Multicity Italian study of congenital cytomegalovirus infection

Congenital Cytomegalovirus Testing Outcomes From the ValEAR Trial

OBJECTIVE

To determine the positivity rate of congenital cytomegalovirus (cCMV) testing among universal, hearing-targeted CMV testing (HT-cCMV) and delayed targeted dried blood spot (DBS) testing newborn screening programs, and to examine the characteristics of successful HT-cCMV testing programs.

STUDY DESIGN

Prospective survey of birth hospitals performing early CMV testing.

SETTING

Multiple institutions.

METHODS

Birth hospitals participating in the National Institutes of Health ValEAR clinical trial were surveyed to determine the rates of cCMV positivity associated with 3 different testing approaches: universal testing, HT-cCMV, and DBS testing. A mixed methods model was created to determine associations between successful HT-cCMV screening and specific screening protocols.

RESULTS

Eighty-two birth hospitals were surveyed from February 2019 to December 2021. Seven thousand six hundred seventy infants underwent universal screening, 9017 infants HT-cCMV and 535 infants delayed DBS testing. The rates of cCMV positivity were 0.5%, 1.5%, and 7.3%, respectively. The positivity rate for universal CMV screening was less during the COVID-19 pandemic than that reported prior to the pandemic. There were no statistically significant drops in positivity for any approach during the pandemic. For HT-cCMV testing, unique order sets and rigorous posttesting protocols were associated with successful screening programs.

CONCLUSION

Rates of cCMV positivity differed among the 3 approaches. The rates are comparable to cohort studies reported in the literature. Universal CMV prevalence decreased during the pandemic but not significantly. Institutions with specific order set for CMV testing where the primary care physician orders the test and the nurse facilitates the testing process exhibited higher rates of HT-cCMV testing.

Molecular diagnosis of Cytomegalovirus infection: clinical performance of the Aptima transcription-mediated amplification assay toward conventional qPCR chemistry on whole blood samples

Human Cytomegalovirus (HCMV) infection is life-threatening for immunocompromised patients. Quantitative molecular assays on whole blood or plasma are the gold standard for the diagnosis of invasive HCMV infection and for monitoring antiviral treatment in individuals at risk of HCMV disease. For these reasons, an accurate standardization toward the WHO 1st International Standard among different centers and diagnostic kits represents an effort for better clinical management of HCMV-positive patients. Herein, we evaluate, for the first time, the performance of a new transcription-mediated amplification (TMA) assay versus quantitative polymerase chain reaction (qPCR) chemistry, used as a routine method, on whole blood samples. A total of 755 clinical whole blood specimens were collected and tested simultaneously with TMA and qPCR assays. The data showed a qualitative agreement of 99.27% for positive quantified samples and 89.39% for those undetected between the two tested methods. Evaluation of viremia in positive samples highlighted a good correlation between TMA and qPCR chemistries in terms of International Units (ΔLog10 IU/mL: -0.29 ± 0.40). The TMA assay showed a significant correlation with qPCR in patients monitored for up to 3 months, thus allowing an accurate assessment of viremia in transplant patients. Therefore, TMA chemistry showed good agreement with qPCR testing, used as a current diagnostic routine. It also offers important advantages, such as FDA approval on plasma and In Vitro Diagnostic (IVD) on both plasma and whole blood, automated workflow with minimal hands-on time, and random access loading, thus enabling a rapid and reliable diagnostic in HCMV-infected patients.

IMPORTANCE

In this paper, we describe the clinical performance of a novel transcription-mediated amplification (TMA) assay for the detection and quantification of human Cytomegalovirus (HCMV) DNA from whole blood samples. This is a pivotal analysis in immunocompromised patients [transplanted, HIV-positive, and Hematopoietic Stem Cell (HSC) recipients], and molecular tests with high sensitivity and specificity are necessary to evaluate the HCMV viral load in these patients. To our knowledge, this is the first in-depth evaluation of TMA chemistry for HCMV diagnosis on whole blood samples. Moreover, also technical aspects of this assay make it suitable for clinical diagnostics.

NGS Technology in Monitoring the Genetic Diversity of Cytomegalovirus Strains

Modern molecular genetic methods, massive parallel sequencing in particular, allow for genotyping of various pathogens with the aim of their epidemiological marking and improvement of molecular epidemiological surveillance of actual infections, including cytomegalovirus infection. The aim of the study is to evaluate the next-generation sequencing (NGS) technology for genotyping clinical isolates of cytomegalovirus (CMV).

Materials and Methods

The object of the study were samples of biological substrates (leukocyte mass, saliva, urine) taken from patients who underwent liver and kidney transplantation. Detection of CMV DNA was carried out by a real-time PCR using commercial diagnostic AmpliSense CMV-FL test systems (Central Research Institute for Epidemiology, Moscow, Russia). DNA extraction was performed using DNA-sorb AM and DNA-sorb V kits (Central Research Institute for Epidemiology) in accordance with manufacturer's manual. The quality of the prepared DNA library for sequencing was assessed by means of the QIAxcel Advanced System capillary gel electrophoresis system (QIAGEN, Germany). Alignment and assembly of nucleotide sequences were carried out using CLC Genomics Workbench 5.5 software (CLC bio, USA). The sequencing results were analyzed using BLAST of NCBI server.

Results

CMV DNA samples were selected for genotyping. The two variable genes, UL55(gB) and UL73(gN), were used for CMV genotype determination, which was performed using NGS technology MiSeq sequencer (Illumina, USA). Based on the exploratory studies and analysis of literature sources, primers for genotyping on the UL55(gB) and UL73(gN) genes have been selected and the optimal conditions for the PCR reaction have been defined. The results of sequencing the UL55(gB) and UL73(gN) gene fragments of CMV clinical isolates from recipients of solid organs made it possible to determine the virus genotypes, among which gB2, gN4c, and gN4b were dominant. In some cases, association of two and three CMV genotypes has been revealed.

Conclusion

The application of the NGS technology for genotyping cytomegalovirus strains can become one of the main methods of CMV infection molecular epidemiology, as it allows for obtaining reliable results with a significant reduction in research time.

Congenital CMV, Lights and Shadows on Its Management: The Experience of a Reference Center in Northern Italy

Congenital cytomegalovirus infection (cCMV) is the most common congenital viral infection, with a consistent rate of morbidity, mortality, and long-term sequelae, especially in the case of late diagnosis. Nevertheless, a universal screening for CMV is not currently recommended, and global awareness about this infection, as well as accurate and shared indications on follow-up and treatment, are still lacking. We reviewed data about 59 suspect cCMV cases who referred to our center from 2014 to 2021. We report 41 cases of confirmed cCMV diagnosed at birth, with clinical or radiological abnormalities in 36.6% of them. Other five patients received a late diagnosis and all presented neurological impairment. Twelve patients received therapy with Valganciclovir within the first month of life, with favorable outcome in nine cases. Therapy after the first month of life was attempted in four patients, with improvement in one case. The overall awareness about cCMV infection was 32.6%. Considering our population, maternal serological screening followed by targeted testing of neonates could be an effective strategy. Some aspects of cCMV infection management should be further investigated, such as indication of treatment after the first month of life or in asymptomatic patients. Awareness about the infection should be improved to implement preventive strategies.

Seroprevalence of antibodies to cytomegalovirus in pregnant women in the Apulia region (Italy)

Introduction

Cytomegalovirus is ubiquitous and easily transmitted by contact. Following the first infection, the virus becomes latent and periodic reactivation could occur due to immunosuppression. If the infection is acquired in pregnancy, especially in the first trimester, the foetal consequences could be serious. The present study was conducted to assess the serological profile of pregnant women with respect to cytomegalovirus in Apulia from 2016 to 2019.

Methods

Serum samples were tested by commercial ELISA kit for the detection of specific IgM and IgG antibodies against cytomegalovirus.

Results

The data showed that most of the pregnant women (70.8%), especially those of ≥ 40 years of age (80.6%), has antibodies against cytomegalovirus, though these do not confer fully protective immunity against infection by different strains nor can prevent the re-activation of the latent one. Conversely, most of the youngest women are seronegative (44.4% in women < 25 years of age) and vulnerable during pregnancy.

Conclusions

Currently, cytomegalovirus screening for pregnant women is not mandatory in Italy. Considering that congenital cytomegalovirus is the leading non-genetic cause of sensorineural hearing loss, it would be extremely useful and cost-saving to screen women of childbearing age and women at early stage of pregnancy for cytomegalovirus infection in addition to increase awareness of cytomegalovirus infection and consequences among pregnant women, health care workers and the public.

Congenital Cytomegalovirus Infection Burden and Epidemiologic Risk Factors in Countries With Universal Screening: A Systematic Review and Meta-analysis

IMPORTANCE

Congenital cytomegalovirus (cCMV) infection is the most common congenital infection and the leading acquired cause of developmental disabilities and sensorineural deafness, yet a reliable assessment of the infection burden is lacking.

OBJECTIVES

To estimate the birth prevalence of cCMV in low- and middle-income countries (LMICs) and high-income countries (HICs), characterize the rate by screening methods, and delineate associated risk factors of the infection.

DATA SOURCES

MEDLINE/PubMed, Scopus, and Cochrane Database of Systematic Reviews databases were searched from January 1, 1960, to March 1, 2021, and a total of 1322 studies were identified.

STUDY SELECTION

Studies that provided data on the prevalence of cCMV derived from universal screening of infants younger than 3 weeks were included. Targeted screening studies were excluded.

DATA EXTRACTION AND SYNTHESIS

Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline was followed. Extraction was performed independently by 3 reviewers. Quality was assessed using the Newcastle-Ottawa Scale for cohort studies. Random-effects meta-analysis was undertaken. Metaregression was conducted to evaluate the association of sociodemographic characteristics, maternal seroprevalence, population-level HIV prevalence, and screening methods with the prevalence of cCMV.

MAIN OUTCOMES AND MEASURES

Birth prevalence of cCMV ascertained through universal screening of infants younger than 3 weeks for CMV from urine, saliva, or blood samples.

RESULTS

Seventy-seven studies comprising 515 646 infants met the inclusion criteria from countries representative of each World Bank income level. The estimated pooled overall prevalence of cCMV was 0.67% (95% CI, 0.54%-0.83%). The pooled birth prevalence of cCMV was 3-fold greater in LMICs (1.42%; 95% CI, 0.97%-2.08%; n = 23 studies) than in HICs (0.48%; 95% CI, 0.40%-0.59%, n = 54 studies). Screening methods with blood samples demonstrated lower rates of cCMV than urine or saliva samples (odds ratio [OR], 0.38; 95% CI, 0.23-0.66). Higher maternal CMV seroprevalence (OR, 1.19; 95% CI, 1.11-1.28), higher population-level HIV prevalence (OR, 1.22; 95% CI, 1.05-1.40), lower socioeconomic status (OR, 3.03; 95% CI, 2.05-4.47), and younger mean maternal age (OR, 0.85; 95% CI, 0.78-0.92, older age was associated with lower rates) were associated with higher rates of cCMV.

CONCLUSIONS AND RELEVANCE

In this meta-analysis, LMICs appeared to incur the most significant infection burden. Lower rates of cCMV were reported by studies using only blood or serum as a screening method.

Cytomegalovirus Disease in Renal Transplanted Patients: Prevalence, Determining Factors, and Influence on Graft and Patients Outcomes

The prevalence and the factors related to cytomegalovirus (CMV) disease (CMVd) during the 1st year of renal transplantation (RTx) and the relationship between CMVd and early and long-term graft and RTx-patient (RTx-p) survival were evaluated. In 505 RTx-p, followed up for 8(5-11) years, data were recorded after 1-(T1) and 12-(T12) months of RTx. CMVd was defined either by CMV replication without clinical signs of disease (CMVr, 43%), or CMV replication with signs of disease (CMVs, 57%). During the 1st year of RTx, 45% of RTx-p had CMVd (CMVd+). CMVd+ patients were older than CMVd- patients. Female gender and Donor CMV-IgG+ (CMV IgG-D+)/recipient IgG- (CMV IgG-R-) status were more prevalent in CMVd+. At T1, CMVd+ had lower albumin, haemoglobin, and higher uric-acid and reactive C-protein than CMVd- and, at T1 and T12, received more steroids. Albumin-T1 was the unique factor in determining CMVd+, maintaining its significance also after the inclusion of IgG-D+/IgG-R- status to the model. CMVs had higher prevalence of CMV IgG-D+/IgG-R- than CMVr. CMVd, CMVr, and CMVs had no impact on graft loss (11% of RTx-p) and RTx-p death (8% of RTx-p). CMVd is highly prevalent during the 1st year of RTx. Albumin-T1 influences CMVd insurgence. CMVd did not impact on RTx and RTx-p loss.

A prospective study evaluating congenital CMV infection in Mayotte and La Reunion Islands (France)

OBJECTIVES Congenital cytomegalovirus infection (cCMV) affects around 3400 newborns each year in France, of whom 700 will develop sequelae, primarily sensorineural hearing loss. Our objectives were (1) to evaluate incidence of cCMV in two French departments located in the Indian Ocean: Mayotte and La Reunion, and (2) evaluate interest and feasibility/acceptability of universal screening of cCMV at birth. MATERIAL AND METHODS We implemented a universal neonatal CMV screening in Mayotte during 7 months in 2019 and in La Reunion during one month in March 2020. Saliva swabs were collected in the first three days of life, and tested for CMV DNA by PCR. A short survey allowed evaluating whether this screening is acceptable and feasible. RESULTS: A total of 1026 newborns were screened: 854 in Mayotte and 172 in La Reunion. In Mayotte, cCMV incidence was evaluated at a minimum of 1.6 % (95 % CI 0.94-2.81). In La Reunion, cCMV incidence was evaluated at a minimum of 1.2 % (95 % CI -0.20-4.57). All cCMV infants were born to mothers with non-primary CMV infection. Only 0.7 % parents refused the screening. CONCLUSIONS cCMV incidence in Mayotte and La Reunion is higher than in metropolitan France. This diagnosis should not be overlooked, especially since the time dedicated to screening and its feeling by the parents seem to be acceptable.

Potential Therapeutic Approaches Against Brain Diseases Associated with Cytomegalovirus Infections

Cytomegalovirus (CMV) is one of the major human health threats worldwide, especially for immunologically comprised patients. CMV may cause opportunistic infections, congenital infections, and brain diseases (e.g., mental retardation and glioblastoma). The etiology of brain diseases associated with human CMV (HCMV) infections is usually complex and it is particularly difficult to treat because HCMV has a life-long infection in its hosts, high mutation rate, and latent infections. Moreover, it is almost impossible to eradicate latent viruses in humans. Although there has been progress in drug discovery recently, current drugs used for treating active CMV infections are still limited in efficacy due to side effects, toxicity, and viral resistance. Fortunately, letermovir which targets the HCMV terminase complex rather than DNA polymerase with fewer adverse reactions has been approved to treat CMV infections in humans. The researchers are focusing on developing approaches against both productive and latent infections of CMV. The gene or RNA targeting approaches including the external guide sequences (EGSs)-RNase, the clustered regularly interspaced short palindromic repeats (CRISPR)/CRISPR-associated protein 9 (Cas9) system and transcription activator-like effector nucleases (TALENs) are being investigated to remove acute and/or latent CMV infections. For the treatment of glioblastoma, vaccine therapy through targeting specific CMV antigens has improved patients’ survival outcomes significantly and immunotherapy has also emerged as an alternative modality. The advanced research for developing anti-CMV agents and approaches is promising to obtain significant outcomes and expecting to have a great impact on the therapy of brain diseases associated with CMV infections.

Antiviral Agents as Therapeutic Strategies Against Cytomegalovirus Infections

Cytomegalovirus (CMV) is a threat to human health in the world, particularly for immunologically weak patients. CMV may cause opportunistic infections, congenital infections and central nervous system infections. CMV infections are difficult to treat due to their specific life cycles, mutation, and latency characteristic. Despite recent advances, current drugs used for treating active CMV infections are limited in their efficacy, and the eradication of latent infections is impossible. Current antiviral agents which target the UL54 DNA polymerase are restricted because of nephrotoxicity and viral resistance. CMV also cannot be prevented or eliminated with a vaccine. Fortunately, letermovir which targets the human CMV (HCMV) terminase complex has been recently approved to treat CMV infections in humans. The growing point is developing antiviral agents against both lytically and latently infected cells. The nucleic acid-based therapeutic approaches including the external guide sequences (EGSs)-RNase, the clustered regularly interspaced short palindromic repeats (CRISPR)/CRISPR-associated protein 9 (Cas9) system and transcription activator-like effector nucleases (TALENs) are being explored to remove acute and/or latent CMV infections. HCMV vaccine is being developed for prophylaxis. Additionally, adoptive T cell therapy (ACT) has been experimentally used to combate drug-resistant and recurrent CMV in patients after cell and/or organ transplantation. Developing antiviral agents is promising in this area to obtain fruitful outcomes and to have a great impact on humans for the therapy of CMV infections.

Impact of Maternal Immunity on Congenital Cytomegalovirus Birth Prevalence and Infant Outcomes: A Systematic Review

Congenital cytomegalovirus (cCMV) is the leading non-genetic cause of sensorineural hearing loss (SNHL), and efforts are geared towards prevention through vaccine development. Transmission rates following primary maternal infection occur at rates of 30-40%, however reported placental rates upon non-primary maternal infection is reported to be less than <4%. There is significant debate about whether this reduction in transmission rate is due to pre-existing maternal immunity, which could identify possible immunologic targets for vaccines. To address this question, we performed a systemic review of the literature using Preferred Reporting Items for Systematic Review and Analysis (PRISMA) guidelines. We identified cohort studies in high CMV seroprevalent (>80%) areas or in developing regions that examined a cohort of at least 50 infants for congenital CMV acquisition. We identified 19 articles that met criteria and were further categorized based on pre-conception serology, maternal seroprevalence, or previously known seroprevalence. Birth prevalence rates ranged from 0.4% to 6% (median 1.1%), with the studies reporting on clinical outcome (16/19 studies) noting the majority of infected infants as asymptomatic. We also utilized a recent study that differentiated primary maternal infections from chronic infections in a highly seropositive population to calculate a placental transmission rate in women with pre-existing immunity compared to that of no pre-existing immunity. This work confirms a low cCMV birth prevalence in highly seropositive populations, indicates via a calculated placental transmission rate that the CMV placental transmission rate is lower in non-primary infection than that of primary infection, and reveals gaps in data for further research aiming to identify targets for vaccine development.

Congenital Cytomegalovirus Infection and Tetralogy of Fallot: An Unusual Association in a Three-month-old Baby

Congenital cytomegalovirus (cCMV) infection is the leading cause of infant morbidity and mortality worldwide. Despite being associated with significant neurological sequelae in infected infants, it remains an under-recognized public health entity. Symptomatic newborns most frequently display hepatosplenomegaly, petechiae, jaundice, microcephaly, intrauterine growth restriction, chorioretinitis, purpura, and seizures. Progressive sensorineural hearing loss is the most prominent adverse outcome of both symptomatic and asymptomatic CMV infections in infants. We report the case of a three-month-old baby who presented with complaints of progressive jaundice for three months and a two days history of fever associated with one episode of fits. The baby was diagnosed with congenital CMV infection on the basis of positive CMV IgM and IgG and positive maternal serum CMV IgG. Finding a murmur on physical examination prompted echocardiography which revealed Tetralogy of Fallot (TOF). The child was managed with a 6-week course of ganciclovir after which his symptoms improved and he was referred to cardiology for the evaluation of his heart defect. Follow-ups at the clinic have shown normal growth and development. This is the first reported association of cCMV infection with TOF. This case highlights the need to consider the possibility of the presence of heart defects in all infants with cCMV infection in addition to neurodevelopmental abnormalities. Clinicians should maintain a high degree of suspicion for cCMV infection in all neonates to ensure timely intervention and to prevent long-term neurological sequelae.

Implications of dried blood spot testing for congenital CMV on management of children with hearing loss: A preliminary report

INTRODUCTION

Non-genetic, congenital sensorineural hearing loss (cSNHL) is commonly caused by congenital CMV infection (cCMV). Hearing loss related to cCMV is variable in degree, often progressive, and can affect one or both ears.

OBJECTIVES

We sought to examine the outcomes of DBS testing in California, and the hearing outcomes of cCMV-positive children.

METHODS

This is a retrospective study of patients with SNHL of unknown etiology aged 6 months to 17 years old presenting to a tertiary care pediatric center and evaluated for cCMV by DBS testing.

RESULTS

114 children (228 ears) with SNHL of unknown origin were included. 6/114 (5.3%) tested positive for cCMV versus 108/114 (94.7%), who tested negative. None of the cCMV-positive children had symmetric bilateral hearing loss, compared with 56.5% (61/108) of cCMV-negative children (p < 0.05). cCMV-positive children were more likely to have profound SNHL in the worse-hearing ear (5/6 (83%) vs 16/108 (14.9%) of cCMV-negative children, p < 0.001). 86% (5/6) exhibited progressive hearing loss, including progression or new-onset hearing loss in the previously better hearing ear. 3 of the 6 children with cCMV underwent CI.

CONCLUSION

A small proportion of patients presenting with SNHL tested positive on DBS. Of cCMV-positive children, most presented with profound hearing loss in the worse-hearing ear, and 50% of cCMV-positive children developed progressive hearing loss in the initially better-hearing ear. Prognostic information afforded by etiologic confirmation of cCMV infection informed decision-making concerning cochlear implantation in these cases.

The seroprevalence of cytomegalovirus infection in Belgium anno 2002 and 2006: a comparative analysis with hepatitis A virus seroprevalence

Cytomegalovirus (CMV) infection is endemic worldwide but its seroprevalence varies widely. The goal of this study was to estimate the age-specific seroprevalence of CMV infection in Belgium based on two cross-sectional serological datasets from 2002 and 2006. The seroprevalence was estimated relying on diagnostic test results based on cut-off values pre-specified by the manufacturers of the tests as well as relying on mixture models applied to continuous pathogen-specific immunoglobulin G antibody titre concentrations. The age-specific seroprevalence of hepatitis A virus (HAV), based on three Belgian cross-sectional serological datasets from 1993, 2002 and 2006, was used as a comparator since individuals acquire lifelong immunity upon recovery, implying an increasing seroprevalence with age. The age group weighted overall CMV seroprevalence derived from the mixture model was 32% (95% confidence interval (CI) 31-34%) in 2002 and 31% (95% CI 30-32%) in 2006. We demonstrated that CMV epidemiology differs from the immunizing infection HAV. This was the first large-scale study of CMV and HAV serial datasets in Belgium, estimating seroprevalence specified by age and birth cohort.

Congenital Cytomegalovirus and HIV Perinatal Transmission

BACKGROUND

Congenital cytomegalovirus (CMV) infection (cCMV) is an important cause of hearing loss and cognitive impairment. Prior studies suggest that HIV-exposed children are at higher risk of acquiring cCMV. We assessed the presence, magnitude and risk factors associated with cCMV among infants born to HIV-infected women, who were not receiving antiretrovirals during pregnancy.

METHODS

cCMV and urinary CMV load were determined in a cohort of infants born to HIV-infected women not receiving antiretrovirals during pregnancy. Neonatal urines obtained at birth were tested for CMV DNA by qualitative and reflex quantitative real-time polymerase chain reaction.

RESULTS

Urine specimens were available for 992 (58.9%) of 1684 infants; 64 (6.5%) were CMV-positive. Mean CMV load (VL) was 470,276 copies/ml (range: < 200-2,000,000 copies/ml). Among 89 HIV-infected infants, 16 (18%) had cCMV versus 42 (4.9%) of 858 HIV-exposed, uninfected infants (P < 0.0001). cCMV was present in 23.2% of infants with in utero and 9.1% infants with intrapartum HIV infection (P < 0.0001). Rates of cCMV among HIV-infected infants were 4-fold greater (adjusted OR, 4.4; 95% CI: 2.3-8.2) and 6-fold greater among HIV in utero-infected infants (adjusted OR, 6; 95% CI: 3-12.1) compared with HIV-exposed, uninfected infants. cCMV was not associated with mode of delivery, gestational age, Apgar scores, 6-month infant mortality, maternal age, race/ethnicity, HIV viral load or CD4 count. Primary cCMV risk factors included infant HIV-infection, particularly in utero infection.

CONCLUSION

High rates of cCMV with high urinary CMV VL were observed in HIV-exposed infants. In utero HIV infection appears to be a major risk factor for cCMV in infants whose mothers have not received combination antiretroviral therapy in pregnancy.

Prevalence of Congenital Cytomegalovirus Infection Assessed Through Viral Genome Detection in Dried Blood Spots in Children with Autism Spectrum Disorders

BACKGROUND/AIM

Autism spectrum disorders (ASD) are neurodevelopmental disorders without a definitive etiology in most cases. Environmental factors, such as viral infections, have been linked with anomalies in brain growth, neuronal development, and functional connectivity. Congenital cytomegalovirus (CMV) infection has been associated with the onset of ASD in several case reports. The aim of this study was to evaluate the prevalence of congenital CMV infection in children with ASD and in healthy controls.

PATIENTS AND METHODS

The CMV genome was tested by polymerase chain reaction (PCR) on dried blood spots collected at birth from 82 children (38 with ASD and 44 controls).

RESULTS

The prevalence of congenital CMV infection was 5.3% (2/38) in cases and 0% (0/44) in controls (p=0.212).

CONCLUSION

The infection rate was about 10-fold higher in patients with ASD than in the general Italian population at birth. For this reason, detection of CMV-DNA on dried blood spots could be considered in the work-up that is usually performed at ASD diagnosis to rule-out a secondary form. Given the potential prevention and treatment of CMV infection, this study could have intriguing consequences, at least for a group of patients with ASD.

Hyperimmune globulin in pregnancy for the prevention of congenital cytomegalovirus disease

INTRODUCTION

Cytomegalovirus (CMV) is the most common and serious cause of congenital infections in developed countries since it is capable of infecting the fetus after both primary and recurrent maternal infection, and can be spread for years by infected children. Areas covered: Animal and human pregnancy studies about the prevention of congenital CMV infection and disease by CMV-specific hyperimmune globulin (HIG). Commercial HIG is manufactured from the plasma of selected donors with high anti-CMV antibody avidity and titers. Expert commentary: Currently available experimental and clinical studies and case reports support the possible effectiveness and safety of HIG infusions in pregnancy for the prevention of congenital CMV disease. The knowledge about the potential efficacy of preventive or therapeutic HIG administration should be enlarged by multi-center randomized studies, which may be favored by the implementation of CMV screening. Meanwhile, if ultrasound examinations show signs of fetal injury, or CMV is detected in the amniotic fluid, the patients should be advised about the possible option of HIG therapy.

An Italian Prospective Experience on the Association Between Congenital Cytomegalovirus Infection and Autistic Spectrum Disorder

The aim of this retrospective study, with prospective data collection, was to correlate congenital cytomegalovirus (CMV) infection with autism spectrum disorder (ASD) and to define its prevalence. Seventy proven congenitally-infected infants, born between 2007 and 2012, were referred to our centre for CMV diagnosis and follow-up, which consisted of a consolidated protocol allowing an early evaluation of autism. We considered four children 2-year old, two of whom, at the age of 3, were diagnosed with ASD demonstrating a 2-3 fold higher prevalence (2.86%), than that in general Italian population (0.66-1.36%).Our protocol enabled us to make the earliest diagnosis and highlight the role of the virus among other causes of autism, which may be a long term sequela of congenital CMV.

Hearing and neurodevelopmental outcomes for children with asymptomatic congenital cytomegalovirus infection: A systematic review

INTRODUCTION

Congenital CMV is one of the commonest congenital infections and a recognised cause of sensorineural hearing loss and neurodevelopmental impairment. Ninety percent are clinically inapparent at birth but are reported to be at risk of developing such abnormalities throughout childhood, the extent of which requires further elucidation.

METHODS

A systematic literature review was conducted using Medline and Embase databases, manual citation review, and personal libraries for articles reporting primary data on hearing and neurodevelopmental outcomes for children with asymptomatic congenital CMV. PROSPERO registration number CRD42015025407.

RESULTS

Thirty-seven of 480 articles identified between 1969 and 2016 met the eligibility criteria. Twenty-nine of these contributed primary data on hearing outcomes and 20 on neurodevelopmental outcomes (12 of the 37 studies contributed data on both). Cumulative incidence of sensorineural hearing loss with follow-up to at least 5 years was 7% to 11%, which is more than healthy controls but less than children with symptomatic congenital CMV (34%-41%). The onset, course, and severity of hearing loss was variable with no reliable virological prognostic marker. In comparison to controls, children with asymptomatic congenital CMV did not perform worse than controls in neurodevelopmental assessments and performed better than children with symptomatic congenital CMV.

CONCLUSIONS

Studies show children with asymptomatic congenital CMV are at increased risk of developing hearing loss but perform equally well on neurodevelopmental assessments when compared with healthy controls. There is no reliable virological marker to determine which infants will develop sequelae. Regular follow-up until school entry is supported by the literature.

The Role of Cytomegalovirus in Congenital and Early Postnatal Infections in Northeastern Bulgaria

BACKGROUND

Human cytomegalovirus is a ubiquitous, large enveloped DNA β-herpesvirus that, like other herpesviruses, establishes lifelong latency following primary infection. It is the most frequent cause of congenital, neonatal and early postnatal infections with long lasting sequelae.

AIM

The aim of the present study was to assess the prevalence of cytomegalovirus among a cohort of newborns and 1-3-month-old children with neurological symptoms, physical retardation, prolonged jaundice, thrombocytopenic purpura and other disabilities.

MATERIALS AND METHODS

The study was a retrospective cross-sectional analysis of serological screening data for detection of specific anti-cytomegalovirus IgM and IgG in children from Northeastern Bulgaria.

RESULTS

Between 2003 and 2015, average prevalences of 18.8% (95% CI: 15.4 to 22.2) for anti-CMV IgM antibodies (suggesting acute infection) and 84.7% (95% CI: 81.6 to 87.8) for anti-CMV IgG antibodies were measured in a total number of 517 samples. The prevalence rate of anti-CMV IgM in 1-3-month-old children was 4-fold higher than that in newborns [25.8% (95% CI: 21.1 to 30.5) and 6.4% (95% CI: 2.9 to 9.9, respectively]. In contrast, no significant difference was found for anti- CMV IgG positivity between newborns and 1-3-month-old infants (84% and 85%, respectively).

CONCLUSIONS

The data obtained strongly encourage screening of pregnant women for anti-CMV IgG and IgM to avoid transmission of the infection and severe complications of congenital infection.

Analysis of archived newborn dried blood spots (DBS) identifies congenital cytomegalovirus as a major cause of unexplained pediatric sensorineural hearing loss

PURPOSE

Congenital cytomegalovirus (cCMV) infection is the most common non-genetic cause of sensorineural hearing loss (SNHL). However, accurate diagnosis of cCMV as the etiology of SNHL is problematic beyond the neonatal period. This study therefore examined whether cCMV infection could be identified retrospectively in children presenting with unexplained SNHL to a multidisciplinary diagnostic outpatient otolaryngology clinic at an academic medical center in Minnesota.

METHODS

Over a 4-year period, 57 patients with an age range of 3months to 10years with unexplained SNHL were recruited to participate in this study. Informed consent was obtained to test the archived dried blood spots (DBS) of these patients for cCMV infection by real-time PCR, targeting a highly conserved region of the CMV UL83 gene. Results were normalized to recovery of an NRAS gene control. Chart review was conducted to identify subjects who underwent genetic testing and/or neurodiagnostic imaging to investigate possible genetic, syndromic, or anatomical causes of SNHL.

RESULTS

In total, 15 of the 57 children with unexplained SNHL tested positive for CMV DNA in their DBS (26%). A mean viral load of 8.3×10⁴ (±4.1×10⁴) [range, 1×10³-6×10⁵] copies/μg DNA was observed in subjects retrospectively diagnosed with cCMV. No statistically significant correlation was found between viral load and SNHL severity.

CONCLUSIONS

A retrospective DBS analysis demonstrated that 26% of patients presenting with unexplained SNHL in childhood had cCMV. DBS testing is useful in the retrospective diagnosis of cCMV, and may provide definitive diagnostic information about the etiology of SNHL.

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.

Hearing loss and congenital CMV infection: a systematic review

BACKGROUND AND OBJECTIVE

Hearing loss caused by congenital cytomegalovirus (cCMV) infection was first observed in 1964. Today cCMV is the most common cause of nonhereditary sensorineural hearing loss in childhood. Our objective was to provide an overview of the prevalence of cCMV-related hearing loss, to better define the nature of cCMV-associated hearing loss, and to investigate the importance of cCMV infection in hearing-impaired children.

METHODS

Two reviewers independently used Medline and manual searches of references from eligible studies and review articles to select cohort studies on children with cCMV infection with audiological follow-up and extracted data on population characteristics and hearing outcomes.

RESULTS

Thirty-seven studies were included: 10 population-based natural history studies, 14 longitudinal cohort studies, and 13 retrospective studies. The prevalence of cCMV in developed countries is 0.58% (95% confidence interval, 0.41-0.79). Among these newborns 12.6% (95% confidence interval, 10.2-16.5) will experience hearing loss: 1 out of 3 symptomatic children and 1 out of 10 asymptomatic children. Among symptomatic children, the majority have bilateral loss; among asymptomatic children, unilateral loss predominates. In both groups the hearing loss is mainly severe to profound. Hearing loss can have a delayed onset, and it is unstable, with fluctuations and progression. Among hearing-impaired children, cCMV is the causative agent in 10% to 20%. Despite strict selection criteria, some heterogeneity was found between selected studies.

CONCLUSIONS

This systematic review underscores the importance of cCMV as a cause of sensorineural hearing loss in childhood.

A diagnostic paradigm including cytomegalovirus testing for idiopathic pediatric sensorineural hearing loss

OBJECTIVES/HYPOTHESIS

To determine the feasibility and cost effectiveness of incorporating cytomegalovirus (CMV) testing to determine the etiology of pediatric hearing loss.

STUDY DESIGN

Retrospective study of children presenting with sensorineural hearing loss (SNHL) at one institution from 2008 to 2013.

METHODS

Children aged 3 years or younger who presented to the senior author (A.P.) between May 2008 and September 2013 with confirmed SNHL were evaluated. These children underwent a sequential diagnostic paradigm that incorporated CMV testing if no obvious etiology could be determined from the history or physical examination.

RESULTS

One hundred eleven children with SNHL were evaluated between 2008 and 2013. Eighty-three children underwent CMV testing, imaging, and a genetic evaluation. Those with confirmed or probable CMV-induced SNHL made up 30% of all children tested (n = 25), the largest group identified. CMV screening had the lowest cost compared to genetic testing or imaging for all types of hearing loss, except for those with auditory neuropathy spectrum disorder.

CONCLUSION

We present the first sequential diagnostic paradigm utilizing CMV testing for children presenting with SNHL. The relatively high incidence of CMV-induced SNHL, the low cost for this assay, and the indirect benefits from early diagnosis support the role of early CMV testing for these patients.

LEVEL OF EVIDENCE

4.

Quantitation of cytomegalovirus DNA load in dried blood spots correlates well with plasma viral load

An assay to accurately quantitate cytomegalovirus (CMV) load in finger-stick-collected dried blood spots (DBS) could potentially be useful for field studies or for analyzing patient self-collected specimens. We therefore assessed CMV DNA load in paired venipuncture-collected plasma samples and finger-stick DBS, using a previously validated quantitative PCR assay. Assay variability, sensitivity, and changes in viral load during antiviral therapy in finger-stick DBS were compared to the reference plasma quantitative PCR assay, using 106 prospectively collected pairs of finger-stick DBS and plasma samples from 35 solid-organ transplant (SOT) patients. The DBS assay showed good agreement with the reference plasma viral load assay on the log10 scale (Pearson correlation coefficient, 0.92; P < 0.001). The 95% limit of detection of the DBS assay was estimated at 2,700 plasma copies/ml (675 plasma IU/ml). In 94% (76/81) of paired DBS and plasma samples above the limit of detection, the difference in CMV load was <1 log10. CMV viral load changes during antiviral treatment were comparable in plasma and DBS. We conclude that finger-stick DBS provides a convenient sample type for quantitation of CMV load that correlates well with plasma levels. Future studies to optimize and evaluate this methodology for patient self-collected samples are warranted.

Long-term outcomes of congenital cytomegalovirus infection in Sweden and the United Kingdom

BACKGROUND

Congenital cytomegalovirus (CMV) is an important cause of neurological problems, particularly sensorineural hearing loss, but data on long-term sequelae and the impact of nonprimary maternal infection are limited. We report updated findings on childhood outcomes from 2 large prospective studies.

METHODS

Pregnant women in Malmö, Sweden, and London, United Kingdom, were included between 1977 and 1986, and newborns were screened for CMV (virus culture of urine or saliva). Cases and matched controls underwent regular, detailed developmental assessments up to at least age 5 years.

RESULTS

One hundred seventy-six congenitally infected infants were identified among >50 000 screened (Malmö: 76 [4.6/1000 births]; London: 100 [3.2/1000 births]); 214 controls were selected. Symptoms were recorded in 11% of CMV-infected neonates (19/176) and were mostly mild; only 1 neonate had neurological symptoms. At follow-up, 7% of infants (11/154) were classified as having mild, 5% (7/154) moderate, and 6% (9/154) severe neurological sequelae. Four of 161 controls (2%) had mild impairment. Among children symptomatic at birth, 42% (8/19) had sequelae, versus 14% (19/135) of the asymptomatic infants (P = .006). All moderate/severe outcomes were identified by age 1; mild sequelae were first identified at age 2-5 years in 6 children, and age 6-7 years in 3. Among the 16 children with moderate/severe outcomes, 2 had mothers with confirmed and 7 with presumed nonprimary infection.

CONCLUSIONS

Moderate or severe outcomes were reported in 11% of children with congenital CMV identified through population screening, all by 1 year; all impairment detected after this age was mild. Nonprimary infections contributed substantially to the burden of childhood congenital CMV disease.

Cytomegalovirus and Epstein-Barr virus may be associated with some cases of cerebral palsy

OBJECTIVE

Intrauterine infection is a risk factor for cerebral palsy. Previous work reported a high frequency of viral DNA in newborn screening cards from cerebral palsy cases and controls possibly due to contamination.

METHODS

Retrospective case-control study using improved methodologies to minimize contamination during PCR-based detection of viral DNA sequences. Newborn screening cards of 339 Caucasian children with cerebral palsy and 594 controls were examined. Viruses tested were herpes simplex viruses 1 and 2 (HSV1 and 2), varicella zoster virus (VZV), Epstein-Barr virus (EBV), cytomegalovirus (CMV), human herpes viruses 6, 7 and 8 (HHV6, HHV7 and HHV8), and parvovirus B19. Genotyping was performed on DNA extracted from dried blood spots.

RESULTS

CMV and EBV were detected in 5 (1.5%) and 3 (0.9%) of 339 cases, respectively, but not in controls (p = 0.047 and 0.006). Frequencies of detection of the other viruses examined were similar for cases and controls. DNA from at least one of the nine viruses tested was found in 4.4% of cases and 3.1% of controls [OR 1.4 95% CI (0.71-2.76)].

CONCLUSION

Evidence of congenital viral infection was uncommon in cases of cerebral palsy and controls. However, CMV and EBV were significantly associated with cerebral palsy.

Seroprevalence of cytomegalovirus antibodies amongst normal pregnant women in Nigeria

OBJECTIVE

Cytomegalovirus (CMV), a ubiquitous virus belonging to the herpes family, is known to be transmitted frequently to developing fetuses in pregnancy. In an immunocompromised state like pregnancy, primary infection through blood transfusion or reactivation of a latent CMV infection can cause severe illness. The study was carried out to determine the seroprevalence of the immunoglobulin G (IgG) antibody to cytomegalovirus amongst pregnant women in correlation with previous exposure to blood transfusion.

METHODS

A cross sectional study was carried out amongst 179 HIV negative pregnant women attending the antenatal clinic of Lagos State University Teaching Hospital (LASUTH), Ikeja, Nigeria. Five mL of blood was collected and stored in a plain bottle, centrifuged on the same day and the serum stored at -20°C. All samples were screened for anti-CMV IgG antibodies using the enzyme linked immunosorbent assay (ELISA). Consenting participants were instructed to fill a semi-structured questionnaire to obtain demographic and other related information. Statistical analysis of the results was done using Pearson's chi squared test for analytical assessment.

RESULTS

A total of 97.2% of the pregnant women recruited for this study were anti-CMV IgG positive. Out of the 179 recruited for the study 174 responded to the question on previous history of blood transfusion, 14.9% of the respondents (26 of 174) had a previous history of blood transfusion and all tested positive to the anti-CMVIgG antibody. However, past history of blood transfusion and educational level were found to be insignificant to the risk of acquiring CMV infection.

CONCLUSION

The seroprevalence of the CMV antibody amongst pregnant women in this environment is high in relation to findings in other developing countries. There is the need to assess anti-CMV immunoglobulin M antibodies in pregnant women, which is a determinant of active infection.

Prevalence of congenital cytomegalovirus infection in Slovenia: a study on 2,841 newborns

Human cytomegalovirus (CMV) is the most frequent cause of congenital infection in humans. In the first prevalence study of congenital CMV infection in Eastern and Central Europe, all neonates born in a 22-month period in two Slovenian maternity units (total of 2,841 newborns) were screened prospectively for congenital CMV infection by a real-time polymerase chain reaction (PCR) in urine. In all newborns with positive screening results, plasma and dried blood spots (DBS) collected at birth were tested additionally for CMV DNA. Congenital CMV infection was confirmed by virus isolation from a urine sample collected within the first 2 weeks of life. Congenital CMV infection was identified in four out of 2,841 newborns tested (incidence 0.14%; 95% CI, 0.05-0.39%). In four newborns with confirmed congenital infection, the concentration of CMV DNA in urine ranged from 4.68 to 8.18 log(10)  copies/ml, all four newborns had detectable CMV DNA in plasma taken at birth (1.26-3.34 log(10)  copies/ml) and two out of four had detectable CMV DNA in DBS collected during newborn metabolic screening. None of the four newborns with confirmed congenital CMV infection was symptomatic. The study showed that the prevalence of congenital CMV infection at birth in Slovenia is among the lowest in the world and that CMV DNA PCR testing of urine is a suitable and affordable real-time screening strategy for congenital CMV infection. If it is performed in 24 mini-pools, the cost of screening is 1.4 €/newborn and the cost of detecting a single newborn with congenital CMV infection 1,000 €.

Screening for congenital cytomegalovirus infection using newborn urine samples collected on filter paper: feasibility and outcomes from a multicentre study

Background As congenital cytomegalovirus (CMV) infection causes significant clinical consequences not only at birth but also later as neurological sequelae, it is critical to establish a strategy for screening congenitally infected newborns. Previous studies have identified an insufficient sensitivity in screening methods based on the use of dried blood spots (DBSs). Objectives To evaluate the feasibility of the authors' recently developed method for large-scale screening for congenital CMV infection and to identify risk factors for congenital infection. Methods More than 21 000 newborns were enrolled at 25 sites in six geographically separate areas of Japan. Urine was collected onto filter cards placed in the diapers, which were then analysed by quantitative PCR using the filter disc directly as a template. Clinical and physical findings of the newborns were extracted from their medical records. CMV strains from the cases and their siblings were genetically compared. Viral loads in DBSs obtained from some of the cases were compared with those in the urine filters. Results Congenital CMV infection was identified in 0.31% (95% CI 0.24% to 0.39%) of the newborns, and 30% of the cases (20/66) had typical clinical manifestations and/or showed abnormalities in brain images at birth. Although the positive predictive value of our screening was 94%, the lack of any comparison with a gold standard assay prevented calculation of the negative predictive value. Almost two-thirds of the cases had siblings, a significantly higher frequency than for uninfected newborns. Most of the cases (21/25) excreted CMV strains identical to those of their siblings. CMV DNA was undetectable in three out of 12 retrievable DBS specimens. Conclusions Implementation of an effective large-scale screening programme for congenital CMV infection is feasible. Siblings are the major risk factor for congenital CMV infection, which emphasises the need for education of mothers-to-be as well as vaccine development.

Prospective identification of congenital cytomegalovirus infection in newborns using real-time polymerase chain reaction assays in dried blood spots

BACKGROUND

Congenital cytomegalovirus (CMV) infection is a public health issue, and implementation of neonatal screening has been debated. Detection of CMV DNA by polymerase chain reaction (PCR) of dried blood spots (DBS) routinely collected for metabolic screening from all newborns has been proposed for congenital CMV infection screening. The goal of this study was to prospectively assess the performance of 2 CMV PCR assays of DBS for CMV neonatal screening in a selected population of neonates.

METHODS

We studied prospective congenital CMV screening in a population of neonates either born with symptoms compatible with congenital CMV or born to mothers with a history of primary infection during pregnancy. For each neonate, 2 CMV PCR assays of DBS were blindly performed in parallel with a gold standard technique (ie, CMV PCR of a urine sample).

RESULTS

Two hundred seventy-one neonates were studied, and CMV infection, defined by a positive urine sample in the first week of life, was confirmed in 64 (23.6%). Nineteen infected (29.7%) neonates were symptomatic, and 45 (70.3%) were asymptomatic. The ranges of sensitivity, specificity, positive predictive value, and negative predictive value for the 2 CMV PCR assays of DBS were 95.0%-100%; 98.1%-99.0%; 94.1%-96.9%, and 98.5%-100%, respectively.

CONCLUSIONS

The sensitivity and specificity of both CMV PCR assays of DBS to identify congenital CMV were very high in this population of neonates with a high risk of sequelae. These new data should be considered in the ongoing debate on the appropriateness of the use of DBS as a sample to screen for congenital CMV infection.

Human cytomegalovirus infection and clinical status of infants born to human immunodeficiency virus type 1 infected mothers

OBJECTIVE

Human cytomegalovirus (HCMV) is one of the most common congenital infections worldwide and a frequent opportunistic infection that aggravates the condition of human immunodeficiency virus (HIV)-infected patients. The aim of the study was to evaluate the frequency and factors influencing HCMV infection among infants of HIV-positive women.

METHODS

The study included 35 infants born to HIV-1-infected mothers examined for congenital infections. Children were evaluated for human immunodeficiency virus type 1 (HIV-1), HCMV, and HCV infection by serological and molecular methods.

RESULTS

HIV-1 infection was found in one child whose mother did not receive antiretroviral treatment during pregnancy, and HCV infection in another infant. HCMV-DNA in the urine was present in 13/35 infants (37.14%) on the 10th day and 24/35 infants (68.57%) in the 4th week of life. The majority of HCMV-infected infants were asymptomatic, although they manifested microcephaly and low birth weight significantly more frequently (p = 0.006 and p = 0.02, respectively). Type HIV prophylaxis did not influence HCMV transmission.

CONCLUSIONS

Although often asymptomatic, HCMV infection in infants born to HIV-infected mothers is frequent and may be associated with prematurity, low birth weight, and microcephaly. Diagnostic procedures in children of HIV-infected mothers should involve HCMV.

Congenital cytomegalovirus infection in pediatric hearing loss

OBJECTIVES

To compare the prevalence of congenital cytomegalovirus (CMV) infection in Washington State in children with hearing loss (HL) and the general population and to compare the characteristics of HL in children with and without congenital CMV infection.

DESIGN

Matched case-control; case cohort.

SETTING

Regional pediatric hospital, Washington State Department of Health (WSDOH).

PATIENTS

Cases were children 4 years and older with HL born in Washington State. Control individuals matched for demographic characteristics were identified at random through the WSDOH.

MAIN OUTCOME MEASURES

Congenital CMV status determined using quantitative polymerase chain reaction testing on newborn heel stick blood spots archived by the WSDOH. Audiologic data were used to characterize HL.

RESULTS

Congenital CMV testing was performed for 222 matched cases and controls. Congenital CMV infection was detected in 1.4% of controls and in 9.9% of cases (odds ratio, 10.5; 95% confidence interval, 2.6-92.4). An estimated 8.9% of HL in children in Washington can be attributed to CMV infection. After inclusion of an additional 132 children with HL (for a total of 354 cases in the case cohort), we observed that children with congenital CMV had more severe HL (P < .001) and higher proportions of progressive (P = .02) and unilateral (P = .002) HL compared with children without congenital CMV infection. In the 35 children with congenital CMV infection, there was no relationship between neonatal CMV load and severity of HL.

CONCLUSIONS

In Washington State, children with HL had a far higher prevalence of congenital CMV viremia than did the general pediatric population, and CMV infection seems to be responsible for an appreciable fraction of pediatric HL in Washington State.

Congenital cytomegalovirus infection: treatment, sequelae and follow-up

Cytomegalovirus (CMV) is the most common cause of congenital infection affecting about 1% of all the live births worldwide. Its prevalence in the developed world seems to be slightly lower, ranging between 0.6 and 0.7%. Symptoms can be detected at birth in 10-15% of the congenitally infected of which 50-90% will develop sequelae, the most frequent being sensorineural hearing loss (SNHL), visual defect, psychomotor impairment, mental retardation, cerebral palsy and seizures. Eighty-five to 90% of the infected newborns are asymptomatic but 10-15% of them are equally at risk for sensorineural sequelae, like 20-30% of all the infected children. Therefore it is important a time prolonged and closer follow-up of infected children that we propose should be until 6 years of age. This should lead to an early intervention, better management and eventually even control the long-term sequelae. Infants born with symptomatic congenital infection have a worse prognosis than those with no evidence of clinical disease, and ganciclovir (GCV) intravenous 6 mg/kg every 12 h for 6 weeks is the most used therapy for symptomatic newborns. Valganciclovir (V-GCV) syrup is a pro-drug of GCV and presents high oral bioavailability. To date, it is possible to administer this drug at home, and the tolerability profile may allow for wider indications and longer treatments.

Review of cytomegalovirus seroprevalence and demographic characteristics associated with infection

Cytomegalovirus establishes a lifelong latent infection following primary infection that can periodically reactivate with shedding of infectious virus. Primary infection, reactivation and reinfection during pregnancy can all lead to in utero transmission to the developing fetus. Congenital CMV infections are a major cause of permanent hearing loss and neurological impairment. In this literature review, we found that CMV infection was relatively common among women of reproductive age, with seroprevalence ranging from 45 to 100%. CMV seroprevalence tended to be highest in South America, Africa and Asia and lowest in Western Europe and United States. Within the United States, CMV seroprevalence showed substantial geographic variation as well, differing by as much as 30 percentage points between states, though differences might be explained by variation in the types of populations sampled. Worldwide, seroprevalence among non-whites tended to be 20-30 percentage points higher than that of whites (summary prevalence ratio (PR) = 1.59, 95% confidence interval (CI) = 1.57-1.61). Females generally had higher seroprevalences than males, although in most studies the differences were small (summary PR = 1.13, 95% CI = 1.11-1.14). Persons of lower socioeconomic status were more likely to be CMV seropositive (summary PR = 1.33, 95% CI = 1.32-1.35). Despite high seroprevalences in some populations, a substantial percentage of women of reproductive age are CMV seronegative and thus at risk of primary CMV infection during pregnancy. Future vaccine or educational campaigns to prevent primary infection in pregnant women may need to be tailored to suit the needs of different populations.

Dried blood spot real-time polymerase chain reaction assays to screen newborns for congenital cytomegalovirus infection

CONTEXT

Reliable methods to screen newborns for congenital cytomegalovirus (CMV) infection are needed for identification of infants at increased risk of hearing loss. Since dried blood spots (DBS) are routinely collected for metabolic screening from all newborns in the United States, there has been interest in using DBS polymerase chain reaction (PCR)-based methods for newborn CMV screening.

OBJECTIVE

To determine the diagnostic accuracy of DBS real-time PCR assays for newborn CMV screening.

DESIGN, SETTING, AND PARTICIPANTS

Between March 2007 and May 2008, infants born at 7 US medical centers had saliva specimens tested by rapid culture for early antigen fluorescent foci. Results of saliva rapid culture were compared with a single-primer (March 2007-December 2007) and a 2-primer DBS real-time PCR (January 2008-May 2008). Infants whose specimens screened positive on rapid culture or PCR had congenital infection confirmed by the reference standard method with rapid culture testing on saliva or urine.

MAIN OUTCOME MEASURES

Sensitivity, specificity, and positive and negative likelihood ratios (LRs) of single-primer and 2-primer DBS real-time PCR assays for identifying infants with confirmed congenital CMV infection.

RESULTS

Congenital CMV infection was confirmed in 92 of 20,448 (0.45%; 95% confidence interval [CI], 0.36%-0.55%) infants. Ninety-one of 92 infants had positive results on saliva rapid culture. Of the 11,422 infants screened using the single-primer DBS PCR, 17 of 60 (28%) infants had positive results with this assay, whereas, among the 9026 infants screened using the 2-primer DBS PCR, 11 of 32 (34%) screened positive. The single-primer DBS PCR identified congenital CMV infection with a sensitivity of 28.3% (95% CI, 17.4%-41.4%), specificity of 99.9% (95% CI, 99.9%-100%), positive LR of 803.7 (95% CI, 278.7-2317.9), and negative LR of 0.7 (95% CI, 0.6-0.8). The positive and negative predictive values of the single-primer DBS PCR were 80.9% (95% CI, 58.1%-94.5%) and 99.6% (95% CI, 99.5%-99.7%), respectively. The 2-primer DBS PCR assay identified infants with congenital CMV infection with a sensitivity of 34.4% (95% CI, 18.6%-53.2%), specificity of 99.9% (95% CI, 99.9%-100.0%), positive LR of 3088.9 (95% CI, 410.8-23 226.7), and negative LR of 0.7 (95% CI, 0.5-0.8). The positive and negative predictive values of the 2-primer DBS PCR were 91.7% (95% CI, 61.5%-99.8%) and 99.8% (95% CI, 99.6%-99.9%), respectively.

CONCLUSION

Among newborns, CMV testing with DBS real-time PCR compared with saliva rapid culture had low sensitivity, limiting its value as a screening test.

Congenital cytomegalovirus infection in high-risk Canadian infants: Report of a pilot screening study

OBJECTIVES

Congenital cytomegalovirus (cCMV) is the most common congenital infection; however, the epidemiology in Canada has not been recently examined. The present prospective study pilots tools for a population-based study of cCMV infection in Canada by determining the maternal seroprevalence and risk factors, the clinical characteristics and the incidence of cCMV using a variety of diagnostic tests in a cohort of high-risk infants in northern Alberta.

METHODS

All infants born at the Royal Alexandra Hospital in Edmonton, Alberta, from June 1, 2003, to May 31, 2004, were screened for the study. Eligible infants were those with very low birth weights (VLBWs) or small for gestational age (SGA). Maternal CMV serostatus was determined, and chart review and parental interviews were completed. Neonatal urine and throat cultures, and polymerase chain reaction (PCR) were performed. Dried blood spots (DBS) were tested for CMV by PCR.

RESULTS

In total, 213 infants were eligible for the study. Of these, 137 entered the study (79 VLBW and 58 SGA). Some families were not contacted for participation in the study due to neonatal deaths or early discharge. The mean age of the mothers was 27.6 years; 68% of the mothers were Caucasian and 16% were Aboriginal. The maternal CMV seroprevalence was 55%. Seropositivity was significantly associated with ethnicity (First Nations [100%]; Caucasian [34%]) and country of birth (outside Canada [94%]; Canadian born [45%]). The rate of cCMV was two in 137 (1.5%), with a rate of one in 79 (1.3%) for the VLBW infants and one in 58 (1.7%) for the SGA infants. Both had positive throat or urine specimens, but only the symptomatic infant was positive on DBS.

CONCLUSIONS

A cCMV screening program should be universal and routine to successfully screen all newborns. Maternal CMV seropositivity varies widely within the Canadian population. In the present pilot study, DBS PCR was not a sensitive screening tool and throat swab was the best screening specimen.

[Retrospective diagnosis of congenital CMV infection in DBS from Guthrie cards: French experience]

Systematic screening for cytomegalovirus congenital infection is not performed in France. For children with hearing loss or other neurological CMV compatible symptoms, retrospective diagnosis is possible by PCR detection of CMV DNA in dried blood spot of neonatal Guthrie cards. We report here the results obtained with this technique in the French national reference laboratory for cytomegalovirus.

Birth prevalence and natural history of congenital cytomegalovirus infection in a highly seroimmune population

BACKGROUND

The natural history of congenital cytomegalovirus (CMV) infection is scarcely known in populations with high maternal CMV seroprevalence. This study evaluated the birth prevalence, clinical findings at birth, and hearing outcome in CMV-infected children from such a population.

METHODS

Consecutively born infants were screened for the presence of CMV in urine and/or saliva specimens during the first 2 weeks after birth. Neonatal clinical findings were recorded, and CMV-infected children were tested to document hearing function during follow-up. A subset of mothers of CMV-infected infants were prenatally tested for the presence of anti-CMV immunoglobulin G antibodies.

RESULTS

Congenital CMV infection was confirmed in 87 (1.08%; 95% confidence interval [CI], 0.86%-1.33%) of 8047 infants. Seven infants (8.1%; 95% CI, 3.3%-15.9%) had at least 1 clinical finding suggestive of CMV infection, and 4 (4.6%; 95% CI, 1.3%-11.3%) had >3 findings of systemic disease. Sensorineural hearing loss was found in 5 (8.6%; 95% CI, 2.9%-19.0%) of 58 children tested at a median age of 21 months. Bilateral profound hearing loss was observed in 2 children, and the hearing threshold was >60 decibels in all 5 children with hearing loss, including 2 children born to mothers with probable nonprimary CMV infection.

CONCLUSIONS

The results of this large newborn screening study in a population with high CMV seroimmunity provide additional evidence that congenital CMV disease occurs in populations with high seroprevalence rates, with a similar incidence of CMV-related hearing loss to that reported in the offspring of women from populations in developed countries with lower rates of seroimmunity to CMV.

Incidence and risk of cytomegalovirus infection during pregnancy in an urban area of Northern Italy

The fetal consequences of CMV infection make it one of the most serious infections contracted during pregnancy, but the scientific community is divided over the proposed implementation of preventive screening for anti-CMV antibodies. The aim of this study was to assess the incidence and risk of infection during pregnancy in 2817 women who underwent anti-CMV IgG and IgM antibody screening during the period 2005–2007. The prevalence of anti-CMV IgG antibodies was 68.3% (95% CI: 66.6–70.0); the seroconversion rate in the 892 seronegative women was 0.32%; the results of IgG avidity testing revealed an cumulative incidence of 1.4% (95% CI: 0.97–1.83), density incidence of 0.8% (as cases/pregnant woman-trimester) (95% CI: 0.47–1.13), and a risk of infection of 0.5% (95% CI: 0.24–0.76). The screening identified 13 cases of primary infection (84.6% of which occurred in the first trimester of pregnancy). The possibility to identify these cases and consequently to plan appropriate interventions, supports the use of screening during pregnancy, especially in the first trimester when the risk of infection is greater.

[Congenital cytomegalovirus infection: is serological screening during pregnancy necessary?]

Primary cytomegalovirus (CMV) infection occurs during pregnancy in 1% to 4% of seronegative women and may be transmitted to the fetus in up to 40% of cases. Up to 10% of intrauterine CMV infections result in symptomatic congenital disease at birth. Half of these children and 13% of those born with asymptomatic infection will develop significant clinical sequelae in infancy, especially sensorineural hearing loss. Routine CMV screening during pregnancy is not recommended in Spain owing to the absence of an effective CMV vaccine, the lack of preventive measures or therapy during pregnancy, the difficulty in diagnosing a reactivated infection, and the possibility of symptomatic congenital infections in children of immune women. However, sensitive and specific methods to diagnose primary maternal and fetal infection now exist, and new preventive and therapeutic measures have been developed. Currently, these procedures are not universally available and need to be tested in larger trials. Furthermore, the prevalence of seropositive status in pregnant women, the frequency of congenital infection, and the percentage of infants born with hearing impairment and mental retardation in our country are not known. Therefore, it would not be appropriate to introduce routine screening for CMV in pregnancy at the present time. However, increased efforts should be made to inform women about congenital CMV disease, to develop the diagnosis of fetal infection and methods to determine the extent of involvement in the case of suggestive ultrasound findings, and to treat symptomatic infected newborns with antivirals to reduce hearing impairment.

Measurement of the sensitivity of different commercial assays in the diagnosis of CMV infection in pregnancy

To evaluate the performance of different commercial assays for the detection of recent cytomegalovirus (CMV) in pregnancy, the sensitivity and specificity of assays for CMV-specific IgM antibodies were compared. Routine specimens from pregnant women were screened for CMV IgM using the Abbott AxSYM assay. Sera that were reactive according to AxSYM were further tested for IgM by other commercial assays. In selected IgM positive samples a CMV IgG avidity assay (Radim) and virus isolation from urine (shell vial) were also performed. The positivity rate for IgM anti-CMV by AxSYM was relatively high (140 out of 492, combining reactive and grayzone results). Only 26 of the 140 samples were positive for IgM according to Radim. The IgG avidity was low in 16 of the 43 samples tested, and the Radim and DiaSorin IgM assays were negative in 5 of them; 2 of the latter cases were also positive for viral isolation according to a shell vial method. There are differences in the sensitivity of the commercially available tests for CMV antibodies. CMV screening in pregnancy is performed as a first step by immunoassays and the choice of highly sensitive IgM test associated with further serological and virological methods could help to identify early primary infections.

[Congenital cytomegalovirus infection]

INTRODUCTION

Cytomegalovirus (CMV) is the most frequent cause of intrauterine infection and an important cause of auditory system damage and mental retardation in humans. Clinical presentation varies from asymptomatic form to lethal systemic dissemination.

OBJECTIVES

To describe clinical and laboratories manifestations, age at the moment of diagnostic, treatment and diagnostic test used in congenital cytomegalovirus infection.

POPULATION, MATERIAL AND METHODS

Observational, retrospective and descriptive study. Clinical histories of congenital CMV infected infants evaluated by Infectology Department of the Hospital General de Niños Dr. Ricardo Gutiérrez between January 2002 and December 2006 were analyzed.

RESULTS

Seventeen patients were evaluated. Mean age at diagnosis was 2.6 months. The most frequent symptom/sign were hepato-splenomegaly (76 %), jaundice (47 %), petechiae and hearing deficit (41 %). Anemia (53 %) and thrombocytopenia (40 %) were the most common laboratory abnormalities. Diagnosis was made exclusively by polymerase chain reaction (PCR)-CMV in one third of the patients, whereas one third was diagnosed by serology and the other third for both test. Five patients received ganciclovir as treatment. Only one had neutropenia.

CONCLUSIONS

Differential diagnosis of all newborns with hepatoesplenomegaly, jaundice and petechiae and anemia and/or thrombocytopenia must include congenital cytomegalo-virus infection. Early diagnosis allows a prompt intervention and a strict audiological follow up.