Early clinical manifestations and intellectual outcome in children with symptomatic congenital cytomegalovirus infection

Is fetal gender a risk factor for severe congenital cytomegalovirus infection?

Cytomegalovirus is the main cause of congenital viral infection and amniotic fluid viral load appears to be the single nonclinical prognostic factor. However, as in other infectious diseases, host genetics may influence the severity of the disease. To test this hypothesis, we looked retrospectively at the fetal gender in cases of severe congenital cytomegalovirus infection in our database. We also analyzed the international English literature covering this subject between 1985 and 2003. The proportion of females with brain abnormalities was statistically different from that of males (62/258: 24% vs 30/251: 12%, p = 0.004). The risk of abnormal brain development in infected fetuses was twice as high in females than in males (Chi(2) = 8.7; OR = 2, IC [1.26-3.21]). In our cases, amniotic fluid CMV DNA load was not significantly higher in males than in females (p = 0.06) and was also similar in severely and non-severely infected fetuses (p = 0.09).

Chronological changes of incidence and prognosis of children with asymptomatic congenital cytomegalovirus infection in Sapporo, Japan

BACKGROUND

Chronological changes of the incidence of congenital cytomegalovirus (CMV) infection and the longitudinal prognosis in children with asymptomatic congenital infection were investigated.

METHODS

Congenital CMV infection, as demonstrated by isolation of the virus within the first week of life, was diagnosed in infants born in Sapporo, Japan, during the 26-year period between 1977 and 2002.

RESULTS

Congenital infection was diagnosed in 37 (0.31%) of 11,938 infants. Thirty-two infants were (86.5%) asymptomatic and 5 (13.5%) were symptomatic at birth.

CONCLUSIONS

Although a decrease in the total incidence of congenital CMV infection has been seen in recent years, screening of congenital infection at birth seems to be necessary to detect late-onset neurodevelopmental sequelae.

Predictors of hearing loss in children with symptomatic congenital cytomegalovirus infection

OBJECTIVE

Congenital cytomegalovirus (CMV) infection is a major cause of sensorineural hearing loss (SNHL) and neurologic impairment in children. Although the majority of children with symptomatic congenital CMV infection develop hearing loss, many symptomatic infants have normal hearing. The purpose of this study was to identify indicators present in the newborn period that have predictive value for the development of hearing loss in children with symptomatic congenital CMV infection.

METHODS

Of the 190 children who had symptomatic congenital CMV infection and were born between 1966 and 1997 and enrolled in a follow-up study, hearing outcome was known for 180 children. Follow-up data were analyzed using univariate and multivariate logistic regression analyses to determine the specific demographic, newborn clinical, and laboratory findings predictive of hearing loss. The amount of infectious CMV in urine was quantified in a subset of 21 children who were born between 1994 and 1998.

RESULTS

The presence of intrauterine growth retardation, petechiae, hepatosplenomegaly, hepatitis, thrombocytopenia, and intracerebral calcifications was associated with the development of hearing loss on univariate analysis. The presence of microcephaly and other neurologic abnormalities was not predictive of hearing loss. Logistic regression analysis revealed that only petechiae and intrauterine growth retardation independently predicted hearing loss. None of the demographic and other newborn findings predicted progressive hearing loss. The children who developed hearing loss had higher urine CMV titers during infancy than those with normal hearing.

CONCLUSION

In children with symptomatic congenital CMV infection, evidence of disseminated infection with or without the presence of neurologic involvement at birth was predictive of the development of hearing loss. However, it was not possible to identify factors that are independently predictive of the development of progressive hearing loss.

Immunological evaluation and clinical aspects of children with congenital cytomegalovirus infection

To determine the ability of immunological response to human cytomegalovirus (CMV), the flow cytometric assay was evaluated as a tool for real-time monitoring of specific cellular immunity in children with congenital CMV infection. Longitudinal cohort study of 2 children with asymptomatic and 2 with symptomatic congenital CMV infection evaluated at birth and followed up with serial age-appropriate neurodevelopmental testing. Frequencies of CMV-specific CD4 (+) T cell in these children were detected by intracellular cytokines (ICC), interferon (IFN)-gamma and tumor necrosis factor (TNF)-alpha, staining. Findings detected by CT and MRI were the most sensitive predictor for neurodevelopmental prognosis. Frequencies of CMV-specific CD4(+) T cells detected by ICC, both IFN-gamma and TNF-alpha, were higher in 2 children with symptomatic congenital CMV infection than those in 2 children with asymptomatic congenital infection. Frequencies of CMV-specific CD4(+) T cells in 2 children with symptomatic congenital infection were significantly higher than those in 6 healthy children of 1 to 5-years of age with serum anti-CMV IgG antibody without serum anti-CMV IgM antibody and viral excretion in to urine (p < 0.01). The ICC assay reflects immunological activity against CMV infection in children with asymptomatic or symptomatic congenial infection. Categorizing findings obtained by the ICC assay may helps to determine the prognosis of children with congenital CMV infection.

Human cytomegalovirus as a direct pathogen: correlation of multiorgan involvement and cell distribution with clinical and pathological findings in a case of congenital inclusion disease

The human cytomegalovirus (HCMV), a member of the Herpesviridae, is the most frequent cause of congenital virus infections and a major cause of morbidity and mortality in immunocompromised patients. Due to the lack of an appropriate animal model, insight into the pathogenesis of HCMV infections originates primarily from in situ examination of HCMV-infected tissues. Although in immunocompromised adults such tests are complicated frequently by the presence of additional misleading pathogens, the absence of additional pathogens renders congenital inclusion disease the most suitable access for investigation of pathogenetic aspects of HCMV infections. Immunohistochemical examination of tissue sections from a boy with fatal congenital inclusion disease was undertaken to detect the extent of multiorgan and cell involvement. Adrenal gland, bone marrow, diencephalon, heart, kidney, liver, lung, pancreas, placenta, small bowel and spleen were included in this study. Detection of virus antigens from different phases of viral replication revealed that all investigated organs were infected by HCMV. Simultaneous detection of cell type specific marker molecules showed that a variety of cell types stained positive for HCMV antigens including endothelial cells, epithelial cells, smooth muscle cells, mesenchymal cells, hepatocytes, monocytes/macrophages and granulocytes. The lung, the pancreas, the kidneys and the liver were the major target organs with a high number of HCMV infected cells. This correlated with multiorgan failure as the cause of death and strongly indicates direct pathogenetic effects of HCMV.

Early predictors of neurodevelopmental outcome in symptomatic congenital cytomegalovirus infection

OBJECTIVE

To determine the ability of neonatal clinical, audiologic, and computed tomography (CT) findings to predict long-term neurodevelopmental outcome in children with symptomatic congenital cytomegalovirus (CMV) infection.

METHODS

Longitudinal cohort study of children (n = 41) with symptomatic congenital CMV infection evaluated at birth and followed up with serial age-appropriate neurodevelopmental testing. The performance of birth characteristics as predictors of long-term outcome were determined, and clinical and CT scoring systems were developed and correlated with intellectual outcome.

RESULTS

Microcephaly was the most specific predictor of mental retardation (100%; 95% CI 84.5-100) and major motor disability (92.3%; 95% CI 74.8-99). An abnormality detected by CT was the most sensitive predictor for mental retardation (100%; 95% CI 82.3-100) and motor disability (100%; 95% CI 78.2-100). A highly significant (P <.001) positive correlation was found between head size at birth and the intelligence/developmental quotient (IQ/DQ). Approximately 29% of children had an IQ/DQ >90. There was no association between sensorineural hearing loss at birth and cognitive outcome. However, children with sensorineural hearing loss on follow-up (congenital and late-onset) had a lower IQ/DQ (P =.006) than those with normal hearing.

CONCLUSIONS

The presence of microcephaly at birth was the most specific predictor of poor cognitive outcome in children with symptomatic congenital CMV infection, whereas children with normal findings on head CT and head circumference proportional to weight exhibited a good cognitive outcome.

Prenatal indicators of congenital cytomegalovirus infection

OBJECTIVE

To assess the validity of a diagnostic protocol designed to predict the outcome of newborns of mothers suspected to have primary cytomegalovirus (CMV) infection during the first 4 months of pregnancy.

STUDY DESIGN

Anti-CMV immunoglobulin (Ig) M detection by enzyme immunoassay and immunoblot together with the determination of anti-CMV IgG avidity allowed us to classify 456 women as (1) uninfected, (2) undergoing either a primary or a recurrent infection, or (3) having an undefined serologic condition. Prenatal diagnosis was carried out at 21 to 23 weeks' gestation for women. The presence of the virus in the amniotic fluid was determined by culture, polymerase chain reaction, and quantitative polymerase chain reaction. Macroscopic and histologic examinations were undertaken on tissue from aborted fetuses, whereas for newborns culture was performed on urine sampled during the first week of life.

RESULTS

Congenital infections were found exclusively among women undergoing a primary infection. The quantitative determination of CMV DNA in the amniotic fluid of at least 10(3) genome equivalents gave a 100% certainty of detecting an infected fetus. Higher viral loads were associated with fetuses or newborns with symptoms.

CONCLUSIONS

IgM tests and the IgG avidity determination can identify all women at risk of transmitting CMV. Furthermore, a high CMV DNA load in amniotic fluid could be an indicator of symptomatic congenital infection at a relatively early stage of pregnancy.

Maternal IgG avidity and IgM detected by blot as diagnostic tools to identify pregnant women at risk of transmitting cytomegalovirus

In this study, we determined the avidity index (AI) of anticytomegalovirus (CMV) immunoglobulin G (IgG) and the anti-CMV immunoglobulin M (IgM) profile in 124 pregnant women, 87 of whom were considered at risk of transmitting CMV infection to their offspring and 37 of whom were at no risk. IgG avidity and blot for IgM were performed on two serum samples from each woman, at 6-18 weeks' gestation and at 20-23 weeks' gestation. Pregnancy outcomes were monitored. The results obtained showed that the determination of anti-CMV IgG avidity at 6-18 weeks' gestation can identify all women who would have an infected fetus/newborn (100% sensitivity), whereas IgM detected by blot had poorer results (69% sensitivity). Interestingly, at 20-23 weeks' gestation, the sensitivity of IgM detection by blot was higher than that obtained by avidity (75 % and 63%, respectively) and the combination of IgG avidity and IgM by blot yielded the best results (81% sensitivity).

Peptidomimetic inhibitors of the human cytomegalovirus protease

The development of peptidomimetic inhibitors of the human cytomegalovirus (HCMV) protease showing sub-micromolar potency in an enzymatic assay is described. Selective substitution of the amino acid residues of these inhibitors led to the identification of tripeptide inhibitors showing improvements in inhibitor potency of 27-fold relative to inhibitor 39 based upon the natural tetrapeptide sequence. Small side chains at P1 were well tolerated by this enzyme, a fact consistent with previous observations. The S2 binding pocket of HCMV protease was very permissive, tolerating lipophilic and basic residues. The substitutions tried at P3 indicated that a small increase in inhibitor potency could be realized by the substitution of a tert-leucine residue for valine. Substitutions of the N-terminal capping group did not significantly affect inhibitor potency. Pentafluoroethyl ketones, alpha,alpha-difluoro-beta-keto amides, phosphonates and alpha-keto amides were all effective substitutions for the activated carbonyl component and gave inhibitors which were selective for HCMV protease. A slight increase in potency was observed by lengthening the P1' residue of the alpha-keto amide series of inhibitors. This position also tolerated a variety of groups making this a potential site for future modifications which could modulate the physicochemical properties of these molecules.

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.

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.

Pathogenesis of ocular cytomegalovirus infection in the immunocompromised host

Balb/C nude and C.B-17 SCID mice were inoculated with salivary gland passaged cytomegalovirus (SG-MCMV) intraperitoneally. Dissemination of the virus in the systemic and ocular tissues was studied by the direct immunofluorescence test, and the virus growth in each tissue was titrated in mouse embryonic fibroblasts. The mode of viral spread was assessed by inhibiting macrophage function by silica and administering polyclonal murine anti-MCMV antibody in the circulation. The virus first reached the eyelid, conjunctiva, and cornea. Subsequently, it spread in the outer ocular muscles and chorioretinal layer. Ocular tissues were involved as part of a generalized infection. Abrogation of macrophage function by silica did not affect the outcome of the viral distribution. Administration of antibody prior to and 3 days after the viral infection prevented virus dissemination. Ocular CMV infection occurred initially at the anterior segment of the eye in an immunocompromised host. Free virus, not macrophage-bound virus, disseminated via the bloodstream.

The natural history of fetal cytomegalovirus infection as assessed by serial ultrasound and fetal blood sampling: a case report

A patient in whom intrauterine fetal cytomegalovirus (CMV) infection was diagnosed at approximately 25 weeks' gestation is presented. The fetus was evaluated by serial fetal blood samplings and ultrasound examinations. The fetus manifested evidence of severe thrombocytopenia and hepatic inflammation, with recovery over a period of approximately 8 weeks. The initial sonographic findings of marked fetal ascites and cardiomegaly gradually resolved; ventriculomegaly developed during the third trimester. At delivery, the baby was morphologically normal with the exception of mild ventriculomegaly. Cord blood was negative for CMV IgM but urine was culture-positive for CMV. At age 3, the child has a severe but stable unilateral hearing deficit and is otherwise developmentally normal. This case demonstrates the utility of serial ultrasound and fetal blood sampling in the prenatal diagnosis and management of fetal CMV infection.

Predicting the outcome of symptomatic congenital cytomegalovirus infection

The prognosis of babies with symptomatic congenital cytomegalovirus (CMV) infection is worse than for those with asymptomatic CMV, but is difficult to quantify. Babies affected as a result of primary maternal CMV are at greater risk than after reactivation CMV. Chorioretinitis occurs in 10-15% of symptomatic babies and almost always indicates significant mental impairment. Microcephaly occurs in around 50% at birth, but does not always persist, and does not necessarily imply later neurological handicap. Investigative findings that increase the likelihood of handicap include radiographic or computerized tomography scan finding of intracranial calcification and raised cerebrospinal fluid protein. Late deafness is always unpredictable and all babies with congenital CMV infection should have an audiological follow up. The mortality of symptomatic congenital CMV infection is about 30%.

The impact of perioperative factors on subsequent intelligence quotient deficits in children treated for medulloblastoma/posterior fossa primitive neuroectodermal tumors

BACKGROUND

Despite success in treating children with medulloblastoma/posterior fossa primitive neuroectodermal tumor (PF PNET), some children survive with significant neurocognitive sequelae. This study was performed to understand better the significance of perioperative factors on subsequent full scale intelligence quotient (FSIQ) deterioration in these children.

METHODS

Twenty-eight children who underwent prospective and serial neurocognitive testing were studied. All children underwent surgery followed by radiotherapy with or without chemotherapy between 1983 and 1987 for medulloblastoma/PF PNET and were disease free when this study was conducted. IQ testing was performed before surgery and after the completion of radiation therapy. The clinical courses of the patients were correlated with changes in the corresponding intelligence quotients of each child. Factors correlating with neurocognitive declines were examined by chi-square or Fisher exact test analysis. Differences in mean IQs were examined by the t test. Factors found to be significant were analyzed by exact logistic regression analysis.

RESULTS

The presence of adverse factors such as neurologic deficits, meningitis, or shunt infections, or the need for repeat surgery was correlated significantly with IQ deficits after treatment. Of the subset of children with one or more of these factors, 13 of 16 (81%) sustained decreases in FSIQ; 7 of 16 (43.8%) had decreases of 20 points of more. In contrast, only 3 of 12 (25%) of the children without the factors sustained FSIQ decreases, and no child sustained a decrease of more than 13 points. The mean FSIQ change after treatment in the group with factors was -15.7 (95% confidence interval [CI]: -24.0, -8.4), and the median was -18. The mean FSIQ change in the group without factors was 4.8 (95% CI: -0.5, 10.1), and the median was 5. The difference in mean FSIQ change between the two groups was significant (P < 0.0001). On univariate analysis, both the presence of adverse factors and an age less than six years correlated with neurocognitive deficit. On regression analysis, only the presence of adverse factors was significant (odds ratio 11.53; 95% CI, 1.65-116.58; P = 0.009), whereas age was not (P = 0.27).

CONCLUSIONS

Perioperative events or complications may account for some of the neurocognitive deterioration seen in these children after treatment, especially in the very young. The occurrence of these factors is associated with a significantly greater risk of IQ deterioration. Studies of the neurocognitive effects of treatment for children with medulloblastoma/PF PNET should include an analysis of these postoperative factors.

A comparative study of congenital and postnatally acquired human cytomegalovirus infection in infants: lack of expression of viral immediate early protein in congenital cases

Postmortem tissues from infants with congenital and postnatally acquired human cytomegalovirus (HCMV) infection were examined by routine histology, immunohistochemistry (IHC) and in situ hybridization (ISH) to determine the dynamics of viral replication in vivo. Histologically, infants in both groups showed characteristic inclusion-bearing cells most commonly in lung, kidney, liver and pancreas. IHC for late proteins using a rabbit polyclonal antibody and ISH for viral genomes detected most of the infected cells as nuclear and/or cytoplasmic signals. However, immunostaining with a monoclonal antibody against viral immediate early (IE) proteins was variable depending on the stage of viral replication within an individual infected cell. In tissues of infants with postnatal HCMV infection, many cells harboured IE antigens, while in tissues from congenital cases most of the affected cells lacked IE antigens and only a few showed cytoplasmic staining. The difference was not caused by the antigenic diversity among viral strains as confirmed by in vitro study. Our findings suggested that congenital infections exhibited uniformly late stage proteins with inactive viral replication at death, while acquired ones remained active. The different viral activity may reflect the immune status of congenital and acquired HCMV infections.

Ganciclovir therapy for symptomatic congenital cytomegalovirus infection in infants: a two-regimen experience

The efficacy of two regimens of ganciclovir therapy was evaluated in 12 infants with symptomatic congenital cytomegalovirus (CMV) infection. Virologic investigations included culture from urine, saliva, and cerebrospinal fluid, detection of CMV DNA by polymerase chain reaction, and detection of CMV class-specific antibodies (IgG, IgA, IgM) by enzyme immunoassays. Six infants were given ganciclovir, 5 mg/kg twice daily for 2 weeks (group 1); the other six infants were given 7.5 mg/kg twice daily for 2 weeks and 10 mg/kg three times weekly for 3 months (group 2). In group 1 the CMV cultures of specimens from three infants became sterile; two of these infants also had negative results on CMV DNA studies; results of culture and CMV DNA study were still positive after ganciclovir therapy in the remaining three infants. Subsequently, normal outcome was observed in only two patients. In group 2, all infants had negative CMV-culture and CMV DNA results; clinical improvement was evident in five infants, one of whom had later development of mild psychomotor retardation. In another infant, severe psychomotor retardation and hearing loss developed after transient improvement developed. These preliminary data indicate that a ganciclovir regimen including a higher dose and more prolonged therapy might be more effective in infants with symptomatic congenital CMV infection.

Cerebral palsy

Over the last century, our understanding of cerebral palsy has broadened. For example, we now know that it results more commonly from prenatal abnormalities than from perinatal difficulties. Yet, in most cases we are still no closer to understanding the operant mechanism of injury or how the injury results in the expressed motor disorder. Hopefully, the strides being made in neurodevelopmental physiology and neurotransmitter communication will help elucidate the mechanism of injury in cerebral palsy and thereby lead to methods of prevention. Meanwhile, comprehensive clinical evaluation and treatment and periodic reassessment will help tailor strategies to the individual needs of the child. This should enable the child with cerebral palsy to optimize his or her function in society.

Ganciclovir therapy of congenital cytomegalovirus disease

A newborn with cytomegalovirus disease with cerebral involvement was treated with ganciclovir for 21 days. The treatment resulted in only temporary cessation of virus shedding in the urine and probably had no ameliorating effect on the long-term clinical outcome.

Congenital infections and the nervous system

Despite vaccines, new antimicrobials, and improved hygienic practices, congenital infections remain an important cause of death and long-term neurologic morbidity among infants world-wide. Important agents include Toxoplasma gondii, cytomegalovirus, Treponema pallidum, herpes simplex virus types 1 and 2, and rubella virus. In addition, several other agents, such as the varicella zoster virus, human parvovirus B19, and Borrelia burgdorferi, can potentially infect the fetus and cause adverse fetal outcomes. This article provides an overview of these infectious disorders and outlines current strategies for acute treatment and long-term management.

Evaluation of a microtiter plate fluorescent-antibody assay for rapid detection of human cytomegalovirus infection

The use of monoclonal antibody (MAb) p63-27, which is reactive with the major immediate-early human cytomegalovirus (HCMV) protein pp72, was explored for the rapid diagnosis of HCMV viruria. The rapid assay detected all but 1 of 19 specimens identified by standard virus isolation methods from 1,676 newborn urine specimens, achieving a sensitivity of 94.5% and a specificity of 100%. The monoclonal antibody recognized 260 randomly obtained clinical isolates of HCMV, indicating the suitability of this reagent for use in screening assays. The sensitivity of the microtiter plate method declined rapidly for specimen from older infants and children with congenital CMV infection and virus-infected children attending a day-care center and was judged to be unacceptable for screening populations in this age group.

Teratology in pediatric practice

A range of infections, physical agents, maternal diseases and metabolic states, drugs, and chemicals have been demonstrated to be human teratogens. These agents cause structural or functional disabilities postnatally in exposed embryos and fetuses. Such disabilities are potentially totally preventable through public education and awareness. Pediatricians must be able to recognize potential teratogenic exposures, diagnose teratogenically-induced disabilities, and be knowledgeable in the natural history of these disorders so that they can support and educate those who care for these children in the home and in the community.

Outcome of confirmed symptomatic congenital cytomegalovirus infection

Sixty five neonates with confirmed symptomatic congenital cytomegalovirus infection were followed up prospectively until they were 3 to 4 year of age. Twenty nine children (45%) had neurological impairment of whom 22 had gross motor or psychomotor abnormalities; in the remaining seven sensorineural deafness was the main abnormality. Infants who had had neurological signs during the neonatal period had a worse prognosis than those who had not, with 16/22 (73%) and 13/43 (30%) having neurological deficit at follow up, respectively. Our results indicate that the prognosis for infants with symptomatic congenital cytomegalovirus infection is better than previously reported.

Lissencephaly-pachygyria associated with congenital cytomegalovirus infection

We report the presence of major cerebral migrational defects in five severely, multiply handicapped children with congenital cytomegalovirus (CMV) infection. These patients had both computed tomographic (CT) scan and magnetic resonance imaging (MRI) evidence of marked migrational central nervous system defects consistent anatomically with the spectrum of lissencephaly-pachygyria, a disorder commonly idiopathic or associated with chromosomal abnormalities or with unknown early gestational insults. Neuroradiologic features included broad, flat gyri, shallow sulci, incomplete opercularization, ventriculomegaly, periventricular calcifications, and white-matter hypodensity on CT scans or increased signal intensity on long-TR MRI scans. Evidence for congenital CMV infection included prenatal onset of microcephaly, periventricular calcifications, neonatal jaundice, hepatomegaly, elevated CMV-specific immunoglobulin M, or viral isolation from urine. Previous reports of the neurologic sequelae of CMV have emphasized varying degrees of psychomotor retardation, cerebral palsy and epilepsy due to polymicrogyria, periventricular calcification, microcephaly, or rarely, hydrocephalus. Our patients appear to represent extremely severe examples of the effects of CMV on neurologic growth, maturation, and development. Recognition of these severe migrational abnormalities was improved by use of MRI, a technique that affords superior definition of the nature and extent of gyral and white-matter abnormalities. We suggest that these abnormalities may be more common than has previously been recognized.

Cytomegalovirus testing: antibody determinations and virus cultures with recommendations for use

Human cytomegalovirus is a ubiquitous virus with the property of becoming latent in the immunocompetent host. It can also cause devastating infections in the immunocompromised patient. Several different assays are available to detect either cytomegalovirus antibodies or cytomegalovirus itself, five of which are used at the University of Wisconsin Hospitals and Clinics and the Wisconsin State Laboratory of Hygiene. The latex agglutination (LA) test is used to detect antibody positivity in transplant donors, transplant recipients, and others. The complement fixation (CF) test is used to detect seroconversion or reactivation of infection in the CMV positive host. The immunofluorescent antibody-IgM (IFA-IgM) test is used to diagnose infection in congenitally or neonatally infected infants. The "routine" CMV culture is the "gold standard" for the detection of the cytomegalovirus in patient secretions. The shell vial assay, a rapid method of detecting virus, is most useful when contemplating therapy for active CMV infection. The advantages and limitations, as well as the timing and appropriateness of each test, are reviewed.

Outcome in children with symptomatic congenital cytomegalovirus infection

To determine factors that are associated with adverse developmental outcome after congenital cytomegalovirus infection, we reviewed the clinical, laboratory, and radiographic findings in 18 children with symptomatic congenital cytomegalovirus infections. When children with adverse outcomes (intelligence or developmental quotients of 50 or less, n = 10) were compared with children with mild sequelae (intelligence or developmental quotients of 70 or higher, n = 8), we found no relationship between developmental outcome and neonatal clinical features (birth weight, jaundice, hepatomegaly, splenomegaly, or petechiae). With the possible exception of intracranial calcifications, no single clinical or radiographic feature was associated with a specific developmental outcome. However, children who had postnatal microcephaly, postnatal seizures, and an abnormal central nervous system imaging study were more likely to have severe developmental sequelae.

Intellectual ability of children after perinatal cytomegalovirus infection

The intellectual ability of 16 children who had not had congenital cytomegalovirus (CMV) infection, but acquired it before the age of six months, was compared with that of two other groups: one comprising 32 children who had had CMV-excreting mothers but who were not infected themselves: the other comprising 18 healthy controls. Serial audiological, ophthalmological and psychometric examinations were performed. The only statistically significant difference found was that the children with acquired CMV infection had lower mean arithmetic scores. The results suggest that healthy term infants who acquire early CMV infection are not at increased risk of intellectual impairment.

Human cytomegalovirus nucleic acids in tissues from congenitally infected infants

In situ nucleic acid hybridization methods were used to study autopsy tissues from 2 infants with clinical or pathologic evidence of congenital cytomegalovirus infections: a premature infant with multiple congenital malformations and inclusion bodies in several organs and an infant with culture-proved symptomatic congenital cytomegalovirus infection. Cytomegalovirus nucleic acids were detected in lung, kidney, adrenal, thyroid, skin, pancreas, and anterior pituitary tissues. In the second infant, hybridization studies of neural tissues failed to reveal cytomegalovirus nucleic acids despite neuropathologic abnormalities consisting of extensive necrotizing ependymitis and periventricular cavitation.

Epidemiologic patterns in childhood hearing loss: a review

In an attempt to clarify international epidemiologic trends, a review of the published literature pertaining to childhood hearing loss is presented. Inconsistencies of methodology and classification, which complicate the interpretation of data and make difficult the quantification of the influence of genuine population differences, are discussed. Selective review of the literature allows certain crude statements to be made regarding childhood hearing loss. In developed countries, serous otitis media is the most common cause of hearing loss in children, affecting up to two thirds of preschool children. In addition, 1.0-2.0/1000 children have bilateral SNHL of at least 50 dB. In underdeveloped countries, suppurative middle ear disease is common and is still frequently associated with either an intratemporal or intracranial complication. SNHL appears to occur almost twice as often as in developed countries, with a greater proportion being of infectious etiology. In specific populations, the Inuits, Amerindians and Aboriginals, acute and chronic suppurative otitis media are almost endemic, yet both cholesteatoma and serous otitis media are uncommon.

Acquisition of cytomegalovirus infection: an update

Human cytomegalovirus (CMV) is a ubiquitous deoxyribonucleic acid virus that commonly infects a majority of individuals at some time during their life. Although most of these CMV infections are asymptomatic, certain patient groups are at risk to develop serious illness. Understanding the epidemiology of this virus is a key element in the development of strategies for preventing CMV disease. However, a number of features of this virus complicate such understanding. Following infection, CMV can remain latent, with subsequent reactivation; the factors controlling latency and reactivation and those factors which determine whether a CMV infection will be symptomatic are unknown. CMV disease can be acquired by natural routes, including horizontal and vertical transmission. Due to the ubiquity of CMV, the delineation of CMV transmission by these natural routes is complicated by the myriad of possible sources. Moreover, concerns over the risk of CMV transmission to the seronegative pregnant female have been raised in relation to preventing CMV transmission. By using molecular biologic techniques, much knowledge has been gained regarding the transmission of CMV disease by natural routes; however, a number of questions remain unanswered. The transmission of CMV infection by natural routes is therefore reviewed and the issues are highlighted. Primary infection, reactivation, and reinfection are the types of active CMV infections that can occur in an immunocompromised patient. In addition to natural routes of infection, introduction of presumably latently infected organs and requirements for multiple blood transfusions increase potential exposure to CMV in the immunocompromised patient. Understanding the epidemiology of CMV infections in the immunocompromised patient is difficult and in some instances controversial due to the complexity and interdependency of a number of factors which lead to CMV infection. In an immunocompromised individual, a major risk factor in developing overt CMV-related disease is associated with the serological status of an organ donor, the recipient, and the blood product given to these patients. In addition, a large body of inferential data supports the transmission of CMV by blood products or organs from seropositive donors; however, the mechanisms by which transmission occurs remain unclear. The possible sources and mechanisms of transmission of CMV infections in the immunocompromised host are reviewed. Lastly, strategies for the ultimate prevention of CMV disease are discussed in light of the epidemiology of CMV infections. To date, these strategies have included use of CMV-seronegative blood products or organs, antiviral agents, and vaccines.(ABSTRACT TRUNCATED AT 400 WORDS)