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Choodinatha HK, Jeon MR, Choi BY, Lee KN, Kim HJ, Park JY. Cytomegalovirus infection during pregnancy. Obstet Gynecol Sci 2023; 66:463-476. [PMID: 37537975 PMCID: PMC10663402 DOI: 10.5468/ogs.23117] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/06/2023] [Accepted: 07/04/2023] [Indexed: 08/05/2023] Open
Abstract
Cytomegalovirus (CMV) infection during pregnancy is a global silent problem. Additionally, it is the leading cause of congenital infections, non-genetic sensorineural hearing loss, and neurodevelopmental delays in infants. However, this has barely been recognized globally. This condition lacks adequate attention, which is further emphasized by the lack of awareness among healthcare workers and the general population. The impact of CMV infection is often overlooked because of the asymptomatic nature of its presentation in infected pregnant women and newborns, difficulty in diagnosis, and the perception that infants born to women with pre-existing antibodies against CMV have normal neonatal outcomes. This article highlights the latest information on the epidemiology, transmission, clinical manifestations, and development of CMV infection and its management. We reviewed the pathophysiology and clinical manifestations of CMV infection in pregnant women, diagnostic methods, including screening and prognostic markers, and updates in treatment modalities. Current advancements in research on vaccination and hyperimmunoglobulins with worldwide treatment protocols are highlighted.
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Affiliation(s)
- Harshitha Kallubhavi Choodinatha
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Korea
| | - Min Ryeong Jeon
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Korea
| | - Bo Young Choi
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Korea
| | - Kyong-No Lee
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Korea
| | - Hyeon Ji Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Korea
| | - Jee Yoon Park
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Korea
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Rybak-Krzyszkowska M, Górecka J, Huras H, Staśkiewicz M, Kondracka A, Staniczek J, Górczewski W, Borowski D, Grzesiak M, Krzeszowski W, Massalska-Wolska M, Jaczyńska R. Ultrasonographic Signs of Cytomegalovirus Infection in the Fetus-A Systematic Review of the Literature. Diagnostics (Basel) 2023; 13:2397. [PMID: 37510141 PMCID: PMC10378321 DOI: 10.3390/diagnostics13142397] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 07/02/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND congenital cytomegalovirus (cCMV) infection during pregnancy is a significant risk factor for fetal and neonatal morbidity and mortality. CMV detection is based on the traditional ultrasound (US) and MRI (magnetic resonance) approach. METHODS the present review used the PRISMA protocol for identification of studies associated with CMV infection and sonographic analysis. Various search terms were created using keywords which were used to identify references from Medline, Pubmed, PsycInfo, Scopus and Web of Science. RESULTS sonographic analysis of the cCMV infection identified several of the key features associated with fetuses. The presence of abnormal patterns of periventricular echogenicity, ventriculomegaly and intraparenchymal calcifications is indicative of CMV infection in the fetus. Hyperechogenic bowels were seen frequently. These results correlate well with MRI data, especially when targeted transvaginal fetal neurosonography was carried out. CONCLUSIONS ultrasonography is a reliable indicator of fetal anomalies, due to cCMV. Fetal brain and organ changes are conclusive indications of infection, but many of the ultrasonographic signs of fetal abnormality could be due to any viral infections; thus, further research is needed to demarcate CMV infection from others, based on the ultrasonographic approach. CMV infection should always be an indication for targeted fetal neurosonography, optimally by the transvaginal approach.
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Affiliation(s)
- Magda Rybak-Krzyszkowska
- Department of Obstetrics and Perinatology, University Hospital, 30-551 Krakow, Poland
- Hi-Gen Centrum Medyczne, 30-552 Krakow, Poland
| | - Joanna Górecka
- Department of Obstetrics and Perinatology, University Hospital, 30-551 Krakow, Poland
| | - Hubert Huras
- Department of Obstetrics and Perinatology, University Hospital, 30-551 Krakow, Poland
| | - Magdalena Staśkiewicz
- Department of Obstetrics and Perinatology, University Hospital, 30-551 Krakow, Poland
| | - Adrianna Kondracka
- Department of Obstetrics and Pathology of Pregnancy, Medical University of Lublin, 20-081 Lublin, Poland
| | - Jakub Staniczek
- Department of Gynecology, Obstetrics and Gynecologic Oncology, Medical University of Silesia, 40-055 Katowice, Poland
| | - Wojciech Górczewski
- Obstetrics and Gynecology Ward, Independent Public Healthcare Institution in Bochnia, The Blessed Marta Wiecka District Hospital, 32-700 Bochnia, Poland
| | - Dariusz Borowski
- Provincial Combined Hospital in Kielce, Clinic of Obstetrics and Gynaecology, 25-736 Kielce, Poland
| | - Mariusz Grzesiak
- Department of Perinatology, Obstetrics and Gynecology, Polish Mother's Memorial Hospital-Research Institute in Lodz, 93-338 Lodz, Poland
- Department of Obstetrics and Gynecology, Medical University of Lodz, 93-338 Lodz, Poland
| | - Waldemar Krzeszowski
- Department of Perinatology, Obstetrics and Gynecology, Polish Mother's Memorial Hospital-Research Institute in Lodz, 93-338 Lodz, Poland
- Salve Medica, 91-210 Lodz, Poland
| | - Magdalena Massalska-Wolska
- Clinical Department of Gynecological Endocrinology and Gynecology, University Hospital, 30-551 Krakow, Poland
| | - Renata Jaczyńska
- Department of Obstetrics, Perinatology and Gynecology, Medical University of Warsaw, 02-091 Warsaw, Poland
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Nigro G, Muselli M. Prevention of Congenital Cytomegalovirus Infection: Review and Case Series of Valaciclovir versus Hyperimmune Globulin Therapy. Viruses 2023; 15:1376. [PMID: 37376675 PMCID: PMC10302477 DOI: 10.3390/v15061376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 06/05/2023] [Accepted: 06/08/2023] [Indexed: 06/29/2023] Open
Abstract
Cytomegalovirus (CMV) is the most common cause of congenital infections in developed countries because is capable of infecting the fetus after both primary and recurrent maternal infection, and because the virus may be spread for years through infected children. Moreover, CMV is the most serious congenital infection associated with severe neurological and sensorineural sequelae, which can occur at birth or develop later on. Hygienic measures can prevent CMV transmission, which mainly involve contact with children under 3 years of age and attending a nursery or daycare. In animal and human pregnancies, many observational and controlled studies have shown that CMV-specific hyperimmune globulin (HIG) is safe and can significantly decrease maternal-fetal transmission of CMV infection and, mostly, the occurrence of CMV disease. Recently, valaciclovir at the dosage of 8 g/day was also reported to be capable of decreasing the rates of congenital infection and disease. However, comparing the results of our two recent case series, the infants born to women treated with HIG showed significantly lower rates of CMV DNA positivity in urine (9.7% vs. 75.0%; p < 0.0001) and abnormalities after follow-up (0.0% vs. 41.7%; p < 0.0001). The implementation of CMV screening would enable primary prevention via hygiene counseling, improve the understanding and awareness of congenital CMV infection, and increase the knowledge of the potential efficacy of preventive or therapeutic HIG or antiviral administration.
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Affiliation(s)
- Giovanni Nigro
- Non-Profit Association Mother-Infant Cytomegalovirus Infection (AMICI), 00198 Rome, Italy
| | - Mario Muselli
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy;
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Hawkins-Villarreal A, Moreno-Espinosa AL, Castillo K, Hahner N, Picone O, Mandelbrot L, Simon I, Gratacós E, Goncé A, Eixarch E. Brain cortical maturation assessed by magnetic resonance imaging in unaffected or mildly affected fetuses with cytomegalovirus infection. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 61:566-576. [PMID: 36349881 DOI: 10.1002/uog.26110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 10/07/2022] [Accepted: 10/17/2022] [Indexed: 05/04/2023]
Abstract
OBJECTIVES To assess by magnetic resonance imaging (MRI) the cortical maturation pattern in fetuses with cytomegalovirus (CMV) infection with mild or no abnormalities on ultrasound (US) and MRI, and to establish possible differences compared with healthy controls. METHODS This was a retrospective case-control study of consecutive pregnancies with a CMV-infected fetus undergoing prenatal MRI as a complementary diagnostic tool in two centers, and a control group of singleton low-risk pregnancies without fetal structural abnormalities, with normal fetal growth and with healthy newborns. CMV infection was confirmed by extraction of CMV-DNA from fetal and neonatal samples. Only fetuses with mild (mildly affected) or no (unaffected) neuroimaging abnormalities on US and MRI were included. MRI measurements of fetal parieto-occipital sulcus, cingulate sulcus and calcarine sulcus depth, Sylvian fissure depth and Sylvian fissure angles were performed and cortical development grading of specific cortical areas and sulci were assessed by one operator who was blinded to CMV infection status. Data were compared between controls and fetuses with CMV infection, using linear regression and non-parametric trend analysis. RESULTS Twenty-four CMV-infected fetuses (seven unaffected and 17 mildly affected) and 24 healthy controls that underwent fetal MRI between 27 and 36 weeks' gestation were included. Compared with controls, CMV-infected fetuses showed significantly larger median lateral ventricular width (right side, 7.8 (interquartile range (IQR), 5.9-9.9) mm vs 3.9 (IQR, 2.6-5.3) mm; left side, 7.5 (IQR, 6.0-10.9) mm vs 4.2 (IQR, 3.2-5.3) mm), significantly decreased parieto-occipital sulcus depth (right side, 12.6 (IQR, 11.3-13.5) mm vs 15.9 (IQR, 13.5-17.3) mm; left side, 12.3 (IQR, 10.6-13.5) mm vs 16.0 (IQR, 13.3-17.5) mm) and calcarine sulcus depth (right side, 15.4 (IQR, 14.4-16.3) mm vs 17.5 (IQR, 16.1-18.7) mm; left side, 14.6 (IQR, 14.1-15.6) mm vs 16.7 (IQR, 15.6-18.9) mm) (P < 0.001 for all). Compared with controls, CMV-infected fetuses also had significantly smaller upper (right side, 42.8° (IQR, 35.8-45.8°) vs 48.9° (IQR, 38.4-64.7°); left side, 40.9° (IQR, 34.2-45.8°) vs 48.2° (IQR, 41.9-60.7°)) and lower (right side, 41.6° (IQR, 34.4-49.2°) vs 48.9° (IQR, 40.6-60.9°); left side, 42.2° (IQR, 38.8-46.9°) vs 48.9° (IQR, 39.5-57.5°)) Sylvian fissure angles (P < 0.05 for all). In addition, the mildly affected CMV-infected fetuses had a significantly lower cortical development grading in the temporal and parietal areas, and the parieto-occipital and calcarine sulci compared with healthy fetuses (P < 0.05). These differences persisted when adjusting for gestational age, ipsilateral atrium width, fetal gender and when considering small-for-gestational age as a confounding factor. CONCLUSIONS Unaffected and mildly affected CMV-infected fetuses showed delayed cortical maturation compared with healthy controls. These results suggest that congenital CMV infection, even in non-severely affected fetuses that are typically considered of good prognosis, could be associated with altered brain cortical structure. Further research is warranted to better elucidate the correlation of these findings with neurodevelopmental outcomes. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- A Hawkins-Villarreal
- BCNatal-Fetal Medicine Research Center, Hospital Clínic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Fetal Medicine Service, Obstetrics Department, Hospital 'Santo Tomás', University of Panama, Panama City, Panama
- Iberoamerican Research Network in Obstetrics, Gynecology and Translational Medicine
| | - A L Moreno-Espinosa
- BCNatal-Fetal Medicine Research Center, Hospital Clínic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Fetal Medicine Service, Obstetrics Department, Hospital 'Santo Tomás', University of Panama, Panama City, Panama
- Iberoamerican Research Network in Obstetrics, Gynecology and Translational Medicine
| | - K Castillo
- BCNatal-Fetal Medicine Research Center, Hospital Clínic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - N Hahner
- BCNatal-Fetal Medicine Research Center, Hospital Clínic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - O Picone
- Department of Gynecology and Obstetrics, Hôpital Louis-Mourier, AP-HP, Féderation Hospitalo-Universitaire PREMA, Colombes, Paris, France
- Université Paris Cité, Paris, France
- Inserm IAME UMR1137, Paris, France
| | - L Mandelbrot
- Department of Gynecology and Obstetrics, Hôpital Louis-Mourier, AP-HP, Féderation Hospitalo-Universitaire PREMA, Colombes, Paris, France
- Université Paris Cité, Paris, France
- Inserm IAME UMR1137, Paris, France
| | - I Simon
- Department of Radiology, Hôpital Louis-Mourier, AP-HP, Colombes, France
| | - E Gratacós
- BCNatal-Fetal Medicine Research Center, Hospital Clínic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centre for Biomedical Research on Rare Diseases (CIBERER), Barcelona, Spain
| | - A Goncé
- BCNatal-Fetal Medicine Research Center, Hospital Clínic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centre for Biomedical Research on Rare Diseases (CIBERER), Barcelona, Spain
| | - E Eixarch
- BCNatal-Fetal Medicine Research Center, Hospital Clínic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centre for Biomedical Research on Rare Diseases (CIBERER), Barcelona, Spain
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Sartori P, Egloff C, Hcini N, Vauloup Fellous C, Périllaud-Dubois C, Picone O, Pomar L. Primary, Secondary, and Tertiary Prevention of Congenital Cytomegalovirus Infection. Viruses 2023; 15:v15040819. [PMID: 37112800 PMCID: PMC10146889 DOI: 10.3390/v15040819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/11/2023] [Accepted: 03/20/2023] [Indexed: 04/29/2023] Open
Abstract
Cytomegalovirus infection is the most common congenital infection, affecting about 1% of births worldwide. Several primary, secondary, and tertiary prevention strategies are already available during the prenatal period to help mitigate the immediate and long-term consequences of this infection. In this review, we aim to present and assess the efficacy of these strategies, including educating pregnant women and women of childbearing age on their knowledge of hygiene measures, development of vaccines, screening for cytomegalovirus infection during pregnancy (systematic versus targeted), prenatal diagnosis and prognostic assessments, and preventive and curative treatments in utero.
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Affiliation(s)
- Pauline Sartori
- School of Health Sciences (HESAV), University of Applied Sciences and Arts Western Switzerland, 1011 Lausanne, Switzerland
- Department Woman-Mother-Child, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Charles Egloff
- Assistance Publique-Hôpitaux de Paris APHP, Nord, Service de Gynécologie Obstétrique, Hôpital Louis Mourier, 92700 Colombes, France
- Université de Paris, 75006 Paris, France
- INSERM, IAME, B.P. 416, 75870 Paris, France
| | - Najeh Hcini
- Department of Obstetrics and Gynaecology, West French Guiana Hospital Center, French 97320, Guyana
- CIC Inserm 1424 et DFR Santé Université Guyane, 97320 ST Laurent du Maroni, France
| | - Christelle Vauloup Fellous
- Université Paris-Saclay, INSERM U1193, 94804 Villejuif, France
- Laboratoire de Virologie, AP-HP, Hôpital Paul-Brousse, 94804 Villejuif, France
- Groupe de Recherche sur les Infections Pendant la Grossesse (GRIG), 75000 Paris, France
| | - Claire Périllaud-Dubois
- Université de Paris, 75006 Paris, France
- INSERM, IAME, B.P. 416, 75870 Paris, France
- Virology Laboratory, AP-HP, Sorbonne Université, Hôpital Saint-Antoine, F-75012 Paris, France
| | - Olivier Picone
- Assistance Publique-Hôpitaux de Paris APHP, Nord, Service de Gynécologie Obstétrique, Hôpital Louis Mourier, 92700 Colombes, France
- Université de Paris, 75006 Paris, France
- INSERM, IAME, B.P. 416, 75870 Paris, France
- Groupe de Recherche sur les Infections Pendant la Grossesse (GRIG), 75000 Paris, France
| | - Léo Pomar
- School of Health Sciences (HESAV), University of Applied Sciences and Arts Western Switzerland, 1011 Lausanne, Switzerland
- Department Woman-Mother-Child, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
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Hawkins-Villarreal A, Moreno-Espinosa AL, Martinez-Portilla RJ, Castillo K, Hahner N, Nakaki A, Trigo L, Picone O, Siauve N, Figueras F, Nadal A, Eixarch E, Goncé A. Fetal Liver Volume Assessment Using Magnetic Resonance Imaging in Fetuses With Cytomegalovirus Infection†. Front Med (Lausanne) 2022; 9:889976. [PMID: 35652074 PMCID: PMC9150546 DOI: 10.3389/fmed.2022.889976] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 04/08/2022] [Indexed: 11/13/2022] Open
Abstract
Objective To assess fetal liver volume (FLV) by magnetic resonance imaging (MRI) in cytomegalovirus (CMV)-infected fetuses compared to a group of healthy fetuses. Method Most infected cases were diagnosed by the evidence of ultrasound abnormalities during routine scans and in some after maternal CMV screening. CMV-infected fetuses were considered severely or mildly affected according to prenatal brain lesions identified by ultrasound (US)/MRI. We assessed FLV, the FLV to abdominal circumference (AC) ratio (FLV/AC-ratio), and the FLV to fetal body volume (FBV) ratio (FLV/FBV-ratio). As controls, we included 33 healthy fetuses. Hepatomegaly was evaluated post-mortem in 11 cases of congenital CMV infection. Parametric trend and intraclass correlation analyses were performed. Results There were no significant differences in FLV between infected (n = 32) and healthy fetuses. On correcting the FLV for AC and FBV, we observed a significantly higher FLV in CMV-infected fetuses. There were no significant differences in the FLV, or the FLV/AC or FLV/FBV-ratios according to the severity of brain abnormalities. There was excellent concordance between the fetal liver weight estimated by MRI and liver weight obtained post-mortem. Hepatomegaly was not detected in any CMV-infected fetus. Conclusion In CMV-infected fetuses, FLV corrected for AC and FBV was higher compared to healthy controls, indicating relative hepatomegaly. These parameters could potentially be used as surrogate markers of liver enlargement.
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Affiliation(s)
- Ameth Hawkins-Villarreal
- BCNatal - Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), Universitat de Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Fetal Medicine Service, Department of Obstetrics, Hospital “Santo Tomás”, University of Panama, Panama City, Panama
- Iberoamerican Research Network in Obstetrics, Gynecology and Translational Medicine, Mexico City, Mexico
| | - Ana L. Moreno-Espinosa
- BCNatal - Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), Universitat de Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Fetal Medicine Service, Department of Obstetrics, Hospital “Santo Tomás”, University of Panama, Panama City, Panama
- Iberoamerican Research Network in Obstetrics, Gynecology and Translational Medicine, Mexico City, Mexico
| | - Raigam J. Martinez-Portilla
- BCNatal - Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), Universitat de Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Iberoamerican Research Network in Obstetrics, Gynecology and Translational Medicine, Mexico City, Mexico
| | - Karen Castillo
- BCNatal - Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), Universitat de Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Nadine Hahner
- BCNatal - Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), Universitat de Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Ayako Nakaki
- BCNatal - Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), Universitat de Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Lucas Trigo
- BCNatal - Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), Universitat de Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Olivier Picone
- Department of Gynaecology and Obstetrics, Hôpital Louis Mourier, Hôpitaux Universitaires Paris Nord, APHP, Université Paris Diderot, Paris, France
| | - Nathalie Siauve
- Department of Radiology, Hôpital Louis-Mourier, Hôpitaux Universitaires Paris Nord, APHP, Université Paris Diderot, Paris, France
| | - Francesc Figueras
- BCNatal - Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), Universitat de Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centre for Biomedical Research on Rare Diseases (CIBERER), Barcelona, Spain
| | - Alfons Nadal
- BCNatal - Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), Universitat de Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Department of Clinical Pathology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Elisenda Eixarch
- BCNatal - Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), Universitat de Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centre for Biomedical Research on Rare Diseases (CIBERER), Barcelona, Spain
- *Correspondence: Elisenda Eixarch,
| | - Anna Goncé
- BCNatal - Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), Universitat de Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centre for Biomedical Research on Rare Diseases (CIBERER), Barcelona, Spain
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Moradi B, Parooie F, Kazemi MA, Hashemi H, Miratashi Yazdi SN. Fetal brain imaging: A comparison between fetal ultrasonography and intra uterine magnetic resonance imaging (a systematic review and meta-analysis). JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:491-499. [PMID: 35266167 DOI: 10.1002/jcu.23158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 02/05/2022] [Accepted: 02/10/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE The aim of this study was to compare ultrasound (US) and intra uterine MRI (IUMRI) of the brain in the diagnosis of fetal brain abnormalities. METHODS The present systematic review is done based on guidelines for preferred reporting items for systematic reviews and meta-analysis. All major articles comparing fetal US with IUMRI in fetuses with suspected brain abnormalities were qualified. Articles published before 2010 were excluded from the study. An I2 > 20% was considered as a sign of significant change. The statistical analysis was done using STATA -15 and Meta-Disk 1.4 applications. RESULTS Five articles were considered for meta-analysis. The sensitivity of US and IUMRI in diagnosing fetal abnormalities were 86% and 95%, respectively. The corresponding rates for specificity were 77% and 80%. IUMRI and US were concordant in 72.5% (95% CI: 68%-77%) of diagnoses. However, IUMRI added information in 21.7% of cases, while US added value was only 1.48. CONCLUSION Our results approved the good diagnostic performance of both US and IUMRI in confirming fetal brain normal development and emphasized that US is an appropriate screening technique in pregnancy. In cases of detected abnormalities in US, IUMRI is suggested as it was the most accurate imaging method and added information about the diagnosis in 22.2% of cases.
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Affiliation(s)
- Behnaz Moradi
- Department of Radiology, Women's Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Department of Radiology, Medical Imaging Center, Imam Khomeini Hospital Complex(IKHC), Tehran University of Medical Sciences, Tehran, Iran
| | - Fateme Parooie
- Pediatric Gastroenterology and Hepatology Research Center, Zabol University of Medical Sciences, Zabol, Iran
| | - Mohammad Ali Kazemi
- Department of Radiology, Women's Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Department of Radiology, Amiralam Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Hassan Hashemi
- Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran University of Medical Sciences, Tehran, Iran
| | - Seyedeh Nooshin Miratashi Yazdi
- Department of Radiology, Medical Imaging Center, Imam Khomeini Hospital Complex(IKHC), Tehran University of Medical Sciences, Tehran, Iran
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Zlatkin R, Bilavsky E, Pardo J, Salman L, Bardin R, Hadar E, Shmueli A. The association between maternal cytomegalovirus urinary excretion and congenital infection rate. BMC Pregnancy Childbirth 2021; 21:741. [PMID: 34724918 PMCID: PMC8559400 DOI: 10.1186/s12884-021-04194-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 10/06/2021] [Indexed: 11/10/2022] Open
Abstract
Background In utero Cytomegalovirus (CMV) vertical transmission occurs predominantly during primary maternal infection. There are no known non-invasive methods for diagnosis of fetal infection before delivery, however some risk factors have been suggested. We aimed to evaluate the association between maternal CMV urinary excretion and congenital CMV infection. Methods A retrospective cohort study of all women who were diagnosed with primary CMV infection during pregnancy in a single university affiliated tertiary medical center, between 2012 and 2016. We examined congenital CMV infection and disease rates among infants born to women with and without CMV urinary excretion. Results Overall, 126 women were included, 77 in the positive urinary excretion group, and 49 in the negative urinary excretion group. There was no difference in maternal symptoms between the groups. We found no difference in congenital CMV infection and disease rates between infants born to women with and without urinary excretion of CMV (congenital infection rate 37.1% vs. 24.4%, p = 0.209, congenital disease rate of 18.2% vs. 22.4%, p = 0.648). Women with positive urinary CMV excretion had lower IgG avidity values (36.7% vs 54.6%, p = 0.007), with no additional difference in serology pattern. Compared to asymptomatic women, those with CMV related symptoms did not have significantly higher rates of urinary excretion of CMV (70% vs. 60.5%, p = 0.38) or congenital infection rates (40.7% vs. 31.2%, p = 0.48). Conclusion Among infants of women with primary CMV infection in pregnancy, we did not find an association between urinary excretion of CMV and congenital CMV infection.
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Affiliation(s)
- Rita Zlatkin
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Efraim Bilavsky
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Schneider Children's Medical Center, Petach Tikva, Israel
| | - Joseph Pardo
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center, 49100, Tikva, Israel
| | - Lina Salman
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center, 49100, Tikva, Israel
| | - Ron Bardin
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center, 49100, Tikva, Israel
| | - Eran Hadar
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center, 49100, Tikva, Israel
| | - Anat Shmueli
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. .,Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center, 49100, Tikva, Israel.
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9
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Gorenstein L, Katorza E, Bar-Yosef O, Hoffmann C, Shrot S. Quantitative and qualitative analysis of fetal temporal lobe T2 signal in cytomegalovirus infected fetuses and normal controls. Quant Imaging Med Surg 2021; 11:4399-4407. [PMID: 34603994 DOI: 10.21037/qims-21-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 05/11/2021] [Indexed: 11/06/2022]
Abstract
Background Temporal lobe T2 hyperintensity has been described in association with prenatal cytomegalovirus (CMV) infection on fetal MRI. However, these findings are often perplexing with high inter-observer variability. Our objective was to evaluate temporal lobe T2 signal quantitatively in prenatal CMV infection. Methods In this retrospective study, 119 fetuses, of which 51 fetuses with suspected CMV exposure (29-36 weeks of gestation) based on maternal seroconversion and age-matched 68 normal controls, were included. Mean and maximal temporal lobe T2 signal were evaluated quantitatively by measuring the T2 signal in the temporal lobes relative to the amniotic fluid's signal. Intra-observer, inter-observer variability and diagnostic performance were assessed. The occurrence of neonatal sensorineural hearing loss (SNHL) was recorded. Results Relative temporal lobe T2 signal did not change along with the examined gestational age. Of our suspected CMV cohort, 29 fetuses were positive for fetal CMV infection on polymerase chain reaction (PCR) analysis. There were no statistically significant differences in the relative mean or maximal temporal lobes T2 signal between CMV positive, CMV negative fetuses, or normal controls. No correlation was found between neonatal SNHL and temporal lobe T2 signal. Conclusions When temporal lobe T2 signal is analyzed quantitatively, CMV infected fetuses do not present an increased signal than age-matched controls. Thus, reported subjective temporal T2 hyperintensities should be interpreted carefully and should have a limited effect on pregnancy management, especially as an isolated finding. Our study illustrates the importance of quantitative imaging in diagnostic neuroradiology.
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Affiliation(s)
- Larisa Gorenstein
- Section of Neuroradiology, Division of Diagnostic Imaging, Sheba Medical Center, Ramat-Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eldad Katorza
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Antenatal Diagnostic Unit, Sheba Medical Center, Ramat-Gan, Israel
| | - Omer Bar-Yosef
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Neurology Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat-Gan, Israel
| | - Chen Hoffmann
- Section of Neuroradiology, Division of Diagnostic Imaging, Sheba Medical Center, Ramat-Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shai Shrot
- Section of Neuroradiology, Division of Diagnostic Imaging, Sheba Medical Center, Ramat-Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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10
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Congenital Human Cytomegalovirus Infection: A Narrative Review of Maternal Immune Response and Diagnosis in View of the Development of a Vaccine and Prevention of Primary and Non-Primary Infections in Pregnancy. Microorganisms 2021; 9:microorganisms9081749. [PMID: 34442828 PMCID: PMC8398868 DOI: 10.3390/microorganisms9081749] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 08/09/2021] [Accepted: 08/13/2021] [Indexed: 12/19/2022] Open
Abstract
Congenital cytomegalovirus infection (cCMV) may affect about 1% of all newborns all over the world as a result of either a primary or recurrent human cytomegalovirus (HCMV) infection. While about 90% of infants affected by cCMV are asymptomatic at birth, the remaining 10% are symptomatic often with neurodevelopmental impairment and sensorineural hearing loss. In view of identifying the best approach to vaccine prevention of cCMV, this review will examine the most important steps made in the study of the immune response to, and diagnosis of, HCMV infection. The maternal immune response and immune correlates of protection are being partially identified with a partial contribution given by our laboratory. The diagnosis of primary infection is often difficult to achieve in the first three months of pregnancy, which is the time primarily involved in virus transmission to the fetus in association with the most severe symptoms and sequelae. Prevention of cCMV is anticipated by prevention of primary infection in early pregnancy by means of different measures, such as (i) behavioral-educational measures, (ii) immunoglobulin administration, (iii) antiviral treatment with valaciclovir. However, the most promising approach to cCMV prevention appears to be the development of a non-living vaccine, including at least three viral antigens: gB, pentamer complex gHgLpUL128L, and pp65, which have been shown to be able to stimulate both the humoral and the cellular arms of the maternal immune response. Primary HCMV infection may be managed in pregnancy by counseling of the couples involved by a team of specialists that includes virologists, obstetricians, infectivologists and neonatologists.
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11
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Leruez-Ville M, Guilleminot T, Stirnemann J, Salomon LJ, Spaggiari E, Faure-Bardon V, Magny JF, Ville Y. Quantifying the Burden of Congenital Cytomegalovirus Infection With Long-term Sequelae in Subsequent Pregnancies of Women Seronegative at Their First Pregnancy. Clin Infect Dis 2021; 71:1598-1603. [PMID: 31665306 DOI: 10.1093/cid/ciz1067] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 10/25/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND In women seronegative before pregnancy, congenital cytomegalovirus (cCMV)-related sequelae are exclusively seen in those infected in the first trimester of pregnancy. Following a maternal primary infection in the first trimester, up to 30% of infected neonates suffer long-term sequelae. Maternal parity is an established risk factor of cCMV in previously seronegative women. Our objective was to quantify, in a population of women seronegative at their first pregnancy, the risk of cCMV and related sequelae following primary infections in the first trimester in subsequent pregnancies. METHODS There were 739 women seronegative at their first pregnancy who had at least 1 of 971 subsequent pregnancies and deliveries managed at our institution. All women had CMV immunoglobin (Ig) G and IgM testing at 11-14 weeks of each pregnancy. RESULTS Between 2 consecutive pregnancies, 15.6% (115/739) of women seroconverted. Of these seroconversions, 29% (33/115) occurred in the periconceptional period or in the first trimester. The risks for cCMV and related sequelae (neurologic and/or hearing loss) following a maternal infection in the first trimester were, respectively, 24- and 6-fold higher (risk ratios, 24 [95% confidence interval {CI}, 10.8-62.3] and 6 [95% CI 1.5-24], respectively) than in the general pregnant population. Of all primary maternal infections and fetal infections in the first trimester, 88% (29/33) and 92% (11/12), respectively, occurred when the inter-pregnancy interval was ≤2 years. CONCLUSIONS Women seronegative at their first pregnancy with a subsequent pregnancy within 2 years have the highest risk of delivering a child with cCMV-related sequelae. These women should be made aware of the risk and given the opportunity of serology screening in the first trimester.
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Affiliation(s)
- Marianne Leruez-Ville
- Paris Descartes University, Paris, France.,Virology Laboratory, Reference Laboratory for Cytomegalovirus Infections, Assistance Publique-Hopitaux de Paris, Hospital Necker, Paris, France
| | - Tiffany Guilleminot
- Paris Descartes University, Paris, France.,Virology Laboratory, Reference Laboratory for Cytomegalovirus Infections, Assistance Publique-Hopitaux de Paris, Hospital Necker, Paris, France
| | - Julien Stirnemann
- Paris Descartes University, Paris, France.,Maternity, Assistance Publique-Hopitaux de Paris, Hospital Necker, Paris, France
| | - Laurent J Salomon
- Paris Descartes University, Paris, France.,Virology Laboratory, Reference Laboratory for Cytomegalovirus Infections, Assistance Publique-Hopitaux de Paris, Hospital Necker, Paris, France
| | - Emmanuel Spaggiari
- Paris Descartes University, Paris, France.,Maternity, Assistance Publique-Hopitaux de Paris, Hospital Necker, Paris, France
| | - Valentine Faure-Bardon
- Paris Descartes University, Paris, France.,Maternity, Assistance Publique-Hopitaux de Paris, Hospital Necker, Paris, France
| | - Jean-Francois Magny
- Paris Descartes University, Paris, France.,Neonatal Intensive Care Unit, Assistance Publique-Hopitaux de Paris, Hospital Necker, Paris, France
| | - Yves Ville
- Paris Descartes University, Paris, France.,Maternity, Assistance Publique-Hopitaux de Paris, Hospital Necker, Paris, France
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12
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Buca D, Di Mascio D, Rizzo G, Giancotti A, D'Amico A, Leombroni M, Makatsarya A, Familiari A, Liberati M, Nappi L, Flacco ME, Manzoli L, Salomon LJ, Scambia G, D'Antonio F. Outcome of fetuses with congenital cytomegalovirus infection and normal ultrasound at diagnosis: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:551-559. [PMID: 33030767 DOI: 10.1002/uog.23143] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 08/23/2020] [Accepted: 09/25/2020] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To report the outcome of fetuses with congenital cytomegalovirus (CMV) infection and normal ultrasound at the time of diagnosis, and to evaluate the rate of an additional anomaly detected only on magnetic resonance imaging (MRI). METHODS Medline, EMBASE, CINAHL and Cochrane databases were searched for studies reporting on the outcome of fetuses with congenital CMV infection. Inclusion criteria were fetuses with confirmed CMV infection and normal ultrasound assessment at the time of the initial evaluation. The outcomes observed were an anomaly detected on a follow-up ultrasound scan, an anomaly detected on prenatal MRI but missed on ultrasound, an anomaly detected on postnatal assessment but missed prenatally, perinatal mortality, symptomatic infection at birth, neurodevelopmental outcome and hearing and visual deficits. Neurodevelopmental outcome was assessed only in cases of isolated CMV infection confirmed at birth. Subgroup analysis was performed according to the trimester in which maternal infection occurred. Random-effects meta-analysis of proportions was used to analyze the data. RESULTS Twenty-six studies were included, comprising 2603 fetuses with congenital CMV infection, of which 1178 (45.3%) had normal ultrasound at the time of diagnosis and were included in the analysis. The overall rate of an associated central nervous system (CNS) anomaly detected on a follow-up ultrasound scan was 4.4% (95% CI, 1.4-8.8%) (32/523; 15 studies), while the rates of those detected exclusively on prenatal MRI or on postnatal imaging were 5.8% (95% CI, 1.9-11.5%) (19/357; 11 studies) and 3.2% (95% CI, 0.3-9.0%) (50/660; 17 studies), respectively. The rate of an associated extra-CNS anomaly detected on a follow-up ultrasound scan was 2.9% (95% CI, 0.8-6.3%) (19/523; 15 studies), while the rates of those detected exclusively on MRI or on postnatal imaging were 0% (95% CI, 0.0-1.7%) (0/357; 11 studies) and 0.9% (95% CI, 0.3-1.8%) (4/660; 17 studies), respectively. Intrauterine death and perinatal death each occurred in 0.7% (95% CI, 0.3-1.4%) (2/824; 23 studies) of cases. In cases without an associated anomaly detected pre- or postnatally, symptomatic infection was found in 1.5% (95% CI, 0.7-2.7%) (6/548; 19 studies) of infants, the overall rate of a neurodevelopmental anomaly was 3.1% (95% CI, 1.6-5.1%) (16/550; 19 studies), and hearing problems affected 6.5% (95% CI, 3.8-10.0%) (36/550; 19 studies) of children. Subanalyses according to the trimester in which maternal infection occurred were affected by the very small number of included cases and lack of comparison of the observed outcomes in the original studies. Compared with fetuses infected in the second or third trimester, those infected in the first trimester had a relatively higher risk of having an additional anomaly detected on follow-up ultrasound or MRI, abnormal neurodevelopmental outcome and hearing problems. CONCLUSIONS In fetuses with congenital CMV infection in which no anomalies are detected on prenatal ultrasound or MRI, the risk of adverse postnatal outcome is lower than that reported previously in the published literature when not considering the role of antenatal imaging assessment. The results from this review also highlight the potential role of MRI, even in fetuses with no anomalies detected on ultrasound, as an anomaly can be detected exclusively on MRI in about 6% of cases. The findings from this study could enhance prenatal counseling of pregnancies with congenital CMV infection with normal prenatal imaging. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- D Buca
- Centre for High Risk Pregnancy and Fetal Care, Department of Obstetrics and Gynecology, University of Chieti, Italy
| | - D Di Mascio
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - G Rizzo
- Division of Maternal and Fetal Medicine, Ospedale Cristo Re, University of Rome Tor Vergata, Rome, Italy
- Department of Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - A Giancotti
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - A D'Amico
- Centre for High Risk Pregnancy and Fetal Care, Department of Obstetrics and Gynecology, University of Chieti, Italy
| | - M Leombroni
- Centre for High Risk Pregnancy and Fetal Care, Department of Obstetrics and Gynecology, University of Chieti, Italy
| | - A Makatsarya
- Department of Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - A Familiari
- Department of Clinical and Community Sciences, University of Milan, and Department of Woman Child and Neonate, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - M Liberati
- Centre for High Risk Pregnancy and Fetal Care, Department of Obstetrics and Gynecology, University of Chieti, Italy
| | - L Nappi
- Department of Obstetrics and Gynecology, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - M E Flacco
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - L Manzoli
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - L J Salomon
- Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Université Paris Descartes and Fetus & LUMIERE team, Paris, France
| | - G Scambia
- Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Fondazione Policlinico A. Gemelli, Rome, Italy
| | - F D'Antonio
- Department of Obstetrics and Gynecology, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
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13
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Cytomegalovirus infection in pregnancy - An update. Eur J Obstet Gynecol Reprod Biol 2020; 258:216-222. [PMID: 33454510 DOI: 10.1016/j.ejogrb.2020.12.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 12/01/2020] [Accepted: 12/08/2020] [Indexed: 12/25/2022]
Abstract
Cytomegalovirus (CMV) is a ubiquitous DNA virus with a global seroprevalence of 83 %. It is the most common pathogen causing teratogenic congenital infection. It is therefore a major public health concern. Maternal infection is associated with congenital CMV (cCMV), the leading cause of non-genetic sensorineural hearing loss. cCMV also causes impairment of cognitive development and cerebral palsy. Transmission of CMV occurs through direct contact with bodily fluids such as saliva, urine or semen from someone who is actively shedding the virus. Transmission rates are higher after primary infection with the rate of transmission increasing with gestational age. Severe fetal effects are however more common when infection occurs before 20weeks. Past infection does not confer immunity to mother or protect the fetus. cCMV may present with cerebral or extracerebral abnormalities on ultrasound, fetal growth restriction and fetal loss. Diagnosis of primary maternal CMV in pregnancy should be based on seroconversion in pregnancy (de novo appearance of virus-specific immunoglobulin G (IgG) in the serum of pregnant women who were previously seronegative) or on detection of specific immunoglobulin M (IgM) and IgG antibodies in association with low IgG avidity. Prenatal diagnosis of fetal CMV is imperfect and based on amniocentesis performed at least 8 weeks after presumed maternal infection and after 17 weeks of gestation. Hygiene information and education of pregnant women is currently the most effective strategy for prevention of CMV infection. The role of vaccines, antiviral drugs and immunoglobulins remains unproven.
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14
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Lipitz S, Elkan Miller T, Yinon Y, Weissbach T, De-Castro H, Hoffman C, Katorza E, Weisz B. Revisiting short- and long-term outcome after fetal first-trimester primary cytomegalovirus infection in relation to prenatal imaging findings. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:572-578. [PMID: 31858642 DOI: 10.1002/uog.21946] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 11/30/2019] [Accepted: 12/09/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To determine the short- and long-term outcome of pregnancies with proven first-trimester fetal cytomegalovirus (CMV) infection in a large prospective cohort. METHODS This was a prospective cohort study of pregnancies with documented primary maternal CMV infection in the first trimester and evidence of fetal infection, referred for further evaluation between January 2011 and January 2018. Maternal serological diagnosis of primary CMV infection was documented by seroconversion. Vertical CMV transmission was identified by amniocentesis with polymerase chain reaction (PCR) for the CMV genome. After birth, fetal infection was re-tested by PCR in neonatal urine or saliva samples. All patients underwent serial prenatal ultrasound scans and fetal magnetic resonance imaging (MRI) at 32-33 weeks' gestation. All neonates underwent ocular fundus examination, an ultrasound brain scan and hearing evaluation, and were followed periodically for a median of 2 years (range, 6 months to 10 years). Follow-up information was obtained from hospital charts and by telephone interviews with parents. The CMV-associated outcomes assessed were sensorineural hearing loss (SNHL), neurodevelopmental abnormality, composite clinical outcome (including SNHL and neurodevelopmental abnormality) and composite outcome (additionally including termination of pregnancy (TOP)). The association between prenatal ultrasound or MRI findings and abnormal outcome was assessed. RESULTS Primary CMV infection in the first trimester occurred in 123 patients. The rate of an abnormal ultrasound finding was 30.9%, and the rate of an abnormal MRI finding was 30.1% overall and 14.1% in the subgroup of patients with normal ultrasound. Of the 85 patients with normal ultrasound, 12 had an abnormal MRI finding, of whom five (5.9%) had true anatomical findings. Fifteen patients decided to terminate the pregnancy owing to abnormal prenatal findings on either ultrasound or MRI. Overall, the rate of CMV-associated postnatal and childhood sequelae was 27.8%, with a rate of 16.7% for SNHL and 11.1% for neurodevelopmental abnormalities, mostly slight motor or verbal delay. Approximately half of the cases with CMV-associated sequelae did not have any abnormal prenatal imaging findings. Abnormal prenatal findings on ultrasound were not associated significantly with SNHL, neurodevelopmental delay or composite clinical outcome (P = 0.084, 0.109 and 0.176, respectively), but they were associated with the composite outcome including TOP (P < 0.001). We identified a non-significant trend for a higher rate of SNHL in the group with abnormal ultrasound than in those with normal ultrasound. For abnormal MRI findings, we found a correlation only with neurodevelopmental abnormality and composite outcome (P = 0.014 and P < 0.001, respectively). CONCLUSIONS The risk of childhood sequelae after first-trimester fetal CMV infection is most often associated with abnormal prenatal imaging findings. However, normal imaging does not rule out the development of SNHL and minor neurodevelopmental abnormalities. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- S Lipitz
- Institute of Obstetrical and Gynecological Imaging, Fetal Medicine Unit, Sheba Medical Center, Tel-Hashomer, Tel Aviv University, Tel Aviv, Israel
| | - T Elkan Miller
- Institute of Obstetrical and Gynecological Imaging, Fetal Medicine Unit, Sheba Medical Center, Tel-Hashomer, Tel Aviv University, Tel Aviv, Israel
| | - Y Yinon
- Institute of Obstetrical and Gynecological Imaging, Fetal Medicine Unit, Sheba Medical Center, Tel-Hashomer, Tel Aviv University, Tel Aviv, Israel
| | - T Weissbach
- Institute of Obstetrical and Gynecological Imaging, Fetal Medicine Unit, Sheba Medical Center, Tel-Hashomer, Tel Aviv University, Tel Aviv, Israel
| | - H De-Castro
- Institute of Obstetrical and Gynecological Imaging, Fetal Medicine Unit, Sheba Medical Center, Tel-Hashomer, Tel Aviv University, Tel Aviv, Israel
| | - C Hoffman
- Department of Radiology, Sheba Medical Center, Tel-Hashomer, Tel Aviv University, Tel Aviv, Israel
| | - E Katorza
- Institute of Obstetrical and Gynecological Imaging, Fetal Medicine Unit, Sheba Medical Center, Tel-Hashomer, Tel Aviv University, Tel Aviv, Israel
| | - B Weisz
- Institute of Obstetrical and Gynecological Imaging, Fetal Medicine Unit, Sheba Medical Center, Tel-Hashomer, Tel Aviv University, Tel Aviv, Israel
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15
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Chiopris G, Veronese P, Cusenza F, Procaccianti M, Perrone S, Daccò V, Colombo C, Esposito S. Congenital Cytomegalovirus Infection: Update on Diagnosis and Treatment. Microorganisms 2020; 8:microorganisms8101516. [PMID: 33019752 PMCID: PMC7599523 DOI: 10.3390/microorganisms8101516] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/25/2020] [Accepted: 09/28/2020] [Indexed: 01/25/2023] Open
Abstract
Congenital cytomegalovirus (cCMV) infection is the most common congenital viral infection and is the leading non-genetic cause of sensorineural hearing loss (SNLH) and an important cause of neurodevelopmental disabilities. The risk of intrauterine transmission is highest when primary infection occurs during pregnancy, with a higher rate of vertical transmission in mothers with older gestational age at infection, while the risk of adverse fetal effects significantly increases if fetal infection occurs during the first half of pregnancy. Despite its prevalence and morbidity among the neonatal population, there is not yet a standardized diagnostic test and therapeutic approach for cCMV infection. This narrative review aims to explore the latest developments in the diagnosis and treatment of cCMV infection. Literature analysis shows that preventive interventions other than behavioral measures during pregnancy are still lacking, although many clinical trials are currently ongoing to formulate a vaccination for women before pregnancy. Currently, we recommend using a PCR assay in blood, urine, and saliva in neonates with suspected cCMV infection. At present, there is no evidence of the benefit of antiviral therapy in asymptomatic infants. In the case of symptomatic cCMV, we actually recommend treatment with oral valganciclovir for a duration of 12 months. The effectiveness and tolerability of this therapy option have proven effective for hearing and neurodevelopmental long-term outcomes. Valganciclovir is reserved for congenitally-infected neonates with the symptomatic disease at birth, such as microcephaly, intracranial calcifications, abnormal cerebrospinal fluid index, chorioretinitis, or sensorineural hearing loss. Treatment with antiviral drugs is not routinely recommended for neonates with the mildly symptomatic disease at birth, for neonates under 32 weeks of gestational age, or for infants more than 30 days old because of insufficient evidence from studies. However, since these populations represent the vast majority of neonates and infants with cCMV infection and they are at risk of developing late-onset sequelae, a biomarker able to predict long-term sequelae should also be found to justify starting treatment and reducing the burden of CMV-related complications.
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Affiliation(s)
- Giulia Chiopris
- Paediatric Clinic Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, 43121 Parma, Italy; (G.C.); (P.V.); (F.C.); (M.P.)
| | - Piero Veronese
- Paediatric Clinic Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, 43121 Parma, Italy; (G.C.); (P.V.); (F.C.); (M.P.)
| | - Francesca Cusenza
- Paediatric Clinic Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, 43121 Parma, Italy; (G.C.); (P.V.); (F.C.); (M.P.)
| | - Michela Procaccianti
- Paediatric Clinic Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, 43121 Parma, Italy; (G.C.); (P.V.); (F.C.); (M.P.)
| | - Serafina Perrone
- Neonatology Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, 43121 Parma, Italy;
| | - Valeria Daccò
- Cystic Fibrosis Unit, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milan, Italy; (V.D.); (C.C.)
| | - Carla Colombo
- Cystic Fibrosis Unit, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milan, Italy; (V.D.); (C.C.)
| | - Susanna Esposito
- Paediatric Clinic Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, 43121 Parma, Italy; (G.C.); (P.V.); (F.C.); (M.P.)
- Correspondence: ; Tel.: +39-0521-903524
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16
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Picone O, Mandelbrot L. Role of magnetic resonance imaging in management of congenital cytomegalovirus infection. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:632. [PMID: 33001497 DOI: 10.1002/uog.23105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 03/16/2020] [Indexed: 06/11/2023]
Affiliation(s)
- O Picone
- Assistance Publique-Hôpitaux de Paris, Hôpital Louis Mourier, Service de Gynécologie-Obstétrique, Colombes, France, Université de Paris, Paris, France; Inserm IAME-U1137, Paris, France; Groupe de Recherche sur les Infections pendant la Grossesse (GRIG), Velizy, France
| | - L Mandelbrot
- Assistance Publique-Hôpitaux de Paris, Hôpital Louis Mourier, Service de Gynécologie-Obstétrique, Colombes, France, Université de Paris, Paris, France; Inserm IAME-U1137, Paris, France; Groupe de Recherche sur les Infections pendant la Grossesse (GRIG), Velizy, France
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Leruez-Ville M, Foulon I, Pass R, Ville Y. Cytomegalovirus infection during pregnancy: state of the science. Am J Obstet Gynecol 2020; 223:330-349. [PMID: 32105678 DOI: 10.1016/j.ajog.2020.02.018] [Citation(s) in RCA: 117] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 02/06/2020] [Accepted: 02/10/2020] [Indexed: 12/25/2022]
Abstract
Cytomegalovirus is the most common congenital infection, affecting 0.5-2% of all live births and the main nongenetic cause of congenital sensorineural hearing loss and neurological damage. Congenital cytomegalovirus can follow maternal primary infection or nonprimary infection. Sensorineurological morbidity is confined to the first trimester with up to 40-50% of infected neonates developing sequelae after first-trimester primary infection. Serological testing before 14 weeks is critical to identify primary infection within 3 months around conception but is not informative in women already immune before pregnancy. In Europe and the United States, primary infection in the first trimester are mainly seen in young parous women with a previous child younger than 3 years. Congenital cytomegalovirus should be evoked on prenatal ultrasound when the fetus is small for gestation and shows echogenic bowel, effusions, or any cerebral anomaly. Although the sensitivity of routine ultrasound in predicting neonatal symptoms is around 25%, serial targeted ultrasound and magnetic resonance imaging of known infected fetuses show greater than 95% sensitivity for brain anomalies. Fetal diagnosis is done by amniocentesis from 17 weeks. Prevention consists of both parents avoiding contact with body fluids from infected individuals, especially toddlers, from before conception until 14 weeks. Candidate vaccines failed to provide more than 75% protection for >2 years in preventing cytomegalovirus infection. Medical therapies such as cytomegalovirus hyperimmune globulins aim to reduce the risk of vertical transmission but 2 randomized controlled trials have not found any benefit. Valaciclovir given from the diagnosis of primary infection up to amniocentesis decreased vertical transmission rates from 29.8% to 11.1% in the treatment group in a randomized controlled trial of 90 pregnant women. In a phase II open-label trial, oral valaciclovir (8 g/d) given to pregnant women with a mildly symptomatic fetus was associated with a higher chance of delivering an asymptomatic neonate (82%), compared with an untreated historical cohort (43%). Valganciclovir given to symptomatic neonates is likely to improve hearing and neurological symptoms, the extent of which and the duration of treatment are still debated. In conclusion, congenital cytomegalovirus infection is a public health challenge. In view of recent knowledge on diagnosis and pre- and postnatal management, health care providers should reevaluate screening programs in early pregnancy and at birth.
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Affiliation(s)
- Marianne Leruez-Ville
- Assistance Publique-Hôpitaux de Paris, Hôpital Necker Enfants-Malade, Laboratoire de Virologie, Centre National de Reference des Herpes Virus-Laboratoire Associé Infection Congénitale à Cytomégalovirus, Paris, France; EA Fetus, Paris Descartes Université, Université de Paris, Paris, France.
| | - Ina Foulon
- Department of Otolaryngology-Head and Neck Surgery, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium; De Poolster Rehabilitation Centre, Brussels, Belgium
| | - Robert Pass
- Department of Pediatrics, University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Yves Ville
- EA Fetus, Paris Descartes Université, Université de Paris, Paris, France; Assistance Publique-Hôpitaux de Paris, Hôpital Necker Enfants-Malade, Maternité, Paris, France
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Leruez‐Ville M, Ville Y. Is it time for routine prenatal serological screening for congenital cytomegalovirus? Prenat Diagn 2020; 40:1671-1680. [DOI: 10.1002/pd.5757] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 04/27/2020] [Accepted: 05/23/2020] [Indexed: 01/12/2023]
Affiliation(s)
- Marianne Leruez‐Ville
- AP‐HP, Hôpital Necker Enfants‐Malade, Laboratoire de Virologie Centre National de Reference des herpes virus‐ Laboratoire associé infection congénitale à cytomégalovirus Paris France
- EA 7328, Paris Descartes Université Université de Paris Paris France
| | - Yves Ville
- EA 7328, Paris Descartes Université Université de Paris Paris France
- AP‐HP Hospital Necker Enfants‐Malade, Maternité Paris France
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19
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Bianchi DW, Deprest J, Levy B, Chitty LS, Ghidini A, Hui L, van Mieghem T, George ST. The 2019 Malcolm Ferguson-Smith Young Investigator Award. Prenat Diagn 2020; 40:763-765. [PMID: 32597540 DOI: 10.1002/pd.5763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Diana W Bianchi
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Jan Deprest
- Departments of Obstetrics and Gynaecology, University Hospitals, Leuven, Belgium
| | - Brynn Levy
- Departments of Pathology and Cell Biology, Columbia University, New York, NY, USA
| | - Lyn S Chitty
- Genetic and Genomic Medicine, University College London, Great Ormond Street Institute of Child Health, London, UK
| | - Alessandro Ghidini
- Antenatal Testing Center, Inova Alexandria Hospital, Alexandria, VA, USA
| | - Lisa Hui
- Departments of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
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Management of cytomegalovirus infection in pregnancy: is it time for valacyclovir? Clin Microbiol Infect 2020; 26:1151-1154. [PMID: 32289479 DOI: 10.1016/j.cmi.2020.04.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 03/26/2020] [Accepted: 04/05/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Congenital cytomegalovirus (CMV) infection is the leading infectious cause of neurological impairment for which, currently, there are no approved antenatal treatment options. OBJECTIVES The aim of this article was to summarize the available evidence on the use of valacyclovir during pregnancy to prevent and treat congenital CMV infection and disease. SOURCES Two databases (PubMed and ClinicalTrial.gov) were reviewed. CONTENT Six relevant documents were identified, namely one observational study, three clinical trials, two case reports. Most relevant findings were those from two clinical trials. A phase 2/3 placebo-controlled study showed a decrease of 71% (5 of 45 vs 14 of 47) in rate of CMV vertical transmission in women treated with 8 g/day valacyclovir following primary CMV infection in pregnancy. A phase 2, single-arm clinical trial, showed that 8 g/day valacyclovir administered to mothers of symptomatic infected foetuses increased the portion of asymptomatic neonates to 82% (34 of 41), compared with 43% (20 of 47) in untreated pregnancies from a historical cohort. IMPLICATIONS Studies in favour of using valacyclovir during pregnancy for prevention and treatment of congenital CMV infection are emerging but are still few. Randomized clinical trials on large cohorts of patients investigating the efficacy on prevention and treatment of congenital CMV are required. Unfortunately, this will be probably not be feasible at least in the short period. In the meantime, data on the 'off label' use of valacyclovir for CMV in pregnancy could be collected within a multicentre observational study.
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Kyriakopoulou A, Serghiou S, Dimopoulou D, Arista I, Psaltopoulou T, Dinopoulos A, Papaevangelou V. Antenatal imaging and clinical outcome in congenital CMV infection: A field-wide systematic review and meta-analysis. J Infect 2020; 80:407-418. [PMID: 32097687 DOI: 10.1016/j.jinf.2020.02.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 02/08/2020] [Accepted: 02/12/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Postnatal outcome in fetuses with congenital cytomegalovirus infection (cCMV) varies from asymptomatic infection to severe neurodevelopmental impairment. Αntenatal biomarkers of long-term clinical outcome, have yet to be established. Α systematic review and meta-analysis was performed to examine whether prenatal cerebral ultrasonography (US) and magnetic resonance imaging (MRI) findings in cCMV fetuses may predict clinical outcome. METHODS PubMed and the Web of Science were systematically searched to identify studies reporting on any prenatal US and/or MRI imaging of fetuses with cCMV as well as their postnatal clinical outcome. All reported associations between imaging and postnatal clinical outcome were systematically extracted. Where appropriate, the reported associations were quantitatively synthesized within Bayesian random-effects meta-analyses. RESULTS A total of 1336 studies were screened to identify 26 eligible observational studies. Overall, 4181 fetuses were studied, of which 1518 had been diagnosed with cCMV. All studies performed fetal US while in 14 (54%) MRI was also performed. Studies substantially varied in timing of fetal imaging, reporting of abnormalities, definition of poor outcome and statistical analysis. Among studies reporting on statistical significance, 6/6 for US and 3/4 for MRI identified significant associations between imaging findings and outcome. In our meta-analyses, within isolated abnormalities, only microcephaly had greater than 95% probability of being associated with poor outcome (OR 26.7; 95% CI, 1.44-1464.5; I2, 19%). Effect sizes for US were higher than those for MRI findings. CONCLUSIONS Although studies displayed significant heterogeneity in both methodology and analytical decisions, it became evident that when both prenatal cerebral US and MRI are normal the negative predictive value of poor outcome is high. This is important for clinicians when consulting pregnant women. Need to standardize practices and definitions become evident. FUNDING There was no source of funding.
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Affiliation(s)
- Aikaterini Kyriakopoulou
- Third Department of Paediatrics, Attikon University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens 115 27, Greece.
| | - Stylianos Serghiou
- Department of Epidemiology and Population Health, Stanford School of Medicine, Stanford University, Stanford, CA, United States; Meta-Research Innovation Center at Stanford, Stanford University, Stanford, CA, United States
| | - Dimitra Dimopoulou
- Third Department of Paediatrics, Attikon University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens 115 27, Greece
| | - Ioli Arista
- Health Economist, Independent Researcher, Athens, Greece
| | - Theodora Psaltopoulou
- Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Athens 115 27, Greece
| | - Argyrios Dinopoulos
- Third Department of Paediatrics, Attikon University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens 115 27, Greece
| | - Vassiliki Papaevangelou
- Third Department of Paediatrics, Attikon University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens 115 27, Greece
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Tomic K, Schönberger H, Weber P, Lapaire O, Manegold-Brauer G. Significance of isolated borderline ventriculomegaly. Childs Nerv Syst 2020; 36:393-399. [PMID: 31079183 DOI: 10.1007/s00381-019-04189-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 04/30/2019] [Indexed: 11/24/2022]
Abstract
PURPOSE Foetal ventriculomegaly (VM) is one of the most commonly diagnosed brain abnormalities. The aims of this study were to assess cases with isolated VM, describe the prenatal course and assess short- and long-term follow-up at the age of 2 years. METHODS We performed a retrospective analysis from our prenatal data base and included all children that were prenatally diagnosed with VM in our unit between 2008 and 2013 (n = 250). Prenatal management, postnatal outcome and neurologic development at the age of 2 years were evaluated. RESULTS A total of 106 children were born at our institution and were diagnosed prenatally with isolated borderline VM. A total of 1.9% (n = 2/106) was transferred to the neonatal unit. A total of 0.9% (n = 1/106) showed abnormal findings in postnatal brain ultrasound. A total of 1.9% (n = 2/106) showed mild neurologic abnormalities after birth, but none had to be seen by a neuropediatrician. At the follow-up at 2 years, 2.5% (n = 1/40) had an insertion of a shunt. CONCLUSION Based on our analysis, the majority of isolated borderline VM do not show short- or long-term neurological abnormalities. However, all cases of VM should be referred to a detailed prenatal ultrasound exam by a specialist.
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Affiliation(s)
- Katrin Tomic
- Division of Prenatal Diagnostics and Gynecologic Ultrasound, Women's Hospital, Basel University Hospital, Basel, Switzerland
| | - Heidrun Schönberger
- Division of Prenatal Diagnostics and Gynecologic Ultrasound, Women's Hospital, Basel University Hospital, Basel, Switzerland
| | - Peter Weber
- Division of Neuro- and Developmental Paediatrics, University Children's Hospital Basel (UKBB), Basel, Switzerland
| | - Olav Lapaire
- Division of Prenatal Diagnostics and Gynecologic Ultrasound, Women's Hospital, Basel University Hospital, Basel, Switzerland
| | - Gwendolin Manegold-Brauer
- Division of Prenatal Diagnostics and Gynecologic Ultrasound, Women's Hospital, Basel University Hospital, Basel, Switzerland.
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23
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Lazzarotto T, Blázquez-Gamero D, Delforge ML, Foulon I, Luck S, Modrow S, Leruez-Ville M. Congenital Cytomegalovirus Infection: A Narrative Review of the Issues in Screening and Management From a Panel of European Experts. Front Pediatr 2020; 8:13. [PMID: 32083040 PMCID: PMC7006044 DOI: 10.3389/fped.2020.00013] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 01/10/2020] [Indexed: 01/01/2023] Open
Abstract
Maternal primary and non-primary cytomegalovirus (CMV) infection during pregnancy can result in in utero transmission to the developing fetus. Congenital CMV (cCMV) can result in significant morbidity, mortality or long-term sequelae, including sensorineural hearing loss, the most common sequela. As a leading cause of congenital infections worldwide, cCMV infection meets many of the criteria for screening. However, currently there are no universal programs that offer maternal or neonatal screening to identify infected mothers and infants, no vaccines to prevent infection, and no efficacious and safe therapies available for the treatment of maternal or fetal CMV infection. Data has shown that there are several maternal and neonatal screening strategies, and diagnostic methodologies, that allow the identification of those at risk of developing sequelae and adequately detect cCMV. Nevertheless, many questions remain unanswered in this field. Well-designed clinical trials to address several facets of CMV treatment (in pregnant women, CMV-infected fetuses and both symptomatic and asymptomatic neonates and children) are required. Prevention (vaccines), biology and transmission factors associated with non-primary CMV, and the cost-effectiveness of universal screening, all demand further exploration to fully realize the ultimate goal of preventing cCMV. In the meantime, prevention of primary infection during pregnancy should be championed to all by means of hygiene education.
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Affiliation(s)
- Tiziana Lazzarotto
- Virology Lab, Polyclinic St. Orsola Malpighi, University of Bologna, Bologna, Italy
| | - Daniel Blázquez-Gamero
- Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Universidad Complutense, Instituto de Investigación Hospital 12 de Octubre (Imas12), Translational Research Network in Pediatric Infectious Diseases (RITIP), Madrid, Spain
| | | | - Ina Foulon
- Department of Otolaryngology - Head and Neck Surgery, Vrije Universiteit Brussel, Brussels, Belgium
| | - Suzanne Luck
- Kingston Hospital NHS Trust, Kingston upon Thames, United Kingdom.,Paediatric Infectious Diseases Research Group, St George's University of London, London, United Kingdom
| | - Susanne Modrow
- Institute of Medical Microbiology, University of Regensburg, Regensburg, Germany
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24
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Abstract
OBJECTIVES To review the principles of prenatal diagnosis of congenital cytomegalovirus (CMV) infection and to describe the outcomes of the affected pregnancies. OUTCOMES Effective management of fetal infection following primary and secondary maternal CMV infection during pregnancy. Neonatal signs include intrauterine growth restriction (IUGR), microcephaly, hepatosplenomegaly, petechiae, jaundice, chorioretinitis, thrombocytopenia and anemia, and long-term sequelae consist of sensorineural hearing loss, mental retardation, delay of psychomotor development, and visual impairment. These guidelines provide a framework for diagnosis and management of suspected CMV infections. EVIDENCE Medline was searched for articles published in English from 1966 to 2009, using appropriate controlled vocabulary (congenital CMV infection) and key words (intrauterine growth restriction, microcephaly). Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis and incorporated into the guideline. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. RECOMMENDATIONS The quality of evidence reported in this document has been assessed using the evaluation of evidence criteria in the Report of the Canadian Task Force on Preventive Health Care (Table 1).
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25
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Hawkins-Villarreal A, Moreno-Espinosa AL, Eixarch E, Marcos MA, Martinez-Portilla RJ, Salazar L, Garcia-Otero L, Lopez M, Borrell A, Figueras F, Goncé A. Blood parameters in fetuses infected with cytomegalovirus according to the severity of brain damage and trimester of pregnancy at cordocentesis. J Clin Virol 2019; 119:37-43. [PMID: 31473566 DOI: 10.1016/j.jcv.2019.08.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 08/16/2019] [Accepted: 08/19/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND OBJECTIVE Cytomegalovirus (CMV) remains a major cause of congenital infection and disease. During pregnancy, symptomatic cases can be detected through ultrasound (US) features, nevertheless, prognostic assessment is difficult. The aim of this study was to assess the predictive value of specific blood parameters in CMV infected fetuses. STUDY DESIGN Twenty-eight CMV-infected fetuses in which a cordocentesis had been performed were included. Fetuses were considered severely or mildly affected according to prenatal US/MRI brain damage. Fetal blood parameters were assessed for the prediction of severe brain abnormalities, and compared according to the trimester of pregnancy. Logistic regression and receiver operating curve analysis were performed. RESULTS Thrombocytopenia (≤100,000/mm3; p:0.03) and high levels of gamma-glutamyl transpeptidase (GGT) (≥151 IU/L; p:0.02) signaled severity. For the prediction of brain damage, GGT levels ≥ 183 UI/l achieved 71% sensitivity, 83% specificity (AUC: 0.78), and OR of 2.05 (95% CI: 1.22-3.43) per 100 IU/l increase, adjusted for gestational age. However, thrombocytopenia (91% vs 50%; p: 0.04), β2 microglobulin >10.4 mg/l (60% vs 0% p: 0.03), CMV-DNA >50,000 copies/ml (80% vs 25%; p: 0.02), and positive IgM (70% vs 17%; p: 0.04) were observed significantly more often in severely damaged fetuses sampled ≤28 weeks than thereafter. CONCLUSION In CMV infected fetuses, thrombocytopenia and high levels of GGT are associated with severe US/MRI brain abnormalities. Nevertheless, among severely affected fetuses, blood parameters, with exception of GGT, change according to gestational age. Fetal blood could be less predictive of brain damage in the third trimester.
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Affiliation(s)
- Ameth Hawkins-Villarreal
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecología, Obstetricia i Neonatologia, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain; Fetal Medicine Service, Obstetrics Department, Hospital "Santo Tomás", University of Panama, Panama City, Panamá in behalf of the Iberoamerican Research Network in Translational, Molecular and Maternal Fetal Medicine
| | - Ana L Moreno-Espinosa
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecología, Obstetricia i Neonatologia, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain; Fetal Medicine Service, Obstetrics Department, Hospital "Santo Tomás", University of Panama, Panama City, Panamá in behalf of the Iberoamerican Research Network in Translational, Molecular and Maternal Fetal Medicine
| | - Elisenda Eixarch
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecología, Obstetricia i Neonatologia, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain; Centre for Biomedical Research on Rare Diseases (CIBERER), Barcelona, Spain
| | - M Angeles Marcos
- Department of Clinical Microbiology, Hospital Clinic, University of Barcelona, Institute for Global Health (ISGlobal), Barcelona, Spain
| | - Raigam J Martinez-Portilla
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecología, Obstetricia i Neonatologia, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain
| | - Laura Salazar
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecología, Obstetricia i Neonatologia, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain
| | - Laura Garcia-Otero
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecología, Obstetricia i Neonatologia, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain
| | - Marta Lopez
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecología, Obstetricia i Neonatologia, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain; Centre for Biomedical Research on Rare Diseases (CIBERER), Barcelona, Spain
| | - Antoni Borrell
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecología, Obstetricia i Neonatologia, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain; Centre for Biomedical Research on Rare Diseases (CIBERER), Barcelona, Spain
| | - Francesc Figueras
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecología, Obstetricia i Neonatologia, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain; Centre for Biomedical Research on Rare Diseases (CIBERER), Barcelona, Spain
| | - Anna Goncé
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecología, Obstetricia i Neonatologia, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain; Centre for Biomedical Research on Rare Diseases (CIBERER), Barcelona, Spain.
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Bianchi DW, Ghidini A, Levy B, Deprest J, van Mieghem T, Chitty LS, Hui L, McLean-Inglis A. The 2018 Malcolm Ferguson-Smith Young Investigator Award. Prenat Diagn 2019; 39:835-837. [PMID: 31414475 DOI: 10.1002/pd.5533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 07/18/2019] [Indexed: 11/08/2022]
Affiliation(s)
- Diana W Bianchi
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Alessandro Ghidini
- Department of Obstetrics and Gynecology, Inova Alexandria Hospital, Alexandria, VA, USA
| | - Brynn Levy
- Department of Pathology and Cell Biology, Columbia University, New York, NY, USA
| | - Jan Deprest
- Academic Department of Development and Regeneration, Woman and Child, Biomedical Sciences, and Clinical Department of Obstetrics and Gynaecology, KU Leuven, Leuven, Belgium
| | - Tim van Mieghem
- Departments of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, Canada
| | - Lyn S Chitty
- Genetics and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Lisa Hui
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia
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Smiljkovic M, Renaud C, Tapiero B, Lamarre V, Kakkar F. Head ultrasound, CT or MRI? The choice of neuroimaging in the assessment of infants with congenital cytomegalovirus infection. BMC Pediatr 2019; 19:180. [PMID: 31167649 PMCID: PMC6549373 DOI: 10.1186/s12887-019-1562-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 05/29/2019] [Indexed: 11/11/2022] Open
Abstract
Background Despite growing interest in universal screening for congenital CMV infection (cCMV), and data to support treatment for cases with central nervous system (CNS) involvement, there is limited regarding the optimal imaging modalities to identify CNS involvement. The objective of this study was to assess the concordance between head ultrasound (US) and magnetic resonance imaging (MRI) or computed tomography (CT), in identifying neurological abnormalities in infants with cCMV infection, and to determine whether the addition of advanced neuroimaging after US had an impact on clinical management. Methods Retrospective review of infants with cCMV infection, referred to the Centre d’Infectiologie Mère-Enfant (CIME) at Sainte-Justine Hospital Center in Montreal, between 2008 and 2016. Only patients who underwent head US followed by and brain MRI or CT scan were included in this analysis. Results Of 46 cases of cCMV identified during the study period, 34 (74%) had a head US followed by MRI (n = 28, 61%), or CT scan (n = 6, 13%). In the majority of cases (n = 24, 71%), both images were concordant (11 both reported abnormal, 13 both reported normal). In 5 cases, US was reported normal and subsequent imaging (MRI = 4, CT = 1); reported abnormal. In all 5 cases patients were clinically symptomatic and met treatment criteria even in the absence of neuroimaging findings. In 5 cases, US was reported abnormal with a subsequent normal MRI (4) or CT (1); in 2 of these cases, patients were clinically symptomatic and met treatment criteria regardless of neuroimaging findings. However, in 3 cases, the patients were clinically asymptomatic, and in 2 of these cases, treated based only on the abnormal US findings. Conclusions In this study, we found that that sequential US and MRI were concordant in the majority (71%) of cases in detecting abnormalities potentially associated with cCMV infection. While the addition of MRI to baseline head ultrasound did not influence the decision to treat in clinically symptomatic infants, the addition of MRI to infants with abnormal HUS imaging who are clinically asymptomatic could help refine treatment decisions in these cases.
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Affiliation(s)
- Mina Smiljkovic
- Department of Pediatrics, Division of Infectious Diseases, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Christian Renaud
- Department of Microbiology and Infectious Diseases, CHU Sainte-Justine, Université de Montréal, Montréal, QC, Canada
| | - Bruce Tapiero
- Department of Pediatrics, Division of Infectious Diseases, CHU Sainte-Justine, Université de Montréal, 3175 Côte Sainte-Catherine, Montreal, QC, Canada
| | - Valérie Lamarre
- Department of Pediatrics, Division of Infectious Diseases, CHU Sainte-Justine, Université de Montréal, 3175 Côte Sainte-Catherine, Montreal, QC, Canada
| | - Fatima Kakkar
- Department of Pediatrics, Division of Infectious Diseases, CHU Sainte-Justine, Université de Montréal, 3175 Côte Sainte-Catherine, Montreal, QC, Canada.
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Mathias CR, Joung SJS. Diagnostic challenges in congenital cytomegalovirus infection in pregnancy: A case report. Case Rep Womens Health 2019; 22:e00119. [PMID: 31192993 PMCID: PMC6510697 DOI: 10.1016/j.crwh.2019.e00119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 04/20/2019] [Accepted: 04/25/2019] [Indexed: 11/26/2022] Open
Abstract
Cytomegalovirus is the most common congenital viral infection. Infection can cause developmental delay, sensorineural deafness and fetal death. Fetal damage is more severe when infection occurs in the first trimester of pregnancy. Prenatal ultrasound findings may be cerebral, such as ventriculomegaly, microcephaly and periventricular leukomalacia, as well as non-cerebral, such as echogenic bowel, ascites and pericardial effusion. We present a case of congenital cytomegalovirus infection in which the only ultrasound sign noted at routine second-trimester scan was low-grade echogenic bowel, a soft marker, which progressed to severe disease in the third trimester, when further investigation was prompted, leading to the diagnosis. Patients need to be counselled regarding the possible perinatal prognosis. Ultrasound markers can often but not always predict severity and, hence, counselling can be a challenge. Conclusion: A meticulous anatomy survey in mid-trimester remains the norm and ultrasound soft markers should prompt comprehensive testing for viral infections in pregnancy. Fetal damage caused by infection with CMV is more severe when the infection occurs in the first trimester of pregnancy. CMV is the most common congenital viral infection causingdevelopmental delay, sensorineural deafness and fetal death. Ultrasound markers can often but not always predict the severity of congenital infection. A meticulous anatomy survey in mid-trimester remains the norm. Ultrasound soft markers should prompt comprehensive testing for viral infections in pregnancy.
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Affiliation(s)
- Caroline Ruth Mathias
- Department of Obstetrics and Gynaecology, Nepean Hospital, Kingswood 2747, NSW, Australia
| | - Steven Jin Sung Joung
- Department of Obstetrics and Gynaecology, Nepean Hospital, Kingswood 2747, NSW, Australia
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Marques VDM, Santos CS, Santiago IG, Marques SM, Nunes Brasil MDG, Lima TT, Costa PS. Neurological Complications of Congenital Zika Virus Infection. Pediatr Neurol 2019; 91:3-10. [PMID: 30591235 DOI: 10.1016/j.pediatrneurol.2018.11.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 10/30/2018] [Accepted: 11/02/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND In utero Zika virus infection resulted in many newborns with congenital defects; this public health issue was followed by unprecedented scientific productivity in this field. Many questions remain about congenital Zika virus infection and its maternal transmission, pathogenesis, clinical events, and the resulting neurological damage. There are few review articles that synthesize the current knowledge of congenital neurological complications as well as the gaps in the pediatric literature. OBJECTIVE We review the full range of data on neurological complications in the newborns and infants born to Zika virus-infected women. METHODS A research question (PCC: Population, newborns and infants of infected mothers; Concept, neurological outcomes at birth; Context, congenital Zika virus infection) was created to guide our review in searching several databases: PubMed, Lilacs, CINAHL, Cochrane Library, and OpenGrey literature. A total of 34 articles were included in the final review. RESULTS Central nervous system calcifications, mainly at the cortical-subcortical junction, were the most prevalent neurological birth defects related to Zika infection (104/112, 92.9% from seven studies). Also, microcephaly occurred in 39.7% of all infected infants (1561/3931 patients in all the studies) and ventriculomegaly and/or hydrocephalus occurred in 63.1% (157/249 patients analyzed in 12 studies). A total of 10 articles detailed ocular findings, including macular lesions, focal pigment mottling of the retina, chorioretinal atrophy, optic nerve abnormalities, cataract, microphthalmia, and strabismus, among others. CONCLUSIONS Neurological and related malformations are common lesions in individuals with congenital Zika syndrome. Long-term follow-up studies in this field are lacking.
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Affiliation(s)
- Vinícius de Melo Marques
- Department of Pediatrics, School of Medicine, Universidade Federal de Goiás - UFG, Goiânia, GO, Brazil
| | - Camilla Sousa Santos
- Department of Pediatric Neurology, Universidade Federal de São Paulo - UNIFESP, São Paulo, SP, Brazil
| | - Isabella Godinho Santiago
- Department of Pediatric Neurology, Hospital das Clínicas, Universidade Federal de Goiás - UFG, Goiânia, GO, Brazil
| | - Solomar Martins Marques
- Department of Pediatrics, School of Medicine, Universidade Federal de Goiás - UFG, Goiânia, GO, Brazil
| | | | - Talita Toledo Lima
- Department of Ophtalmology, Hospital das Clínicas, Universidade Federal de Goiás - UFG, Goiânia, GO, Brazil
| | - Paulo Sucasas Costa
- Department of Pediatrics, School of Medicine, Universidade Federal de Goiás - UFG, Goiânia, GO, Brazil.
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Birnbaum R, Ben-Sira L, Lerman-Sagie T, Malinger G. The use of fetal neurosonography and brain MRI in cases of cytomegalovirus infection during pregnancy: A retrospective analysis with outcome correlation. Prenat Diagn 2018; 37:1335-1342. [PMID: 29119569 DOI: 10.1002/pd.5180] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 10/23/2017] [Accepted: 10/29/2017] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To analyze ultrasound (US) and magnetic resonance imaging (MRI) results and developmental outcome in cases of maternal primary cytomegalovirus (CMV) infection during pregnancy. METHODS We retrospectively reviewed the results of fetal neurosonography and brain MRI of CMV-infected fetuses (Group 1). Cases of maternal infection in which the fetal status was unknown, and subsequently had a negative CMV postnatal urine analysis, were independently analyzed (Group 2). Imaging results were classified as follows: positive, negative, or inconclusive. Developmental landmarks were followed up. RESULTS Eighty-one women were included in the study: 48 (59.2%) in Group 1 and 33 (40.8%) in Group 2. In Group 1, termination of pregnancy was performed in 8 cases (16.7%) following the diagnosis of brain abnormalities. Among the remaining cases, concordance rate between US and MRI was 78%. False negative rates for US and MRI were 5.5% and 6.4%, respectively (hearing deficits). For MRI, we found 17.5% of false positive/inconclusive results, while for the US, we found 5% of inconclusive results. In Group 2, false positive rates for US and MRI were 6.5% and 12.9%, respectively. CONCLUSIONS Adding MRI in CMV-infected cases with a normal neurosonographic follow-up should be weighed against a nonnegligible rate of false positive and inconclusive findings.
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Affiliation(s)
- Roee Birnbaum
- OB-GYN Ultrasound Unit, Lis Maternity Hospital, Tel Aviv Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Liat Ben-Sira
- Pediatric Radiology Unit, Tel Aviv Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tally Lerman-Sagie
- Fetal Neurology Clinic, Pediatric Neurology Unit, Wolfson Medical Center, Holon, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gustavo Malinger
- OB-GYN Ultrasound Unit, Lis Maternity Hospital, Tel Aviv Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Bianchi DW, Ghidini A, Levy B, Deprest J, Van Mieghem T, Chitty LS, McLean-Inglis AJL. The 2017 Malcolm Ferguson-Smith Young Investigator Award. Prenat Diagn 2018; 38:545-546. [PMID: 29952009 DOI: 10.1002/pd.5289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Diana W Bianchi
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | | | - Brynn Levy
- Department of Pathology and Cell Biology, Columbia University, New York, NY, USA
| | - Jan Deprest
- Academic Department of Development and Regeneration, Woman and Child, Biomedical Sciences, and Clinical Department of Obstetrics and Gynaecology, KU Leuven, Leuven, Belgium
| | - Tim Van Mieghem
- Departments of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, Canada
| | - Lyn S Chitty
- Genetics and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
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32
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Hayat TTA, Rutherford MA. Neuroimaging perspectives on fetal motor behavior. Neurosci Biobehav Rev 2018; 92:390-401. [PMID: 29886176 DOI: 10.1016/j.neubiorev.2018.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 05/22/2018] [Accepted: 06/01/2018] [Indexed: 12/19/2022]
Abstract
We are entering a new era of understanding human development with the ability to perform studies at the earliest time points possible. There is a substantial body of evidence to support the concept that early motor behaviour originates from supraspinal motor centres, reflects neurological integrity, and that altered patterns of behaviour precede clinical manifestation of disease. Cine Magnetic Resonance Imaging (cineMRI) has established its value as a novel method to visualise motor behaviour in the human fetus, building on the wealth of knowledge gleaned from ultrasound based studies. This paper presents a state of the art review incorporating findings from human and preclinical models, the insights from which, we propose, can proceed a reconceptualisation of fetal motor behaviour using advanced imaging techniques. Foremost is the need to better understand the role of the intrauterine environment, and its inherent unique set of stimuli that activate sensorimotor pathways and shape early brain development. Finally, an improved model of early motor development, combined with multimodal imaging, will provide a novel source of in utero biomarkers predictive of neurodevelopmental disorders.
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Affiliation(s)
- Tayyib T A Hayat
- Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, United Kingdom.
| | - Mary A Rutherford
- Centre for the Developing Brain, Perinatal Imaging & Health, Imaging Sciences & Biomedical Engineering Division, King's College London, London, United Kingdom
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Neuberger I, Garcia J, Meyers ML, Feygin T, Bulas DI, Mirsky DM. Imaging of congenital central nervous system infections. Pediatr Radiol 2018; 48:513-523. [PMID: 29550865 DOI: 10.1007/s00247-018-4092-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 01/08/2018] [Accepted: 01/19/2018] [Indexed: 10/17/2022]
Abstract
Congenital central nervous system (CNS) infections are a cause of significant morbidity and mortality. The recent Zika virus outbreak raised awareness of congenital CNS infections. Imaging can be effective in diagnosing the presence and severity of infection. In this paper we review the clinical presentations and imaging characteristics of several common and less common congenital CNS infections.
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Affiliation(s)
- Ilana Neuberger
- Department of Radiology, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 E. 16th Ave., Box B125, Aurora, CO, 80045, USA
| | - Jacquelyn Garcia
- Department of Radiology, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 E. 16th Ave., Box B125, Aurora, CO, 80045, USA
| | - Mariana L Meyers
- Department of Radiology, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 E. 16th Ave., Box B125, Aurora, CO, 80045, USA
| | - Tamara Feygin
- Department of Radiology, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Dorothy I Bulas
- Department of Radiology, Children's National Health System, George Washington School of Medicine and Health Sciences, Washington, DC, USA
| | - David M Mirsky
- Department of Radiology, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 E. 16th Ave., Box B125, Aurora, CO, 80045, USA.
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34
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Griffiths P, Mooney C, Bradburn M, Jarvis D. Should we perform in utero MRI on a fetus at increased risk of a brain abnormality if ultrasonography is normal or shows non-specific findings? Clin Radiol 2018; 73:123-134. [DOI: 10.1016/j.crad.2017.09.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 06/29/2017] [Accepted: 09/12/2017] [Indexed: 12/11/2022]
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Yinon Y, Farine D, Yudin MH. Archivée: No 240-Infection à cytomégalovirus pendant la grossesse. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 40:e142-e150. [DOI: 10.1016/j.jogc.2017.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Levine D, Jani JC, Castro-Aragon I, Cannie M. How Does Imaging of Congenital Zika Compare with Imaging of Other TORCH Infections? Radiology 2017; 285:744-761. [PMID: 29155634 DOI: 10.1148/radiol.2017171238] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The acronym TORCH is used to refer to congenital infections, such as toxoplasmosis, other infections (such as syphillis, varicella-zoster, and parvovirus B19), cytomegalovirus, and herpes simplex virus. The classic findings in patients with TORCH infections include rash in the mother during pregnancy and ocular findings in the newborn. Zika virus has emerged as an important worldwide congenital infection. It fits well with other congenital TORCH infections since there is a rash in the mother and there are commonly ocular abnormalities in the newborn. TORCH infections are recognized to have neurologic effects, such as ventriculomegaly, intraventricular adhesions, subependymal cysts, intracerebral calcifications, and microcephaly; however, the Zika virus is intensely neurotropic. Thus, it targets neural progenitor cells, leading to a more severe spectrum of central nervous system abnormalities than is typically seen in other TORCH infections, while relatively sparing the other organ systems. In this review, nonspecific findings of congenital infections initially will be described, then individual TORCH infections will be described and compared with the imaging findings associated with congenital Zika virus infection. For the radiologist, awareness of imaging features of common congenital infections may facilitate early diagnosis and may, at times, lead to prompt initiation of therapy. Online supplemental material is available for this article.
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Affiliation(s)
- Deborah Levine
- From the Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA 02215 (D.L.); Departments of Obstetrics and Gynecology (J.C.J.) and Radiology (M.C.), University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium; Department of Radiology, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium (M.C.); and Department of Radiology, Boston Medical Center, Boston University, Boston, Mass (I.C.)
| | - Jacques C Jani
- From the Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA 02215 (D.L.); Departments of Obstetrics and Gynecology (J.C.J.) and Radiology (M.C.), University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium; Department of Radiology, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium (M.C.); and Department of Radiology, Boston Medical Center, Boston University, Boston, Mass (I.C.)
| | - Ilse Castro-Aragon
- From the Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA 02215 (D.L.); Departments of Obstetrics and Gynecology (J.C.J.) and Radiology (M.C.), University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium; Department of Radiology, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium (M.C.); and Department of Radiology, Boston Medical Center, Boston University, Boston, Mass (I.C.)
| | - Mieke Cannie
- From the Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA 02215 (D.L.); Departments of Obstetrics and Gynecology (J.C.J.) and Radiology (M.C.), University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium; Department of Radiology, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium (M.C.); and Department of Radiology, Boston Medical Center, Boston University, Boston, Mass (I.C.)
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37
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Kotovich D, Guedalia JSB, Hoffmann C, Sze G, Eisenkraft A, Yaniv G. Apparent Diffusion Coefficient Value Changes and Clinical Correlation in 90 Cases of Cytomegalovirus-Infected Fetuses with Unremarkable Fetal MRI Results. AJNR Am J Neuroradiol 2017; 38:1443-1448. [PMID: 28522662 DOI: 10.3174/ajnr.a5222] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 03/06/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Cytomegalovirus is the leading intrauterine infection. Fetal MR imaging is an accepted tool for fetal brain evaluation, yet it still lacks the ability to accurately predict the extent of the neurodevelopmental impairment, especially in fetal MR imaging scans with unremarkable findings. Our hypothesis was that intrauterine cytomegalovirus infection causes diffusional changes in fetal brains and that those changes may correlate with the severity of neurodevelopmental deficiencies. MATERIALS AND METHODS A retrospective analysis was performed on 90 fetal MR imaging scans of cytomegalovirus-infected fetuses with unremarkable results and compared with a matched gestational age control group of 68 fetal head MR imaging scans. ADC values were measured and averaged in the frontal, parietal, occipital, and temporal lobes; basal ganglia; thalamus; and pons. For neurocognitive assessment, the Vineland Adaptive Behavior Scales, Second Edition (VABS-II) was used on 58 children in the cytomegalovirus-infected group. RESULTS ADC values were reduced for the cytomegalovirus-infected fetuses in most brain areas studied. The VABS-II showed no trend for the major domains or the composite score of the VABS-II for the cytomegalovirus-infected children compared with the healthy population distribution. Some subdomains showed an association between ADC values and VABS-II scores. CONCLUSIONS Cytomegalovirus infection causes diffuse reduction in ADC values in the fetal brain even in unremarkable fetal MR imaging scans. Cytomegalovirus-infected children with unremarkable fetal MR imaging scans do not deviate from the healthy population in the VABS-II neurocognitive assessment. ADC values were not correlated with VABS-II scores. However, the lack of clinical findings, as seen in most cytomegalovirus-infected fetuses, does not eliminate the possibility of future neurodevelopmental pathology.
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Affiliation(s)
- D Kotovich
- From The Faculty of Medicine (D.K., A.E.), Institute for Research in Military Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
- The Israel Defense Forces Medical Corps (D.K., A.E.), Chevy Chase, Maryland
| | - J S B Guedalia
- Neuropsychology Unit (J.S.B.G., G.Y.), Shaare Zedek Medical Center, Jerusalem, Israel
| | | | - G Sze
- Department of Radiology and Biomedical Imaging (G.S., G.Y.), Yale School of Medicine, New Haven, Connecticut
| | - A Eisenkraft
- From The Faculty of Medicine (D.K., A.E.), Institute for Research in Military Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
- The Israel Defense Forces Medical Corps (D.K., A.E.), Chevy Chase, Maryland
| | - G Yaniv
- Neuropsychology Unit (J.S.B.G., G.Y.), Shaare Zedek Medical Center, Jerusalem, Israel
- Dr. Pinchas Bornstein Talpiot Medical Leadership Program (G.Y.), Sheba Medical Center, Tel HaShomer, Ramat Gan, Israel
- Department of Radiology and Biomedical Imaging (G.S., G.Y.), Yale School of Medicine, New Haven, Connecticut
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Ghidini A, Bianchi DW, Levy B, Deprest J, van Mieghem T, Chitty LS, McLean-Inglis A. The 2016 Malcolm Ferguson-Smith Young Investigator Award. Prenat Diagn 2017. [DOI: 10.1002/pd.5074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
| | | | - Brynn Levy
- Clinical Cytogenetics Laboratory; Columbia University; New York NY USA
| | - Jan Deprest
- Clinical Department of Obstetrics and Gynaecology; University Hospitals Leuven & Academic Department Development and Regeneration, Cluster Woman & Child, Biomedical Sciences; KU Leuven Leuven Belgium
| | | | - Lyn S. Chitty
- University College London NHS Foundation Trust; London UK
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Tumor Necrosis Factor Alpha-Induced Recruitment of Inflammatory Mononuclear Cells Leads to Inflammation and Altered Brain Development in Murine Cytomegalovirus-Infected Newborn Mice. J Virol 2017; 91:JVI.01983-16. [PMID: 28122986 PMCID: PMC5375689 DOI: 10.1128/jvi.01983-16] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 01/06/2017] [Indexed: 12/24/2022] Open
Abstract
Congenital human cytomegalovirus (HCMV) infection is a significant cause of abnormal neurodevelopment and long-term neurological sequelae in infants and children. Resident cell populations of the developing brain have been suggested to be more susceptible to virus-induced cytopathology, a pathway thought to contribute to the clinical outcomes following intrauterine HCMV infection. However, recent findings in a newborn mouse model of the infection in the developing brain have indicated that elevated levels of proinflammatory mediators leading to mononuclear cell activation and recruitment could underlie the abnormal neurodevelopment. In this study, we demonstrate that treatment with tumor necrosis factor alpha (TNF-α)-neutralizing antibodies decreased the frequency of CD45+ Ly6Chi CD11b+ CCR2+ activated myeloid mononuclear cells (MMCs) and the levels of proinflammatory cytokines in the blood and the brains of murine CMV-infected mice. This treatment also normalized neurodevelopment in infected mice without significantly impacting the level of virus replication. These results indicate that TNF-α is a major component of the inflammatory response associated with altered neurodevelopment that follows murine CMV infection of the developing brain and that a subset of peripheral blood myeloid mononuclear cells represent a key effector cell population in this model of virus-induced inflammatory disease of the developing brain.IMPORTANCE Congenital human cytomegalovirus (HCMV) infection is the most common viral infection of the developing human fetus and can result in neurodevelopmental sequelae. Mechanisms of disease leading to neurodevelopmental deficits in infected infants remain undefined, but postulated pathways include loss of neuronal progenitor cells, damage to the developing vascular system of the brain, and altered cellular positioning. Direct virus-mediated cytopathic effects cannot explain the phenotypes of brain damage in most infected infants. Using a mouse model that recapitulates characteristics of the brain infection described in human infants, we have shown that TNF-α plays a key role in brain inflammation, including recruitment of inflammatory mononuclear cells. Neutralization of TNF-α normalized neurodevelopmental abnormalities in infected mice, providing evidence that virus-induced inflammation is a major component of disease in the developing brain. These results suggest that interventions limiting inflammation associated with the infection could potentially improve the neurologic outcome of infants infected in utero with HCMV.
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Rawlinson WD, Boppana SB, Fowler KB, Kimberlin DW, Lazzarotto T, Alain S, Daly K, Doutré S, Gibson L, Giles ML, Greenlee J, Hamilton ST, Harrison GJ, Hui L, Jones CA, Palasanthiran P, Schleiss MR, Shand AW, van Zuylen WJ. Congenital cytomegalovirus infection in pregnancy and the neonate: consensus recommendations for prevention, diagnosis, and therapy. THE LANCET. INFECTIOUS DISEASES 2017; 17:e177-e188. [PMID: 28291720 DOI: 10.1016/s1473-3099(17)30143-3] [Citation(s) in RCA: 472] [Impact Index Per Article: 67.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 12/13/2016] [Accepted: 12/20/2016] [Indexed: 01/25/2023]
Abstract
Congenital cytomegalovirus is the most frequent, yet under-recognised, infectious cause of newborn malformation in developed countries. Despite its clinical and public health importance, questions remain regarding the best diagnostic methods for identifying maternal and neonatal infection, and regarding optimal prevention and therapeutic strategies for infected mothers and neonates. The absence of guidelines impairs global efforts to decrease the effect of congenital cytomegalovirus. Data in the literature suggest that congenital cytomegalovirus infection remains a research priority, but data are yet to be translated into clinical practice. An informal International Congenital Cytomegalovirus Recommendations Group was convened in 2015 to address these questions and to provide recommendations for prevention, diagnosis, and treatment. On the basis of consensus discussions and a review of the literature, we do not support universal screening of mothers and the routine use of cytomegalovirus immunoglobulin for prophylaxis or treatment of infected mothers. However, treatment guidelines for infected neonates were recommended. Consideration must be given to universal neonatal screening for cytomegalovirus to facilitate early detection and intervention for sensorineural hearing loss and developmental delay, where appropriate. The group agreed that education and prevention strategies for mothers were beneficial, and that recommendations will need continual updating as further data become available.
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Affiliation(s)
- William D Rawlinson
- Serology & Virology Division, SEALS Microbiology, Prince of Wales Hospital, Sydney, NSW, Australia; School of Medical Sciences, University of New South Wales, NSW, Australia; School of Biotechnology and Biomolecular Sciences, University of New South Wales, NSW, Australia.
| | - Suresh B Boppana
- Department of Pediatrics & Microbiology, University of Alabama at Birmingham, AL, USA
| | - Karen B Fowler
- Department of Pediatrics & Microbiology, University of Alabama at Birmingham, AL, USA
| | - David W Kimberlin
- Division of Pediatric Infectious Diseases, University of Alabama at Birmingham, AL, USA
| | - Tiziana Lazzarotto
- Operative Unit of Clinical Microbiology, Laboratory of Virology, Polyclinic St. Orsola-Malpighi, Department of Specialised Experimental and Diagnostic Medicine, University of Bologna, Bologna, Italy
| | - Sophie Alain
- National Reference Center for Cytomegalovirus, CHU Limoges, Laboratoire de Bactériologie-Virologie, Université de Limoges, Limoges, France
| | - Kate Daly
- Congenital Cytomegalovirus Association, NSW, Australia
| | - Sara Doutré
- National Cytomegalovirus Foundation, Tampa, FL, USA
| | - Laura Gibson
- Departments of Medicine and Pediatrics, Division of Infectious Diseases and Immunology, University of Massachusetts Medical School, MA, USA
| | - Michelle L Giles
- Department of Obstetrics and Gynaecology and Department of Infectious Diseases, Monash University, VIC, Australia
| | | | - Stuart T Hamilton
- Serology & Virology Division, SEALS Microbiology, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Gail J Harrison
- Department of Pediatrics and Pathology & Immunology, Baylor College of Medicine, TX, USA
| | - Lisa Hui
- Department of Perinatal Medicine, Mercy Hospital for Women, Heidelberg, VIC, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, VIC, Australia
| | - Cheryl A Jones
- Marie Bashir Institute for Infectious Diseases and Biosecurity, Discipline of Paediatrics and Child Health, University of Sydney, Sydney, NSW, Australia; The Children's Hospital, Westmead, NSW, Australia
| | - Pamela Palasanthiran
- School of Women's and Child Health, University of New South Wales, NSW, Australia; Department of Immunology and Infectious Diseases, Sydney Children's Hospital, NSW, Australia
| | - Mark R Schleiss
- Center for Infectious Diseases and Microbiology Translational Research, Division of Pediatric Infectious Diseases and Immunology, University of Minnesota Medical School, MN, USA
| | - Antonia W Shand
- Menzies School Health Policy, University of Sydney, Sydney, NSW, Australia; Department of Maternal Fetal Medicine, Royal Hospital for Women, Sydney, NSW, Australia
| | - Wendy J van Zuylen
- Serology & Virology Division, SEALS Microbiology, Prince of Wales Hospital, Sydney, NSW, Australia; School of Medical Sciences, University of New South Wales, NSW, Australia
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41
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Fetal cytomegalovirus infection. Best Pract Res Clin Obstet Gynaecol 2016; 38:97-107. [PMID: 27923540 DOI: 10.1016/j.bpobgyn.2016.10.005] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 10/10/2016] [Accepted: 10/10/2016] [Indexed: 01/06/2023]
Abstract
Cytomegalovirus (CMV) congenital infection affects 0.7% of live births worldwide and is the leading cause of congenital neurological handicap of infectious origin. However, systematic screening for this infection has not been implemented in pregnancy or at birth in any country. This apparent paradox had been justified by persisting gaps in the knowledge of this congenital infection: uncertain epidemiological data, difficulty in the diagnosis of maternal infection, absence of validated prenatal prognostic markers, unavailability of an efficient vaccine and scarcity of data available on the treatment. However, in the last decade, new data have emerged towards better management of this congenital infection, including solid epidemiological data, good evidence for the accuracy of diagnosis of maternal CMV infection and good evidence for the feasibility of predicting the outcome of fetal infection by a combination of fetal imaging and fetal laboratory parameters. There is also some evidence that valaciclovir treatment of mothers carrying an infected fetus is feasible, safe and might be effective. This review provides an update on the evidence for diagnosis, prognosis and treatment of congenital infection in the antenatal period. These suggest a benefit to a proactive approach for prenatal congenital infections.
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Soares de Oliveira-Szejnfeld P, Levine D, Melo ASDO, Amorim MMR, Batista AGM, Chimelli L, Tanuri A, Aguiar RS, Malinger G, Ximenes R, Robertson R, Szejnfeld J, Tovar-Moll F. Congenital Brain Abnormalities and Zika Virus: What the Radiologist Can Expect to See Prenatally and Postnatally. Radiology 2016; 281:203-18. [DOI: 10.1148/radiol.2016161584] [Citation(s) in RCA: 196] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Leruez-Ville M, Ghout I, Bussières L, Stirnemann J, Magny JF, Couderc S, Salomon LJ, Guilleminot T, Aegerter P, Benoist G, Winer N, Picone O, Jacquemard F, Ville Y. In utero treatment of congenital cytomegalovirus infection with valacyclovir in a multicenter, open-label, phase II study. Am J Obstet Gynecol 2016; 215:462.e1-462.e10. [PMID: 27083761 DOI: 10.1016/j.ajog.2016.04.003] [Citation(s) in RCA: 115] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 03/22/2016] [Accepted: 04/04/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Congenital infection with human cytomegalovirus is a major cause of morbidity and mortality. A randomized controlled trial showed that high-dosage valacyclovir prevents cytomegalovirus disease in transplant recipients. Fetuses showing ultrasound features of infection are at high risk of being symptomatic at or before birth. In a pilot study, oral administration of high-dosage valacyclovir to mothers significantly decreased viral load and produced therapeutic concentrations in the blood of infected fetuses. A randomized controlled trial comparing prenatal treatment with valacyclovir against placebo in infected fetuses failed to recruit because women declined randomization. Randomized controlled trials in fetal medicine have often proven unacceptable by women who decline termination of pregnancy and are not prepared to resign themselves to the odds of the natural history of the disease. OBJECTIVE We evaluated the efficacy of oral valacyclovir, 8 g daily, for pregnant women carrying a symptomatic cytomegalovirus-infected fetus, targeting a high-risk group for developing both neurosensory and neurological impairment. STUDY DESIGN We designed a multicenter, open-label, phase II study with 1 arm, using one of Simon's optimal 2-stage designs. Symptomatic fetuses were defined by the presence of measurable extracerebral or mild cerebral ultrasound symptoms. They were treated in utero from prenatal diagnosis at a median of 25.9 weeks' gestation until delivery or termination of pregnancy. Fetuses with severe brain anomalies on ultrasound were not included as were cases completely asymptomatic at presentation, because treatment was unlikely to modify either outcome. The primary endpoint was the proportion of asymptomatic neonates born to treated mothers. RESULTS At the interim analysis, 8 of 11 women delivered an asymptomatic neonate (required: ≥7). In step 2, 32 additional cases were included for a total of 43; the final number of asymptomatic neonates was 34, more than the 31 required to indicate efficacy according to the Simon 2-stage design. They remained asymptomatic at 12 months. High-dosage valacyclovir given for a median of 89 days to pregnant women carrying a moderately infected fetus was efficient at giving birth to asymptomatic neonates. Fetal blood viral loads decreased and platelet counts increased, both significantly (P = .01 and P < .001, respectively), between treatment initiation and birth after treatment completion, regardless of duration of fetal infection. Compared with a historical cohort obtained by a metaanalysis of the literature, the use of valacyclovir (8 g daily) significantly increased the proportion of asymptomatic neonates from 43% without treatment to 82% with treatment. Although the pill burden was high (16 pills a day) adherence to treatment was >90%. Finally, valacyclovir at this high dosage was extremely well tolerated. CONCLUSION Our results indicate that high-dosage valacyclovir given in pregnancy is effective for improving the outcome of moderately symptomatic infected fetuses. Although this study is not a randomized controlled trial, this is the first study reporting the efficacy of an antiviral drug to treat cytomegalovirus-infected fetuses. Moreover, this first study will allow new trials to be conducted, using valacyclovir as a baseline safe and effective treatment in pregnancy, to be compared to the new emerging and more potent anticytomegalovirus drugs that have not currently been tested in pregnancy.
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Feasibility of predicting the outcome of fetal infection with cytomegalovirus at the time of prenatal diagnosis. Am J Obstet Gynecol 2016; 215:342.e1-9. [PMID: 27063062 DOI: 10.1016/j.ajog.2016.03.052] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 03/31/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Congenital cytomegalovirus infection occurs in 0.7% of live births with 15-20% of infected children developing long-term disability including hearing loss and cognitive deficit. Fetal cytomegalovirus infection is established by viral DNA amplification by polymerase chain reaction in amniotic fluid obtained by amniocentesis following maternal seroconversion or after the diagnosis of ultrasound features suggestive of fetal infection. Severe brain ultrasound anomalies are associated with a poor prognosis. The prognosis of an infected fetus showing either no ultrasound features or nonsevere ultrasound anomalies is difficult to establish up until late in the second or third trimester of pregnancy. OBJECTIVE We sought to evaluate the prognostic value of fetal ultrasound, amniotic fluid, and fetal blood analysis at the time of prenatal diagnosis of fetal infection. STUDY DESIGN We reviewed all cases of fetal cytomegalovirus infection with a sample of amniotic fluid positive for viral DNA and/or fetal blood analyzed in our laboratory from 2008 through 2013. Prenatal ultrasound features along with cytomegalovirus DNA loads in amniotic fluid and in fetal blood and fetal platelet counts were reviewed in relation to gestational age at maternal infection, neonatal examination, and postnatal follow-up or postmortem examination. RESULTS In all, 82 fetuses were infected following maternal infection mainly in the first trimester. At the time of prenatal diagnosis at a median of 23 weeks, 19, 22, and 41 fetuses showed severe brain ultrasound abnormalities, nonsevere ultrasound features, and normal ultrasound examination, respectively. Nonsevere ultrasound features, higher DNA load in amniotic fluid, fetal platelet count ≤114,000/mm(3), and DNA load ≥4.93 log10 IU/mL in fetal blood were associated with a symptomatic status at birth in univariate analysis (P < .001, P = .001, and P = .018, respectively). Bivariate analysis combining ultrasound results and either adjusted viral load in amniotic fluid or fetal blood profile showed that these were independent prognostic factors of a symptomatic status at birth. Both fetal blood parameters were better predictors than amniotic fluid viral load. At the time of prenatal diagnosis, the ultrasound negative predictive value for symptoms at birth or at termination of pregnancy was 93%. The combined negative predictive values of ultrasound and viral load in amniotic fluid and that of ultrasound and fetal blood parameters were 95% and 100%, respectively. In fetuses presenting with nonsevere ultrasound features, the positive predictive values of ultrasound alone and in combination with amniotic fluid viral load or with fetal blood parameters were 60%, 78%, and 79%, respectively. CONCLUSION Risk assessment of infected fetuses for being symptomatic at birth is possible as early as the time of diagnosis by using a combination of targeted ultrasound examination along with viral load in amniotic fluid and in fetal blood together with platelet count. The advantage of using amniotic fluid is that it is available at prenatal diagnosis. One may wonder if increasing the negative predictive value of the overall assessment of an infected fetus from 95-100% is worth the additional risk of cordocentesis for fetal blood sampling. This can only be an individual decision made by well-informed women and it seems therefore appropriate to use the figures presented here and their confidence intervals for counseling.
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Ghidini A, Bianchi DW, Levy B, Deprest J, van Mieghem T, Chitty LS, McLean-Inglis A. The 2015 Malcolm Ferguson-Smith Young Investigator Award. Prenat Diagn 2016; 36:599-600. [PMID: 27381265 DOI: 10.1002/pd.4855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | | | - Brynn Levy
- Clinical Cytogenetics Laboratory, Columbia University, New York, USA
| | | | | | - Lyn S Chitty
- University College London NHS Foundation Trust, London, United Kingdom
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Yaniv G, Hoffmann C, Weisz B, Lipitz S, Katorza E, Kidron D, Bergman D, Biegon A. Region-specific reductions in brain apparent diffusion coefficient in cytomegalovirus-infected fetuses. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 47:600-607. [PMID: 25412951 DOI: 10.1002/uog.14737] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 09/29/2014] [Accepted: 11/17/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To evaluate the effects of cytomegalovirus (CMV) infection on apparent diffusion coefficient (ADC) values of the fetal brain in utero. METHODS In this retrospective analysis we compared 58 fetal head magnetic resonance imaging (fhMRI) scans of PCR-verified CMV-infected fetuses, obtained in 2008-2012, with those of a normal control group of 36 gestational age (GA)-matched uninfected fetuses scanned between 2006 and 2012. Estimated GA at infection ranged from 1 to 32 weeks, and fhMRI was performed at 24 to 38 weeks. The frontal, parietal, temporal and occipital lobes (mainly white matter), basal ganglia, thalamus, pons and cerebellum were analyzed by assessing ADC values. Two pregnancies were terminated and postmortem confirmation was available in these cases. RESULTS ADC values of CMV-infected fetuses correlated significantly and negatively with GA in all brain regions except the basal ganglia. The cerebellum had the greatest reduction (r = -0.52, P < 0.0001). Maternal age correlated positively with ADC in the frontal lobe (P < 0.05). GA at infection and overt pathological changes did not affect ADC significantly. Compared with non-infected fetuses, ADC values of affected fetuses were significantly reduced in the frontal (P < 0.0001), parietal (P < 0.0001), occipital (P = 0.0005) and temporal (P = 0.001) lobes and thalamus (P = 0.006). CONCLUSION CMV infection of the fetal brain results in a highly significant, region-dependent reduction of ADC values in the frontal, parietal, occipital and temporal lobes and thalamus, probably reflecting hypercellularity and inclusion bodies in damaged areas. Further studies are needed to determine if reduction in ADC values may serve as a prognostic factor in CMV-infected fetuses. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- G Yaniv
- Department of Diagnostic Imaging, Sheba Medical Center, Tel Hashomer, Israel
- Institute for Research in Military Medicine, Faculty of Medicine, The Hebrew University of Jerusalem, Israel and the Israeli Defence Force Medical Corps
| | - C Hoffmann
- Department of Diagnostic Imaging, Sheba Medical Center, Tel Hashomer, Israel
| | - B Weisz
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Tel Aviv University, Tel Aviv, Israel
| | - S Lipitz
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Tel Aviv University, Tel Aviv, Israel
| | - E Katorza
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Tel Aviv University, Tel Aviv, Israel
| | - D Kidron
- Department of Pathology, Meir Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - D Bergman
- Department of Diagnostic Imaging, Sheba Medical Center, Tel Hashomer, Israel
| | - A Biegon
- Department of Neurology, Stony Brook University School of Medicine, Stony Brook, NY, USA
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Leruez-Ville M, Ville Y. Optimum treatment of congenital cytomegalovirus infection. Expert Rev Anti Infect Ther 2016; 14:479-88. [DOI: 10.1586/14787210.2016.1173540] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Audiovestibular consequences of congenital cytomegalovirus infection. Eur Ann Otorhinolaryngol Head Neck Dis 2016; 133:413-418. [PMID: 27067701 DOI: 10.1016/j.anorl.2016.03.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Congenital cytomegalovirus (CMV) infection is the second most frequent cause of mental retardation and sensorineural hearing loss, after genetic factors. Recently, pediatric forensic and fetopathological studies have led to progress in understanding the pathophysiological mechanisms underlying the various neurosensory sequelae. Thanks to the identification of certain prognostic factors of hearing loss, therapeutic protocols based on antiviral molecules are now proposed for target populations. This treatment has shown efficacy in limiting hearing threshold deterioration and even, in some cases, seems to provide partial recovery of hearing in symptomatic congenitally infected CMV neonates. However, optimal treatment duration and administration modalities are not clearly defined. This article reviews recent data concerning audiovestibular sequelae and their management in children congenitally infected by CMV.
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Hadar E, Salzer L, Dorfman E, Amir J, Pardo J. Antenatal risk factors for symptomatic congenital CMV disease following primary maternal CMV infection. J Perinat Med 2016; 44:339-44. [PMID: 26352057 DOI: 10.1515/jpm-2014-0322] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2014] [Accepted: 07/22/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVES This study aimed to evaluate antenatal risk factors associated with symptomatic congenital cytomegalovirus (CMV) disease, following in utero vertical infection. METHODS This study included a retrospective cohort of 155 neonates with congenital CMV infection, following primary maternal CMV infection during pregnancy, and were divided to symptomatic (n=95) and asymptomatic (n=60) newborns. RESULTS Young maternal age (29.1±5.12 vs. 31.6±5.36 years, P=0.005), high risk occupation for viral exposure (20.0% vs. 11.7%, P=0.04), CMV IgG seroconversion at diagnosis (83.1% vs. 63.3%, P=0.005) and abnormal fetal MRI (11.6% vs. 0%, P=0.003) were found to be prognostic risk factors associated with symptomatic CMV disease of the newborn. Maternal febrile illness at diagnosis, IgG avidity, US findings and the timing of maternal infection were not associated with the occurrence of neonatal symptoms. CONCLUSIONS Knowledge of the reported risk factors may assist in counseling parents with intra uterine CMV infection.
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Cannie MM, Devlieger R, Leyder M, Claus F, Leus A, De Catte L, Cossey V, Foulon I, Van der valk E, Foulon W, Cos T, Bernaert A, Oyen R, Jani JC. Congenital cytomegalovirus infection: contribution and best timing of prenatal MR imaging. Eur Radiol 2016; 26:3760-9. [DOI: 10.1007/s00330-015-4187-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 12/04/2015] [Accepted: 12/21/2015] [Indexed: 10/22/2022]
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