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Key Features

  • Most CMV infections are asymptomatic

  • CMV seroprevalence increases with

    • Age

    • Lower socioeconomic status

    • Number of sexual partners

    • History of prior sexually transmitted infections

    • Employment in child day care centers

  • Acute acquired CMV infection is similar to infectious mononucleosis, except pharyngeal symptoms unusual

  • Virus can be isolated from a variety of tissues under nonpathogenic conditions

  • Serious disease occurs primarily in immunocompromised persons

Clinical Findings

  • Perinatal disease and CMV inclusion disease

    • Jaundice, hepatosplenomegaly, thrombocytopenia, purpura, microcephaly, periventricular CNS calcifications, mental retardation, and motor disability

    • Hearing loss develops in greater than 50% of infants who are symptomatic at birth

    • Most infected neonates are asymptomatic, but neurologic deficits may ensue later in life, including hearing loss in 15% and mental retardation in 10–20%

    • Perinatal infection acquired through breast-feeding or blood products typically shows a benign clinical course

  • CMV infection in immunocompetent persons

    • Mononucleosis-like syndrome with negative heterophil antibodies

    • The mononucleosis-like syndrome can also occur post-splenectomy, often years later

    • Fever, malaise, myalgias and arthralgias, splenomegaly, atypical lymphocytes, and abnormal liver function tests

    • Cutaneous rashes are common

    • Typically, leukopenia is followed by leukocytosis

    • Complications

      • Mucosal gastrointestinal damage

      • Encephalitis

      • Severe hepatitis

      • Thrombocytopenia (on occasion, refractory)

      • Guillain–Barré syndrome

      • Pericarditis

      • Myocarditis

  • CMV infection in immunocompromised persons

    • CMV retinitis, with neovascular and proliferative retinal lesions, occurs primarily in advanced AIDS

    • GI and hepatobiliary CMV, with esophagitis, small bowel inflammation, colitis, or cholangiopathy, occurs in AIDS or with high-dose chemotherapy

    • Pneumonitis occurs in transplant recipients and AIDS

    • Neurologic manifestations include polyneuropathy, transverse myelitis, encephalitis

Diagnosis

  • Characteristic clinical symptoms in immunosuppressed patients

  • Tzanck smear, CMV antibodies, and polymerase chain reaction (PCR) helpful in the proper clinical context

  • Tissue biopsy showing characteristic histology is used to document invasive disease

  • Pregnant women should be tested for CMV viremia every 3 months if an assay during the first trimester is seropositive

Treatment

  • Sight-threatening CMV retinitis

    • Ganciclovir induction therapy (5 mg/kg intravenously every 12 hours for 14–21 days) followed by maintenance therapy at lower doses (5 mg/kg intravenously daily)

    • Intravitreal injections of ganciclovir or foscarnet may be used as adjunct therapy

    • In less severe retinal disease, valganciclovir (900 mg twice daily for 14–21 days followed by 900 mg/day maintenance) is preferred

    • Due to potential toxicities, foscarnet. cidofovir, and formvirsen are usually reserved for CMV infections that are resistant to ganciclovir

    • Combinations of ganciclovir and foscarnet are shown to be safe and effective in treating clinically resistant CMV retinitis

  • For non-severe CMV disease post-transplant

    • Oral valganciclovir (900 mg twice daily) or intravenous ganciclovir (5 mg/kg every 12 hours)

    • Valganciclovir is noninferior to intravenous ganciclovir-based therapy in solid organ transplant patients and is associated with less clinical resistance than ganciclovir

  • For severe CMV disease post-transplant

    • Intravenous ganciclovir remains the treatment of choice

    • Dosage adjustments of all medications are needed for kidney dysfunction

    • Reduction of immunosuppression should be attempted when possible (especially for muromonab, azathioprine, or mycophenolate mofetil)

    • Treatment ...

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