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Leruez-Ville M, Chatzakis C, Lilleri D, Blazquez-Gamero D, Alarcon A, Bourgon N, Foulon I, Fourgeaud J, Gonce A, Jones CE, Klapper P, Krom A, Lazzarotto T, Lyall H, Paixao P, Papaevangelou V, Puchhammer E, Sourvinos G, Vallely P, Ville Y, Vossen A. Consensus recommendation for prenatal, neonatal and postnatal management of congenital cytomegalovirus infection from the European congenital infection initiative (ECCI). THE LANCET REGIONAL HEALTH. EUROPE 2024; 40:100892. [PMID: 38590940 PMCID: PMC10999471 DOI: 10.1016/j.lanepe.2024.100892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 03/12/2024] [Accepted: 03/14/2024] [Indexed: 04/10/2024]
Abstract
Congenital cytomegalovirus (cCMV) infection carries a significant burden with a 0.64% global prevalence and a 17-20% chance of serious long-term effects in children. Since the last guidelines, our understanding, particularly regarding primary maternal infections, has improved. A cCMV guidelines group was convened under the patronage of the European Society of Clinical Virology in April 2023 to refine these insights. The quality and validity of selected studies were assessed for potential biases and the GRADE framework was employed to evaluate quality of evidence across key domains. The resulting recommendations address managing cCMV, spanning prevention to postnatal care. Emphasizing early and accurate maternal diagnosis through serological tests enhances risk management and prevention strategies, including using valaciclovir to prevent vertical transmission. The guidelines also strive to refine personalized postnatal care based on risk assessments, ensuring targeted interventions for affected families.
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Affiliation(s)
- Marianne Leruez-Ville
- Université Paris Cité, URP 7328 FETUS, F-75015, Paris, France
- Virology Laboratory, Reference Laboratory for Cytomegalovirus Infections, Hôpital Necker Enfants Malades, GHU Paris Centre, AP-HP, Paris, France
| | - Christos Chatzakis
- Obstetrics, Fetal Medicine Surgery and Imaging Unit, Hôpital Necker Enfants Malades, GHU Paris Centre, AP-HP, Paris, France
- Second Department of Obstetrics and Gynecology of Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Daniele Lilleri
- Microbiology and Virology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Daniel Blazquez-Gamero
- Pediatric Infectious Diseases Unit, Hospital Universitario 12 de Octubre, Instituto de Investigación Hospital 12 de Octubre (imas12), Universidad Complutense, Madrid, Spain
| | - Ana Alarcon
- Department of Neonatology, Hospital Hospital Sant Joan de Déu, BCNatal (Barcelona Center for Maternal, Fetal and Neonatal Medicine), Institut de Recerca Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
| | - Nicolas Bourgon
- Obstetrics, Fetal Medicine Surgery and Imaging Unit, Hôpital Necker Enfants Malades, GHU Paris Centre, AP-HP, Paris, France
| | - Ina Foulon
- Department of Otorhinolaryngology and Head & Neck Surgery, Vrije Universiteit Brussels, University Hospital UZ Brussel, Brussels Health Campus. De Poolster, Rehabilitation Centre, Brussels, Belgium
| | - Jacques Fourgeaud
- Université Paris Cité, URP 7328 FETUS, F-75015, Paris, France
- Virology Laboratory, Reference Laboratory for Cytomegalovirus Infections, Hôpital Necker Enfants Malades, GHU Paris Centre, AP-HP, Paris, France
| | - Anna Gonce
- BCNatal: Fetal Medicine Research Center (Hospital Clínic and Hospital Sant Joan de Déu), Universitat de Barcelona, Barcelona, Spain
| | - Christine E. Jones
- Faculty of Medicine and Institute for Life Sciences, University of Southampton and NIHR Southampton Clinical Research Facility and NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, United Kingdom
| | - Paul Klapper
- Microbiology and Virology Unit (EIGen), School of Biological Sciences, University of Manchester, Manchester, M139PT, UK
| | - André Krom
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, the Netherlands
| | - Tiziana Lazzarotto
- Microbiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | | | - Paulo Paixao
- CHRC, NOVA Medical School/Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, 1169-056, Lisbon, Portugal
| | - Vassiliki Papaevangelou
- Third Department of Pediatrics, School of Medicine, National and Kapodistrian University of Athens, Greece
| | | | - George Sourvinos
- Laboratory of Clinical Virology, Medical School, University of Crete, Heraklion, Crete, 71003, Greece
| | - Pamela Vallely
- Microbiology and Virology Unit (EIGen), School of Biological Sciences, University of Manchester, Manchester, M139PT, UK
| | - Yves Ville
- Université Paris Cité, URP 7328 FETUS, F-75015, Paris, France
- Obstetrics, Fetal Medicine Surgery and Imaging Unit, Hôpital Necker Enfants Malades, GHU Paris Centre, AP-HP, Paris, France
| | - Ann Vossen
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, the Netherlands
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Mussi-Pinhata MM, Yamamoto AY, Aragon DC, Duarte G, Fowler KB, Boppana S, Britt WJ. Seroconversion for Cytomegalovirus Infection During Pregnancy and Fetal Infection in a Highly Seropositive Population: "The BraCHS Study". J Infect Dis 2018; 218:1200-1204. [PMID: 29868783 PMCID: PMC6129109 DOI: 10.1093/infdis/jiy321] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 05/25/2018] [Indexed: 12/29/2022] Open
Abstract
We determined the risk of seroconversion in seronegative pregnant women living in a high seroprevalence population. Cytomegalovirus (CMV)-immunoglobulin G reactivity was determined at the 1st trimester in all women and sequentially for seronegative women. A total of 1915 of 1952 (98.1%; 95% confidence interval [CI], 97.4%-98.7%) women were seropositive, and 36 (1.8%; 95% CI, 1.3%-2.6%) were seronegative. Five of the 36-seronegative women seroconverted for a cumulative rate of 13.9% (95% CI, 4.8%-30.6%). Congenital CMV infection was diagnosed in 1 of 36 infants (2.8%; 95% CI, 0.5%-63.9%) born to seronegative women compared with 8 of 1685 (0.5%; 95% CI, 0.2%-1.0%) infants born to seropositive mothers. Even with a high risk of primary infection in seronegative women, most CMV-infected infants were born to women with pre-existing seroimmunity.
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Affiliation(s)
| | | | - Davi C Aragon
- Departments of Pediatrics, University of São Paulo, Brazil
| | - Geraldo Duarte
- Departments of Gynecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, Brazil
| | - Karen B Fowler
- Department of Pediatrics, The University of Alabama at Birmingham
| | - Suresh Boppana
- Department of Pediatrics, The University of Alabama at Birmingham
| | - William J Britt
- Department of Pediatrics, The University of Alabama at Birmingham
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Yamamoto Y, Kato Y, Tabuchi H, Fukushima A. Case of cytomegalovirus retinitis aggravated by sub-Tenon injection of triamcinolone acetonide with subsequent metastatic liver cancer. Clin Ophthalmol 2013; 7:411-5. [PMID: 23467884 PMCID: PMC3589115 DOI: 10.2147/opth.s41361] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Indexed: 11/23/2022] Open
Abstract
We report a case of cytomegalovirus (CMV) retinitis in an immunocompetent patient who was resistant to antiviral treatment, and in whom fatal metastatic liver cancer was later detected. A 74-year-old Japanese man visited our ophthalmology clinic in May 2011. He had a history of well controlled type 2 diabetes and colon cancer, and underwent successful surgical treatment in 2008. In April 2011, he was diagnosed with uveitis affecting his left eye and received posterior sub-Tenon injection of triamcinolone acetonide. He was referred to us because of aggravation of the retinal lesion. Funduscopic examination of the left eye revealed arcuate, whitish, necrotizing retinitis with hemorrhage along the temporal arcade of the retina. Polymerase chain reaction of the aqueous fluid was positive for CMV DNA. Because of diagnosis of CMV retinitis in his left eye, he was referred to an internist and investigated for systemic CMV infection or any serious disease which could cause immunocompromise, but neither was detected. Despite an intensive course of intravitreous ganciclovir and oral valganciclovir, the retinitis did not resolve. In June 2012, 14 months after the initial ocular symptoms, metastatic liver cancer was found and the patient passed away. When CMV retinitis is resistant to antiviral treatment or recurs in an immunocompetent patient, it is important that ophthalmologists undertake systemic investigation for occult malignancy.
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Affiliation(s)
- Yumiko Yamamoto
- Department of Ophthalmology and Visual Science, Kochi Medical School, Kochi, Japan
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Inde Y, Yamaguchi S, Kamoi S, Takeshita T. Transition of cytomegalovirus seropositivity in Japanese puerperal women. J Obstet Gynaecol Res 2010; 36:488-94. [PMID: 20598026 DOI: 10.1111/j.1447-0756.2010.01176.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
AIM To investigate the latest serological tendency of cytomegalovirus (CMV) in Japanese puerperal women and to estimate the sequential influence on child-bearing women in Japan. METHODS We studied 3966 puerperal women registered at a cord blood bank. Serum samples were obtained from umbilical cords at delivery and on the third day after delivery. CMV immunoglobulin G (IgG) and CMV immunoglobulin M (IgM) antibodies were determined using enzyme immunoassay kits. Scatter diagrams between seroprevalences and perinatal details were generated, and Pearson product-moment correlation coefficients (r) and coefficients of determination (R(2)) were calculated. RESULTS The overall CMV seroprevalence was 68.4% for the IgG antibody and 3.9% for the IgM antibody. IgM seroconversion had occurred separately in 0.28% of the cases without IgG seroconversion. Including outliers on scatter plots, linear decreasing trends were observed for IgG seropositivity with measurement year (r = -0.72, P < 0.05, R(2) = 51.8%) and maternal birth year (r = -0.43, P < 0.05, R(2) = 18.2%). There was a linear increasing tendency for IgG seroprevalence with maternal age (r = 0.46, P < 0.05, R(2) = 21.4%). Without the outlier, a linear decreasing tendency was found for IgM seropositivity (r = -0.85, P < 0.01, R(2) = 71.6%). CONCLUSION CMV seropositivity decreased with maternal youth in Japanese puerperal women. A possible contradiction was identified: decreasing tendencies in the seroprevalence of both IgG and IgM might coexist. We assume that actual CMV infections spread in a transient epidemic manner in which it may not be possible to observe a linear tendency and/or that the actual risk of maternal CMV infection might be decreasing.
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Affiliation(s)
- Yusuke Inde
- Department of Obstetrics and Gynaecology, Nippon Medical School, Bunkyo-ku, Tokyo, Japan.
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Cannon MJ, Schmid DS, Hyde TB. Review of cytomegalovirus seroprevalence and demographic characteristics associated with infection. Rev Med Virol 2010; 20:202-13. [PMID: 20564615 DOI: 10.1002/rmv.655] [Citation(s) in RCA: 945] [Impact Index Per Article: 67.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cytomegalovirus establishes a lifelong latent infection following primary infection that can periodically reactivate with shedding of infectious virus. Primary infection, reactivation and reinfection during pregnancy can all lead to in utero transmission to the developing fetus. Congenital CMV infections are a major cause of permanent hearing loss and neurological impairment. In this literature review, we found that CMV infection was relatively common among women of reproductive age, with seroprevalence ranging from 45 to 100%. CMV seroprevalence tended to be highest in South America, Africa and Asia and lowest in Western Europe and United States. Within the United States, CMV seroprevalence showed substantial geographic variation as well, differing by as much as 30 percentage points between states, though differences might be explained by variation in the types of populations sampled. Worldwide, seroprevalence among non-whites tended to be 20-30 percentage points higher than that of whites (summary prevalence ratio (PR) = 1.59, 95% confidence interval (CI) = 1.57-1.61). Females generally had higher seroprevalences than males, although in most studies the differences were small (summary PR = 1.13, 95% CI = 1.11-1.14). Persons of lower socioeconomic status were more likely to be CMV seropositive (summary PR = 1.33, 95% CI = 1.32-1.35). Despite high seroprevalences in some populations, a substantial percentage of women of reproductive age are CMV seronegative and thus at risk of primary CMV infection during pregnancy. Future vaccine or educational campaigns to prevent primary infection in pregnant women may need to be tailored to suit the needs of different populations.
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Affiliation(s)
- Michael J Cannon
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, GA 30329, USA.
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Numazaki K, Fujikawa T. Chronological changes of incidence and prognosis of children with asymptomatic congenital cytomegalovirus infection in Sapporo, Japan. BMC Infect Dis 2004; 4:22. [PMID: 15236662 PMCID: PMC481070 DOI: 10.1186/1471-2334-4-22] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2003] [Accepted: 07/06/2004] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronological changes of the incidence of congenital cytomegalovirus (CMV) infection and the longitudinal prognosis in children with asymptomatic congenital infection were investigated. METHODS Congenital CMV infection, as demonstrated by isolation of the virus within the first week of life, was diagnosed in infants born in Sapporo, Japan, during the 26-year period between 1977 and 2002. RESULTS Congenital infection was diagnosed in 37 (0.31%) of 11,938 infants. Thirty-two infants were (86.5%) asymptomatic and 5 (13.5%) were symptomatic at birth. CONCLUSIONS Although a decrease in the total incidence of congenital CMV infection has been seen in recent years, screening of congenital infection at birth seems to be necessary to detect late-onset neurodevelopmental sequelae.
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Affiliation(s)
- Kei Numazaki
- Department of Pediatrics, Sapporo Medical University School of Medicine Sapporo, 060-8543, Japan
| | - Tomoko Fujikawa
- Department of Pediatrics, Sapporo Medical University School of Medicine Sapporo, 060-8543, Japan
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Numazaki K, Fujikawa T, Asanuma H. Immunological evaluation and clinical aspects of children with congenital cytomegalovirus infection. Congenit Anom (Kyoto) 2002; 42:181-6. [PMID: 12502897 DOI: 10.1111/j.1741-4520.2002.tb00891.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
To determine the ability of immunological response to human cytomegalovirus (CMV), the flow cytometric assay was evaluated as a tool for real-time monitoring of specific cellular immunity in children with congenital CMV infection. Longitudinal cohort study of 2 children with asymptomatic and 2 with symptomatic congenital CMV infection evaluated at birth and followed up with serial age-appropriate neurodevelopmental testing. Frequencies of CMV-specific CD4 (+) T cell in these children were detected by intracellular cytokines (ICC), interferon (IFN)-gamma and tumor necrosis factor (TNF)-alpha, staining. Findings detected by CT and MRI were the most sensitive predictor for neurodevelopmental prognosis. Frequencies of CMV-specific CD4(+) T cells detected by ICC, both IFN-gamma and TNF-alpha, were higher in 2 children with symptomatic congenital CMV infection than those in 2 children with asymptomatic congenital infection. Frequencies of CMV-specific CD4(+) T cells in 2 children with symptomatic congenital infection were significantly higher than those in 6 healthy children of 1 to 5-years of age with serum anti-CMV IgG antibody without serum anti-CMV IgM antibody and viral excretion in to urine (p < 0.01). The ICC assay reflects immunological activity against CMV infection in children with asymptomatic or symptomatic congenial infection. Categorizing findings obtained by the ICC assay may helps to determine the prognosis of children with congenital CMV infection.
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Affiliation(s)
- Kei Numazaki
- Department of Pediatrics, School of Medicine, Sapporo Medical University, Sapporo 060-8543, Japan.
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