Ileal perforation caused by congenital or perinatal cytomegalovirus infection

Cytomegalovirus Colitis in Immunocompetent and Immunocompromised Children: A 2-Center Study

BACKGROUND

Data about cytomegalovirus (CMV) colitis in children are scarce. We aimed to describe the characteristics of childhood CMV colitis in terms of risk factors, clinical symptoms, diagnosis, therapeutic approaches, and outcomes.

METHODS

Inflammatory bowel disease (IBD) and non-IBD patients with CMV colitis diagnosed by histology and tissue CMV PCR at 2 tertiary centers between January 2017 and November 2019 were studied. Clinical and laboratory data were retrieved from medical records. Underlying conditions, immune status, response to therapy and outcomes were described and followed up to 6 months after diagnosis.

RESULTS

A total of 16 children (8 non-IBD, 7 ulcerative colitis and 1 Crohn's disease) with CMV colitis were included. All patients had persistent diarrhea (bloody in 13 cases). There was a significant age difference between IBD and non-IBD children (P < 0.05). The final diagnosis in 1 patient was immunodeficiency with a mutation in JAK1 gene. Three children were categorized as apparently immunocompromised and 4 children as apparently immunocompetent. Ulcer was not visible in 2 children from the non-IBD group. The mean fecal calprotectin level of IBD children was significantly higher than that of non-IBD children (376.12 ± 231.21 µg/g vs. 160.96 ± 69.94 µg/g, P < 0.05). After follow-up, 1 patient died because of another reason. Ganciclovir was used in 14 of 16 children for 3 weeks and the treatment was continued with valganciclovir in selected 6 children.

CONCLUSIONS

CMV colitis is a rare but overlooked cause of prolonged diarrhea in immunocompetent and immunocompromised children. CMV colitis might present without any ulcer formation at colonoscopy in infants.

Severe Postnatal Cytomegalovirus Enterocolitis in Immunocompetent Term Infants Requiring Total Parenteral Nutrition

Postnatal cytomegalovirus enterocolitis is uncommon in immunocompetent infants. We report a 10-week-old term boy with severe and prolonged secretory diarrhea, leading to dependence on total parenteral nutrition and a 10-week hospitalization. Cytomegalovirus enterocolitis was diagnosed based on duodenal biopsy in the context of marked viremia, and the child recovered promptly on initiation of ganciclovir. Collated case reports reveal delayed diagnoses as the norm but rapid improvement with antiviral treatment. Cytomegalovirus enterocolitis should be considered early as a differential diagnosis in infants with refractory diarrhea.

Cytomegalovirus enteritis with intractable diarrhea in infants from a tertiary care center in China

Background: Cytomegalovirus (CMV) is rarely thought to be the cause of significant gastrointestinal infection in immunocompetent children. CMV colitis is seldom observed in young infants. This study aims to examine the clinical features of CMV colitis in Chinese children.Methods: Patients with infantile onset CMV colitis diagnosed in intestinal tissue at Children's Hospital of Fudan University from 1st January 2017, to 31st January 2019 were enrolled. Clinical data were retrieved from medical records, and the literature on infant CMV colitis was also reviewed.Results: Ten patients were included with a median age of 2.5 months [interquartile range 2.0, 6.3 months]. All 10 patients had diarrhea, 10 patients had anemia, seven patients reported hematochezia, five patients had hypoalbuminemia, five patients had retinitis, two patients had hearing impairment, and one patient had perianal abscess and anal fistula. The patients had punched-out ulcerations, longitudinal ulcerations or irregular ulcerations on the rectum and/or colon. Typical histologic evaluation showed crypt distortion and inflammatory infiltration. CMV inclusion bodies were noted in four patients. Immunohistochemistry on intestinal tissue was performed to diagnose CMV, with all patients positive. After follow-up, all patients are clinically recovered or in remission; six patients received antiviral therapy, and five patients had healed ulcers on endoscopic examination.Conclusions: CMV colitis might be a rare cause of intractable diarrhea in immunocompetent children. Clinicians should be aware of the possibility of CMV colitis in patients with intractable diarrhea.

Detection of Cytomegalovirus in Intestinal Tissue of Infants with Necrotizing Enterocolitis or Spontaneous Intestinal Perforation

OBJECTIVE

To determine the frequency of detection of cytomegalovirus (CMV) in surgical or autopsy intestinal tissue from infants with necrotizing enterocolitis (NEC) or spontaneous intestinal perforation (SIP) of the small bowel.

STUDY DESIGN

This was a retrospective cohort study of infants in the neonatal intensive care unit at Nationwide Children's Hospital, Columbus, Ohio, with NEC (Bell stage ≥2B) or SIP from 2000 to 2016. Paraffin-embedded surgical or autopsy intestinal tissues were examined for CMV by polymerase chain reaction (PCR) and immunohistochemistry (IHC), and clinical characteristics of CMV-positive vs CMV-negative cases were compared.

RESULTS

CMV was detected by PCR or IHC in 7 (4%) of 178 infants with surgical or autopsy- confirmed NEC (n = 6) or SIP (n = 1). Among 143 NEC cases (123 surgical, 20 autopsy), CMV was detected in 6 (4%): 4 (2 surgical, 2 autopsy) by both PCR and IHC, and 2 (surgical) by PCR only. Among 35 SIP cases (32 surgical, 3 autopsy), 1 (3%) surgical case was positive, by PCR only. CMV-associated NEC cases had lower median gestational age (24 vs 28 weeks; P = .02), birth weight (649 vs 1121 g; P = .04), and platelet count (16 000/mm³ vs 50 000/mm³; P = .018) compared with CMV-negative cases, respectively. No association was found with receipt of maternal milk, age at NEC diagnosis, male sex, cholestasis, or mortality.

CONCLUSIONS

CMV was detected in intestinal tissue from 4% of NEC or SIP cases (NEC, 4%; SIP, 3%). Lower gestational age, lower birth weight, and thrombocytopenia were significantly associated with detection of CMV in NEC or SIP cases.

Intestinal manifestations of postnatal and congenital cytomegalovirus infection in term and preterm infants

To review the relevant literature on cytomegalovirus-(CMV-)related intestinal problems in neonates, supplemented by two own cases of volvulus, a PubMed search and separate additional searches with characterizing terms were performed. 46 hits were found, 15 of which had to be excluded because they did not report clinical cases, yielding a total of 47 infants. Symptoms in both preterm and term infants with proven postnatal infection (n=16) included abdominal distension, bloody diarrhoea, necrotising enterocolitis (NEC) with perforation and intestinal stricture, with lethal outcome in 3 patients. Manifestations in congenital or unclearly allocated CMV-infections, including volvulus, were similar. We report on 2 additional cases with volvulus in extremely low gestational age neonates (ELGANs) with proven postnatal CMV-infection and concurrent detection of CMV positive cells within the resected intestinal stroma. As a conclusion volvulus should be added to other known intestinal manifestations of breastmilk (BM) related postnatal CMV disease in extremely preterm infants.

Cytomegalovirus Enterocolitis in Immunocompetent Young Children: A Report of Two Cases and Review of the Literature

Cytomegalovirus (CMV) causes significant morbidity and mortality in congenitally infected children and immunocompromised hosts. Among healthy individuals, CMV is generally thought to cause mild, self-limited illness. CMV enterocolitis, in particular, is rarely considered among immunocompetent children presenting with diarrhea. We describe 2 cases of invasive CMV colitis in immunocompetent infants presenting with diarrhea and review the literature to date on this topic. Although invasive CMV enterocolitis has been sporadically reported among immunocompetent children, it remains an underrecognized cause of infectious diarrhea in this population and indications for antiviral therapy are lacking. We propose that CMV should be included in the differential diagnosis of intractable diarrhea in immunocompetent children.

Incidence and impact of CMV infection in very low birth weight infants

BACKGROUND AND OBJECTIVES

Congenital cytomegalovirus (CMV) is the leading cause of nongenetic deafness in children in the United States and can cause neurodevelopmental impairment in term infants. Limited data exist regarding congenital CMV infections in preterm infants. We aimed to determine the incidence and association with outcomes of congenital CMV in very low birth weight (VLBW) preterm infants.

METHODS

VLBW infants born in 1993 to 2008 and admitted to the University of Alabama in Birmingham Regional Neonatal ICU were screened on admission for congenital CMV. CMV status and clinical outcomes were identified by using internal patient databases and hospital-based medical records. The primary outcome was death. Secondary outcomes included evidence of neurologic injury in the form of abnormal cranial ultrasound findings, sensorineural hearing loss, or abnormal motor development. Multivariate analysis was performed.

RESULTS

Eighteen of 4594 VLBW infants had congenital CMV (0.39%; 95% confidence interval, 0.25%-0.62%). An additional 16 infants (0.35%; 95% confidence interval, 0.21%-0.57%) were identified who acquired CMV postnatally. Congenital CMV was not associated with death. Compared with controls, congenitally infected VLBW infants were more likely to have hearing loss at initial screening (67% vs. 9%, P < .0001) and confirmed at follow-up (83% vs. 2.1%, P < .0001). Congenital CMV was also associated with abnormal neuroimaging (72% vs. 25%, P < .0001) and adverse developmental motor outcomes (43% vs. 9%, P = .02). Acquired CMV was not associated with any adverse outcomes.

CONCLUSIONS

Congenital CMV in VLBW infants is associated with high rates of neurologic injury and hearing loss but not death.

Asymptomatic DNAemia heralds CMV-associated NEC: case report, review, and rationale for preemption

Human cytomegalovirus (CMV) infection may be acquired in very low birth weight and extremely low birth weight (ELBW) infants from breast milk. The clinical relevance of such infections is uncertain. There is no consensus on whether screening breast milk for CMV, freezing/pasteurizing milk before feeding, or performing virological monitoring on at-risk infants is warranted. We describe an ELBW infant who acquired CMV postnatally from breast milk and developed CMV sepsis syndrome and clinical evidence of necrotizing enterocolitis (NEC) at ≈ 5 weeks of age. The availability of serial dried blood spots from day of life (DOL) 4 to 21, coincidentally obtained for a metabolic study, provided the novel opportunity to retrospectively test for and quantify the magnitude of CMV DNAemia. DNAemia was present for several weeks before the onset of severe CMV disease, first being noted on DOL 18 and increasing in magnitude daily to 4.8 log10 genomes/mL on DOL 21, approximately 8 days before the onset of abdominal distension and 15 days before the onset of CMV sepsis syndrome and NEC. After surgical resection, supportive care, and ganciclovir therapy, the infant recovered. This case underscores the importance of including CMV infection in the differential diagnosis of sepsis and NEC in premature infants. This case also suggests the value of prospective virological monitoring in at-risk low birth weight and ELBW infants. Future studies should examine the potential utility of preemptive monitoring for, and possibly treatment of, CMV DNAemia in premature infants, which may herald the onset of serious disease.

Cytomegalovirus Enterocolitis Mimicking Necrotizing Enterocolitis: Case Reports and Review of the Literature

A case of necrotizing enterocolitis (NEC) with pathologic evidence of cytomegalovirus (CMV) infection is presented. This preterm infant developed abdominal distention and tachycardia, and a clinical diagnosis of NEC was made. Acute bowel obstruction occurred 20 days later. Biopsy specimens of the ileum obtained during laparotomy showed extensive CMV inclusion bodies and positive immunoperoxidase staining for CMV. Urine culture and polymerase chain reaction from the blood were also positive for CMV. The patient was treated with ganciclovir and recovered. Thirty-two similar cases of CMV enterocolitis and intestinal obstruction in premature and full term babies are reviewed here.

Infant death due to CMV enterocolitis

An infant was admitted with symptoms of diarrhoea and vomiting. After initial improvement she unexpectedly died. Postmortem confirmed a diagnosis of cytomegalovirus (CMV) enterocolitis. The authors report this case and review other published cases of immunocompetent infants who presented with this infection. Clinicians should consider stool CMV PCR test or referral for endoscopy and biopsy in young babies who present with profuse and prolonged episodes of diarrhoea. The value of ganciclovir in immunocompetent infants who suffer with CMV gastrointestinal involvement is still not clear.

Cytomegalovirus enterocolitis presenting as abdominal compartment syndrome in a premature neonate

BACKGROUND

Cytomegalovirus (CMV) enterocolitis is an uncommon intestinal disorder of newborns that is often initially misdiagnosed as necrotizing enterocolitis.

METHODS

We treated a premature twin boy with CMV enterocolitis who presented with abdominal compartment syndrome requiring urgent decompression. All patients with neonatal CMV enterocolitis reported were reviewed.

RESULTS

Nine previously reported patients with neonatal CMV enterocolitis presented with abdominal distention and signs of sepsis. At the time of surgery, either perforation or stricture was identified. The current report is the first to present with clinical signs of abdominal compartment syndrome.

CONCLUSION

CMV is a rare cause of neonatal enterocolitis. Surgical intervention is required for bowel perforation, stricture, or abdominal compartment syndrome.

[Review and guidelines on the prevention, diagnosis and treatment of post-natal cytomegalovirus infection]

Postnatal cytomegalovirus (CMV) infection in the newborn can occur from exposure to maternal cervical secretions during birth, ingestion of breast milk, transfusion of blood products or transmission by body fluids of infected people. Breast milk is the main source of infection, given the high rate of CMV-positive mothers excreting CMV in milk. Freezing reduces the risk of CMV transmission by breastfeeding, although it does not eliminate it completely. Pasteurisation prevents such transmission, but it can alter the immunological properties of breast milk. Postnatal CMV infection is usually asymptomatic, as it normally results from viral reactivation in the mother, and the neonate is born with protective antibodies. However, in the very low birth weight premature infant the amount of transferred antibodies is smaller and a symptomatic infection can occur. Symptomatic post-natal CMV infection in the newborn typically causes hepatitis, neutropenia, thrombocytopenia or sepsis-like syndrome. Pneumonitis and enteritis are less common, but very characteristic. Diagnosis is based on urine virus detection at the time of onset of symptoms. Postnatal CMV infection in the newborn generally resolves spontaneously without antiviral treatment. Ganciclovir should be reserved for severe cases. Unlike congenital CMV disease, post-natal CMV infection in the preterm infant does not seem to be associated with hearing loss or abnormal neuro-development in long term follow-up.

[Cytomegalovirus infection causing protracted diarrhea in an immunocompetent child]

Cytomegalovirus infection is a frequent cause of complications in immunodeficient patients. In healthy hosts, cytomegalovirus infection is usually asymptomatic. We describe a case of a 3 month old immunocompetent boy who suffered from protracted diarrhoea that required parenteral nutrition. After treatment with ganciclovir he recovered without any after effects.

Cytomegalovirus-associated ileal stricture in a preterm neonate

Gastrointestinal (GI) manifestations of post-natally acquired cytomegalovirus (CMV) in preterm neonates can vary from mild diarrhoea to severe necrotising enterocolitis. However, the suspicion of CMV-related GI disease remains low. Mild CMV disease localised to the GI tract may go undiagnosed initially until a more obvious complication such as strictures manifest. A case of CMV-associated enteritis in an extremely preterm neonate is presented. The diagnosis was established after the histopathology of the surgical specimen showed the presence of CMV inclusion bodies. Testing the stool specimen for CMV to establish the diagnosis when the pathology is limited to the GI tract is also discussed.

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.

Sequence variability of human cytomegalovirus UL146 and UL147 genes in low-passage clinical isolates

OBJECTIVES

Human cytomegalovirus (HCMV) infects a number of organs and cell types in vivo. The different symptoms and tissue tropisms of HCMV infection perhaps result from the genetic polymorphism. A new region of DNA containing at least 19 open reading frames (ORFs - denoted UL133-151) was found in the low-passage HCMV clinical strain Toledo and several other low-passage clinical isolates, but not present in the HCMV laboratory strain AD169. Two of these genes, UL146 and UL147, encode proteins with sequence characteristics of CXC (alpha) chemokines, suggesting that they might influence the behavior of neutrophils during infection. This research was to study the sequence variability of UL146 and UL147 ORFs in HCMV clinical isolates and examine the possible associations between gene variability and the outcome of HCMV infection.

METHODS

UL146 and UL147 genes from strains obtained from suspected congenitally HCMV-infected infants were PCR amplified and sequenced.

RESULTS

High variability was found in UL146 and UL147 gene among HCMV clinical strains. However, the alpha chemokine motif in UL146 and UL147 genes was conserved in almost all sequences. According to the phylogenetic analysis, all sequences of UL146 in clinical isolates could be divided into three groups. All strains from congenital megacolon infants existed in G2A only, and all from asymptomatic infants existed in G2B peculiarly.

CONCLUSIONS

Sequence variability among HCMV clinical strains may affect the ability of UL146 and UL147 to attract human neutrophils and influence viral dissemination. No obvious linkage was observed between UL146 polymorphisms and outcome of suspected congenital HCMV infection.

Another cause of bloody diarrhoea in infancy: cytomegalovirus colitis in an immunocompetent child

Although a ubiquitous pathogen, cytomegalovirus (CMV) is very rarely thought to be the cause of significant gastrointestinal infection in the immunocompetent child. We report the case of a 2-month-old infant who presented with bloody diarrhoea and severe dehydration, which was subsequently diagnosed as CMV enterocolitis and resolved spontaneously without antiviral treatment.

Esophagatis and perinatal cytomegalovirus infection

A 6-week-old male infant presented to hospital with a large upper gastrointestinal hemorrhage. Endoscopic biopsies of his esophagus and duodenum showed cytomegalovirus (CMV) inclusions and CMV early antigen was detected by immunohistochemistry. There were no other signs of congenital CMV infection. This case adds to the clinical spectrum of perinatal CMV infection and may be more common than is currently recognized.