Congenital and perinatal infections with cytomegalovirus

Pulmonary Complications of Cytomegalovirus Infection in Neonates and Infants: A Systematic Review of Case Reports and Pooled Analysis

BACKGROUND

Cytomegalovirus (CMV) causes intrauterine infections in 0.67% of neonates, with 12.7% displaying symptoms at birth. CMV can lead to severe multiorgan involvement, and mortality in symptomatic cases is around 30%. Pulmonary complications are rare in infants with CMV. This review assesses pulmonary complications and outcomes in infants with CMV infection.

METHODS

A systematic literature search was conducted using PubMed, SCOPUS and Ovid SP to retrieve case reports on pulmonary complications in infants with congenital or perinatal CMV infection. Descriptive analysis and pooled analysis were conducted for the case reports.

RESULTS

A total of 28 articles with 38 patients were included in this systematic review. The reported pulmonary complications in the case reports were CMV pneumonitis (34.2%), persistent pulmonary hypertension of the newborn (18.4%), emphysema and chronic lung disease (15.8%), diaphragmatic dysfunction (13.2%), lung cysts and calcifications (10.5%), Pneumocystis jirovecii infection (7.9%), pulmonary hypoplasia (5.3%) and bronchial atresia (2.6%). Seven (18.4%) of 38 patients passed away because of the pulmonary complications of CMV infection. Congenital transmission ( P = 0.0108), maternal CMV ( P = 0.0396) and presence of neonatal comorbidities ( P = 0.0398) were independent risk factors for mortality.

CONCLUSIONS

This systematic review demonstrated infrequent occurrence of severe pulmonary involvement in CMV infection but should be considered in infants with persistent or severe respiratory symptoms.

Cytomegalovirus pneumonia of infants in Africa: a narrative literature review

Cytomegalovirus pneumonia has repeatedly been described in the context of HIV-exposed uninfected and HIV-infected infants. Despite its significant role in the etiology of childhood pneumonia, there is still a paucity of literature generally, and specifically in Africa, suggesting that it might be a neglected disease. Emerging evidence highlights the importance of postnatal transmission through breastmilk. The pathogenetic significance of the multiplicity of strains acquired through repeated re-infections in early infancy is unknown. The development of cheap, accurate diagnostic tools and safe, effective antivirals and the maintenance of effective prevention and treatment of pediatric HIV are needed to manage cytomegalovirus pneumonia in low-resource settings.

Cytomegalovirus and Epstein-Barr Infections: Prevalence and Impact on Patients with Hematological Diseases

Cytomegalovirus (CMV) and Epstein-Barr virus (EBV) infections are widely distributed throughout the world. EBV is linked to various hematological and autoimmune disorders whereas CMV might play important role in the progression of chronic hematological diseases, such as hemoglobinopathies, lymphomas, myelomas, hemophilia, and aplastic and sickle cell anemia. Both viruses produce a viral homolog of human interleukin-10 that can cause general suppression of immune response, increasing susceptibility to other infections. These viruses can remain latent in the host cells and be reactivated when the host immune system is compromised. Studies showing the impact of CMV and EBV infections on hematological disorders are scarce and unclear in the context of coinfection. This review intends to present the biology, prevalence, and impact of CMV and EBV infections in patients with hematological diseases.

Middle cerebral artery peak systolic velocity in perinatal cytomegalovirus infection

A middle cerebral artery peak systolic velocity value (MCA-PSV) persistently greater than 1.5 times the median of the normal population is utilized to detect moderate and severe anemia in fetuses at risk. Cytomegalovirus (CMV) is the most common perinatal infection and can cause fetal anemia. We present four cases with CMV perinatal infection. Although their MCA-PSV values were the highest recorded in normal as well as in anemic fetuses, only two of them developed moderate or severe anemia. These findings suggest that high MCA-PSV values in cases with perinatal CMV infection may have a different pathophysiologic mechanism than anemia.

Long-term hearing outcomes of children with symptomatic congenital CMV treated with valganciclovir

OBJECTIVES

Congenital human cytomegalovirus (cCMV) is a leading cause of pediatric hearing loss. Recent literature has suggested that valganciclovir (VGCV) therapy can improve hearing outcomes. The objective of this study was to evaluate the long-term hearing outcomes among symptomatic CMV patients treated with VGCV.

METHODS

A retrospective chart review of symptomatic CMV patients treated with VGCV was completed. The primary endpoint was the change in best ear hearing scores prior to treatment and after follow-up audiograms. A paired-sample t-test was used to evaluate the data.

RESULTS

A total of 16 children were included in the study and participants were followed for an average of 3.2 years. There was a measurable worsening, but not a statistically significant change in the best ear hearing scores, where the mean change was 11.9 dB (p-value = 0.070). However, 14/16 patients (87.5%, p-value<0.001) were found to have clinically significant worsening of hearing. The mean change in hearing scores for the left and right ear was 14.2 dB (p-value = 0.023) and 15.5 dB (p-value = 0.032), respectively. Mean elapsed time for progressive loss was 2.6 ± 0.2 years. When comparing the better or worse ear, there was no pattern for which ear deteriorated earlier or more frequently.

CONCLUSIONS

Our data did show a measurable, but not a statistically significant worsening outcome in best ear hearing. There was a significant change in both left and right ear hearing. Our results suggest that VGCV may provide only a short-term improvement in hearing outcomes; however, these preliminary post-hoc findings suggest the need for a more rigorous evaluation.

Detection of Cytomegalovirus in Liver Tissue by Polymerase Chain Reaction in Infants With Neonatal Cholestasis

AIM

Cytomegalovirus (CMV) is associated with neonatal cholestasis (NC). Diagnosis of CMV infection is most often based on either positive blood CMV IgM or CMV blood polymerase chain reaction (PCR). Isolation of CMV in liver tissues in patients with NC has rarely been reported. This study was undertaken to see if CMV is present in liver tissues of patients with NC and evaluate the correlation between positive CMV PCR in liver tissue with the serology and blood PCR.

METHODS

This study was conducted in 31 infants with NC from June 2015 to December 2016. All patients underwent blood CMV IgM, blood CMV PCR and liver CMV PCR. Prevalence of CMV in NC based on positive liver CMV PCR was calculated. Sensitivity and specificity of the serologic markers and blood CMV PCR to identify CMV infection in the liver was determined.

RESULTS

CMV IgM was positive in 13 (42%) patients, CMV IgG was positive in 26 (84%) patients and blood CMV PCR was positive in 23 (74%) patients. Liver CMV PCR was positive in 16 (52%) patients. Fifteen (48%) patients had biliary atresia (BA), 10 (32%) patients had neonatal hepatitis, 5 (16%) had paucity of bile ducts and 1 (3%) had ascending cholangitis. Of the 16 patients with positive liver CMV PCR, 8 (50%) had BA, 4 (25%) had neonatal hepatitis, 3 (19%) had paucity of bile ducts and 1 (6%) had ascending cholangitis. Sensitivity of blood CMV IgM in relation to liver CMV PCR was 69% and specificity was 61%. Sensitivity of blood CMV PCR was 61% and specificity was 71% when compared with liver CMV PCR.

CONCLUSION

CMV is present in the liver tissues of more than half the patients with NC. Serology or blood CMV PCR is apparently not an accurate marker of CMV in the liver tissue. Also, CMV infection in children seems to be associated equally with BA or non-BA neonatal hepatitis.

Human cytomegalovirus UL23 inhibits transcription of interferon-γ stimulated genes and blocks antiviral interferon-γ responses by interacting with human N-myc interactor protein

Interferon-γ (IFN-γ) represents one of the most important innate immunity responses in a host to combat infections of many human viruses including human herpesviruses. Human N-myc interactor (Nmi) protein, which has been shown to interact with signal transducer and activator of transcription (STAT) proteins including STAT1, is important for the activation of IFN-γ induced STAT1-dependent transcription of many genes responsible for IFN-γ immune responses. However, no proteins encoded by herpesviruses have been reported to interact with Nmi and inhibit Nmi-mediated activation of IFN-γ immune responses to achieve immune evasion from IFN-γ responses. In this study, we show strong evidence that the UL23 protein of human cytomegalovirus (HCMV), a human herpesvirus, specifically interacts with Nmi. This interaction was identified through a yeast two-hybrid screen and co-immunoprecipitation in human cells. We observed that Nmi, when bound to UL23, was not associated with STAT1, suggesting that UL23 binding of Nmi disrupts the interaction of Nmi with STAT1. In cells overexpressing UL23, we observed (a) significantly reduced levels of Nmi and STAT1 in the nuclei, the sites where these proteins act to induce transcription of IFN-γ stimulated genes, and (b) decreased levels of the induction of the transcription of IFN-γ stimulated genes. UL23-deficient HCMV mutants induced higher transcription of IFN-γ stimulated genes and exhibited lower titers than parental and control revertant viruses expressing functional UL23 in IFN-γ treated cells. Thus, UL23 appears to interact directly with Nmi and inhibit nuclear translocation of Nmi and its associated protein STAT1, leading to a decrease of IFN-γ induced responses and an increase of viral resistance to IFN-γ. Our results further highlight the roles of UL23-Nmi interactions in facilitating viral immune escape from IFN-γ responses and enhancing viral resistance to IFN antiviral effects.

Interferon-γ (IFN-γ) responses are vital for a host to combat infections of many human viruses including human herpesviruses. Upon treatment of IFN-γ, transcription of many genes responsible for IFN-γ immune responses is activated primarily by the signal transducer and activator of transcription (STAT) proteins such as STAT1 protein. Human N-myc interactor (Nmi) protein has been shown to interact with STAT proteins including STAT1 and activate IFN-γ induced STAT-dependent transcription. However, no proteins encoded by herpesviruses have been reported to interact with Nmi and inhibit Nmi-mediated activation of IFN-γ immune responses to achieve immune evasion from IFN-γ responses. In this study, we show strong evidence that the UL23 protein of human cytomegalovirus (HCMV), a human herpesvirus, specifically interacts with Nmi protein. UL23 appears to interact directly with Nmi and inhibit nuclear translocation of Nmi and its associated protein STAT1, leading to a decrease of IFN-γ responses and an increase of viral resistance to IFN-γ. Blocking UL23 expression led to higher transcription of IFN-γ stimulated genes and significant inhibition of viral growth in infected cells. These results suggest that interfering with Nmi function may represent an effective mechanism for a herpesvirus to block Nmi-mediated IFN-γ responses and increase viral resistance to IFN-γ. This also provides a potentially new therapeutic strategy to treat HCMV infection by modulating Nmi activity with blocking the expression of a viral protein.

Characteristics and prognosis of hepatic cytomegalovirus infection in children: 10 years of experience at a university hospital in Korea

Purpose

Studies on cytomegalovirus (CMV) infections in immunocompetent children are lacking, and minimal information is available in the medical literature on hepatic manifestations and complications of CMV. The aims of this study were to evaluate the clinical characteristics, laboratory data, and prognosis of children with CMV hepatitis, and to investigate its prevalence at a single medical center in Korea over a 10-year period.

Methods

One hundred thirty-two children diagnosed with CMV infection based on specific markers (anti-CMV IgM, CMV polymerase chain reaction in blood and urine, or CMV culture of urine) were included in the study. Clinical and biochemical characteristics, immunological markers, and outcomes of hepatic CMV infection were determined.

Results

The median age of patients (n=132) was 8.5 months (range, 14 days–11.3 years). Peak total bilirubin and alanine aminotransferase levels in serum ranged from 0.11–21.97 mg/dL, and 5–1,517 IU/L, respectively. Alanine aminotransferase remained elevated from 2–48 weeks. Jaundice was the most common clinical feature of hepatic CMV infection during infancy. The hematologic findings revealed anemia, leukocytosis, and monocytosis in CMV-infected patients. All participants recovered without administration of ganciclovir.

Conclusion

In children with CMV hepatitis, fever was the most common symptom at presentation, and jaundice was the most common clinical feature of hepatic CMV infection in infants younger than 3 months of age. Hepatic CMV infection in immunocompetent children is often a self-limited illness that does not require antiviral therapy, as most patients in this study had favorable outcomes.

Primary Prevention of Congenital Anomalies: Special Focus on Environmental Chemicals and other Toxicants, Maternal Health and Health Services and Infectious Diseases

Congenital anomalies (CA) represent an important fraction of rare diseases, due to the critical role of non-genetic factors in their pathogenesis. CA are the main group of rare diseases in which primary prevention measures will have a beneficial impact. Indeed, since 2013 the European Union has endorsed a body of evidence-based recommendations for CA primary prevention; the recommendations aim at facilitating the inclusion of primary prevention actions the National Rare Disease Plans of EU Member States and encompass different public health fields, from environment through to maternal diseases and lifestyles.The chapter overviews and discusses the assessment of main risk factors for CA, such as environmental toxicants, maternal health and lifestyles and infections, with a special attention to issues that are emerging or need more knowledge.Overall, the availability of CA registries is important for estimating the health burden of CA, identifying possible hotspots, assessing the impact of interventions and addressing further, fit-to-purpose research.The integration of relevant public health actions that are already in place (e.g., control of noxious chemicals, vaccination programmes, public health services addressing chronic maternal conditions) can increase the affordability and sustainability of CA primary prevention. In developing countries with less primary prevention in place and limited overall resources, a first recognition phase may be pivotal in order to identify priority targets. In the meanwhile, policy makers should be made aware that primary prevention of RD supports publicly endorsed societal values like the knowledge-based promotion of health, empowerment, equity and social inclusiveness.

Lenticulostriate Vasculopathy in Brain Ultrasonography is Associated with Cytomegalovirus Infection in Newborns

BACKGROUND

Lenticulostriate vasculopathy is associated with various disorders, in particular cytomegalovirus infection, which can cause neurological consequences. We wanted to evaluate the association of lenticulostriate vasculopathy and cytomegalovirus infection. We retrospectively collected data on lenticulostriate vasculopathy from 858 neonatal ultrasonography scans.

METHODS

Fifty-five patients with lenticulostriate vasculopathy were diagnosed. Lenticulostriate vasculopathy was classified as severe and mild according to the ultrasonographic findings. We analyzed gender, unilateral and bilateral lenticulostriate vasculopathy, mild and severe lenticulostriate vasculopathy, intrauterine growth retardation, and lenticulostriate vasculopathy associated with other brain malformations to determine whether they were correlated with cytomegalovirus infection.

RESULTS

Neonatal cytomegalovirus infections correlated primarily with lenticulostriate vasculopathy that was associated with brain structure anomalies p < 0.0001, followed by severe lenticulostriate vasculopathy (p = 0.029). Cytomegalovirus urine polymerase chain reaction ratios were 69% for severe and 23% for mild lenticulostriate vasculopathy (p = 0.002; odds ratio = 7.33). Of 72 newborns with intrauterine growth retardation without lenticulostriate vasculopathy, 33 were analyzed for cytomegalovirus, of whom only one was positive, which was significantly different from the newborns with lenticulostriate vasculopathy (p = 0.003; odds ratio = 11.64).

CONCLUSION

Lenticulostriate vasculopathy on neonatal ultrasonography is useful for predicting cytomegalovirus infection, particularly in severe lenticulostriate vasculopathy. When severe lenticulostriate vasculopathy is associated with a brain structure anomaly, cytomegalovirus infection should be considered. The outcomes for the cases in which cytomegalovirus infection was associated with other brain structure anomalies were significantly worse than the outcomes in cases associated with lenticulostriate vasculopathy only.

Evaluation of 98 immunocompetent children with cytomegalovirus infection: importance of neurodevelopmental follow-up

This study aims to analyze and evaluate the clinic and demographic features of immunocompetent children that have been diagnosed with cytomegalovirus (CMV) infection. The data of children diagnosed with CMV infection between January 2005 and December 2010 and their follow-ups for 2 years were retrospectively evaluated. Ninety-eight patients were included, and the median age at admission was 5.6 months (5 days-36 months). 54.1% was male. The diagnosis of CMV infection was performed by measurement of serum anti-CMV specific Ig M and IgG titers and PCR method in blood and/or urine. In 3.06% of the patients, congenital infection was detected, whereas possible congenital infection was observed in 36.7% of the patients. Furthermore, 44 patients (44.8%) were detected to have perinatal infection while postnatal infection was spotted in 15.3% of the patients. The common presenting manifestations were prolonged jaundice, diarrhea, vomiting, abdominal distension, skin eruption, and seizure. And the most common physical examination findings were hepatosplenomegaly, microcephaly, jaundice, and petechia. The mainstream laboratory results were elevated transaminases (50%), anemia (30.6%), leukocytosis (27.5%), and thrombocytopenia (18.3%). There were intracranial calcification in 5.1% and eye findings in 5.1%. On follow-up of patients, complete improvement (59.1%), neuromotor developmental delay (11.2%), epilepsy (10.2%), hearing loss (3.06 %), hemolytic anemia (2.04%), and growth retardation (1.02%) were detected.

CONCLUSION

CMV infection is a significant disease both in congenital and perinatal period. It must be considered that diagnosed patients need to be monitored for a long time with special attention to their neurodevelopmental follow-ups.

Severe leukemoid reaction in a preterm infant with congenital cytomegalovirus infection

Leukemoid reaction, defined as a total leukocyte count of >50,000/mm, is most commonly related to antenatal administration of steroids, infections, and transient myeloproliferative disorder of Down syndrome in newborns. Atypical presentations of viral infections can be a diagnostic challenge in the newborn period. Cytomegalovirus (CMV) infection causes a multisystem disease, and symptomatic infants generally present with intrauterine growth restriction, hepatosplenomegaly, cholestasis, rash, thrombocytopenia, and microcephaly. We present a case of a preterm infant with severe myeloid leukemoid reaction (leukocyte count >100,000/mm) at birth who was diagnosed with congenital CMV infection on the basis of CMV polymerase chain reaction results after the appearance of cholestasis, blueberry muffin rash, and hepatosplenomegaly.

Human cytomegalovirus infection dysregulates the canonical Wnt/β-catenin signaling pathway

Human Cytomegalovirus (HCMV) is a ubiquitous herpesvirus that currently infects a large percentage of the world population. Although usually asymptomatic in healthy individuals, HCMV infection during pregnancy may cause spontaneous abortions, premature delivery, or permanent neurological disabilities in infants infected in utero. During infection, the virus exerts control over a multitude of host signaling pathways. Wnt/β-catenin signaling, an essential pathway involved in cell cycle control, differentiation, embryonic development, placentation and metastasis, is frequently dysregulated by viruses. How HCMV infection affects this critical pathway is not currently known. In this study, we demonstrate that HCMV dysregulates Wnt/β-catenin signaling in dermal fibroblasts and human placental extravillous trophoblasts. Infection inhibits Wnt-induced transcriptional activity of β-catenin and expression of β-catenin target genes in these cells. HCMV infection leads to β-catenin protein accumulation in a discrete juxtanuclear region. Levels of β-catenin in membrane-associated and cytosolic pools, as well as nuclear β-catenin, are reduced after infection; while transcription of the β-catenin gene is unchanged, suggesting enhanced degradation. Given the critical role of Wnt/β-catenin signaling in cellular processes, these findings represent a novel and important mechanism whereby HCMV disrupts normal cellular function.

A large percentage of the world population is infected with HCMV. As a leading viral cause of birth defects in the developed world, HCMV represents a significant public health burden. For the first time, we report that HCMV infection dysregulates the canonical Wnt/β-catenin signaling pathway which is essential in regulating a diverse range of biological functions. We demonstrate that HCMV infection leads to sequestration and degradation of β-catenin protein, the effector transcription factor in the pathway, thus preventing its downstream signaling activities. Since this pathway is essential in regulating mammalian development and homeostasis, the finding that HCMV impairs this pathway becomes globally important for understanding viral pathogenesis, particularly that related to HCMV disease.

The effect of prenatal highly active antiretroviral therapy on the transmission of congenital and perinatal/early postnatal cytomegalovirus among HIV-infected and HIV-exposed infants

BACKGROUND

Before highly active antiretroviral therapy (HAART), congenital cytomegalovirus (CMV) rates were higher among human immunodeficiency virus (HIV)-exposed infants than unexposed infants. This study examines congenital and perinatal/early postnatal (P/EP) CMV among HIV-exposed infants pre- and post- HAART.

METHODS

Infants born to HIV-infected women were evaluated for congenital CMV (CMV-positive culture in first 3 weeks of life) and P/EP CMV (positive culture in first 6 months of life). Prenatal maternal HAART was defined as triple antiretroviral therapy (ART) with at least 1 nonnucleoside reverse-transcriptase inhibitor or protease inhibitor.

RESULTS

Among 414 infants evaluated, 1678 CMV assessment days were completed (mean = 3 assessment days per infant). Congenital CMV rates did not differ by time period, HAART use, or infant HIV infection status. P/EP CMV rates were greater for the 1988-1996 birth cohort (17.9%) compared with the 1997-2002 birth cohort (8.9%) (P < .01), HIV-infected versus uninfected infants (P < .01), and infants with no maternal ART versus those with ART (P < .01). Controlling for potential confounders, P/EP CMV was associated with no maternal ART (odds ratio = 4.7; P < .01), and among those with no maternal ART, P/EP CMV was associated with maternal CD4 count ≤200 cells/μL (P < .01). For HIV-uninfected infants with P/EP CMV, symptoms including splenomegaly, lymphadenopathy, and hepatomegaly were associated with no maternal HAART versus those with HAART (41% vs 6%; P < .05).

CONCLUSIONS

Although congenital CMV rates did not change, the post-HAART era showed reduced P/EP CMV and occurrence of related clinical symptoms. These findings underscore the importance of prenatal HAART for all HIV-infected pregnant women.

Seroprevalence of cytomegalovirus among some voluntary blood donors at the 37 military hospital, accra, ghana

SUMMARY BACKGROUND

Cytomegalovirus (CMV) is one of the most significant pathogens infecting immunosuppressed individuals. CMV is transmissible through transfusion of blood components.

AIM

The goal of this study was to determine the seroprevalence of antibodies to CMV among blood donors seen at the 37 Military Hospital Blood Transfusion Unit, (MHBTU) Accra, Ghana.

METHODS

The seroprevalence of antibodies specific for CMV was tested using CMV IgG/IgM particle agglutination test kit and ELISA.

RESULTS

Of the 264 blood donors, 18 were negative and 246 were positive for CMV IgG antibodies, giving an overall CMV prevalence rate of 93.2%. None of the 264 blood donors was positive for CMV IgM antibodies. About 96% of the donors aged between 30 to 39 years were seropositive for CMV, as against 91.9% in those aged 20-29 years, 88.6% in 40 to 49 years, 75.0% (3 out of 4) in 50 to 59 years, and 100% (1 out 1) in 60-69 years. There was no statistically significant difference (P>0.05) in the CMV IgG status in different age groups. The blood donors comprised largely of male donors (236 out of 264), making sex comparisons statistically undesirable. However, all the female (n=28) donors were positive for CMV IgG.

CONCLUSION

Since about 93% of blood donors at the MHBTU are seropositive for CMV, it would be very useful to screen blood donors in Ghana for CMV to identify the very few CMV-seronegative blood donors, and maintain an inventory of them for use as donors.

The role of decay accelerating factor in the immunopathogenesis of cytomegalovirus infection

A wide variety of the host immune elements play an influential role in the defence against cytomegalovirus (CMV) infection. However, the role of complement in the clearance of CMV infection is less well studied. Decay accelerating factor (DAF/CD55) is a membrane-bound complement regulatory protein that inhibits the formation and accelerates the decay of C3-convertase. Here we hypothesize that murine CMV (MCMV) utilizes DAF as an immunoevasive strategy through down-regulation of host adaptive responses against the virus. To test our hypothesis, DAF knock-out (DAF KO) C57BL/6 mice and wild-type (WT) littermates were infected with a sublethal dose of MCMV, and their immune responses were compared. WT mice lost 7·8% of their initial weight within the first 4 days after infection and quickly began to recover. This is in contrast to the DAF KO mice, that lost a total of 19·4% of their initial weight and did not start recovery until 6 days post-infection. Flow cytometric analysis of lung digests revealed that infected DAF KO mice had a significantly increased infiltration of inflammatory cells, the majority being CD8(+) T lymphocytes. Serum levels of tumour necrosis factor (TNF)-α and interferon (IFN)-γ were also increased markedly in the DAF KO mice compared to the infected WT mice. More interestingly, increased viral genome copies (DNA) in the splenocytes of DAF KO mice was accompanied with mRNA transcripts in the DAF KO mice, an indication of active viral replication. These data suggest an intriguing effect of reduced DAF expression on host responses following in vivo MCMV infection.

Effect of human cytomegalovirus infection on nerve growth factor expression in human glioma U251 cells

OBJECTIVE

To explore the change of endogenic nerve growth factor (NGF) expression in human glioma cells infected with human cytomegalovirus (HCMV).

METHODS

U251 cells were cultured in RPMI 1640 culture medium and infected with HCMV AD169 strain in vitro to establish a cell model of viral infection. Morphologic changes of U251 cells were observed under inverted microscope before and after infection with HCMV. Expression of NGF gene and protein of cells was detected by RT-PCR and Western blotting before and after infection with HCMV.

RESULTS

The cytopathic effects of HCMV-infected cells appeared on day 5 after infection. However, differential NGF expression was evident on day 7. NGF expression was decreased significantly in U251 cells on day 7 after infection in comparison with control group (P < 0.05).

CONCLUSION

HCMV can down-regulate endogenous NGF levels in human glioma cell line U251.

Rehabilitation and outcome of severe profound deafness in a group of 16 infants affected by congenital cytomegalovirus infection

The aim of the study was to characterize the audiological consequences of congenital cytomegalovirus infection (CMV) and to evaluate the outcome of rehabilitation with hearing aids and/or cochlear implant (CI), associated with an adequate speech-language therapy. A retrospective review of data was made from a total of 16 infants, affected by severe to profound hearing loss from congenital CMV infection, referred to a tertiary audiological center for rehabilitation. Audiological evaluation was performed using behavioral audiometry, auditory brainstem responses (ABR) and/or electrocochleography (ECochG). Of the 16 children (median age at diagnosis of hearing loss: 21.33 +/- 0.7 months) with CMV hearing loss, 14 were affected by profound bilateral hearing loss and received a CI, while 2 were affected by bilateral severe hearing loss and received hearing aids. Cochlear implants can provide useful speech comprehension to patients with CMV-related deafness, even if language development is lower when compared to a group of Connexin (Cx) 26+ cochlear-implanted children (eight subjects), matched for age. Congenital CMV infection still represents a serious clinical condition, as well as an important cause of hearing loss in children. More studies have claimed to identify the pathophysiological mechanisms of damage and thus to ensure a better therapeutic approach. Nonetheless, in cases of CMV-deafened babies, the overall outcome of cochlear implantation is good.

Acute respiratory distress syndrome by cytomegalovirus infection in an immunocompetent infant

A 2-month-old female infant was admitted with progressive respiratory distress, fever, and diagnosed with acute respiratory distress syndrome (ARDS). The primary pulmonary pathogen was proven to be cytomegalovirus (CMV) from bronchoalveolar lavage fluid, urine, and blood specimens. Other immunologic findings were normal. CMV-induced ARDS has not been reported previously in immunocompetent infants.

Human cytomegalovirus infection in infants with prolonged neonatal jaundice

BACKGROUND

Although human cytomegalovirus (HCMV) infection in infants has been associated with liver disease, the role of HCMV in infants presenting with prolonged neonatal jaundice is unclear as this clinical picture can be caused by a broad spectrum of underlying conditions.

OBJECTIVES

This study aimed to determine a possible role for HCMV infection in infants with prolonged cholestatic neonatal jaundice that could facilitate the appropriate use of diagnostic assays and specific treatment in this condition.

STUDY DESIGN

HCMV immunohistochemical staining was performed on liver biopsy specimens received for histopathological examination from 85 infants (mean age 3 months) with a clinical history of prolonged neonatal jaundice. HCMV serology was also performed.

RESULTS

One infant with a histological diagnosis of HCMV hepatitis was also positive by immunohistochemical staining, while all other tissue specimens were negative for HCMV. HCMV IgG was positive in 92.3% and HCMV IgM in 39.7% of the infants (n=78).

CONCLUSIONS

The serological results confirm the ubiquitous nature of HCMV with many primary infections occurring within the first year of life. Despite this, HCMV hepatitis was uncommon in this cohort.

Viruses and other infections in stillbirth: what is the evidence and what should we be doing?

In Australia, as in other developed countries, approximately 40-50% of stillbirths are of unknown aetiology. Emerging evidence suggests stillbirths are often multifactorial. The absence of a known cause leads to uncertainty regarding the risk of recurrence, which can cause extreme anguish for parents that may manifest as guilt, anger or bewilderment. Further, clinical endeavours to prevent recurrences in future pregnancies are impaired by lack of a defined aetiology. Therefore, efforts to provide an aetiological diagnosis of stillbirth impact upon all aspects of care of the mother, and inform many parts of clinical decision making. Despite the magnitude of the problem, that is 7 stillbirths per 1000 births in Australia, diagnostic efforts to discover viral aetiologies are often minimal. Viruses and other difficult to culture organisms have been postulated as the aetiology of a number of obstetric and paediatric conditions of unknown cause, including stillbirth. Reasons forwarded for testing stillbirth cases for infectious agents are non-medical factors, including addressing all parents' need for diagnostic closure, identifying infectious agents as a sporadic cause of stillbirth to reassure parents and clinicians regarding risk for future pregnancies, and to reduce unnecessary testing. It is clear that viral agents including rubella, human cytomegalovirus (CMV), parvovirus B19, herpes simplex virus (HSV), lymphocytic choriomeningitis virus (LCMV), and varicella zoster virus (VZV) may cause intrauterine deaths. Evidence for many other agents is that minimal or asymptomatic infections also occur, so improved markers of adverse outcomes are needed. The role of other viruses and difficult-to-culture organisms in stillbirth is uncertain, and needs more research. However, testing stillborn babies for some viral agents remains a useful adjunct to histopathological and other examinations at autopsy. Modern molecular techniques such as multiplex PCR, allow searches for multiple agents. Now that such testing is available, it is important to assess the clinical usefulness of such testing.

The ABCs of CMV

Most infants exposed to cytomegalovirus (CMV) in utero will not be symptomatic; however, infants born with symptomatic CMV will have more severe consequences and poorer prognosis than will asymptomatic infants. The timing of infection during pregnancy largely affects the expected outcomes and consequences to the fetus. It is possible for a fetus to acquire congenital CMV infection from a nonprimary infection, although this accounts for a small number of cases. The presence of microcephaly, intrauterine growth restriction, petechiae, encephalitis, hepatosplenomegaly, and deafness are some of the physical characteristics of a congenital CMV infection. Treatment options remain limited at this time, so no routine screening has been recommended. The need for a vaccine or preventative treatment has been identified as a priority in the United States.

Neuroimaging of herpesvirus infections in children

Six members of the herpesvirus family cause well-described neurologic disease in children: herpes simplex virus-1 (HSV-1), herpes simplex virus-2 (HSV-2), varicella-zoster (VZV), Epstein-Barr (EBV), cytomegalovirus (CMV), and human herpes virus-6 (HHV-6). When herpesviruses infect the central nervous system (CNS), the clinical presentation is non-specific and often confounding. The clinical urgency is often underscored by progressive neurologic deficits, seizures, or even death, and prompt diagnosis and treatment rely heavily on neuroimaging. This review focuses on the spectrum of cerebral manifestations caused by these viruses, particularly on non-congenital presentations. Recent advances in our understanding of these viruses are discussed, including new polymerase chain reaction techniques that allow parallel detection, which has improved our recognition that the herpesviruses are neurotropic and involve the CNS more often than previously thought. Evolving knowledge has also better elucidated viral neuropathology, particularly the role of VZV vasculitis in the brain, HHV-6 in febrile seizures, and herpesvirus reactivation in immunosuppressed patients. The virology, clinical course, and CNS manifestations of each virus are reviewed, followed by descriptions of neuroimaging findings when these agents infect the brain. Characteristic but often subtle imaging findings are discussed, as well as technical pearls covering appropriate use of MRI and MRI adjuncts to help differentiate viral infection from mimics.

The role of perinatal pathological examination in subclinical infection in obstetrics

Infectious agents are associated with a wide range of obstetric complications and pathological processes affecting the placenta, membranes and fetus. In some cases there will be associated maternal symptoms and signs indicating an infectious aetiology, but in the majority such infection is subclinical, and specific diagnosis or confirmation is achieved following pathological examination of the delivered placenta and/or fetus. There are two major groups of microorganism-related mechanisms associated with significant perinatal morbidity and mortality. First, ascending genital-tract infection, almost always bacterial, which ranges from localized choriodecidual inflammation to frank chorioamnionitis with fetal sepsis; this is a major cause of mid-trimester miscarriage and severe preterm delivery, and more recent data suggest that it may also have potentially important effects via cytokine release mediating neonatal cerebral injury. Second, haematogenous spread of maternal systemic infection--bacterial, viral or parasitic--which may result in isolated placental effects or transmission to the fetus with associated developmental abnormalities and neonatal complications. In many cases distinctive histopathological findings are described, and in addition a wide range of techniques is now available for culture and microscopy to confirm these diagnoses; such techniques include highly specific immunohistochemical markers and sensitive molecular diagnostic techniques such as the polymerase chain reaction. It is likely that with increasingly widespread availability of these investigative approaches to obstetric pathology, a greater understanding of the role of infectious agents in obstetric complications will become apparent.

Congenital CMV infection in symptomatic infants in Delhi and surrounding areas

Many viral infections are associated with significant maternal and fetal consequences during pregnancy among which cytomegalovirus is one of the most important agent, globally. Both primary and recurrent infection due to this virus can result in fetal infection. Samples from Congenital Anoammaled babies are referred to NICD from Delhi based Government hospitals and surrounding areas for diagnosis of congenital infections like Toxoplasm, Rubella, CMV and Herpes. In the present study, accumulated data is presented for the most common teratogenic virus--Cytomegalovirus prevalence as a causative agent for congenital infection in New Born babies at Delhi and surrounding areas. 96 samples from symptomatic babies in the age group of few days to 6 months exhibiting different congenital anomalies, were reported between 1 st Jan 04 to 30 th April/05. All the blood samples were tested for the detection of CMV (IgM) antibodies using m-capture ELISA technique. 18(18.75%) samples from babies showed positive titres for CMV-IgM antibodies. None of the mothers of positive babies were found positive for CMV-IgM antibodies but all were serologically exposed to CMV virus previously as their serum samples were positive for CMV-IgG antibodies indicating primary infection in the past or reactivation/reinfection with a different strain of CMV in the early pregnancy.

Comparative sequence analysis of US28 gene of human cytomegalovirus strains isolated from HIV-positive patients

Human Cytomegalovirus (HCVM) encodes several G-protein coupled receptors, such as US28 protein. We determined the US28 gene sequence from clinical isolates obtained from 17 Human Immunodeficiency Virus (HIV)-infected patients with HCMV infection. Two types of clinical specimens were collected: peripheral blood leucocytes (PBLs) from 12 patients with HCMV-positive viremia and cerebro-spinal fluids (CSF) from five patients with HCMV-encephalitis. Comparison of US28 nucleotide sequences between clinical specimens and several HCMV reference strains showed that mutations were clustered at both ends of the gene. The mutations observed at the C-terminus were observed at some sequences whereas the mutations observed at the N-terminus lead us to define five patterns of mutations. These patterns were equally distributed among isolates obtained from CSF or PBLs of HIV-infected patients. For each clinical isolate, the gB genotype was determined. There was no genetic association between gB genotype and US28 patterns. The comparison of the results of the present study and those published from sequences obtained from children with HCMV congenital disease (Arav-Boger, 2002) demonstrates that two motifs appear especifically either in US28 protein sequences obtained from HIV-positive patients (motif 4) or in US28 protein sequences obtained from patients with congenital HCMV infection (motif 5/genotype B). The appearance of these patterns of mutations in other clinical context needs to be studied.

Correlates of placental infection with cytomegalovirus, parvovirus B19 or human herpes virus 7

Vertical transmission of viruses is an important cause of morbidity in the fetus and neonate. Placental viral infection indicates risk of vertical transmission, but not always transmission to, or disease of the fetus. Specimens from mothers and babies from three groups-two prospective and one retrospective cohort-were tested for pathogens of teratogenic potential using multiplex PCR. Placental infection was present in 13% of the 105 samples collected. Assessment of the prospective cohorts showed cytomegalovirus (CMV) detected in 4% of placentae from unselected women, parvovirus B19 in 1% and Ureaplasma parvum in 1% of placentae. In a retrospective cohort of women at high risk of transmitting congenital infection due to seroconversion during pregnancy, miscarriage or stillbirth, CMV was detected in 64% and human herpes virus type 7 in 9% of placentae. Of 14 PCR-positive placentae, two were associated with the birth of a living symptomatic infant, two with stillbirth, one with miscarriage, and two with elective terminations of pregnancy. Directed laboratory assessment of women at high risk of transmitting congenital infection, on the basis of clinical or laboratory markers, is important for accurate diagnosis of adverse outcomes of pregnancy. However, routine screening for viruses in the placentae from women with a low-risk serological profile for transmitting congenital infection is unlikely to result in significant numbers of additional diagnoses and is confounded by inadequacy of current diagnostic methods. The major pathogen detected in all cases of placental infection associated with fetal death was human CMV.

Cytomegalovirus gB genotype and clinical features in Chinese infants with congenital infections

OBJECTIVE

To investigate cytomegalovirus (CMV) glycoprotein B (gB) genotypes and clinical features in Chinese infants with congenital infections.

METHODS

Urine samples were obtained from 79 infants with human CMV infection confirmed by quantitative fluorescence polymerase chain reaction (PCR). A fragment of the gB gene was amplified by nested PCR. CMV gB genotyping was carried out by restriction fragment length polymorphism, and 24 samples of the amplified DNA fragments were verified by DNA sequencing.

RESULTS

The levels of CMV DNA in symptomatic and asymptomatic infants were 2.95 x 10(5) and 4.5 x 10(3) copies/ml, respectively, with a significant difference (p < 0.001). In all these cases, the most prevalent genotype was gB1 (50.63%), followed by gB3 (21.52%), gB2 (17.72%), and coinfection (10.13%); gB4 was not found. Moreover, gB1 was more prevalent in infants with liver damage (22/32) than in other symptomatic infants without liver damage (8/22, p = 0.019) or asymptomatic infants (10/25, p = 0.030). The homology of CMV gB in the 24 strains amplified as compared with the sequences of prototype strains in GenBank ranged from 97.06 to 99.64%.

CONCLUSIONS

The restriction fragment length polymorphism analysis of CMV gB genotypes was definite and reliable. The gB1 genotype is the most prevalent in Chinese infants with congenital CMV disease, especially in those with liver damage, followed by genotypes gB3, gB2, and gB4.

HCMV infection attenuates hydrogen peroxide induced endothelial apoptosis-- involvement of ERK pathway

Human cytomegalovirus (HCMV) exerts anti-apoptotic effect during early stage of infection, which provides HCMV time for propagation. We investigated pathways mediating the resistance to H(2)O(2)-induced cell death - a self-defense mechanism to remove infected cells. We found that human aortic endothelial cells (HAECs) infected with VHL/E strain of HCMV during first 3 days were resistant to H(2)O(2) (0-2 mM) induced apoptosis. This anti-apoptotic effect may be mediated by the upregulation of Bcl-2, an anti-apoptotic protein through the activation pro-survival pathway extracellular signal regulated kinase (ERK). Through this mechanism, HCMV is able to propagate and causes endothelial dysfunction, hence vascular disease.

Human Cytomegalovirus-Induced Inhibition of Cytotrophoblast Invasion in a First Trimester Extravillous Cytotrophoblast Cell Line

Human cytomegalovirus (HCMV) is the leading cause of congenital viral infection in the United States and intrauterine transmission of HCMV occurs in approximately 40% of pregnant women with primary HCMV infection. Although HCMV infection during pregnancy clearly may be detrimental to fetal development, its consequences on placentation remain largely unexplored. In this study, the effects of HCMV infection on cytotrophoblast (CTB) invasion were investigated utilizing the first trimester extravillous CTB cell line SGHPL-4. HCMV infection significantly inhibited SGHPL-4 proliferation, epidermal growth factor (EGF)- and hepatocyte growth factor (HGF)-induced migration and invasion, as well as the secretion of matrix metalloproteinase (MMP)-2 and MMP-9. Both HCMV and EGF activated the EGF receptor (EGFR), inducing receptor tyrosine phosphorylation at specific residues. Of interest, EGFR was differentially activated by HCMV, and viral gene transcription was not required for the observed inhibitory effect on CTB invasiveness. These findings demonstrate that HCMV infection impairs CTB differentiation along the invasive pathway and that the differential regulation of EGFR by HCMV may contribute to impaired CTB function. Elucidating the mechanisms by which HCMV impairs placentation may be key in understanding fetal and maternal pathologies associated with intrauterine HCMV infection.

Epistasis between mouse Klra and major histocompatibility complex class I loci is associated with a new mechanism of natural killer cell-mediated innate resistance to cytomegalovirus infection

Experimental infection with mouse cytomegalovirus (MCMV) has been used to elucidate the intricate host-pathogen mechanisms that determine innate resistance to infection. Linkage analyses in F(2) progeny from MCMV-resistant MA/My (H2 (k)) and MCMV-susceptible BALB/c (H2 (d)) and BALB.K (H2 (k)) mouse strains indicated that only the combination of alleles encoded by a gene in the Klra (also called Ly49) cluster on chromosome 6, and one in the major histocompatibility complex (H2) on chromosome 17, is associated with virus resistance. We found that natural killer cell-activating receptor Ly49P specifically recognized MCMV-infected cells, dependent on the presence of the H2 (k) haplotype. This binding was blocked using antibodies to H-2D(k) but not antibodies to H-2K(k). These results are suggestive of a new natural killer cell mechanism implicated in MCMV resistance, which depends on the functional interaction of the Ly49P receptor and the major histocompatibility complex class I molecule H-2D(k) on MCMV-infected cells.

Synergistic inhibition of human cytomegalovirus replication by interferon-alpha/beta and interferon-gamma

BACKGROUND

Recent studies have shown that gamma interferon (IFN-gamma) synergizes with the innate IFNs (IFN-alpha and IFN-beta) to inhibit herpes simplex virus type 1 (HSV-1) replication in vitro. To determine whether this phenomenon is shared by other herpesviruses, we investigated the effects of IFNs on human cytomegalovirus (HCMV) replication.

RESULTS

We have found that as with HSV-1, IFN-gamma synergizes with the innate IFNs (IFN-alpha/beta) to potently inhibit HCMV replication in vitro. While pre-treatment of human foreskin fibroblasts (HFFs) with IFN-alpha, IFN-beta or IFN-gamma alone inhibited HCMV plaque formation by approximately 30 to 40-fold, treatment with IFN-alpha and IFN-gamma or IFN-beta and IFN-gamma inhibited HCMV plaque formation by 163- and 662-fold, respectively. The generation of isobole plots verified that the observed inhibition of HCMV plaque formation and replication in HFFs by IFN-alpha/beta and IFN-gamma was a synergistic interaction. Additionally, real-time PCR analyses of the HCMV immediate early (IE) genes (IE1 and IE2) revealed that IE mRNA expression was profoundly decreased in cells stimulated with IFN-alpha/beta and IFN-gamma (approximately 5-11-fold) as compared to vehicle-treated cells. Furthermore, decreased IE mRNA expression was accompanied by a decrease in IE protein expression, as demonstrated by western blotting and immunofluorescence.

CONCLUSION

These findings suggest that IFN-alpha/beta and IFN-gamma synergistically inhibit HCMV replication through a mechanism that may involve the regulation of IE gene expression. We hypothesize that IFN-gamma produced by activated cells of the adaptive immune response may potentially synergize with endogenous type I IFNs to inhibit HCMV dissemination in vivo.

Newborn screening for congenital infectious diseases

To estimate the prevalence of congenital toxoplasmosis, Chagas disease, cytomegalovirus, and rubella, blood samples on dried blood spot (DBS) from neonates (day 3–20 of life) were screened for immunoglobulin (Ig) M against Toxoplasma gondii, cytomegalovirus, rubella virus, and IgG against Trypanosoma cruzi by methods used for serum and adapted for use with DBS. Positive samples were further analyzed for IgM and IgG in serum from neonates and mothers. DBS samples from 364,130 neonates were tested for Toxoplasma gondii–specific IgM, and 15,873 neonates were also tested for IgM against cytomegalovirus and rubella virus and for Trypanosoma cruzi–specific IgG. A total of 195 were diagnosed with congenital toxoplasmosis, 16 with cytomegalovirus, and 11 with congenital rubella. One newborn had a confirmed result for Chagas disease, and 21 mothers had positive serum antibodies. These results suggest that infectious diseases should be considered for future inclusion in programs for newborn screening of metabolic diseases in disease-endemic areas.

Postmortem findings in term neonates

Neonatal deaths in infants born at term are relatively rare in the USA, occurring in 0.9/1000 live births. Congenital malformations, perinatal asphyxia, infections and inborn errors of metabolism are the leading causes. Chromosomal malformation syndromes, congenital heart disease, pulmonary hypoplasia and severe neural tube defects comprise the majority of lethal malformations. Several skeletal dysplasias are lethal in the newborn infant. Group B Streptococcus still plays a major role in neonatal mortality while deaths due to other infectious agents have decreased. Hypoxic ischaemic encephalopathy is a significant cause of neonatal death. Inborn errors of metabolism have variable presentations but some, such as the fatty acid oxidation disorders, may present in neonates and cause sudden death.

Severe fetal cytomegalovirus infection associated with cerebellar hemorrhage

Cytomegalovirus (CMV) is the most common cause of congenital infection worldwide. We report on a fatal fetal manifestation of primary maternal CMV infection including cerebellar hemorrhage and hydrops. The diagnosis was established by maternal serological tests, culture and polymerase chain reaction testing of amniotic fluid and fetal blood. The pregnancy was terminated. Postmortem examination confirmed the diagnosis.