Cytomegalovirus (CMV) infection in

newborn infants and immunocompromised

patients

Rozália Pusztai M.D., Ph.D.

Department of Medical Microbiology and Immunobiology,
Faculty of Medicine, University of Szeged,
Szeged, Hungary

4th ESCMID School, Clin Microbiol Infect Dis, Szeged, Hungary, 2005
Human herpesviruses

Herpesviridae
Betaherpesvirinae
human cytomegalovirus (HCMV)
or human herpesvirus 5 (HHV5)

large number of genetic

variants
 HCMV epidemiology, 1

•Humans are the only reservoir for human CMV

•Sources of infection: oropharyngeal secretions, urine,
cervical and vaginal secretions, semen, breast milk,
tears, feces and blood
•Transmission occurs by
•hand to mouth contact with infected body fluids
•sexual contact
•blood transfusion
•organ or bone marrow transplants
•from infected pregnant women to the fetus or newborn
•breastfeeding
 HCMV epidemiology, 2

•Up to 60% of children become infected before the age

of 14 years
The prevalence in adults varies widely (40-100%) and
is dependent on the geography and the socioeconomic
status of the population
•Intermittant shedding of CMV from many sites is
common in seropositive hosts
•Virus excretion may last for years in congenital,
perinatal and early postnatally infected hosts
Seroepidemiology of HCMV
Seroprevalence of HCMV infection by age
and sexual orientation in San Francisco

Adapted from: consensus form on CMV prevention. Triclinica, 1995

 Clinical findings
Normal host
•Primary infection in the normal host usually results in
mononucleosis (about 8% of infectious mononucleosis cases)
•Rare complications include pneumonia, hepatitis and
CNS disease
•In children <7 years of age, CMV infection may result in
severe liver or respiratory disease
•Infection induces both a humoral (IgM, IgG and IgA) and
a cell mediated immune (CMI) response
•Recurrent infection is rare in the normal host, but common in
the immunocompromised
People at increased risk of active CMV
infection and serious complications

•Babies born to women who have a first-time CMV

infection during pregnancy
•Pregnant women who work with infants and children
•Persons with weakened immune systems, including
•organ or bone marrow transplant recipients
•persons with HIV infection
•cancer patients on chemotherapy
 Clinical findings
Immunocompromised host
•Both the morbidity and the mortality are increased for
primary and recurrent infections in the immunocompromised
•Viral excretion is more intense and prolonged with
immunosuppression, and chronic viremia may occur
•The antibody response is similar in primary infection and
reactivation, but the CMI is depressed
•CMV infection predisposes to fatal bacterial, fungal and
parasitic infections
 Vertical transmission of CMV infection

Route Maternal situation Rate of CMV in infant

•Transplacental Primary gestational infection 20-40%

Seropositive before conception 0.2-2.2%

•Intrapartum Seropositive 5%

Virus in genital tract at term 50%

•Breast milk Seropositive mother 25%

Virolactia 65-70%

Fields Virology, 2001

 CMV infection in newborn infants
Incidence
0.5-2.2% (mean 1%)

10-15% symptomatic 85-90% asymptomatic

at birth at birth

20-30% die 5-15% develop sequelae

90% of survivors
develop sequelae 85-95% are normal

10% of survivors
are normal

~ 3 out of 1000 newborns suffer

from a congenital CMV infection
 Epidemiology and pathogenesis of
congenital CMV infection in the USA*
Live births: 4 000 000/year

CMV infection of newborns: 40 000 (1%)

symptomatic at birth: asymptomatic at birth:

2 800 (7%) 37 200 (93%)

fatal survivors with survivors with healthy

disease: sequelae::
sequelae sequelae::
sequelae survivors:
340 2 200 5 600 31 200
(10%) (90%) (15%) (85%)
Fatal outcome and /or sequelae of all live births: 8140 (0.2%)
*Rothe et al., 2000
 Congenital CMV infection
The rate of congenital CMV infection may be higher

Author Country Year Population Infection

infected (%)

Women

Doyle et al. Texas-USA 1996 HIV 6.5

AIDS 21
Congenital CMV infection and maternal
immunity

Seropositive women Women who seroconverted

during pregnancy

Congenital 1.2% 12.9%

CMV infection (22/1828) (15/116)

Preconceptional maternal immunity is protective against congenital CMV

infection, decreasing the risk of infection by 91%

Stagno, 1997
 Congenital CMV infection

Exogenous infection Endogenous infection

(primary or secondary)

every
secretion Pregnant women

Fetus
Hypothetical routes of congenital CMV
infection

•Placental infection
•Local reactivation
(endometrium, cervix, ovary)
•Transovarian infection
•Ascending infection (vaginal tract)
Transmission of CMV via the placenta and
infection of the fetus
Infected mother Viremia Infection of placental trophoblasts

Infection of
oropharynx
Virus in Infection of fetal
amniotic fluid endothelial cells

Fetal viruria Fetal viremia

Viral replication in
target organs (kidney)
Findings in the fetus that should alert the clinician to
the possibility of intrauterine infection
•Oligohydramnios or polyhydramnios
•Non-immune hydrops
•Fetal ascites
•Intrauterine growth retardation
•Microcephaly
•Cerebral ventriculomegaly or hydrocephalus
•Intracranial calcifications
•Pleural or pericardial effusion
•Hepatosplenomegaly
•Intrahepatic calcifications
 Primary CMV infection in pregnant
women
Symptoms
•clinically inapparent (in most cases)
•persistent fever, myalgia, sore throat, cervical
adenopathy, extreme fatigue (frequently)
•infectious mononucleosis (uncommon)

Laboratory findings
•atypical lymphocytosis
•elevated hepatic transaminases
•negative heterophilic antibody response
Diagnosis of maternal CMV infection

CMV-specific laboratory diagnosis

Diagnostic algorithm for CMV serology in
pregnant women
Perform sensitive CMV
IgM and IgG screening assays

M-G- M-G+ M+G+ M+G-

Follow-up test later Recall patient 3 weeks

No further testing later and retest
(remote infection) CMV IgG avidity test
M+G+ M+/-G-
High avidity Low avidity
(remote infection)

No further Primary CMV

testing infection

Prenatal diagnosis at Follow-up

weeks 21-23 of gestation test later
 Advanced CMV diagnosis

•Determination of IgG avidity index

•Application of anti-glycoprotein B IgG serology

•Application of microneutralization
•IgM confirmation by Western blotting
•Isolation of the virus from the urine, saliva or
blood
 Congenital CMV infections
Low IgG avidity is linked to primary infection
70

60
Avidity index (%)

50

40

30

20

10

0
0 5 10 15 20 25 30 35
Weeks after beginning of symptoms

Landini, 1999
Diagnosis of primary CMV infection in pregnancy by additional use of
anti-CMV gB (CG3) IgG ELISA

Rothe et al., 2000

 A confirmatory test for CMV-IgM

New immunoblot µ

Vp150
Purified
1) Contains both structural and Vp82 native
nonstructural proteins Vp65 viral
Vp28 proteins
2) Agrees with consensus of
rp150
different ELISAs
rp52 Recombinant
3) Is easy to standardize rp130
r proteins

4) Is easy to interpret rp38

CKS

Landini, 2000
 Detection of CMV and CMV
products in maternal blood

CMV

CMV antigen
diagnostic at any level
CMV DNA (confirmation of serology)

CMV IE mRNA
 Methods of CMV detection

•culturing of virus

•shell vial
(IE viral protein)
•CMV antigenemia assay
(pp65 protein)
•PCR - for qualitative and quantitative detection of CMV DNA

•RT-PCR or NASBA* - either IE or late mRNA may be detected

*nucleic acid sequence-based amplification
Prenatal diagnosis of congenital CMV
infection

Prevents unnecessary termination in

70% of the cases
Gives the possibility of termination in
30% of the cases
Why?
The newborn will be checked for CMV
infection and, if necessary, treated
with ganciclovir

Prenatal therapy (?)

Landini, 1999
 Prenatal diagnosis of congenital CMV
infection

1. False-negative results may be reported

before this age: the fetus excretes CMV via
the urine into the amniotic fluid, and fetal
diuresis becomes established only after 20-
When? 21 weeks of gestation
At 21-23 weeks of
gestation
2. In most cases, at least 6-9 weeks pass
from the time of maternal infection before
the virus can be detected in the amniotic
fluid and it is known that CMV
transmission is correlated with severe fetal
diseases, mainly when it occurs during the
first 12 weeks of gestation
Landini, 1999
Prenatal diagnosis of congenital CMV
infection
PCR and/or virus isolation from amniotic fluid
Weeks 21-23 of gestation

Positive result

qPCR

Level of fetal risk

Low High
<105 GE/ml ≥ 105 GE/ml
 Conclusion

Congenital CMV infections prenatally can

be diagnosed
 Question

Can the prenatal diagnosis identify fetuses at

high risk of CMV-related symptoms?
 qPCR in 79 amniotic fluids:
relationship with pregnancy outcome

N= newborns F F
F= fetuses
F N F
106 N N FN
CMV-GE/ml

N N F
F
105 F
N
104 N N
103
F
N (n 56) NN N
NN
Uninfected Infected Infected ?
asymptomatic symptomatic
Pregnancy outcomes
Landini, 1999
 Clinical manifestations of congenital CMV
infection
Neonatal evaluation Clinical findings (estimated %)
Symptomatic Hepatosplenomegaly 65-75
(10-15 % of cases) Petechiae or purpura 60-70
Jaundice 50-60
Microcephaly 40-50
IUGR* 40-50
Hypo- or hypertonia 20-30
Chorioretinitis 10-20
Asymptomatic Normal (10-15% exhibit a developmental
delay or a sensoneural hearing loss is
detected in childhood)
*Intrauterine growth retardation
CMV-infected newborns

Blueberry muffin lesions

Congenital CMV infection

The head CT scan demonstrates diffuse

calcifications in the basal ganglion and
subependymal regions of the brain.
The degree of involvement is more
extensive than suspected from US
examination.

Ceola and Angtuaco, 1999

Congenital CMV infection

Cerebellar dysplasia in a neonate with

congenital CMV infection. Note the
lissencephaly of the cerebrum with
large calcifications

Patel and Barkovich, 2002

 Postnatal diagnosis of congenital CMV
infection
First week of life
PCR and/or virus iolation from urine
Antigenemia –viremia

- + Neonatal follow-up

Second week of life

virus isolation
from urine

- + Neonatal follow-up
Prevention of congenital CMV infection

There is currrently no method of proven efficacy

that prevents maternal CMV infection during
pregnancy
 CMV infection in immunocompromised
patients
CMV is a significant opportunistic pathogen in

•Solid organ recipients

•Bone marrow recipients

•AIDS patients
•Patients receiving immunosuppressive therapy
•Subjects with congenital immunodeficiencies
 Mechanisms of CMV infection in
transplant recipients

•Transmission by donor organ

•Blood products
•Reactivation of latent virus in the recipient
 Clinical syndromes associated with CMV
infection in mmunocompromised patients
Syndromes AIDS Solid organ Bone marrow
transplant
Esophagitis + + +
Gastritis + + +
Enterocolitis + + +
Fever/hepatitis + ++ +
Pancreatitis - ++ -
Pneumonitis - + ++
Retinitis ++ + +
Encephalopathy + - -
Polyradiculopathy + - -
CMV enterocolitis in AIDS patients

Cecal ulceration

CMV colitis
Mucosal inflammation with mucosal hemorrhage, edematous
fields and polypoid lesions. Biopsis demonstrated viral inclusions
with CMV

http://www.endoatlas.com/co_co_08.html
 CMV retinitis

Normal retina

Retinas affected by CMV retinitis

http://strc.cc/pages/disease_cytomegalovirus.asp
 CMV inclusions in organs

Characteristic inclusion
in liver

Inclusions in lung
Strategies to prevent CMV infection in solid
organ and bone marrow recipients
•matching the donor-recipient pair by CMV
serologic status
•use of CMV-negative blood products
•antiviral agents to suppress viral replication
•immunoglobulin preparations to provide
passive immunization
•reconstitution of cellular immunity to CMV
in bone marrow recipients
Drugs currently available for treatment

• Ganciclovir
• Foscarnet
• Cidofovir
• Valganciclovir
• Fomivirsen
All antiviral compounds suppress active
replication of the virus, but do not eliminate it
 Therapeutic approaches

•Antiviral prophylaxis
•Pre-emptive treatment
•Treatment of an established disease
 Antiviral prophylaxis

An antiviral drug is administered before any active

CMV infection is detected, in order to prevent its
occurrence
This prophylaxis is recommended for renal transplant
recipients
•when the donor or recipient is seropositive
•if the recipient is subjected to an immuno-
suppressive regimen
 Pre-emptive therapy

Antiviral treatment is initiated when CMV positivity*

is detected in the blood or bronchoalveolar lavage
fluid by using sensitive method in
bone marrow
liver or
lung recipients

* CMV antigenemia or DNAemia

Treatment of established CMV disease

In immunosuppressed subjects:
ganciclovir 5 mg/kg every 12 h or
foscarnet 60 mg/kg every 8 h
iv for 2-3 weeks
 Benefits of host immune response
to CMV

•Maternal immunity ameliorates the effects of intrauterine infection

on the fetus
•Premature neonates with maternal antibody are protected from
postnatal infection
•Pretransplant immunity protects organ allograft recipients from
severe disease
•Passively administered antibody protects organ allograft recipients
•Protective efficacy has been demonstrated in murine and guinea pig
models of (homologous strain) CMV infection using attenuated strains

Plotkin, 2000
 Experimental CMV vaccines

•Live attenuated Towne strain

•Recombinant of Towne with genes from virulent virus
•Multiple genes in canarypox vector
•Subunit gB glycoprotein/MF59 or gB/alum
•Peptide fusion of A2 and pp65 with helper peptide

•DNA plasmids

•Dense bodies
Arvin et al., 2004