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

Is there room for prompt routine ophthalmic examination in neonates with congenital cytomegalovirus (CMV) infection during the neonatal period?

PURPOSE

To establish the clinical necessity of routine targeted ophthalmic examination of newborns with congenital cytomegalovirus (CMV) infection during the neonatal period.

METHODS

This retrospective study included consecutive neonates that were referred for ophthalmological screening within the context of a proven congenital CMV infection. The presence of CMV-related ocular and systemic findings was determined.

RESULTS

Among the 91 patients included in this study, 72 (79.12%) were symptomatic with one or more of the following manifestations: abnormal brain ultrasound (42; 46.15%), small for gestational age (29; 31.87%), microcephaly (23; 25.27%), thrombocytopenia (14; 15.38%), sensory neural hearing loss (13; 14.29%), neutropenia (12; 13.19%), anemia (4; 4.4%), skin lesions (4; 4.4%), hepatomegaly (3; 3.3%), splenomegaly (3; 3.3%), direct hyperbilirubinemia (2; 2.2%). Not one single neonate in this cohort had any of the ocular findings surveyed.

CONCLUSION

The presence of ophthalmological findings among neonates with congenital CMV infection during the neonatal period is infrequent, suggesting that routine ophthalmological screening may be safely deferred for the post-neonatal period.

Pre- and postnatal brain magnetic resonance imaging in congenital cytomegalovirus infection: a case report and a review of the literature

Background

Congenital cytomegalovirus infection (cCMV) is the most common known viral cause of neurodevelopmental delay in children. The risk of severe cerebral abnormalities and neurological sequelae is greatest when the infection occurs during the first trimester of pregnancy. Pre- and postnatal imaging can provide additional information and may help in the prediction of early neurological outcome.

Case presentation

This report presents the case of a newborn with cCMV infection with diffuse parenchymal calcifications, white matter (WM) abnormalities and cerebellar hypoplasia on postnatal brain imaging after magnetic resonance imaging (MRI) and neurosonogram (NSG) at 30 weeks showing lenticulostriate vasculopathy, bilateral temporal cysts and normal gyration pattern according to the gestational age (GA). No calcifications were seen on prenatal imaging.

Conclusion

cCMV infection can still evolve into severe brain damage after 30 weeks of GA. For this reason, a two-weekly follow-up by fetal NSG with a repeat in utero MRI (iuMRI) in the late third trimester is recommended in cases with signs of active infection.

Hearing outcome in congenitally CMV infected children in Finland - Results from follow-up after three years age

OBJECTIVES

Cytomegalovirus (CMV) is the most common congenital infection affecting about 0.6% of all newborns in developed countries. Vertical transmission to fetus can take place either after maternal primary or non-primary CMV infection during pregnancy. It is the most common infectious agent for sensorineural hearing loss (SNHL) in young children. The hearing loss after congenital CMV (cCMV) may be present at birth, or may develop after months or even years. In this study, we evaluated hearing outcome at 3-4 years of age in children (n 32) with cCMV identified in universal saliva CMV-PCR-based screening.

METHODS

Study population consisted of mainly asymptomatic children (median age 3.1 years) with cCMV identified in newborn CMV screening. The type of maternal CMV infection (primary or non-primary) was determined by analyzing CMV antibodies (IgM, IgG and IgG avidity) from preserved maternal serum samples drawn in the end of first trimester of pregnancy. Hearing was evaluated with pure tone audiometry (PTA), or transient-evoked otoacoustic emission (TEOAE) and sound field audiometry (SF).

RESULTS

Unilateral hearing loss occurred in 5/32 (16%) of the children with cCMV. None of the subjects in our cohort had bilateral hearing loss. Hearing loss occurred in 3/15 (20%) of children who were born to mothers with non-primary CMV infection during pregnancy, and in 2/10 (20%) of children whose mother had had a primary CMV infection during the 2-3 trimester. None of the additional 6 children, whose mother had primary infection in the first trimester, had hearing loss by age of 3-4 years. Two children with normal hearing at 1 years age had developed unilateral hearing loss by the age of three.

CONCLUSIONS

Unilateral hearing loss was relatively common among the mainly asymptomatic children with cCMV identified in screening. Long-term follow up of children with cCMV is essential to identify the children with late-onset hearing loss.

Commentary: Development of Therapeutics for Congenital Cytomegalovirus Infection

In the mid 1980’s, I flew from Birmingham, Alabama to San Francisco, rented a car, and drove to Palo Alto so that I could meet with John Martin at Syntex. John, along with Julian Verheyden, synthesized ganciclovir, which had significant in vitro activity against cytomegalovirus (CMV) in vitro. This drug provided my colleagues and me an opportunity to evaluate it as a therapeutic agent for congenital CMV infection, knowing full well that it was mutagenic, teratogenic, and carcinogenic. John in his wisdom convinced the management of Syntex to provide ganciclovir for this disease, allowing me to study this drug in symptomatic congenitally infected children through the NIAID Collaborative Antiviral Study Group (CASG). Certainly, no other person or company would advocate for the use of such a medication in children, regardless of disease severity, because of its toxicity profile. Since these early days, ganciclovir, and subsequently its prodrug valganciclovir, have become the standard of care for the treatment of congenital cytomegalovirus infection. The following commentary defines the need and progress in the development of therapy

Blood genome expression profiles in infants with congenital cytomegalovirus infection

Congenital CMV infection (cCMVi) affects 0.5–1% of all live births worldwide, making it the leading cause of sensorineural hearing loss (SNHL) in childhood. The majority of infants with cCMVi have normal hearing at birth, but are at risk of developing late-onset SNHL. Currently, we lack reliable biomarkers to predict the development of SNHL in these infants. Here, we evaluate blood transcriptional profiles in 80 infants with cCMVi (49 symptomatic, 31 asymptomatic), enrolled in the first 3 weeks of life, and followed for 3 years to assess emergence of late-onset SNHL. The biosignatures of symptomatic and asymptomatic cCMVi are indistinguishable, suggesting that immune responses of infants with asymptomatic and symptomatic cCMVi are not different. Random forest analyses of initial samples in infants with cCMVi, irrespective of their clinical classification, identify a 16-gene classifier signature associated with the development of SNHL with 92% accuracy, suggesting its potential value as a biomarker.

Congenital CMV infection can result in sensorineural hearing loss, but predicting this outcome is not yet possible. Here, the authors show that while blood gene expression profiles are not substantially different between symptomatic and asymptomatic infants with congenital CMV infection, a 16-gene signature is identified and able to predict late-onset hearing loss in these children.

The MRI spectrum of congenital cytomegalovirus infection

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

Inattention and Hyperactivity in Children with Symptomatic and Asymptomatic Congenital Cytomegalovirus

OBJECTIVES

To explore the relationship between congenital cytomegalovirus (CMV) and inattention and hyperactivity among school-aged children.

METHODS

The Behavior Assessment System for Children, Second Edition, parent- and self-report, was completed among children with symptomatic congenital CMV (ScCMV) (n = 36), asymptomatic congenital CMV (AcCMV) (n = 76), and controls (n = 29) enrolled in a longitudinal cohort. The proportions of children with ScCMV, AcCMV, and controls with Attention Problems or Hyperactivity T-scores ever ≥ 65 were compared. Mean T-scores in these domains were also compared and adjusted for IQ.

RESULTS

Children with AcCMV did not differ from controls in the proportion of children with elevated Attention Problems or Hyperactivity T-scores or in mean Attention Problems or Hyperactivity T-scores. Children with ScCMV had a higher proportion of elevated Attention Problems T-scores compared with the AcCMV group but not controls. There were no differences in the proportions of children with elevated Hyperactivity T-scores between ScCMV and AcCMV or control groups. Children with ScCMV had higher mean Attention Problems T-scores versus those with AcCMV and controls and higher mean Hyperactivity T-scores versus those with AcCMV but not controls. After adjustment for IQ, differences in mean Attention Problems or Hyperactivity T-scores were no longer significant.

CONCLUSION

Children with AcCMV are not at increased risk of inattention or hyperactivity compared with controls. However, our study suggests an increased prevalence of inattention and hyperactivity among children with ScCMV. Differences in IQ were confirmed to have a confounding effect. Evaluation for attention-deficit/hyperactivity disorder may be warranted in this population.

Congenital Cytomegalovirus and Neonatal Herpes Simplex Virus Infections: To Treat or Not to Treat?

Congenital cytomegalovirus infections are among the most common of the newborn in the developed world. These infections are the most common cause of sensorineural hearing loss. Studies utilizing ganciclovir and valganciclovir demonstrate improved hearing and Bailey Developmental scores. Because of the ease of administration, valganciclovir is the recommended treatment of choice for 6 months. Therapy should be reserved for those babies with symptomatic disease; no data are available regarding the impact of treatment on those babies with asymptomatic disease.

Pathogenesis of Non-Zika Congenital Viral Infections

A widespread epidemic of Zika virus (ZIKV) infection was reported in 2015 from South and Central America and the Caribbean. Although the full spectrum of ZIKV infection of the newborn has yet to be determined, other maternal viral infections resulting in transmission to the fetus provide instructive lessons that can be applied to the prospective evaluation of individuals with ZIKV infection. This review focuses on those other congenital infections, including rubella, congenital cytomegalovirus, human immunodeficiency virus, hepatitis B virus, and neonatal herpes simplex virus, from which lessons for the evaluation of ZIKV in the newborn can be applied.

The use of fetal neurosonography and brain MRI in cases of cytomegalovirus infection during pregnancy: A retrospective analysis with outcome correlation

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.

Differences in cognitive functions between cytomegalovirus-infected and cytomegalovirus-free university students: a case control study

Cytomegalovirus (CMV) is the herpetic virus, which infects 45–100% people worldwide. Many reports suggest that CMV could impair cognitive functions of infected subjects. Here we searched for indices of effects of CMV on infected subjects’ intelligence and knowledge. The Intelligence Structure Test I-S-T 2000 R was used to compare IQ of 148 CMV-infected and 135 CMV-free university students. Infected students expressed higher intelligence. Paradoxically, their IQ decreased with decreasing concentration of anti-CMV antibodies, which can be used, statistically, as a proxy of the time passed from the moment of infection in young subjects when the age of subjects is statistically controlled. The paradox of seemingly higher intelligence of CMV infected subjects could be explained by the presence of the subpopulation of about 5–10% CMV-positive individuals in the population of “CMV-negative students”. These false negative subjects had probably not only the oldest infections and therefore the lowest concentration of anamnestic antibodies, but also the lowest intelligence among the infected students. Prevalence of CMV infection in all countries is very high, approaching sometimes 90%. Therefore, the total impact of CMV on human intelligence may be large.

Reactive oxygen species-induced parthanatos of immunocytes by human cytomegalovirus-associated substance

Previous studies have examined various immune evasion strategies of human cytomegalovirus (HCMV) to gain understanding of its pathogenesis. Although the mechanism that underlies immunocyte destruction near HCMV‐infected lesions has yet to be established, it is here shown that substances produced by HCMV‐infected cells induce death in several types of immunocytes, but not in fibroblasts or astrocytomas. These substances contain HCMV proteins and were termed HCMV‐associated insoluble substance (HCMVAIS). The mechanism by which HCMVAIS induces cell death was characterized to improve understanding the death of immunocytes near HCMV‐infected lesions. HCMVAIS were found to trigger production of intracellular nicotinamide adenine dinucleotide phosphate oxidase‐derived reactive oxygen species (ROS), resulting in cell death, this effect being reversed following treatment with ROS inhibitors. Cell death was not induced in splenocytes from NOX‐2 knockout mice. It was hypothesized that DNA damage induced by oxidative stress initiates poly ADP‐ribose polymerase‐1 (PARP‐1)‐mediated cell death, or parthanatos. HCMVAIS‐induced cell death is accompanied by PARP‐1 activation in a caspase‐independent manner, nuclear translocation of apoptosis‐inducing factor (AIF), and DNA fragmentation, which are typical features of parthanatos. Treatment with an AIF inhibitor decreased the rate of HCMVAIS‐induced cell death, this being confirmed by hematoxylin and eosin staining; cell death in most HCMV‐positive foci in serial section samples of a large intestine with HCMV infection was TUNEL‐positive, cleaved caspase 3‐negative and CD45‐positive. Taken together, these data suggest that HCMV inhibits local immune responses via direct killing of immunocytes near HCMV‐infected cells through ROS‐induced parthanatos by HCMVAIS.

Combined evaluation of sexually transmitted infections in HIV-infected pregnant women and infant HIV transmission

Background

Sexually transmitted infections (STIs) including Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), Treponema pallidum (TP), and cytomegalovirus (CMV) may lead to adverse pregnancy and infant outcomes. The role of combined maternal STIs in HIV mother-to-child transmission (MTCT) was evaluated in mother-infant pairs from NICHD HPTN 040.

Methodology

Urine samples from HIV-infected pregnant women during labor were tested by polymerase chain reaction (PCR) for CT, NG, and CMV. Infant HIV infection was determined by serial HIV DNA PCR testing. Maternal syphilis was tested by VDRL and confirmatory treponemal antibodies.

Results

A total of 899 mother-infant pairs were evaluated. Over 30% had at least one of the following infections (TP, CT, NG, and/or CMV) detected at the time of delivery. High rates of TP (8.7%), CT (17.8%), NG (4%), and CMV (6.3%) were observed. HIV MTCT was 9.1% (n = 82 infants). HIV MTCT was 12.5%, 10.3%, 11.1%, and 26.3% among infants born to women with CT, TP, NG or CMV respectively. Forty-two percent of HIV-infected infants were born to women with at least one of these 4 infections. Women with these infections were nearly twice as likely to have an HIV-infected infant (aOR 1.9, 95% CI 1.1–3.0), particularly those with 2 STIs (aOR 3.4, 95% CI 1.5–7.7). Individually, maternal CMV (aOR 4.4 1.5–13.0) and infant congenital CMV (OR 4.1, 95% CI 2.2–7.8) but not other STIs (TP, CT, or NG) were associated with an increased risk of HIV MTCT.

Conclusion

HIV-infected pregnant women identified during labor are at high risk for STIs. Co-infection with STIs including CMV nearly doubles HIV MTCT risk. CMV infection appears to confer the largest risk of HIV MTCT.

Trial registration

NCT00099359.

Long-term Visual and Ocular Sequelae in Patients With Congenital Cytomegalovirus Infection

BACKGROUND

Cytomegalovirus (CMV) is the most common congenital viral infection in the United States. Visual and ocular sequelae in adolescents and adults who are congenitally infected with CMV have not been well studied. Better understanding of the long-term visual and ocular sequelae can help with early detection, intervention and appropriate educational accommodations.

METHODS

This study evaluated 237 patients (77 symptomatic, 109 asymptomatic and 51 control) who underwent a series of age-appropriate ophthalmologic, audiologic and neurodevelopmental examinations from 1982 to 2013. The frequency and etiology of visual impairment and other nonophthalmologic findings were recorded for each patient. Ophthalmologic findings were tabulated, and risk factors for abnormalities were analyzed.

RESULTS

Fourteen of the 77 (18.2%) symptomatic and none of the asymptomatic and control subjects had severe visual impairments (P ≤ 0.006). Moderate visual impairment did not differ between symptomatic and asymptomatic subjects. Three asymptomatic subjects had retinal scars. The most common visual or ocular sequelae in the symptomatic group were strabismus (23.4%), chorioretinal scars (19.5%), cortical visual impairment (14.3%), nystagmus (14.3%) and optic nerve atrophy (11.7%). Three symptomatic patients had delayed visual deterioration because of later occurring retinal disorders: peripheral retinal scar, rhegmatogenous retinal detachment and Coats' disease.

CONCLUSION

Symptomatic CMV patients experienced more ophthalmologic sequelae and significantly worse visual outcomes than asymptomatic CMV and control patients. Later occurring retinal disorders were found in symptomatic patients, and there is no clear evidence that CMV can reactivate in the retinas of children who were congenitally infected. Major risk factors for severe visual impairment included symptomatic status, optic nerve atrophy, chorioretinitis, cortical visual impairment and sensorineural hearing loss.

Neurodevelopmental Outcomes in 22 Children With Microcephaly of Different Etiologies

We examined longitudinal neurodevelopmental outcomes in a series of infants with microcephaly. Retrospective review identified neonatal intensive care unit follow-up clinic patients with a diagnostic code of microcephaly, verified by head circumference less than the fifth precentile (WHO growth curves). Data were collected regarding clinical history and developmental assessments by Capute Scales and gross motor age equivalent. Developmental Quotient (DQ) was age adjusted up until 2 years for preterm infants. Twenty-two infants had microcephaly. At latest follow-up (3-66 months, mean 27.2), 73% had delay (DQ < 70) in ≥1 area of development: gross motor 65% (mean DQ 56.8), visual-motor 59% (mean DQ 62.7), and language 59% (mean DQ 65.9). In this sample, postnatal onset and diagnosis of epilepsy were associated with lower DQs. We conclude that infants with microcephaly are at significant risk for delay across all aspects of development and for long-term disability. Postnatal etiologies of microcephaly and infants with comorbid epilepsy had worse outcomes.

Clinical Predictors of Sensorineural Hearing Loss and Cognitive Outcome in Infants with Symptomatic Congenital Cytomegalovirus Infection

The objective of this study was to determine newborn clinical findings predictive of adverse clinical outcomes in infants with symptomatic congenital cytomegalovirus infection. Of 160 infants, significantly more children with central nervous system involvement had sensorineural hearing loss (P = 0.0007) and an IQ ≤70 (P < 0.0001) compared with infants with transient findings or only a petechial rash.

Combined genetic variants of human cytomegalovirus envelope glycoproteins as congenital infection markers

Background

Human cytomegalovirus (HCMV) is still considered to be the main viral cause of birth defects and long-term neurological and sensory sequelae following congenital infection.

Several Authors sustain a key role of HCMV envelope glycoproteins, such as gB, gN and gO - mainly involved in cell targeting, viral penetration and spread - as putative virulence factors. The genes coding for these glycoproteins possess hypervariable regions, resulting in a number of genetic variants in circulating clinical strains. Considering that the genetic polymorphisms underlying the specific differences between gB, gN and gO genotypes can influence the ability of HCMV to preferentially target specific host cells, it is very likely that they play an important role in defining HCMV infection outcome.

In the present study, we analysed HCMV gB, gN and gO gene polymorphisms in viral strains isolated from paediatric patients with congenital or post-natal infection, to investigate whether specific genetic variants may be associated with congenital infection.

Methods

The restriction fragment polymorphisms of genes coding for HCMV gB (UL55), gN (UL73) and gO (UL74) were investigated by analysing viral DNA extracted from 40 urine samples of as many paediatric patients with congenital or post-natal HCMV infection. Randomly selected samples were subjected to DNA sequencing and phylogenetic analysis. Statistical analysis was performed using Fisher’s exact test to assess the significance of single and combined glycoprotein genotypes frequency distribution. Statistical significance was considered at a P <0.05.

Results

While gB genomic variants were quite homogeneously represented in both paediatric groups, the gN4 genotype significantly prevailed in congenitally infected children (89.5 %) vs post-natally infected children (47.6 %), with a predominance of the gN4c variant (47.4 %). A similar trend was observed for gO3 (52.6 % vs 19 %).

Concerning genotypes association, a statistically significant (P = 0.037) gN4-gO3 combination was found specifically in the congenitally infected group.

Conclusions

The results indicate that the gN4 (mostly the gN4c variant) and gO3 combined genotypes could provide useful markers of congenital infection and represent suitable candidate molecules for prophylactic vaccine preparations.

Epidemiological survey of human cytomegalovirus antibody levels in children from Southeastern China

Background

This study investigated infection status and distribution of human cytomegalovirus (HCMV) serum markers in hospitalized children from the Wenzhou region.

Methods

This survey was performed on 10,147 hospitalized children from birth to 14 years of age in Southeastern China (Wenzhou region) from March 2010 to March 2013. IgM and IgG antibodies to HCMV were quantitatively detected by chemiluminescence immunoassay (CLIA). HCMV IgM or IgG detection rates, concentration, and distribution in various age groups were retrospectively analyzed.

Results

In this study of hospitalized children, the overall rates of HCMV IgM⁺ and IgG⁺ were 10.8% (1,099/10,147) and 83.0% (8,425/10,147), respectively. The lowest HCMV IgM⁺ rate (1.0%, P < 0.001) was observed in the group of patients <28 days of age whereas the highest HCMV IgM⁺ rate (19.9%, P < 0.001) occurred in the 28 days ~ 5 months old group. However, the concentrations of HCMV specific IgM in all age groups were not significantly different (P > 0.05). The HCMV IgG⁺ rate was highest in the <28 days group (98.1%, P < 0.001). The 28 days ~ 5 months old group had the lowest HCMV specific IgG concentrations (median, 133.9 AU/mL, P < 0.001). Among 1,099 HCMV IgM⁺ children, 405 (36.9%) were diagnosed with respiratory infections which pneumonia accounted for 18.2% (200/1,099) of the total population. However, children with respiratory infections had the lowest HCMV IgG concentrations (median, 161.1 AU/mL, P < 0.05).

Conclusions

HCMV specific antibody responses are very common in hospitalized children with respiratory infection in Wenzhou region. Protection against HCMV airway infection needs greater emphasis and further studies will be helpful to reveal the role of HCMV in children respiratory disease.

Spectrum of disease and outcome in children with symptomatic congenital cytomegalovirus infection

OBJECTIVE

To evaluate differences in presentation and outcomes in children with symptomatic congenital cytomegalovirus (cCMV) identified on newborn screening (screened group) and those identified based on clinical findings at birth (referred group).

STUDY DESIGN

Data on 178 infants with symptomatic cCMV were analyzed. Demographic characteristics, clinical and laboratory findings documented in the nursery, and sequelae data were compared between the screened and the referred groups using χ(2) or Fisher exact test.

RESULTS

Two or more clinical findings were detected at birth in 91% of referred infants, and only 58% of screened infants (P < .001). Significantly more children in the referred group had hearing loss compared with screened infants (P = .009). Fifty-one percent of screened children were free of sequelae compared with only 28% of the referred group (P < .003).

CONCLUSIONS

Infants with symptomatic cCMV identified based on clinical suspicion have more severe disease at birth and more commonly have sequelae than those identified on newborn screening. Inclusion of referral infants in many previous reports may have overestimated the severity of disease because of selection bias. Defining the complete spectrum of symptomatic disease due to cCMV and providing precise estimates of disease burden can only be gathered from large newborn screening studies.

Clinical, biochemical, and neuroimaging findings predict long-term neurodevelopmental outcome in symptomatic congenital cytomegalovirus infection

OBJECTIVE

To evaluate clinical, biochemical, and neuroimaging findings as predictors of neurodevelopmental outcome in patients with symptomatic congenital cytomegalovirus (CMV).

STUDY DESIGN

The study cohort comprised 26 patients with symptomatic congenital CMV born between 1993 and 2009 in a single center. Absolute and weight deficit-adjusted head circumference were considered. Cerebrospinal fluid (CSF) investigations included standard cytochemical analysis, determination of beta2-microglobulin (β2-m), neuron-specific enolase, and CMV DNA detection. Neuroimaging was classified according to a validated scoring system comprising calcifications, ventriculomegaly, and atrophy, with findings graded from 0 to 3. Systematic long-term neurodevelopmental assessment included motor function, cognition, behavior, hearing, vision, and epilepsy. Sequelae were graded as mild/absent, moderate, or severe; adverse outcome was defined as death or moderate to severe disability.

RESULTS

Three children died. The mean age at follow-up of the survivors was 8.7 ± 5.3 years (range, 19 months to 18.0 years). Neonatal findings showing a significant association with adverse outcome were relative microcephaly, CSF β2-m concentrations, and grade 2-3 neuroimaging abnormalities (P < .05). Receiver operator characteristic curve analysis indicated that the most accurate single factor for predicting unfavorable outcome was CSF β2-m >7.9 mg/L (area under the curve, 0.84 ± 0.08; sensitivity, 69%; specificity, 100%). The combination of CSF β2-m >7.9 mg/L and moderate-severe neuroimaging alterations improved predictive ability (area under the curve, 0.92 ± 0.06; sensitivity, 87%; specificity, 100%).

CONCLUSION

Adjusted head circumference, CSF β2-m level, and neuroimaging studies have prognostic significance for neurodevelopmental outcome in newborns with congenital CMV. A combination of early findings improves the predictive value.

Congenital cytomegalovirus infection: new prospects for prevention and therapy

Cytomegalovirus is the commonest congenital viral infection in the developed world, with an overall prevalence of approximately 0.6%. Approximately 10% of congenitally infected infants have signs and symptoms of disease at birth, and these symptomatic infants have a substantial risk of subsequent neurologic sequelae. These include sensorineural hearing loss, mental retardation, microcephaly, development delay, seizure disorders, and cerebral palsy. Antiviral therapy for children with symptomatic congenital cytomegalovirus infection is effective at reducing the risk of long-term disabilities and should be offered to families with affected newborns. An effective preconceptual vaccine against CMV could protect against long-term neurologic sequelae and other disabilities.

Prenatal exposures associated with neurodevelopmental delay and disabilities

Neurobehavioral teratology refers to the study of the abnormal development of the structure and the behavioral functions of the central nervous system, which result from exposure to exogenous agents during prenatal development. The focus of this review is the effects of various prenatal exposures on human neurodevelopment. Studies that deal with the adverse effects of infectious agents (rubella, cytomegalovirus, and toxoplasma), teratogenic drugs (e.g., antiepileptic drugs such as phenytoin, valproate, and carbamazepine, coumarin derivatives, and retinoids), alcohol, and other substances of abuse will be reviewed. Additionally, prenatal exposure to industrial or environmental chemicals (e.g., lead, methylmercury, and polycarbonated biphenyls) as well as exposure of the embryo or fetus to high amounts of ionizing radiation will be addressed. Possible mechanisms of selected neurobehavioral teratogens will also be discussed.

The "silent" global burden of congenital cytomegalovirus

Human cytomegalovirus (CMV) is a leading cause of congenital infections worldwide. In the developed world, following the virtual elimination of circulating rubella, it is the commonest nongenetic cause of childhood hearing loss and an important cause of neurodevelopmental delay. The seroprevalence of CMV in adults and the incidence of congenital CMV infection are highest in developing countries (1 to 5% of births) and are most likely driven by nonprimary maternal infections. However, reliable estimates of prevalence and outcome from developing countries are not available. This is largely due to the dogma that maternal preexisting seroimmunity virtually eliminates the risk for sequelae. However, recent data demonstrating similar rates of sequelae, especially hearing loss, following primary and nonprimary maternal infection have underscored the importance of congenital CMV infection in resource-poor settings. Although a significant proportion of congenital CMV infections are attributable to maternal primary infection in well-resourced settings, the absence of specific interventions for seronegative mothers and uncertainty about fetal prognosis have discouraged routine maternal antibody screening. Despite these challenges, encouraging results from prototype vaccines have been reported, and the first randomized phase III trials of prenatal interventions and prolonged postnatal antiviral therapy are under way. Successful implementation of strategies to prevent or reduce the burden of congenital CMV infection will require heightened global awareness among clinicians and the general population. In this review, we highlight the global epidemiology of congenital CMV and the implications of growing knowledge in areas of prevention, diagnosis, prognosis, and management for both low (50 to 70%)- and high (>70%)-seroprevalence settings.

Use of ganciclovir in the treatment of acquired cytomegalovirus disease in a preterm infant

The first use of ganciclovir in a preterm infant is reported. The 27 week appropriate-for-gestational-age male infant developed a disseminated cytomegalovirus infection subsequent to a blood transfusion. A daily dose of 10 mg/kg administered intravenously in two divided doses for a total of 14 days was given without adverse clinical or toxic effects. The patient has remained well following discharge from hospital.

The use of antiviral drugs during the neonatal period

Parenteral therapy of viral infections of the newborn and infant began with vidarabine (adenine arabinoside) for the treatment of neonatal herpes simplex virus (HSV) infections in the early 1980s. Acyclovir has become the treatment of choice for neonatal HSV infections and a variety of other herpesvirus infections. Ganciclovir is beneficial for the treatment of congenital cytomegalovirus (CMV) infections involving the central nervous system (CNS). This article reviews the use of acyclovir and ganciclovir in the treatment of neonatal HSV and congenital CMV infections. A brief summary precedes a detailed discussion of available established and alternative therapeutics.

Congenital cytomegalovirus infection - An update

Cytomegalovirus is estimated to be the leading infectious cause of nonheriditary sensorneural loss and a significant cause of mental retardation. Approximately 1% of newborn infants are congenitally infected with the virus. This review summarizes recent developments concerning this infection, including clinical outcome, risk factors for aquisition diagnosis and therapy.

Central nervous system disorders in infants with congenital cytomegalovirus infection

BACKGROUND

Congenital cytomegalovirus is the most common cause of congenital infection in developed countries and a major etiology for neurological disability in children. In many countries, there is low awareness of the importance of this virus as a cause of neurological disorders.

METHODS

We reviewed current knowledge regarding neurological disorders associated to congenital cytomegalovirus infection and analysed the epidemiology of this infection in Latin American countries.

RESULTS

The incidence of congenital cytomegalovirus infection reported from Latin American countries ranges from 0 to 6.8% in different settings. Congenital cytomegalovirus infection is a common cause of hearing deficits and mental impairment in children. However, the impact of this infection as a cause of neurological disorders in Latin American countries remains poorly documented.

DISCUSSION

Actions are needed to increase knowledge regarding the frequency and impact of congenital cytomegalovirus infection on Latin American children, as well as to increase awareness of the general population and the medical community regarding the need to identify infants infected in utero by this virus and to carefully evaluate their neurological development throughout childhood.

DECIBEL study: Congenital cytomegalovirus infection in young children with permanent bilateral hearing impairment in the Netherlands

BACKGROUND

A significant number of asymptomatic newborns infected with congenital cytomegalovirus (CMV) will present with permanent childhood hearing impairment (PCHI) during early childhood.

OBJECTIVES

To investigate the role of congenital CMV infection in causing PCHI in the Netherlands, and assess the efficacy of two different hearing screening strategies and the developmental outcome following each strategy.

STUDY DESIGN

We included 192 children with PCHI at the age of 3-5 years, who were offered hearing screening in their first year of life. Dried blood spots from 171 children were available for CMV detection using real-time PCR. The results of eight previously tested samples were also available. Clinical baseline characteristics were collected from medical records and the Child Development Inventory was used to investigate the developmental outcome.

RESULTS

The rate of congenital CMV among the 179 children was 8% (14/179) and 23% (9/39) among children with profound PCHI. Two of eight CMV-positive children with PCHI at the age of 3-5 years had passed the newborn hearing screening (NHS) test. Developmental outcome measures showed a significantly greater delay in language comprehension in children with both PCHI and congenital CMV infection (the largest in symptomatic children) than in the children with PCHI without congenital CMV infection.

CONCLUSIONS

Congenital CMV infection is important in the etiology of PCHI. Universal NHS is not a guarantee of normal hearing and development in childhood for children with congenital CMV infection. This is a problem which might be solved by universal congenital CMV screening.

Neurodevelopmental outcomes following ganciclovir therapy in symptomatic congenital cytomegalovirus infections involving the central nervous system

BACKGROUND

Ganciclovir protects against hearing deterioration in infants with symptomatic congenital cytomegalovirus (CMV) disease involving the central nervous system (CNS).

OBJECTIVES

To assess the neurodevelopmental impact of ganciclovir therapy in this population.

STUDY DESIGN

100 neonates were enrolled into a controlled Phase III study of symptomatic congenital CMV involving the CNS, and were randomized to either 6 weeks of intravenous ganciclovir or no treatment. Denver developmental tests were performed at 6 weeks, 6 months, and 12 months. For each age, developmental milestones that > or =90% of normal children would be expected to have achieved were identified. The numbers of milestones not met ("delays") were determined for each subject. The average number of delays per subject was compared for each treatment group.

RESULTS

At 6 months, the average number of delays was 4.46 and 7.51, respectively, for ganciclovir recipients and "no treatment" subjects (p=0.02). At 12 months, the average number of delays was 10.06 and 17.14, respectively (p=0.007). In a multivariate regression model, the effect of ganciclovir therapy remained statistically significant at 12 months (p=0.007).

CONCLUSIONS

Infants with symptomatic congenital CMV involving the CNS receiving intravenous ganciclovir therapy have fewer developmental delays at 6 and 12 months compared with untreated infants. Based on these data as well as the previously published data regarding ganciclovir treatment and hearing outcomes, 6 weeks of intravenous ganciclovir therapy can be considered in the management of babies with symptomatic congenital CMV disease involving the CNS. If treatment is initiated, it should be started within the first month of life and patients should be monitored closely for toxicity, especially neutropenia. Since existing data only address the treatment of symptomatic congenital CMV disease involving the CNS, these data cannot be extrapolated to neonates with other manifestations of CMV disease, including asymptomatic babies and symptomatic babies who do not have CNS involvement.

Antiviral therapy for herpesvirus central nervous system infections: neonatal herpes simplex virus infection, herpes simplex encephalitis, and congenital cytomegalovirus infection

Herpesvirus infections of the central nervous system (CNS) are a significant cause of morbidity and mortality, including long-term neurologic sequelae. Among the family of herpesviruses, the most significant CNS infections are due to herpes simplex virus (HSV) and cytomegalovirus (CMV). The onset of HSV CNS infection can occur in neonates as well as older children and adults. CNS infection associated with CMV occurs predominantly in the perinatal period, but may also be seen rarely in children and adults, especially in immunocompromised individuals. Although advances in antiviral agents have led to improved outcomes, there is still a need for more effective treatments.

Trends in hospitalizations for diagnosed congenital cytomegalovirus in infants and children in Australia

Background

Cytomegalovirus (CMV) is responsible for a wide range of diseases in neonates, and has been recognized as a major cause of congenital defects in developed countries for many years. More children suffer serious disabilities caused by congenital CMV than by several better-known childhood maladies. Insight into the epidemiology of congenital CMV disease is needed for the assessment of preventive strategies.

Methods

Using data from the National Hospital Morbidity Database (NHMD) complied by the Australian Institute of Health and Welfare (AIHW), we examined the rates of hospital admissions for children diagnosed with congenital cytomegalovirus (CMV) by year, sex, age group and length of stay.

Results

Over an 8-year period (1993–2001), there were 1314 admissions for the congenital form of CMV disease. Of these admissions, 25% were principally hospitalized because of congenital CMV. The average annual rate of admissions in children aged 0–4, 5–9 and 10–14 years was 9.40, 2.40 and 0.85 per 100,000 Australian population respectively.

Conclusion

Compared with many other congenital illnesses, which are now vaccine preventable, the burden of congenital CMV is comparatively high. A vaccination program would be justifiable should a vaccine become available.

Epilepsy in patients with congenital cytomegalovirus infection

Patients with congenital cytomegalovirus (CMV) infection were at high risk for postnatal seizures, but little is known about epilepsy associated with congenital CMV infection. To define the features of epilepsy, we retrospectively reviewed the clinical, laboratory and neuroradiographic findings in 19 children (male 9) with congenital CMV infection. Seven (37%) patients had developed epilepsy (partial seizure 5 and epileptic spasms 2) at a mean age of 20 months (range 2-37 months). During the clinical course, West syndrome occurred in only three patients. The most common seizure type in our series was partial seizure. At the time of last follow-up (mean 96 months), seizures remained uncontrolled in six patients. Neonatal clinical manifestations (gestational age, gender distribution, birth asphyxia or symptoms at birth) were not predictive of the development of epilepsy. On the contrary, some neuroradiographic findings (ventricular dilatation and migration disorder) were significantly associated with the development of epilepsy.

Physical and intellectual development in children with asymptomatic congenital cytomegalovirus infection: a longitudinal cohort study in Qinba mountain area, China

BACKGROUND

Although about 90% of congenital cytomegalovirus (CMV) infection is asymptomatic in newborn, some of them could show sequelae later in life. Qinba mountain area is a place with high incidence of mental retardation and a high rate of CMV intrauterine transmission in China. The correlation between asymptomatic congenital CMV infection and developmental outcomes of children in this area remain unclear.

OBJECTIVES

To investigate the impact of asymptomatic congenital CMV infection on physical and intellectual development of children during the first 6 years of life in Qinba mountain area.

STUDY DESIGN

Longitudinal cohort study. Forty-nine of all the 54 children with asymptomatic congenital CMV infection were followed prospectively in a study for surveying physical growth and intellectual developments.

RESULTS

Either in neonatal or in infant period, no significant difference was noted between the asymptomatic congenital CMV infection children and the controls in average weight, height and head circumference (both p>0.05). The intellectual development was disproportion in asymptomatic congenital infected children. Compared with the control group, both global development quotient (DQ) and full-scale intelligence quotient (IQ) scores of asymptomatically infected children were worse (t=2.19, p=0.031; t=2.48, p=0.015), especially on language DQ scores (t=3.25, p=0.002) and verbal IQ scores (t=3.88, p=0.000). However, the incidence rates of mental retardation (DQ/IQ<70) were similar in two groups (chi(2)=1.03, p>0.05).

CONCLUSIONS

Although asymptomatic congenital CMV infection did not have significant influence on the neonatal physical development or incidence of mental retardation later in life, it is obviously an important factor correlating with long-time cognitive outcomes, especially on the development of language. It is necessary to survey CMV congenital infection and monitor the early intellectual development of children with asymptomatic congenital CMV infection in this area.

Clinical findings and adverse outcome in neonates with symptomatic congenital cytomegalovirus (SCCMV) infection

INTRODUCTION

Congenital cytomegalovirus (CCMV) infection is a common neonatal infection affecting 1% of all live births, 10% of which are symptomatic. Many of these infants have long-term sequelae. The objective is to document the clinical presentation of SCCMV infection in neonates, the frequency of sequelae and severity of adverse neurologic outcomes and risk factors.

METHODS

A review and analysis of all symptomatic infants diagnosed with SCCMV infection are given. SCCMV was defined as a diagnosis of CCMV infection in the first three weeks of life in the presence of any clinical manifestations. Outcome data from 2 years of age and later are analyzed.

RESULTS

There were 104 patients identified as having SCCMV infection and of these 42 cases had definite infection. The common findings at presentation were hepatosplenomegaly 19/42 (45%), thrombocytopenia 21/42 (50%), elevated transaminases 21/42(50%), abnormal cranial US scan 24/41(56%), abnormal head CT scan 29/41(71%) and abnormal brain MRI 17/19(89%). The risk factors for an adverse outcome including death or deafness or blindness or moderate to severe neurological deficits included an abnormal cranial US scan (OR 8.5), abnormal head CT scan (OR 21) and abnormal brainstem auditory evoked responses (BAER) (OR 8.7).

CONCLUSIONS

There was only three (7%) patients without any deficits and severely affected infants have been identified with a diverse clinical presentation, reinforcing the importance of CMV as a major public health problem.

Beta2-microglobulin concentrations in cerebrospinal fluid correlate with neuroimaging findings in newborns with symptomatic congenital cytomegalovirus infection

OVERVIEW

In newborns with symptomatic congenital cytomegalovirus (CMV) infection, neuroimaging is the best available predictor of neurodevelopmental outcome. Cerebrospinal fluid (CSF) findings in congenital CMV infection have seldom been described. Neonates with central nervous system infections present high CSF Beta(2)-microglobulin (beta(2)-m) levels.

OBJECTIVES

The objectives of this study were: (1) to determine whether CSF beta(2)-m is increased in newborns with symptomatic congenital CMV infection, and (2) to examine its correlation with neuroimaging findings.

MATERIALS AND METHODS

Fourteen newborns with symptomatic congenital CMV infection admitted to La Paz Hospital from 1990 through 2004 underwent determination of CSF beta(2)-m. Ninety-three newborns, constituting the comparison group, underwent CSF beta(2)-m determination as part of a sepsis or meningo/encephalitis work-up, and at discharge had sterile cultures and normal neurological status. Neuroimaging findings were scored according to a semiquantitative system: (0) no abnormalities; (1) single punctate periventricular (PV) calcification and/or hyperechogenic areas in the thalamus and basal ganglia; (2) multiple discrete PV calcifications and/or ventriculomegaly; and (3) extensive PV calcifications and/or brain atrophy.

DISCUSSION AND CONCLUSION

CSF beta(2)-m was increased in newborns with CMV infection (median 6.21 mg/L) compared with controls (1.68 mg/L) (P<.001). beta(2)-m showed a correlation with neuroimaging scores (r (s)=0.753, P=.002). beta(2)-m was higher in patients who scored 2-3 (12.83 mg/L) than in patients who scored 0-1 (5.52 mg/L) (P=.028). CSF beta(2)-m is increased in newborns with symptomatic congenital CMV infection and correlates with neuroimaging abnormalities. beta(2)-m appears to be an indicator of the severity of brain involvement in congenital CMV infection.

Perinatal infections and cerebral palsy

Infections of the mother, the intrauterine environment, the fetus, and the neonate can cause cerebral palsy through a variety of mechanisms. Each of these processes is reviewed. The recently proposed theory of cytokine-induced white matter brain injury and the systemic inflammatory response syndrome with multiple organ dysfunction syndrome is critically evaluated.

Prenatal diagnosis and outcome of congenital cytomegalovirus infection in twin pregnancies

OBJECTIVE

To study the outcome of 20 twin pregnancies with evidence of primary or recurrent cytomegalovirus (CMV) infection during pregnancy.

DESIGN

Observational study.

SETTING

Two tertiary perinatal departments in Israel.

POPULATION

Twenty women with twin pregnancies who were referred because of serologic investigation indicating CMV infection. Seventeen women had evidence of primary CMV infection, and three women appeared to have recurrent CMV infection.

METHODS

Prenatal diagnosis was made by amniocentesis of both sacs after 21 weeks of gestation. CMV isolation was performed by culture on fibroblasts, shell vial technique and polymerase chain reaction (PCR) amplification of CMV DNA. After birth, the neonatal urine and saliva were cultured for CMV.

MAIN OUTCOME MEASURES

Intrauterine CMV infection defined as positive PCR at amniotic fluid analysis and congenital CMV infection defined as positive CMV cultures after birth.

RESULTS

Except for one, all women underwent amniocentesis of both gestational sacs. In 14 (70%) women, no evidence of vertical transmission to any of the 28 fetuses was found and none of the newborns had evidence of congenital CMV infection. Intrauterine infection was detected by amniocentesis in five women and by ultrasound findings with positive maternal serology in one. In three women, CMV was detected in only one amniotic sac. In five of our six total cases, both twins were found to have congenital CMV infection at birth, all of whom had dichorionic-diamniotic placentation, three fused and two separate.

CONCLUSIONS

In twin gestations, as in singletons, intrauterine and congenital CMV infection occurs in about 30% of women with primary or recurrent infection. The placenta type did not predict if one or both twins would be infected. Our data do not exclude the possibility that intrauterine transmission of the virus from one fetus to the other can occur.

Colonic stricture mimicking Hirschsprung's disease: a localized cytomegalovirus infection

The diagnosis of congenital cytomegalovirus (CMV) infection is best established by isolating the virus from urine or saliva within the first 2 weeks of life. Detection beyond this point may reflect perinatal acquisition of CMV. Cytomegalovirus is usually transmitted by direct human-to-human contact through vertical or horizontal routes. Infected persons can excrete CMV in urine, saliva, semen, cervical secretions, or breast milk. Because the virus establishes latent infections, blood products and solid organs can also transmit CMV. In the surgical literature, intestinal CMV-infected cells in infants have prevalently been associated with neonatal necrotizing enterocolitis, and only very few cases of primary CMV infection of the gastrointestinal tract of surgical interest in immunocompetent neonates have been reported. We describe a neonate with congenital or perinatal CMV infection with gastrointestinal involvement who developed a colonic stricture and manifested a clinical picture simulating Hirschsprung's disease. The intestinal lesion was a localized segmental CMV infection of the colon in which inflammation dominated the histopathologic finding. Chorioretinitis was also present.

Neonatal cytomegalovirus blood load and risk of sequelae in symptomatic and asymptomatic congenitally infected newborns

OBJECTIVE

Human cytomegalovirus (CMV) is a ubiquitous human-specific DNA virus and is the main cause of congenital virus infection in developed countries leading to psychomotor impairment and deafness. Diagnostic techniques for CMV detection have greatly improved during recent years with the advent of sophisticated serological and virological methods. The aim of the present study was to assess the diagnostic and prognostic value of detection and quantification of virus in neonatal blood samples of symptomatic and asymptomatic newborns with CMV congenital infection.

METHODS

Between January 1997 and December 2003, we studied 99 newborns who were born to women with primary, recurrent, and undefined CMV infection during pregnancy. CMV congenital infection was identified by isolation of the virus in urine within the second week of life. Fifty-eight of 99 infants were infected and were assessed clinically for disease in the newborn period and classified as having symptomatic or asymptomatic infection on the basis of physical, instrumental, and laboratory findings. The infants were followed up from birth according to a protocol of the tertiary NICU at the University of Bologna in a prospective study of long-term sequelae of congenital infection. Forty-seven blood samples were obtained from 47 infants in the neonatal period: 34 were examined for pp65 antigenemia test and 44 for qualitative and quantitative polymerase chain reaction (PCR and qPCR). Sequelae at 12 months were evaluated in a group of 50 infants.

RESULTS

Antigenemia was positive in only 10 of 34 samples of infected newborns (29.4% sensitivity). PCR was performed in 44 samples of infected newborns and was positive in all (100% sensitivity). qPCR showed a finding of > or =100 copies per 10(5) of polymorphonuclear leukocytes (PMNLs) in 39 of 44 samples; in the other 5 cases, the number of copies per 10(5) PMNLs was <100. Between symptomatic and asymptomatic newborns, the mean values of viral blood load determined by qPCR turned out to be significantly higher in symptomatic newborns. Mean values of neonatal blood viral load were statistically higher in newborns who developed sequelae than in those who did not. Of 20 children with a neonatal viral blood load of <1000 copies per 10(5) PMNLs, 19 did not develop sequelae (negative predictive value: 95%), whereas 2 of 3 with a viral blood load of >10,000 copies did develop sequelae.

CONCLUSIONS

Different viremia value ranges are correlated to a different risk of sequelae: approximately 70% sequelae were found in newborns with a qPCR higher than 10,000 copies per 10(5) PMNLs. Low neonatal viral blood load detected by pp65 antigenemia test and qPCR was highly predictive of absence of sequelae: DNAemia <1000 copies per 10(5) PMNLs has a negative predictive value of 95%. As an independent predictive factor of outcome, neonatal viremia is another useful element for neonatal counseling and therapeutic choices in symptomatic and asymptomatic newborns.

Audiometric, clinical and educational outcomes in a pediatric symptomatic congenital cytomegalovirus (CMV) population with sensorineural hearing loss

OBJECTIVE

To correlate audiometric findings and outcomes with the clinical, radiological and educational findings in a symptomatic congenital cytomegalovirus (CMV) population with sensorineural hearing loss.

METHODS

A retrospective review of data from 21 symptomatic congenital CMV patients identified in a pediatric hearing impaired database of 1500 patients. Clinical data, audiometric thresholds and outcomes, radiographic abnormalities, communication and educational achievements were used as outcome measures.

RESULTS

Twenty-one patients were identified with symptomatic congenital CMV infection at birth; 5 with unilateral hearing loss and 16 with bilateral hearing loss. The median initial pure-tone average (PTA) for the 21 subjects was 86 dB and the median final PTA was 100 dB. Progression of hearing loss was seen in 9 patients (43%). Neurological and radiological sequelae of symptomatic CMV infection were seen in 81% of affected patients. Children with neurological dysfunction were significantly more likely to rely on special education (p = 0.045). There was a significant correlation between the severity of the initial PTA and the development of a progressive hearing loss (p = 0.0058). Initial hearing thresholds were significantly better in those children with a history of jaundice (p = 0.002), hepatosplenomegaly (HSM) (p = 0.022) and cerebral palsy (CP) (p = 0.013). There was a significant correlation between a less severe final PTA and the presence of CP (p = 0.005). A history of mental retardation in children was significantly associated with poorer communication skills (p = 0.043).

CONCLUSIONS

The severity of neurological manifestations in congenital symptomatic CMV infection was positively correlated with the need for total and manual communication and the reliance on special education. Statistical associations between clinical findings such as hepatic dysfunction, CP and hearing level were identified however plausible mechanisms explaining these associations remain ambiguous and are discussed in the context of this complex population of children with congenital symptomatic CMV.

Congenital cytomegalovirus infection: association between virus burden in infancy and hearing loss

OBJECTIVE

To determine the relationship between the virus burden in infancy and hearing loss in congenital CMV infection.

STUDY DESIGN

A cohort of 76 infants with congenital cytomegalovirus (CMV) infection identified by means of newborn virologic screening was monitored for outcome. The amount of infectious CMV was analyzed in urine specimens obtained during early infancy. Peripheral blood (PB) samples obtained during early infancy were available from 75 children and CMV DNA was quantitated with a real-time quantitative polymerase chain reaction.

RESULTS

Infants with clinical abnormalities at birth (symptomatic congenital CMV infection) had higher amounts of CMV in urine (P = .005) and CMV DNA in PB (P = .001) than infants with no symptoms. Eight children with and 4 children without symptoms had hearing loss. Among children without symptoms, those with hearing loss had a significantly greater amount of CMV in urine (P = .03) and PB virus burden (P = .02) during infancy than those with normal hearing. Infants with < 5 x 10(3) pfu/mL of urine CMV and infants with < 1 x 10(4) copies/mL of viral DNA in PB were at a lower risk for hearing loss.

CONCLUSION

In children with asymptomatic congenital CMV infection, hearing loss was associated with increased amounts of urine CMV and PB CMV DNA during early infancy.

Congenital cytomegalovirus infection: outcome and diagnosis

Cytomegalovirus (CMV) is the most common congenital infection in humans and an important cause of morbidity and mortality in immunocompromised hosts. Congenital CMV infection occurs in approximately 0.5 to 1 percent of all newborns in the United States and can result in significant neurological sequelae. The gold standard for diagnosing congenital CMV infection is isolation of the virus from infants within the first 2 weeks of life through conventional or rapid cell culture techniques. Newer molecular diagnostic methods to diagnose congenital CMV infection, including the nucleic acid amplification of viral DNA from the peripheral blood of infants, are being investigated, and the preliminary results show promise. However, more work must be done to standardize and validate these methods before they can be used routinely in establishing the diagnosis of congenital CMV infection.

Mother-to-fetus transmission of cytomegalovirus. A review

Congenital human cytomegalovirus (CMV) infection is the leading infectious cause of mental retardation, sensorineural deafness and visual impairment. It is mainly related to a primary maternal infection. The placenta should be considered the most important site of both the protection of the fetus from CMV infection and the transmission of CMV from mother to fetus. The control of the passage of CMV across the placenta probably involves a cascade of regulatory events. Roles are played by factors relating to the host immune-selective pressures, such as local cytokines and maternal CMV-specific neutralizing antibodies. The presence of other pathogens at the maternal-fetal interface also influences the outcome of CMV infection. Further investigations are needed in which clinical CMV strains are applied in in vitro studies to unravel the molecular mechanism of the intrauterine transmission of CMV and to elucidate the complex regulation that leads to prevention of the in utero transmission of CMV in vivo.