Congenital CMV

Background

• Infection with cytomegalovirus acquired in utero
• See also CMV in pregnancy

Epidemiology

• Maternal seroconversion in about 2% of pregnancies
  • Higher in childcare workers
• Risk of transmission to fetus
  • About 1 in 200 live births in US
  • Primary infection: 30% risk of congenital CMV; higher risk later in pregnancy, but worse outcomes earlier
  • Non-primary
    • Reinfection: 5% risk
    • Reactivation: 1% risk
• Risk of transmission to fetus following primary infection increases with gestational age, but risk of neurological sequelae decreases substantially1

Maternal Serostatus	Trimester	Transmission to Fetus	Severity of Neurological Disease			Overall Probability (of any neurological disease)
			Severe	Mild/Transient	None
Primary	first	30%	5%	30%	65%	10%
	second	40%	0%	15%	85%	6%
	third	70%	0%	0%	100%	0%
Reinfection	overall	5%				<1%
Reactivation	overall	1%				<1%

• Overall, 20% of infected babies will have permanent neurological sequelae
  • 50% of those symptomatic at birth and 15% of those asymptomatic

Clinical Manifestations

• Mother may have had asymptomatic infection
• At birth (10%)
  • Microcephaly (35-50%)
  • Periventricular calcifications
  • Seizure (5-10%)
  • Chorioretinitis (10-15%)
  • Sensorineural hearing loss (35%)
  • Optic nerve atrophy
  • Petechiae (50-75%)
  • Neonatal jaundice (40-70%)
  • Hepatosplenomegaly (40-60%)
  • Small size for gestational age (40-50%)
  • Lethargy and hypotonia (30%)
  • Poor suck (20%)
  • Cytopenias
  • Hemolytic anemia (5-10%)
  • Pneumonia (5-10%)
• Later
  • Cognitive deficits (7%)
  • Sensorineural hearing loss (20%)

Diagnosis

• In mom, IgM antibodies
• In baby, urine PCR within 2 weeks of birth

Management

• Treatment is indicated for symptomatic babies
  • Brain
  • Hearing
  • Eye
• IV ganciclovir or PO valganciclovir, for 6 months
• Monitor CBC while on therapy