterine infection. The glycoprotein (g) envelope trimeric gH/gL/gO and pentameric gH/gL/pUL128/pUL130/pUL131A complexes are required for CMV entry into fibroblasts and endothelial/epithelial cells, respectively, and both are targets for neutralizing antibodies. The role of sequence variability among viral strains in the outcome of congenital CMV infection is controversial. Variation in the CMV UL75 gene encoding glycoprotein H (gH), the UL115 (gL), the UL74 (gO), and the UL128 locus (UL128L) encoding three structural proteins (pUL128, pUL130, and pUL131A) was determined in 82 newborns with congenital CMV infection and 113 infants with postnatal or unproven congenital CMV infection. Genotyping was performed by sequencing analysis of PCR-amplified fragments and the PCR-restriction fragment length polymorphism (RFLP) method, and the viral load was measured by quantitative real-time PCR. The obtained results demonstrated that (1) different CMV variants and mixed CMV infections can be detected in newborns infected congenitally; (2) the gH1 genotype, UL130 variant 6, and UL131A variant 1 were associated with some signs/symptoms within cohort of pediatric patients, mainly consisting of infants with symptomatic CMV infection. The results revealed that pUL130, pUL131A, and gH polymorphisms seemed to be associated with the outcome of CMV infection in infants.

Awareness of congenital cytomegalovirus and acceptance of maternal and newborn screening

Objectives

To assess awareness of cytomegalovirus (CMV); attitudes towards screening; and frequency of behaviors that could increase the risk of prenatal infection.

Methods

We conducted a survey among 726 women at the 2017 Minnesota State Fair. Minnesota residents aged 18–44 were eligible if they had never been pregnant or had been pregnant within the past 10 years. We compared responses between never-pregnant and recently-pregnant women.

Results

Only 20% of study participants had previously heard of CMV. Remarkably, recently-pregnant women were no more likely to be aware of CMV than never-pregnant women after adjusting for potential confounders. After receiving information about CMV, nearly all participants indicated they believed prenatal (96%) or newborn (96%) screening should be offered.

Conclusions

Although baseline awareness of CMV was low (even among recently-pregnant women), after learning more about the risks, women supported screening. Several states have passed or proposed legislation promoting CMV education and/or screening programs. We identified important gaps in knowledge about CMV among women who may benefit from education about how to reduce their risk of exposure and who may need to decide whether they would be willing to screen for CMV in the future.

Awareness and Preventative Behaviours Regarding Toxoplasma, Listeria and Cytomegalovirus Among Pregnant Women

Aim Infection with toxoplasma, listeria and cytomegalovirus (CMV) infections can negatively affect pregnancy outcomes. Awareness of these infections, knowledge of preventive practices and pertinent behaviours was assessed. Methods A survey of patients at antenatal clinics in a Dublin maternity hospital was conducted over a six month period. Analysis was undertaken using SPSS. Results The response rate was 36% (287/800). One in two respondents were aware of toxoplasma, one in four of Listeria but only 1 in 10 of CMV. Overall, knowledge was highest among older, more educated pregnant women. Nativity had a significant effect on knowledge and behaviour, but increasing parity did not. However the majority practised key safe behaviours. Conclusion Information must be conveyed to pregnant women in a user friendly format and in a culturally sensitive way.

Cortical Visual Impairment in Congenital Cytomegalovirus Infection

PURPOSE

To describe the presentation, evolution, and long-term outcome of cortical visual impairment (CVI) in patients with symptomatic congenital cytomegalovirus (CMV) infection, and to identify risk factors for the development of CVI in patients with symptomatic congenital CMV.

METHODS

Retrospective subanalysis of a long-term prospective cohort study with data gathered from 1982 to 2013.

RESULTS

Eleven of 77 (14.3%) patients with symptomatic CMV, 0 of 109 with asymptomatic CMV, and 51 control patients had CVI. Overall, patients with symptomatic CMV had worse vision than patients with asymptomatic CMV, who in turn had worse vision than control patients. Microcephaly, intracranial calcification, dilatation of ventricles, encephalomalacia, seizure at birth, optic atrophy, chorioretinitis/retinal scars, strabismus, and neonatal onset of sensorineural hearing loss were risk factors associated with CVI.

CONCLUSIONS

CVI may result from symptomatic congenital CMV infection. The relationship of CVI and its risk factors in patients with CMV suggests the potential to predict the development of CVI through predictive modeling in future research. Early screening of CVI in children born with symptomatic congenital CMV can facilitate educational, social, and developmental interventions. [J Pediatr Ophthalmol Strabismus. 2019;56(3):194-202.].

Time dependent risk of cytomegalovirus infection in Japan

Cytomegalovirus (CMV), a major cause of congenital infections, has high morbidity and mortality rates associated with it. However, a decline in the proportion of anti-CMV antibody-positive individuals has been observed. The present study aimed to quantify the time-dependent transmission dynamics of CMV infection in Japan by analysing the seroepidemiological datasets for pregnant women collected from five cord blood banks from 1996 to 2009. By employing a mathematical model and using the maternal age distribution of child births from the census data, we computed the seroprevalence among the pregnant Japanese women as a function of time. A decreasing trend was observed for the force of infection, i.e. the rate at which susceptible individuals are infected, which decreased from 0.04 to 0.03 (/year) over the period from 1996 to 2009. While the total number of births has steadily declined in Japan over time, the estimated number of live births at risk of CMV infection has increased over time. Our data reveal that in 2009 in Japan, at least 0.3 million women may have been at risk of contracting a CMV infection during the perinatal period. Moreover, about 2,726 congenital CMV infections were expected to have occurred in 2009. The average age at infection has already reached the child bearing age, and it must be noted that the age at infection can be elevated even more, reaching close to 30 years old which is the ongoing mean age at child delivery. It must be remembered that, if vaccine can become one of the options for the control of CMV in the future, the vaccination can lead to further elevation of age at infection, which may coincide with further elevation of mothers' age of delivery in Japan.

Optic Nerve Aplasia, Chorioretinal Hypoplasia, and Microcornea After In Utero Infection With Cytomegalovirus

Optic nerve aplasia (ONA) is a rare phenomenon characterized by absence of the optic nerve, retinal blood vessels, and retinal ganglion cells. The authors report a case of optic nerve aplasia in association with congenital cytomegalovirus (CMV) infection, conveyed through multimodal imaging including color fundus photography, fluorescein angiography, and B-scan ultrasonography. Furthermore, the authors review the common ocular findings and previously reported cases of ONA in congenital CMV infection. Screening and counseling can be performed to advise parents about the potential risks and severity of this rare clinical manifestation. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:e171-e175.].

Genotyping of Cytomegalovirus from Symptomatic Infected Neonates in Iraq

Among all other viruses, human cytomegalovirus (HCMV) is the most frequent cause of congenital infection worldwide. Strain variation in HCMV may predict severity or outcome of congenital HCMV disease. Previous studies have associated a particular genotype with specific sequelae or more severe illness, but the results were contradictory. There are no previous studies addressing the genotype of HCMV in Iraq. Therefore, the present study is aimed at molecular detection and genotyping of HCMV isolated from symptomatic congenitally/perinatally infected neonates. This prospective study comprised 24 serum samples from symptomatic neonates with congenital/perinatal infection. Viral DNA was extracted from these serum samples; nested polymerase chain reaction was used to amplify the HCMV gB (UL55) gene. Polymerase chain reaction products of the second round of amplification were subjected to direct Sanger sequencing. Bioedit and MEGA5 software (EMBL-EBI, Hinxton, Cambridgeshire, UK) were used for alignment and construction of a phylogenetic tree. Human cytomegalovirus DNA was detected in 23 of 24 samples (95.8%). According to the phylogenetic analysis, three genotypes of the virus were identified; gB1, gB2, and gB3 genotypes. However, the gB4 genotype was not detected. Human cytomegalovirus gB3 was the most frequent genotype: 14 of 24 (58.33%) among symptomatic infected infants, followed by gB1 (6/24; 25%) and gB2 (4/24; 16.67%). A mixed HCMV infection with gB3/gB1 was detected in only one case. Human cytomegalovirus gB3 was the most predominant genotype among symptomatic congenitally/perinatally HCMV-infected neonates. No association was found between B3 genotype and specific clinical presentation. Jaundice was the most common clinical feature among symptomatically infected neonates, followed by hepatosplenomegaly.

Direct Saliva Real-time Polymerase Chain Reaction Assay Shows Low Birth Prevalence of Congenital Cytomegalovirus Infection in Urban Western India

BACKGROUND

Congenital cytomegalovirus (cCMV) infection is the leading infectious cause of mental retardation, developmental delay and sensorineural deafness. Nonprimary infection plays a major role in transmission of this infection in countries with high maternal seroprevalence. Noninvasive sampling and testing is a useful alternative to traditional methods of laboratory detection of congenital CMV infection. The present study was conducted to understand birth prevalence of cCMV infection using molecular techniques, in an urban setting of a developing country with evidence of high maternal seroprevalence.

METHODS

Universal newborn screening for cCMV was performed for 750 infants born at a tertiary care center in Western India. Real-time polymerase chain reaction was directly carried out on saliva samples. Follow-up laboratory testing of saliva, urine and blood was performed for neonates identified as positive. Sequential clinical follow-up was offered to the affected infants.

RESULTS

A birth prevalence of 0.4% (95% CI: 0.13-1.2) was observed with 3 of 750 babies confirmed to be positive for cCMV infection. All 3 babies were born to seropositive mothers (anti-CMV immunoglobulin G positive). One of the babies detected was symptomatic with sepsis like features. All of them survived and did not develop any sequelae up to 1 year of age.

CONCLUSION

The use of direct real-time polymerase chain reaction of saliva samples can be considered as a feasible option for newborn screening of congenital CMV infection in developing countries. Relatively low birth prevalence of cCMV infection was observed in our study, which needs to be corroborated through further studies.

Congenital cytomegalic inclusion disease with disseminated Herpes simplex infection

We report a case of congenital cytomegalovirus and Herpes simplex virus infection suspected via ultrasound indicated by the presence of fetal cerebral abnormalities. The pregnancy was electively terminated at 31 weeks of gestation. The postmortem examination of the foetus showed brain with lissencephaly. The histopathological examination revealed numerous enlarged cells containing cytomegalic inclusions and multinucleated giant cells in multiple fetal organs and placenta. Documented evidence of histopathological detection of cytomegalovirus inclusions in multiple organs are very sparse in literature. This case highlights the causal relationship of viral infections in early pregnancy and abnormalities of the central nervous system.

Long-term hearing outcomes of children with symptomatic congenital CMV treated with valganciclovir

OBJECTIVES

Congenital human cytomegalovirus (cCMV) is a leading cause of pediatric hearing loss. Recent literature has suggested that valganciclovir (VGCV) therapy can improve hearing outcomes. The objective of this study was to evaluate the long-term hearing outcomes among symptomatic CMV patients treated with VGCV.

METHODS

A retrospective chart review of symptomatic CMV patients treated with VGCV was completed. The primary endpoint was the change in best ear hearing scores prior to treatment and after follow-up audiograms. A paired-sample t-test was used to evaluate the data.

RESULTS

A total of 16 children were included in the study and participants were followed for an average of 3.2 years. There was a measurable worsening, but not a statistically significant change in the best ear hearing scores, where the mean change was 11.9 dB (p-value = 0.070). However, 14/16 patients (87.5%, p-value<0.001) were found to have clinically significant worsening of hearing. The mean change in hearing scores for the left and right ear was 14.2 dB (p-value = 0.023) and 15.5 dB (p-value = 0.032), respectively. Mean elapsed time for progressive loss was 2.6 ± 0.2 years. When comparing the better or worse ear, there was no pattern for which ear deteriorated earlier or more frequently.

CONCLUSIONS

Our data did show a measurable, but not a statistically significant worsening outcome in best ear hearing. There was a significant change in both left and right ear hearing. Our results suggest that VGCV may provide only a short-term improvement in hearing outcomes; however, these preliminary post-hoc findings suggest the need for a more rigorous evaluation.

[Diagnostics of congenital cytomegalovirus in Denmark]

Congenital cytomegalovirus (cCMV) is the most common infectious cause of congenital malformations in Denmark. The disease is not notifiable, and there are no national data. A regional Danish prospective study from the 1970s found a cCMV incidence of 0.4%. We propose three algorithms for microbiological diagnosing: 1) Testing of pregnant women should only be -applied, when symptoms compatible with CMV infection are present, and no other diagnoses are found. 2) In children less than three weeks of age urine is the -preferred sample. 3) Retrospectively, cCMV may be diagnosed on dried blood spots, if the mother is CMV IgG-positive.

Human cytomegalovirus utilises cellular dual-specificity tyrosine phosphorylation-regulated kinases during placental replication

INTRODUCTION

Congenital cytomegalovirus (HCMV) infection may cause significant fetal malformation and in severe cases fetal and neonatal death. Fetal injury may be caused indirectly by the placental response to infection. Dual-specificity tyrosine phosphorylation-regulated kinases (DYRKs) have recently been identified as critical kinases for HCMV replication. In this study we provide first evidence that DYRK1A and DYRK1B are utilised during HCMV placental replication.

METHODS

DYRK expression was investigated in AD169- and Merlin-infected TEV-1 trophoblast cells, ex vivo placental explants and naturally infected clinical placentae by immunofluorescence, western blot, co-immunoprecipitation and RT-qPCR.

RESULTS

HCMV-infected placental cells showed accumulation and re-localisation of DYRK1A and DYRK1B protein to areas of cytoplasmic virion assembly complexes and nuclear viral replication compartments, respectively. This accumulation was a result of upregulated DYRK1A/B protein expression with HCMV inducing up to a 5.3-fold increase in DYRK1A and up to a 4.7-fold increase in DYRK1B protein, relative to mock-infected TEV-1 cells (p < 0.0001). Increased DYRK protein expression was correlated with DYRK1A/B mRNA upregulation, with HCMV-infected cells showing up to a 3.7-fold increase and 2.9-fold increase in DYRK1A and DYRK1B mRNA levels respectively (p < 0.05). Protein-protein interactions were detected between DYRK1A/1B complexes and HCMV immediate early IE2p86, early pp65 and pUL44 and late pp150 proteins. Treatment of HCMV-infected TEV-1 cells and placental explants with DYRK inhibitors significantly inhibited HCMV replication (p < 0.05) indicating these cellular kinases are required during HCMV placental replication.

CONCLUSION

HCMV modulates cellular DYRKs during placental replication which may have implications for congenital HCMV pathogenesis and represent promising antiviral targets.

Neonatal HCMV-related polymicrogyria in seroimmune women: What is the optimal pregnancy management?

BACKGROUND

Human cytomegalovirus (HCMV) infection is the most common congenital infection in developed countries. Recent studies highlighted similar percentages of symptoms in HCMV congenitally-infected infants following either primary or non-primary maternal infections.

OBJECTIVES

To highlight correlation between neonatal brain abnormalities, detected by ultrasounds and magnetic resonance image in HCMV congenitally-infected infants, and maternal virological parameters during pregnancy, especially in seroimmune mothers.

STUDY DESIGN

We considered the 36 HCMV congenitally-infected infants (26 asymptomatic and 10 symptomatic) referred to our center over 4 consecutive years. Maternal serologic data during pregnancy were available for all cases. Neonatal cranial ultrasound and magnetic resonance images were related to maternal virological findings during pregnancy.

RESULTS

Polymicrogyria was observed in 6/10 (60.0%) symptomatic and 0/26 (0%) asymptomatic newborns (p < 0.001). The 6 infants with polymicrogyria were all born to mothers who were HCMV IgG reactive with negative specific IgM, in the first trimester of pregnancy (range: 8-14 weeks). For these six women, pre-conceptional HCMV serologic information were absent and they all were considered immune for HCMV during pregnancy, therefore no further serologic investigation or specific educational and hygienic information were recommended during gestation.

CONCLUSION

These data highlight the elevated frequency of polymicrogyria in HCMV congenitally-infected infants born to mothers defined as seroimmune in the early stage of pregnancy and having no pre-existing serologic information. The paper stresses the potential utility of pre-conceptional screening to define maternal infection reliably (primary vs non-primary), and allow evidence-based counseling in women with positive serology, suggesting also preventive hygienic measures during pregnancy.

Biological relevance of Cytomegalovirus genetic variability in congenitally and postnatally infected children

BACKGROUND

Human cytomegalovirus (HCMV) is the leading cause of congenital infections resulting in severe morbidity and mortality among infected children. Although the virus is highly polymorphic, particularly in genes contributing to immune evasion, the mechanisms underlying its genetic variability and pathogenicity are only partially understood.

OBJECTIVES

We aimed to characterize different HCMV clinical strains isolated from 21 congenitally- or postnatally-infected children for in vitro growth properties and genetic polymorphisms.

STUDY DESIGN

The growth of various HCMV isolates was analyzed in different cell culture models. Genetic polymorphism was assessed by genetic and phylogenetic analysis of viral genes involved in virulence (UL144, US28, and UL18), latency (UL133-138), or drug resistance (UL54 and UL97).

RESULTS

Here, we report a high degree of genetic and phenotypic diversity in distinct HCMV clinical isolates, as shown by their in vitro growth properties. In particular, HCMV isolates displayed the highest degree of genetic variability in the UL144 gene, where we were able to define four distinct genotypes within the cohort based on UL144 heterogeneity. Lastly, among all isolates we were able to identify 36 mutations in UL54 and 2 in UL97.

CONCLUSIONS

Our findings indicate that surprisingly high levels of genetic HCMV variability correlate with a high degree of phenotypic polymorphism, which in turn might differentially influence the growth, fitness, and drug susceptibility of HCMV.

A fifty-year odyssey: prospects for a cytomegalovirus vaccine in transplant and congenital infection

INTRODUCTION

It has been almost fifty years since the Towne strain was used by Plotkin and collaborators as the first vaccine candidate for cytomegalovirus (CMV). While that approach showed partial efficacy, there have been a multitude of challenges to improve on the promise of a CMV vaccine. Efforts have been dichotomized into a therapeutic vaccine for patients with CMV-infected allografts, either stem cells or solid organ, and a prophylactic vaccine for congenital infection.

AREAS COVERED

This review will evaluate research prospects for a therapeutic vaccine for transplant recipients that recognizes CMV utilizing primarily T cell responses. Similarly, we will provide an extensive discussion on attempts to develop a vaccine to prevent the manifestations of congenital infection, based on eliciting a humoral anti-CMV protective response. The review will also describe newer developments that have upended the efforts toward such a vaccine through the discovery of a second pathway of CMV infection that utilizes an alternative receptor for entry using a series of antigens that have been determined to be important for prevention of infection.

EXPERT COMMENTARY

There is a concerted effort to unify separate therapeutic and prophylactic vaccine strategies into a single delivery agent that would be effective for both transplant-related and congenital infection.

Congenital Cytomegalovirus and HIV Perinatal Transmission

BACKGROUND

Congenital cytomegalovirus (CMV) infection (cCMV) is an important cause of hearing loss and cognitive impairment. Prior studies suggest that HIV-exposed children are at higher risk of acquiring cCMV. We assessed the presence, magnitude and risk factors associated with cCMV among infants born to HIV-infected women, who were not receiving antiretrovirals during pregnancy.

METHODS

cCMV and urinary CMV load were determined in a cohort of infants born to HIV-infected women not receiving antiretrovirals during pregnancy. Neonatal urines obtained at birth were tested for CMV DNA by qualitative and reflex quantitative real-time polymerase chain reaction.

RESULTS

Urine specimens were available for 992 (58.9%) of 1684 infants; 64 (6.5%) were CMV-positive. Mean CMV load (VL) was 470,276 copies/ml (range: < 200-2,000,000 copies/ml). Among 89 HIV-infected infants, 16 (18%) had cCMV versus 42 (4.9%) of 858 HIV-exposed, uninfected infants (P < 0.0001). cCMV was present in 23.2% of infants with in utero and 9.1% infants with intrapartum HIV infection (P < 0.0001). Rates of cCMV among HIV-infected infants were 4-fold greater (adjusted OR, 4.4; 95% CI: 2.3-8.2) and 6-fold greater among HIV in utero-infected infants (adjusted OR, 6; 95% CI: 3-12.1) compared with HIV-exposed, uninfected infants. cCMV was not associated with mode of delivery, gestational age, Apgar scores, 6-month infant mortality, maternal age, race/ethnicity, HIV viral load or CD4 count. Primary cCMV risk factors included infant HIV-infection, particularly in utero infection.

CONCLUSION

High rates of cCMV with high urinary CMV VL were observed in HIV-exposed infants. In utero HIV infection appears to be a major risk factor for cCMV in infants whose mothers have not received combination antiretroviral therapy in pregnancy.

Maternal Immunity and the Natural History of Congenital Human Cytomegalovirus Infection

Congenital human cytomegalovirus (HCMV) is the most common viral infection of the developing fetus, and a significant cause of neurodevelopmental abnormalities in infants and children. Congenital HCMV infections account for an estimated 25% of all cases of hearing loss in the US. It has long been argued that maternal adaptive immune responses to HCMV can modify both the likelihood of intrauterine transmission of HCMV, and the severity of fetal infection and risk of long term sequelae in infected infants. Over the last two decades, multiple studies have challenged this paradigm, including findings that have demonstrated that the vast majority of infants with congenital HCMV infections in most populations are born to women with established immunity prior to conception. Furthermore, the incidence of clinically apparent congenital HCMV infection in infants born to immune and non-immune pregnant women appears to be similar. These findings from natural history studies have important implications for the design, development, and testing of prophylactic vaccines and biologics for this perinatal infection. This brief overview will provide a discussion of existing data from human natural history studies and animal models of congenital HCMV infections that have described the role of maternal immunity in the natural history of this perinatal infection.

A Quiet Disease With Loud Manifestations

Cytomegalovirus (CMV) is the most common congenital virus passed from mother to fetus in the United States, and the most common acquired cause of sensorineural hearing loss. Neuroimaging in patients with symptomatic congenital CMV demonstrates abnormalities frequently, but many providers are unaware of the extent of these findings. We present a case of a 15-month-old girl with progressive sensorineural hearing loss and developmental delays. Magnetic resonance imaging of her brain was done by her otolaryngologist as part of a routine cochlear implant evaluation where it was found to be drastically abnormal and reported as a likely leukodystrophy. It was subsequently found to be related to congenital CMV on further evaluation. Congenital CMV should be considered in the differential of white matter hyperintensities, especially in the setting of sensorineural hearing loss, developmental delays, or both, and given how common CMV is around the world.