Virus infections of the fetus and newborn infant

Detection of Human Papillomaviruses in the Nasopharynx of Breastfed Infants: New Findings and Meta-Analysis

Vertical transmission of human papillomaviruses (HPVs) from mother to infant is known to occur during labor, delivery or breastfeeding. Infection with mucosal HPV 6 and 11 may cause recurrent respiratory papillomatosis in children, which is a rare and severe respiratory disease. The cutaneous HPV genotypes have also been described to be transmitted from mother to newborn through skin-to-skin contacts and during breastfeeding. To investigate the perinatal transmission of alpha and beta HPVs we collected nasopharyngeal specimens from 0-12-months-old infants born by vaginal delivery and breastfed at the time of sample collection. The mucosal and cutaneous HPVs were searched by nested PCR using the MY09/11-MGPs and CP65/70-CP66/69 primer sets, respectively, and genotypes identified by direct sequencing analysis. Fourteen out of 113 (12.4%) samples tested positive for HPV and sequence analysis allowed us to identify eight beta genotypes (HPV 5b, 20, 25, 100, 107, 124, 152 and RTRX7). Moreover, we performed a comprehensive review of published studies on the prevalence of mucosal and cutaneous HPVs among 5126 newborns and observed that 10% and 53% were positive for alpha and beta HPVs, respectively. In all studies there was an inverse correlation between the rate of alpha HPV positivity and age, while a significant positive trend was observed in beta HPV detection and age with the highest rate among children older than 12 months (Χ² test for trend of 10.6, p < 0.001). Further studies are needed to confirm the hypothesis that beta HPVs are transmitted to breastfeeding infants through shedding of viruses in the breast milk or on the external breast epithelium.

Treatment of perinatal viral infections to improve neurologic outcomes

Viral infections in the fetus or newborn often involve the central nervous system (CNS) and can lead to significant morbidity and mortality. Substantial progress has been made in identifying interventions decreasing adverse neurodevelopmental outcomes in this population. This review highlights progress in treatment of important viruses affecting the CNS in these susceptible hosts, focusing on herpes simplex virus (HSV), cytomegalovirus (CMV), human immunodeficiency virus (HIV), and enteroviruses. The observation that high-dose acyclovir improves mortality in neonatal HSV disease culminated decades of antiviral research for this disease. More recently, prolonged oral acyclovir was found to improve neurologic morbidity after neonatal HSV encephalitis. Ganciclovir, and more recently its oral prodrug valganciclovir, is effective in improving hearing and neurodevelopment after congenital CMV infection. Increasing evidence suggests early control of perinatal HIV infection has implications for neurocognitive functioning into school age. Lastly, the antiviral pleconaril has been studied for nearly two decades for treating severe enteroviral infections, with newer data supporting a role for this drug in neonates. Identifying common mechanisms for pathogenesis of viral CNS disease during this critical period of brain development is an important research goal, highlighted by the recent emergence of Zika virus as a potential cause of fetal neurodevelopmental abnormalities.

Outbreak of coxsackievirus A-14 meningitis among newborns in a maternity hospital ward

During the late winter of 1983, 16 newborns with vague symptoms of failure to thrive, reluctance to feed and a slight rise in body temperature, were found to have meningitis caused by Coxsackievirus A-14. The cerebrospinal fluid showed pleocytosis with polymorphonuclear cells in excess but was otherwise normal. The clinical course was uneventful in all infants, but two of them demonstrated clinical signs of incipient cerebral oedema during the acute phase of the illness. An electroencephalogram (EEG) during the initial course of the disease and at nine months of age was normal in all. During a follow-up period of 2 1/2 years they all developed normally and no sequelae were noted. The presentation also demonstrates the usefulness of Vero cells for the propagation of the responsible virus.

Failure to thrive in the perinatal period

Identification of newborn nutritional inadequacy is one of the major areas in perinatal medicine where intervention can influence outcome. An infant's failure to thrive may be the result of prenatal and/or post-natal causes. Management of failure to thrive in the newborn infant must include identification of the problem, establishment of an efficient therapeutic regimen and means of evaluating the morbidity which may occur.

Cardiovascular diseases due to viruses

In acute myocardiopathy and pericardiopathy, Coxsackie virus B infections are increasingly recognized as a cause of primary myocardial disease and may cause chronic cardiovascular disease. With other viruses, such as cytomegaloviruses and rubella virus, transplacental infection during pregnancy may occur, and this can cause the congenital rubella syndrome, which involves heart abnormalities. Other viruses are now under study. Myocarditis was observed in a newborn infant infected with Coxsackie virus B3, which was isolated by tissue culture methods. Experimental infection of Coxsackie virus A and B was studied in suckling mice and the histopathologic changes in heart muscle were observed. Laboratory findings of viral infection are very useful for clinical diagnosis, however care needs to be taken with respect to the obtaining of specimens, diagnostic procedures, and the assessment of results.

Fatal hepatoadrenal necrosis in the neonate associated with echovirus types 11 and 12 presenting as a surgical emergency

Two neonates presented to our service with suspected intraabdominal surgical emergencies. Both subsequently were found to have hepatoadrenal necrosis due to overwhelming echoviral infection. Echovirus types 11 and 12 were isolated postmortem. The latter virus has not been associated previously with fulminant neonatal illness.

Fetal and maternal immunologic manifestations of intrauterine Adenovirus SV-20 infection

Rhesus monkey fetuses of either immune or nonimmune dams were inoculated in utero with Adenovirus SV-20 (AdSV-20), a virus capable of inducing fetal pneumonia, and studied immunologically at various intervals. AdSV-20 infection at 90-100 days gestational age resulted in absolute lymphopenia in a few fetuses, reduced numbers of peripheral blood lymphocytes (PBL) which formed rosettes with sheep erythrocytes (ERL) and reduced complement-receptor lymphocytes (CRL) in a majority, while Fc fragment-receptor lymphocytes (FcRL) were occasionally increased. There was a tendency for depression of ERL and CRL early in infection of 120-130-day fetuses, followed by stimulation of these populations and FcRL in later phases. Maternal immunity did not protect against these effects of AdSV-20 infection in fetuses. Immune and nonimmune dams were spared adverse clinical effects and had no changes in lymphoid cell populations following inoculation of their fetuses. Despite precocious production of circulating IgM, fetuses of nonimmune dams had little or no demonstrable anti-AdSV-20 serum neutralizing (SN) antibody, indicating that the ability to develop an effective immune response was suppressed or had not been acquired at the gestational ages studied. Nonimmune dams displayed little evidence of seroconversion following inoculation of their fetuses with AdSV-20, except in those dams whose fetuses died in utero, whereby there was a significant antibody response. SN antibody titers of immune dams were not boostered substantially subsequent to inoculation of their fetuses, and fetal SN titers were lower than maternal titers, suggesting absence of an active fetal antibody response in this group also. Direct inoculation of AdSV-20 into 90-130-day rhesus monkey fetuses provided a model system for immunologic study of fetal infection, probably involving complex fetal-maternal interactions, in a situation where the infected, viable fetus and its dam appeared to be microbiologically isolated from one another.

Congenital cytomegalovirus and hearing loss: clinical and experimental observations

The effects of congenital cytomegalovirus infection vary from severe central nervous system destruction to asymptomatic viuria. Yet children with the latter have a high incidence of unsuspected hearing loss. Histopathology of temporal bones from children who die with cytomegalic inclusion disease shows viral infected cells in non-sensory endolabyrinthine epithelium. Experimental mouse cytomegalovirus causes an age related cranial neuronitis and perilabyrinthitis. Immunopathologic localization of different viral antigens in experimental inner ear infections shows differential vulnerability of labyrinthine structures to infections. Adaptation of such techniques to human temporal bone pathology could yield information regarding pathogenesis of viral labyrinthitis. The development of a human cytomegalovirus vaccine may eliminate the risks of this congenital infection.

Wedged hepatic venous pressure in congential heart disease

Seventy cases of congential heart disease including the most frequent types were studied, and wedge hepatic venous pressure (WHVP) was measured in each. The mean pressure was determined in the "jammed position" and in the free hepatic veins, inferior vena cava, and low right atrium. The average mean WHVP was 7.0 mm Hg, 5.0 in inferior vena cava, and 3.4 in the right atrium. A direct relationship was found between wedge hepatic venous pressure of the inferior vena cava and the low right atrium, but not other parameters. Ten patients had a mean pressure above 10 mm Hg. We believe that in many circumstances in patients with congenital heart disease, liver function may be abnormal and high values of wedge hepatic venous pressure may also be found.

Abnormalities of immunglobulins in infants with congenital heart disease

Twenty-eight infants had their serum immunoglobulins estimated (by radial immunodiffusion) in early infancy. The IgG level was abnormal in twelve infants. Elevated levels of IgA were found in ten and IgM in fourteen. These variations, mostly obvious in the first ten days of life, were detected in the absence of clinical or immunological evidence of congenital rubella infection.

Pulmonary involvement with cytomegalovirus infections in children

Among 40 hospitalized infants and children with cytomegalovirus infection, 14 (35%) had interstitial pneumonitis, 4 (10%) had wheezing or tachypnoea but without x-ray evidence of classical interstitial pneumonia, the remaining 22 (55%) were free of pulmonary involvement. Most patients had tachypnoea and nonproductive cough of varying durations: those with underlying pulmonary pathology tended to have persistent and prolonged respiratory symptoms. Mortality and severity of the lung disease were related to the underlying immunodeficiency or concomitant pulmonary process.

Enterovirus infections in neonates

Twenty-seven ill neonates with enterovirus infections were studied to learn if enterovirus infection can be distinguished from neonatal sepsis. Enterovirus infection was associated with the summer-fall season (93%), recent maternal illness (59%), absence of other perinatal problems (81%), and findings of fever (93%), viral meningitis (62%), diarrhea (81%), and rash (41%). Four children developed thrombocytopenia and three necrotizing enterocolitis. Three children died, all with Coxsackie B virus infections that likely were acquired in utero. Although no single feature is pathognomonic, this constellation of epidemiologic and clinical findings, coupled with negative bacterial cultures, should suggest the possibility of neonatal enterovirus infection.

Perinatal immunoglobulin levels in premature and small-for-date infants

In 100 low-birth-weight newborns divided into a group of prematures with adequate birth weight and a group of antenatal hypotrophics, the immunoglobulins in cord serum and in serum at 5 days were determined. The results are expressed in International Units/ml. A significant increase of IgM as compared with cord blood after 5 days of life was found in both groups. In prenatal hypotrophics insignificantly higher levels of IgM were detected both in cord and in 5-day blood. It could be supposed that the dystrophisation of some small-for-date newborns could result from intrauterine infection.

Herpesvirus hominis infection in newborn mice: comparison of the therapeutic efficacy of 1-beta-D-arabinofuranosylcytosine and 9-beta-D-arabinofuranosyladenine

Intranasal inoculation of newborn mice with Herpesvirus hominis type 2 provides an experimental infection that closely resembles disseminated herpesvirus infection of human newborn infants. After inoculation of mice, the virus multiplies in the respiratory tract and is disseminated through the blood to the liver and spleen and to the brain by both a viremia and nerve route transmission. Although therapy with 1-beta-d-arabinofuranosylcytosine (ara-C) did not reduce final mortality, it did increase the mean survival time by 1 day. This effect on the mean survival time was associated with a 1-day delay in the appearance of herpesvirus in the blood, liver, and spleen and a reduction of virus replication in lung and brain for 1 day as compared with untreated control animals. Treatment with 9-beta-d-arabinofuranosyladenine (ara-A) likewise had no effect on final mortality, but increased the mean survival time by 2 days. Therapy with ara-A delayed or suppressed virus replication in blood, lung, liver, spleen, and brain for 2 days. Although treatment with either ara-C or ara-A in this experimental H. hominis type 2 infection resulted in a temporary delay and/or suppression of viral replication in several target organs, neither compound was completely effective in inhibiting viral replication or in protecting animals from eventual death due to the infection.

Viral disease of the labyrinth. I. Review of the literature and discussion of the role of cytomegalovirus in congenital deafness

Review of the literature concerning the histopathology of viral induced deafness indicates two general patterns of viral infection of the inner ear: 1) An endolymphatic labyrinthitis secondary to viremia via the stria vascularis is described in rubella, mumps, rubeola, and cytomegalovirus. 2) A perilymphatic infection secondary to meningeal, perineural, or endoneural spread is seen in varicella-zoster. Pathologic changes of degeneration and atrophy are due to inflammation and seem to be constant no matter if the infection is prenatal or postnatal. Two published reports of prenatal and perinatal cytomegalovirus infection show endolymphatic labyrinthitis similar to that casued by the other viruses. Subsequent clinical studies indicate the presence of hearing loss in mildly symptomatic and/or asymptomatic children with cytomegalovirus infections. Cytomegalovirus infection may prove to be the most significant cause of congenital and/or viral induced deafness in the future as the number of children infected with rubella, rubeola, and mumps decreases due to the use of appropriate vaccines.

Intrauterine virus infections and congenital heart disease

The etiologic basis for the vast majority of cases of congenital heart disease remains largely undefined. Viruses have been considered to be likely candidates since the recognition of the association between intrauterine rubella and congenital heart disease. Although the pathogenesis of cardiovascular defects is poorly understood, information gained from the study of congenital rubella syndrome suggests that mechanisms such as focal endothelial cell damage, resulting in obliteration of vascular supply, decreased growth rate, and shortened survival time of certain cells, and disturbed DNA replication in cells whose chromosomes were damaged secondary to the effects of virus replication may be operative in the production of defects in the developing fetus. In addition to rubella there is suggestive, but not conclusive, evidence that Coxsackie B3 and B4 virus infections during pregnancy can result in the birth of infants with a variety of types of congenital heart lesions and that intrauterine mumps virus infection may be etiologically related to the postnatal development of endocardial fibroelastosis (EFE). Although there are a number of other viruses that are potential etiologic agents of congenital heart disease, the current status of information is inadequate to allow even suggestive associations to be made. The most profitable areas for future investigation appear to be: (1) the epidemiology of congenital heart disease, (2) prospective studies of the association of maternal viral infection with abnormal offspring, (3) the in-depth virologic investigation of the infant with a cardiac defect, and (4) the development of experimental animal models of congenital heart disease. Successful control of virus-induced congenital heart disease will depend on the results of these investigations and the development of vaccines against the identified causative viruses and/or safe and effective antiviral chemotherapy for the woman in early gestation who is infected with a known teratogenic agent.

Immunoglobulin levels in newborn infants with hepatosplenomegaly

Serum IgM and IgA levels were measured in 97 newborn infants with and 141 without hepatosplenomegaly. All were considered normal at birth and had no apparent disease on clinical examination. Thirty per cent. of the infants with hepatosplenomegaly were found to have IgM levels of 20 mg/100 ml or greater, a level established as abnormal when compared with the control group. The number of infants with raised IgM level and the geometric mean level were significantly different (P < 0.001) from those in the control group. No difference, however, was found in serum IgA levels between the two groups of infants. The results suggest that intrauterine infections may sometimes be the cause of hepatosplenomegaly in newborn infants without apparent disease.