Cytomegalovirus (CMV) Infection

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

• An ELISPOT assay is superior to Quantiferon assays in reports from China and may show potential for both diagnosis and monitoring disease in transplant recipients

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 ...