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For further information, see CMDT Part 32-01: Human Herpesviruses

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

  • In immunocompetent persons, CMV infection is usually self-limited and no specific antiviral therapy is needed

  • In immunocompromised persons, treatment of CMV disease is necessary

    • Intravenous ganciclovir: recommended dose is 5 mg/kg every 12 hours (although this needs to be adjusted for kidney function) until two CMV PCRs 1 week apart are negative (usually 14–21 days)

    • Oral valganciclovir dose: 900 mg every 12 hours (also needs to be adjusted for kidney function) is an acceptable alternative in patients with non–life-threatening disease

    • Pneumonia due to CMV in hematopoietic stem cell transplant recipients is treated even more aggressively

      • 5 mg/kg of ganciclovir intravenously every 12 hours for 21 days followed by 5 mg/kg daily for 3–4 weeks plus CMV immunoglobulin (500 mg/kg)

      • CMV immunoglobulin (150 mg/kg) twice per week for 2 weeks and then once weekly for an additional 4 weeks

  • Foscarnet and cidofovir are reserved for treatment of resistant infections

  • Other agents that may be useful in resistant CMV infections include

    • CMV immunoglobulin

      ...

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