David K. Hong, MD
Pediatrics/Infectious Diseases &
Immunology/Allergy
Stanford University Medical School
Santa Clara Valley Medical Center

1. Describe the clinical features of congenital infection with CMV
2. Review current treatment options for congenital CMV infections
3. Discuss the unique features of CMV infections in premature infants

Cytomegalovirus
Beta herpesvirus - dsDNA
Co-evolved with humans
Largest virus to infect humans – 230 proteins
CMV infection is not cleared. Chronic infection leads to intermittent viral shedding
1956 – Margaret Smith isolated virus from human salivary gland
1965 – 1 st recognized CMV disease in a healthy adult (Br Med J. 1965;1099:102)

• Cell enlargement with intranuclear inclusions
– “Cytomegalic inclusion disease”
• Cytomegalia in viscera and parotid glands.
– “salivary gland virus”
Margaret Smith. Proc Soc Exp Biol Med 1956, 92:424

Thomas Weller named virus Cytomegalovirus
Virologic and Clinical Observations on
Cytomegalic Inclusion Disease. Thomas
Weller and JB Hanshaw. NEJM 1962

Clinical Manifestations of acute CMV infection
Immunocompetent Individuals
Primary CMV infection in immunocompetent children and adults is usually asymptomatic
Clinical features of acute infection overlap with EBV
Mononucleosis syndrome – more common in EBV
- fever, lymphadenopathy, lymphocytosis
- Mean duration of fever is 2 weeks
Sore throat with enlarged exudate-covered tonsils – more common in EBV
Low level elevation of liver transaminases common (>90%)

CMV infection is very Common
Prevalence of CMV by Age Group and Ethnic Group
Mexican American females
Mexican American males
Non-Hispanic white females
Non-Hispanic white males
Bates SL et al, CID 2010 vol. 50 (11) pp. 1439-1447

CMV is the most common congenital infection
Stagno S et al, Clin Obstet Gynecol. 1982 Sep;25(3):563-76
Stanford/El Camino Hospital/SCVMC – 0.6%

Stagno S et al, N Engl J Med 1982; 306:945-9

Multiple studies have shown maternal acquisition of CMV leads to fetal infection from 33—75%
Disease rates may be as high as 50% if infection occurs during first half of pregnancy

Disease manifestations – Congenital CMV
90%
10%

5-10%
Death
10%
Symptomatic at birth
50%
Survival
55%
Sensorineural hearing loss
~33% with bilateral hearing loss
IQ < 70
Congenital CMV
Newborn infected with CMV
90%
90%
Asymptomatic
No symptoms
3%
10%
Progressive hearing loss
~3% with bilateral hearing loss
52%
Microcephaly, seizures, paralysis
IQ < 70, Microcephaly, seizures, paralysis

Clinical abnormalities in symptomatic congenital CMV
Clinical Abnormality
Prematurity (<38wks)
Small for gestational age
Petechiae
Jaundice
Hepatosplenomegaly
Purpura
Microcephaly
Lethargy/hypotonia
Poor suck
Seizures
Positive/Total examined (%)
36/106 (34%)
52/106 (50%)
80/106 (76%)
69/103 (67%)
63/105 (60%)
14/105 (13%)
54/102 (53%)
28/104 (27%)
20/103 (19%)
7/105 (7%)
Boppana SB et al, Pediatr Infect Dis J. 1992 Feb;11(2):93-9

Laboratory abnormalities in symptomatic congenital CMV
Laboratory abnormality
Increased ALT
Thrombocytopenia
< 100 x 10 3 /mm 3
< 50 x 10 3 /mm 3
Direct serum bilirubin > 4mg/dL
Hemolysis
Increased CSF Protein > 120 mg/dL
Positive/Total Examined (%)
48/58 (83%)
82/81 (77%)
43/81 (53%)
47/68 (69%)
37/72 (51%)
24/52 (46%)
Boppana SB et al, Pediatr Infect Dis J. 1992 Feb;11(2):93-9

• 10% die
• 45% - 90% will have CNS sequelae
• Sequelae
– Sensorineural hearing loss
– Developmental & cognitive deficits
– Chorioretinitis

• Caring for preschool children in the year before delivery
• Onset of sexual activity <2yrs before delivery
• Sexually transmitted diseases during pregnancy
• Household size > 3 people
• Maternal age < 25
• Seroconversion between children and delivery of subsequent child within 2 years
• HIV infection
• Pre-term delivery
• Lower socioeconomic status
• Black race
Fowler KB, Pass RF Pediatrics (2006) 118:e286; Fowler KB, Stagno S, Pass RF. Clin Infect
Dis 2004; 38:1035–1037; Kenneson A, Cannon MJ. Rev Med Virol 2007; 17:253–276.

• Virus should be isolated within the first 2-3 weeks of life
• Isolation of CMV after this time may represent acquisition at birth or post-natally
• Options for isolation of virus include viral culture or PCR from saliva or urine
• CMV IgM lacks adequate sensitivity or specificity compared with culture or PCR

CMV-infect infants shed virus in their urine for many months
Stagno S et al, N Engl J Med 1982; 306:945-9

• Conventional viral culture can take 2-4 weeks to isolate CMV
• CMV shell vial – identification can occur in 24-
48 hours
• CMV PCR in urine is available at LPCH
Specimen is centrifuged onto cover slip covered with fibroblasts to accelerate virus entry
CMV is detected with fluorescent antibodies against early CMV proteins

1 st test
2 nd test
Shell
Shell
POS
NEG
POS
NEG
3 rd test Shell POS
NEG
Viral culture
POS NEG
13
0
13
1
753
754
14
753
Viral culture
POS NEG
16 1
0 1220
16 1221
17
1220
Viral culture
POS NEG
20 1
0 1530
20 1531
21
1530
Sensitivity = 1
Specificity = .999
PPV = 0.923
NPV = 1
Sensitivity = 1
Specificity = 0.999
PPV = 0.941
NPV = 1
Sensitivity = 1
Specificity = 0.999
PPV = 0.952
NPV = 1
Two CMV urine tests are adequate to screen for CMV infection
Courtesy N. Srinivas, LPCH

• Antiviral against CMV is available
– Ganciclovir - IV
• Which patients do you treat?
• How long do you treat?
• How do you know if it worked?

J Pediatr 2003; 143:16-25
- Enrolled 100 patients with symptomatic CMV disease involving the CNS
- Patients received 6 weeks of IV ganciclovir
- Patients were followed for 1 year and had hearing evaluations at 6 months and 1 year
- Found less hearing loss at 6 months and possibly less hearing loss at 1 year

Kimberlin DW. J Pediatr 2003, 143:16;

Ganciclovir therapy appears to be beneficial
• After 6 weeks of IV ganciclovir…
– At 6 months, 84% (21/25) improved or maintained hearing status
• 59% (10/17) controls
– At 12 months, 21% (5/24) worse hearing
• 68% (13/19) controls
Kimberlin DW. J Pediatr 2003, 143:16;

• 100 subjects enrolled; 42 with full follow-up for analysis
• 63% (29/46) grade 3 or 4 neutropenia
– Dosage modifications 14/29 patients
– GCSF in 2 patients
– Gram negative sepsis in 1 patient
• What about mildly symptomatic or asymptomatic patients?
• How do you know 6 weeks is enough?
– CMV can be detected in inner ear fluid
(perilymph/endolymph) in patients getting cochlear implants

3 Reasons for Prolonged Ganciclovir Therapy
1. Virus in the urine increases after treatment
2. Viral load in blood increases after treatment
3. CMV genome detected in perilymph
Whitley RJ, et al. JID 1997, 175:1080; KImberlin DW, et al. JID, 2008, Mar 15; Bauer PW, et al. Laryngoscope 2005,
115:223Sugiura S, et al. J mEd Virol 2003, 69:72

J Infect Dis (2008) 197:836-45
Valganciclovir is a form of ganciclovir that can be given orally
Dosing information is now available for infants

CASG 112

CASG 112

5-10%
Death
10%
Symptomatic at birth
50%
Survival
55%
Sensorineural hearing loss
~33% with bilateral hearing loss
IQ < 70
Congenital CMV
Newborn infected with CMV
90%
90%
Asymptomatic
No symptoms
3%
10%
Progressive hearing loss
~3% with bilateral hearing loss
52%
Microcephaly, seizures, paralysis
IQ < 70, Microcephaly, seizures, paralysis

• 90% of infants infected with CMV have no symptoms
• 5-10% will progress to sensorineural hearing loss
• We do not know…
– Which infants will have progressive hearing loss.
– If ganciclovir treatment would prevent hearing loss
– If treatment is helpful, how long would you need to treat?
• Routine screening of newborns and treatment of newborns is NOT recommended at this time

Can anti-CMV immunoglobulin prevent severe congenital infection?
Congenital
CMV disease
1 (3%) 7 (50%) 6 (16%) 19 (40%)
Nigro G et al, N Engl J Med 2005 vol. 353 (13) pp. 1350-1362

A Randomized Trial to Prevent Congenital Cytomegalovirus (CMV) - NCT01376778
Prospective, double-blind, placebo-controlled randomized controlled trial evaluating the effectiveness of CMV hyperimmune globulin
(Cytogam) at preventing congenital CMV infection in babies born to moms with primary CMV infection during the first half of pregnancy
Inclusion Criteria:
- Primary CMV infection in a mother prior to :
- 24wks gestational age
- Singleton pregnancy
Intervention:
- Cytogam – 100mg/kg – how many doses?
Primary outcome measures:
- fetal loss (spontaneous or termination)
- confirmed fetal CMV infection from amniocentesis
- neonatal congenital CMV infection diagnosed by urine or saliva collected by 3 weeks of age that is positive for CMV by culture
(the intent will be to obtain in the first two days of life)

The ideal vaccine would:
- induce high levels of CMV neutralizing antibodies
- Would be targeted at women of child-bearing age
- Would have to induce immunity better than natural immunity

CMV glycoprotein B vaccine with MF59
- recent phase 2 trial showed 50% vaccine efficacy at preventing
CMV infection in CMVseronegative women over 42 months
- 1 infant had congenital
CMV in vaccine group
(1%), while 3 infants had congenital CMV in placebo group (3%) – more women became pregnant in the placebo group
Pass RF et al, N Engl J Med (2009) 360:1191

Acquired CMV infection in premature infants
Perinatal infections can be acquired from exposure to virus in maternal genital secretions, breast milk, or transfusion
Incubation period is 4-12 weeks
Most infections are asymptomatic with no long-term sequelae
Premature infants (750-1500g) at greater risk of symptomatic postnatal CMV infection
- CMV from maternal source led to hepatosplenomegaly, neutropenia, lymphocytosis, thrombocytopenia. Longer oxygen requirement
Yeager AS et al, J Pediatr (1983)102:918
Transfusion associated CMV occurred in 13.5% of 74 infants of seronegative mothers who were exposed to blood donors with CMV
Severe or fatal CMV disease in infants born to seronegative mothers who received CMV+ blood – all were 1200g or less (<28 wks)
Yeager AS et al, J Pediatr (1981)98:281-287

What about CMV acquisition via breastmilk in ELBW and VLBW babies?
CMV is shed intermittently in breast milk
Rates of symptomatic infection in VLBW and ELBW infants from breast-milk associated infections range from 0.6 – 18%
Symptoms are variable – asymptomatic infection to severe sepsis
Lower birthweight infants and younger infants were more likely to be infected with CMV
Some data suggests that administering anti-CMV immunoglobulin prophylaxis can decrease symptomatic disease from CMV acquisition
Maschmann J et al, Clin Infect Dis (2001) 33:1998; Hamele M et al, PIDJ
(2010) 29:84; Capretti MG et al, J Pediatr (2009) 154:842