Cytomegalovirus

DR.K.RAJA

GHTMCHENNAI

LEARNING OBJECTIVES

CMV IN IMMUNO COMPETENT PATIENTS

CMV IN IMMUNO COMPROMISED PATIENTS

CMV IN PREGNANT WOMEN

KEY POINTSIN HIV CMV IS REACTIVATION OF LATENT INFECTION

HIV AND CMV COINFECTION – RAPID PROGRESSION OF HIV

CD4 - <50 – CMV IS ACTIVATED AND DISSEMINATED

IN PREGNANCY ONLY PRIMARY INFECTION CAUSES IN VITRO TRANMISSION

NEONATES, INFECTED IN UTERO - RASHES, HEPATITIS, GASTROENTERITIS AND A ORGAN SPECIFIC MALADIES.

SURVIVORS – HEARING LOSS, VISION IMPAIRMENT AND MENTAL RETARDATION.

IN IMMUNO COMPETENT – FLU LIKE SYNDROME

AND REMAIN LATENT LIFE TIME

Human Cytomegalovirus

herpesvirus

betaherpesvirinae subfamily

CMV infected cells may become enlarged (cytomegalia), showing intranuclear inclusions.

Virus StructureEnveloped,

slightly pleomorphic

Spherical 120 – 200 nm in

diameter

CapsidEnvelope

Tegument Genome

double stranded DNA per virion

TRANSMISSION

Transmitted through infected bodily fluids that come in contact with hands

and then are absorbed through the nose or mouth of a susceptible

person.

Transmission can also occur – congenitally

- by sexual contact - through blood

transfusion

CMV may be shed in the bodily fluids urine saliva bloodsemen

breast milk

The shedding of virus- intermittent

- without signs-without causing symptoms.

CMV infection High-risk groups:

(1) infection to the unborn baby during pregnancy

(2) infection to people who work with children

(3) immunocompromised person:

a) organ transplant recipients b) human immunodeficiency virus (HIV)

C)undergoing hemodialysisd) patients with cancer

The primary infection presents as mononucleosis-like syndrome which soon resolves.

Most of them asymptomatic for life.

CMV IN IMMUNO COMPETENT PERSONS

IN PREGNANCY WHEN A WOMEN WHO HAS NEVER HAD CMV INFECTION BECOMES INFECTED WITH CMV,

THERE IS A POTENTIAL RISK THAT AFTER BIRTH THE INFANT MAY HAVE

CMV-RELATED COMPLICATIONS

IN PREGNANCY

NEONATES, INFECTED IN UTERO - RASHES, HEPATITIS, GASTROENTERITIS AND A

ORGAN SPECIFIC MALADIES.

THE MOST COMMON OF WHICH ARE ASSOCIATED WITH HEARING LOSS, VISUAL

IMPAIRMENT, OR DIMINISHED MENTAL AND MOTOR CAPABILITIES.

NEONATES

INFANTS AND CHILDREN WHO ACQUIRE CMV AFTER BIRTH HAVE

FEW, IF ANY, SYMPTOMS OR COMPLICATIONS.

Primary infection - rare in HIV as most have been exposed to CMV

Latent CMV infection is activatedin advanced HIV disease.

CMV IN HIV INFECTION

CMV IN HIV retinitis

oesophagitis encephalitis

myelitis radiculopathy

colitis pneumonitis

adrenalitispancreatitis

CMV Retinitis

small floaters foggy or blurred vision

loss of central or peripheral vision

routine exam when the infectious process is early and located in the

peripheral retina

loss of vision

retinal detachment

CMV Retinitis

CMV – COFACTOR IN THE PROGRESSION OF HUMAN IMMUNODEFICIENCY VIRUS TYPE 1 (HIV-1)

DISEASE.

PROGRESSION

Laboratory tests

CMV antibody - paired serum samples

1) ELISA 2)fluorescence assays 3)indirect hemagglutination4)latex agglutination

A virus culture

Tissue biopsy for culture

CMV blood culture ("buffy coat" culture)

CMV urine culture

CMV sputum cultures

ANTIGEN

CMV shell vial (a method of determining the presence of CMV antigens)

BIOPSY

Biopsies of organs likely to be infected with CMV

Treatment

First line:ganciclovir, powder for injection, 500

mg in vial Adults: 5 mg/kg i.v twice a day for 14-21

days

Second line:foscarnet, solution for injection, 24

mg/ml 250 ml, 500 mlAdults: retinitis; 90 mg/kg i.v daily for

14-21 days for CMV Adults: CMV oesophagitis; 90 mg/kg i.v

twice a day for 14-21 days

Maintenance

First Line:ganciclovir, capsules, 250 mg

Adults: 1 g orally three times a day

Second Line:ganciclovir, powder for injection, 500 mg

in vialAdults: 5 mg/kg i.v daily

Third line:foscarnet, solution for injection, 24

mg/ml 250 ml, 500 mlAdults: 90 mg/kg i.v daily

ALTERNATIVE TREATMENT

Valganciclovir 900mg bid po

Cidofovir 5mg/kg weekly

PROPHYLAXIS

Primary prophylaxis is generally not recommended because of cost concerns,

inconvenience and the potential for development of resistance

MAINTAINENCE

CD4+ cell counts > 100 for > 3 months as a result of potent ART

Prevention

Simple hand washing with soap and water is effective in removing the

virus from the hands.