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congenital cytomegalovirus

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1 congenital cytomegalovirus
Lalith Wijedoru Lalith Wijedoru is a medical graduate of University College London Medical School. He completed Senior House Officer training in paediatrics at Sheffield Children’s Hospital before starting Specialist Registrar posts in Leeds and subsequently Alder Hey Children’s Hospital, Liverpool. He holds a MSc in Tropical Paediatrics from the Liverpool School of Tropical Medicine (LSTM), and a junior clinical lectureship at LSTM. His academic interests relate to the febrile child in resource limited settings in Asia. His particular focus relates to the diagnostic difficulty in distinguishing viral, bacterial and parasitic infections in children, including neonates. Edited by Prof Tom Solomon, Dr Agam Jung and Dr Sam Nightingale congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment This session looks at cytomegalovirus (CMV) which is the most common congenital viral infection worldwide. Neonatal clinical signs, diagnostics, treatment and neurological sequelae in children will be discussed. Public health measures including screening and immunisation will also be considered

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Learning Objectives By the end of this session you will be able to: Recognise the clinical signs of acute CMV infection in the newborn Define both antenatal and postnatal diagnostic methods for congenital CMV Describe the treatment options for acute CMV infection in newborns List the neurological sequelae of neonatal CMV infection in children Discuss the potential public health measures which could reduce CMV-associated neuro-disability in children congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment

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Introduction Congenital infections remain an important source of neurological disability for thousands of children worldwide. Cytomegalovirus (CMV) is the commonest congenital infection in the developed world. 1-4% of women have a primary infection during pregnancy. Most of them are asymptomatic.  congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment The majority of congenitally-infected infants appear normal at birth, but long-term neurological sequelae of psychomotor retardation and/or hearing loss occur in about 10-15%. Clinical signs of acute CMV infection in infants include growth retardation, microcephaly, thrombocytopenia, and jaundice. Microbiology including serology, biochemical markers and radiology can be used in both the antenatal and postnatal diagnosis of CMV. The efficacy and duration of treatment is controversial, with ganciclovir and valganciclovir demonstrating encouraging trial results. Prevention strategies of maternal CMV infection including immunisation and screening. These remain the subject of debate given the current evidence of both vaccine efficacy and anti-viral treatment.

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Congenital Infections and Neurology I Infections associated with pregnancy may be with or without foetal consequence. Serious adverse effects include: • Foetal death • Stillbirth • Intrauterine growth retardation • Congenital malformations congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment

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Congenital Infections and Neurology II Symptomatic at birth: Those who are symptomatic at birth generally have significant long-term neurological sequelae. Asymptomatic at birth: Those are asymptomatic at birth may never manifest evidence of neurological damage, or this may become clinically evident later in life. TORCH(ES) agents: Specific congenitally-acquired infections are often referred to as the TORCH(ES) agents… Toxoplasmosis Rubella Cytomegalovirus Herpes (including varicella zoster and herpes simplex) HIV Syphilis UK public health campaigns for the majority of these infectious agents are fairly robust. However, the herpes viruses (including CMV) are considered to be neglected in this context. Prevalence: In northern Europe, the overall rate of congential CMV infection is estimated at 1% of all live births. It is estimated that between 4000 and 6000 children born each year in the United States will develop permanent neurological deficits as a result of CMV. congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment

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Microbiology Cytomegaloviruses (CMV) belong to the β-herpesviruses sub-family of herpes viruses. These viruses are highly species-specific and infect many animals. Infection is common in human populations, but rarely symptomatic in hosts with normal immune function. congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment In contrast, it can cause multi-organ disease in immuno-compromised patients of all ages. Foetuses and neonates with their relative poor immune function are particularly at risk. Like with other herpes viruses, primary infection with CMV leads to persistent infection. CMV can be transmitted from mother to child transplacentally, during birth, and in the postpartum period. Early transplacental transmission during the first trimester is associated with the greatest neurological damage to the foetus. The majority of transmission occurs in the third trimester and during delivery. Intrapartum transmission of CMV occurs in around 50% of infants born to mothers shedding CMV from the cervix or vagina. Up to 70% of sero-positive women shed CMV in breast milk

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Epidemiology I CMV is found worldwide. In developed countries, the sero-prevalence of CMV is 40% to 60% in individuals of middle to upper socio-economic status, and <80% among those of lower socio-economic status. congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment

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Epidemiology II Congenital infection Congenital infection can occur as the result of a primary CMV infection, re-infection with a new strain of CMV, or reactivation of latent infection. Maternal immunity to CMV Maternal immunity to CMV provides some protection against vertical transmission. Infection in immediate pre-conception period If a primary CMV infection occurs in the immediate pre-conception period, the risk of transmission is around 9%. Infection in 1st, 2nd, 3rd trimester Primary maternal CMV infection occurring in the first, second, and third trimester results in congenital infection in approximately 25%, 50% and 75% of foetuses respectively. Infection after recurrent maternal infection In contrast, the risk of CMV transmission to the foetus after a recurrent maternal infection is only 0.15 to 2%. However, despite the risk reduction preconception immunity affords, >60% of infants with congenital CMV are born to mothers with pre-pregnancy CMV immunity.  congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment

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Epidemiology III - Maternal Seroprevalence Incidence of congenital CMV infection increases with maternal seroprevalence. The incidence of congenital human CMV infection and maternal seroprevalance rates from published studies carried out in North America, Europe, South America and Africa were plotted as shown opposite. Note that as the rate of maternal seroprevalence increases, so does the incidence of congenital CMV infection. This suggests a threshold level of immunity that would eliminate transmission within human populations may not be attainable [1]. congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment Adapted from – Britt, W “Manifestations of Human Cytomegalovirus Infection Proposed Mechanisms of Acute and Chronic Disease” in Current Topics in Microbiology and Human Immunology eds. Shenk, T E & Stinski, M F. Springer-Verlag, Berlin, 2008.

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Clinical Features I CMV primarily affects the cerebral ventricles, the ependymal cells, the organ of Corti, and the neurons of the eighth (vestibulocochlear) cranial nerve. 90% of congenitally-infected infants are reported to be asymptomatic at birth. The remaining symptomatic 10% may demonstrate signs such as microcephaly, growth restriction and thrombocytopenia. Jaundice, petechiae, and hepatosplenomegaly are the most common findings. congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment Other clinical manifestations include… Poly or oligohydramnios Prematurity Hypotonia Poor feeding Seizures Cerebral ventriculomegaly Intracranial periventricular calcifications “Blueberry muffin” spots Sensorineural deafness (10%) Mental retardation (10-20%) Other less frequent findings include… Hydrocephalus Pneumonitis Haemolytic anaemia

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Clinical Features II About 10% of infants with symptomatic congenital CMV infection die during early infancy because of multi-organ disease with severe hepatic dysfunction, bleeding diatheses, and secondary bacterial infections. However, infants asymptomatic at birth may also develop sensorineural hearing loss (7–15%), chorioretinitis and CNS malformations. congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment

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Clinical Features III - Clinical Studies The frequency of various clinical and laboratory findings in 106 neonates with symptomatic congenital CMV infection is illustrated in the table on the next slide. 68% of infants had at least one clinical finding suggestive of neurological impairment Petechiae, jaundice, and hepatosplenomegaly were the most frequently noted abnormalities, present in approximately 75% of symptomatic neonates Physiological unconjugated jaundice is generally very common in well neonates, thus identifying a raised conjugated bilirubin fraction in an otherwise asymptomatic infant is important Over half were microcephalic and small for gestational age, and about a third born prematurely About two-thirds of symptomatic infants had clinical neurological abnormalities such as microcephaly, lethargy/hypotonia, poor suck, or seizures Of the neonates who had ophthalmological assessments, chorioretinitis or optic atrophy was noted in 20% Of the babies who had audiological assessments, 50% were found to have an abnormal hearing screen congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment

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Clinical Features IV – Clinical Studies congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment Adapted from Boppana SB et al. Newborn findings and outcome in children with symptomatic congenital CMV infection. Pediatr Res 1992.

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Clinical Findings and Deficits I The risk for neurological sequelae is increased when CMV infection occurs in the first trimester. The majority of infants with symptomatic congenital CMV infection at birth have evidence of central nervous system (CNS) impairment. The outcome and neurological deficits in 38 symptomatic congenital CMV infants are outlined in the table opposite. congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment Table adapted from Kylat RI, Edmond NK, Ford-Jones EL. Clinical findings and adverse outcomes in neonates with symptomatic congenital cytomegalovirus infection. Eur J Pediatr (2006)

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Clinical Findings and Deficits II Ocular manifestations secondary to congenital CMV include: chorioretinitis corneal opacities anterior polar cataracts optic nerve hypoplasia optic nerve coloboma (and even) anophthalmia Late onset neurologic symptoms include: - learning disability cerebral palsy - sensorineural hearing loss (SNHL) It is important to note that there is an unrecognised burden of CMV-associated neuro-disability in the paediatric population. The clinical findings and deficits listed in the table may be described as an 'unclassified' neurological syndrome in children with psychomotor retardation, with diagnoses often made retrospectively. congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment

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Sensorineural Hearing Loss Of infants with asymptomatic congenital CMV infection at birth, 10% to 15% will go on to develop symptoms, typically manifested as sensorineural hearing loss (SNHL). Congenital CMV infection is the most common non-genetic cause of SNHL in children. In the DECIBEL study, 23% of children with profound SNHL had congenital CMV infection. Permanent hearing loss occurs in approximately 14% of children with congenital CMV infection.  SNHL from congenital CMV can present later in childhood. However, symptomatic infection at birth appears to be much more likely to be associated with delayed SNHL than asymptomatic infection. Rates of delayed-onset hearing loss in symptomatic newborns are in the vicinity of %. congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment

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Estimates of Long-term Sequelae in Infants with Congential CMV In a given cohort of 1000 infants with congenital CMV, will have permanent sequelae, of whom one out of three is from the symptomatic group and two out of three are from the asymptomatic group [2]. congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment 17-20% of all infants with congenital CMV will have permanent sequelae. Adapted from Sung H & M R Schleiss Update on the current status of human cytomegalovirus vaccines. Expert Review Vaccines 9 (11),

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Diagnosis I - Prenatal Diagnosis Although the culture and polymerase chain reaction (PCR) of amniotic fluid for the detection of CMV or CMV DNA allows for prenatal identification of the majority of infected infants, the specificity of the PCR assay is only between 50 and 80%. The sensitivity of amniotic fluid culture or PCR is lower when the procedure is carried out before 21 weeks of gestation. However, the presence of CMV or CMV DNA in amniotic fluid and foetal blood samples does not appear to correlate with symptomatic congenital infection or an adverse long-term outcome in infected children. Maternal sero-conversion is another strategy used to demonstrate acute maternal CMV infection. However, there is a high rate of false positives and false negatives. Current serological diagnostic methods utilising CMV-specific IgM require more specific evaluation. congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment Studies using ultrasonography, amniocentesis and fetal blood sampling have demonstrated that it is possible to make a prenatal diagnosis of congenital CMV infection. The variable prognosis of CMV infection limits the value of prenatal diagnosis.

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Diagnosis II - Primary Maternal CMV Infection congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment Adapted from Nyholm J L & Schleiss M R Prevention of maternal cytomegalovirus infection current status and future prospects. International Journal of Women’s Health

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Diagnosis III - Microbiological Diagnosis Congenital CMV infection is proven by isolation (culture) of the virus from body fluids during the first 3 weeks of life. Urine and saliva are useful for this purpose as neonates shed high levels of virus. PCR methods can also be used on urine and saliva samples, although these need  further evaluation. Viraemia is not present in all newborn infants with congenital CMV infection; therefore detection of virus in peripheral blood should not be relied upon to diagnose congenital infection. Detection of IgM antibody to CMV is not as reliable as viral isolation and is not recommended for diagnosis. The age of the patient at the time of sample collection for detection of CMV is of some importance. Neonates who acquire CMV during birth or from breast milk shed virus after 3 weeks of age. Thus, detection of CMV in urine or saliva after 3 weeks of age is not unequivocal proof of CMV acquisition in utero. congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment

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Diagnosis IV - Laboratory Diagnosis The laboratory abnormalities seen in infants with symptomatic congenital CMV infection include (in decreasing order of frequency): Elevated serum aspartate aminotransferase Conjugated hyperbilirubinemia Thrombocytopenia – Is noted in the first few days of life in the majority of CMV-infected infants. This normalizes in most patients by the third week of life. Atypical lymphocytosis Haemolytic anaemia Elevated cerebrospinal (CSF) fluid protein – CSF protein levels appear to correlate positively with clinical indicators of CNS damage. congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment Elevations of serum transaminases and conjugated bilirubin are present in the immediate newborn period and peak during the second week of life. However, hyperbilirubinemia and liver function abnormalities often persist beyond the neonatal period, resolving over a few months. Invasive procedures such as liver biopsy are therefore not justified on the basis of persistent liver function abnormalities.

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Diagnosis V – Sero-Diagnosis Sero-conversion from negative to positive Similarly, sero-conversion from negative to positive could be considered. Pregnant women with an infectious mononucleosis-like illness could be detected this way with early testing, but this is unlikely to happen in obstetric practice. CMV-specific IgM in cord blood The diagnosis could also be established by the presence of CMV-specific IgM in cord blood or in the infant’s blood in the first 3 weeks of life. This can be detected in only 70% of congenitally-infected infants, as the titres may rise only late in acute infection. The diagnosis cannot be confirmed using CMV-specific IgG titre from cord blood as this may be a reflection of passive placental transmission. Sero-diagnosis is also used in both maternal and neonatal CMV. There are certain parameters which would suggest evidence of CMV infection. Four-fold rise in anti-CMV IgG titres A four-fold rise in anti-CMV IgG titres would be suggestive, but this requires serial blood testing to demonstrate use congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment

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Neuro-imaging I Imaging findings of congenital CMV infection include intracranial calcification, ventriculomegaly, white matter disease, neuronal migrational disorders, lissencephaly and cortical atrophy. Not all of these findings are seen in every patient, and abnormalities may range from mild to severe. In fact, unenhanced head CT results may be normal in as many as 68% of infants with symptomatic congenital CMV infection that was confirmed at birth. An abnormal CT scan is a sensitive indicator of poor cognitive outcome in symptomatic patients. Intracranial calcification is the most frequently reported imaging finding of congenital CMV infection, occurring in 34%–70% of patients. Ventriculomegaly is the second most common and is often associated with cerebral volume loss. White matter abnormalities are common in those with congenital CMV infection, occurring in as many as 22% of patients. congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment

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Neuro-imaging II The 4 sample images demonstrate ventriculomegaly and scattered periventricular calcification. These radiological findings are consistent with intrauterine TORCH infection, such as CMV. Image by Radswiki.net from Radiopaedia.org congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment

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Treatment I In some infants, there was even an improvement in audiometric parameters compared to untreated infants, of whom 41% showed auditory function deterioration. However, at age 12 months, hearing had deteriorated in 21% of the treated infants. This suggests that 6 weeks of treatment may not be sufficient to prevent hearing loss. Side-effects of ganciclovir therapy are thrombocytopenia, neutropenia, and gonadal toxicity.  congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment Ganciclovir Ganciclovir is a synthetic acyclic nucleotide analog of guanine which blocks viral DNA synthesis. It has been used for just under two decades in the treatment of congenital CMV. There is only one large randomised controlled study of the effect of ganciclovir on hearing loss (Amir et al., 2010). The results showed that 6 weeks of intravenous ganciclovir prevented hearing deterioration at 6 months.

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Treatment II Given the observations of rebound viraemia and incomplete resolution of symptoms, clinical trials have been conducted looking at intravenous ganciclovir followed by long-term oral valganciclovir for the treatment of infants with symptomatic congenital CMV disease. Passive immunisation with hyper-immune globulin (CMV HIG) has been studied for the in utero treatment and prevention of congenital CMV infection. CMV HIG is a pooled, high-titre immunoglobulin preparation derived from donors with high levels of CMV antibody. This intervention is still in early phase trials. congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment Valganciclovir Valganciclovir is another guanine derivative which is a pro-drug of ganciclovir. It has been used as CMV prophylaxis in paediatric transplant recipients. In some centres in the United States, treatment for symptomatic infants with congenital CMV has been either intravenous ganciclovir or valganciclovir. 

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Vaccines I A vaccine for congenital cytomegalovirus (CMV) infection is a public health priority. Analysis of cost–effectiveness indicates that a vaccine could have a major impact on the economic burden of paediatric neuro-disability caused by congenital CMV. Like other herpes viruses, CMV has immune evasion genes which makes it difficult to develop appropriate vaccine targets. The vaccine table summarises CMV vaccines that have undergone clinical trial evaluation since A breakthrough came with the publication of a Phase II study of a purified, recombinant vaccine based on adjuvant glycoprotein B. This vaccine demonstrated an efficacy of approximately 50% against acquisition of HMV infection in a clinical trial among young women [4]. Novel approaches to CMV vaccines include vectored vaccines, DNA vaccines, bacterial artificial chromosome (BAC)-based vaccines, and genetically engineered, live attenuated vaccines. These vaccines are in various stages of pre-clinical and clinical development [2]. congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment

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Vaccines II Vaccine table Source Sung H & M R Schleiss Update on the current status of human cytomegalovirus vaccines.  Expert Review Vaccines 9 (11), 1303–1314. congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment

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Key Points Cytomegalovirus is a herpesvirus, and the commonest congenitally-transmitted infection in the developed world Most infections are asymptomatic in both mothers and infants, although microcephaly, jaundice, and thrombocytopenia are common acute manifestations in the newborn The major long-term neurological sequelae of congenital CMV are sensorineural hearing loss, ophthalmic deficits, and general psychomotor retardation Isolation of the virus from bodily fluids is the mainstay of CMV diagnosis. Sero-diagnosis has numerous limitations Treatment with intravenous ganciclovir is recommended, with extended oral treatment with valganciclovir undergoing clinical trials Vaccines for CMV are currently being developed and tested. Pushes for more robust screening programmes for CMV remain controversial congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment

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Summary Having completed this session you will now be able to: Recognise the clinical signs of acute CMV infection in the newborn Define both antenatal and postnatal diagnostic methods for congenital CMV Describe the treatment options for acute CMV infection in newborns List the neurological sequelae of neonatal CMV infection in children Discuss the potential public health measures which could reduce CMV-associated neuro-disability in children References Britt, W. 'Manifestations of Human Cytomegalovirus Infection: Proposed Mechanisms of Acute and Chronic Disease' in Current Topics in Microbiology and Human Immunology eds. Shenk, T E & Stinski, M F. Springer-Verlag, Berlin, 2008.Kimberlin et al., 2003. Sung & Schleiss, 2010. Kimberlin et al., 2003. Pass, Zhang, Evans et al., 2009 CDC. View. Neuroimaging of Pediatric Central Nervous System Cytomegalovirus Infection congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment

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Further Reading Nyholm J L & Schleiss M R. Prevention of maternal cytomegalovirus infection: current status and future prospects. International Journal of Women's Health 2010;2:25-35 Boppana SB et al. Newborn findings and outcome in children with symptomatic congenital CMV infection. Pediatric Research. 1992;31:158A Britt, W. 'Manifestations of Human Cytomegalovirus Infection: Proposed Mechanisms of Acute and Chronic Disease' in Current Topics in Microbiology and Human Immunology eds. Shenk, TE & Stinski, MF. Springer-Verlag, Berlin. 2008 Amir J, Wolf DG, Levy I. Treatment of symptomatic congenital cytomegalovirus infection with intravenous ganciclovir followed by long-term oral valganciclovir. European Journal of Pediatrics. 2010;169:1061–1067 Fink KR et al. Neuroimaging of Pediatric Central Nervous System.Cytomegalovirus Infection  View Kimani R W et al. Sensorineural Hearing Loss in a Paediatric Population. Arch Otolaryngol Head Neck Surg. 2010;136(10): Dollard SC, Schleiss MR, Grosse SD. Public health and laboratory considerations regarding newborn screening for congenital cytomegalovirus. J Inherit Metab Dis ;(Suppl 2):S249–S254 Sung H & M R Schleiss. Update on the current status of human cytomegalovirus vaccines. Expert Review Vaccines. 2010;9(11), 1303–1314 congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment

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Self Assessment Question 1 congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment Which one of the following is a common neurological sequelae of neonatal CMV infection? Spastic quadriplegia/hemiplegia Sensorineural hearing loss Seizures/epilepsy Visual impairment

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Self Assessment Question 1 congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment Which one of the following is a common neurological sequelae of neonatal CMV infection? Spastic quadriplegia/hemiplegia Sensorineural hearing loss Seizures/epilepsy Visual impairment INCORRECT Please choose another option.

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Self Assessment Question 1 congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment Which one of the following is a common neurological sequelae of neonatal CMV infection? Spastic quadriplegia/hemiplegia Sensorineural hearing loss Seizures/epilepsy Visual impairment B. CORRECT Click here to move onto the next question

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Self Assessment Question 1 congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment Which one of the following is a common neurological sequelae of neonatal CMV infection? Spastic quadriplegia/hemiplegia Sensorineural hearing loss Seizures/epilepsy Visual impairment C. INCORRECT Please choose another option.

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Self Assessment Question 1 congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment Which one of the following is a common neurological sequelae of neonatal CMV infection? Spastic quadriplegia/hemiplegia Sensorineural hearing loss Seizures/epilepsy Visual impairment D. INCORRECT Please choose another option.

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Self Assessment Question 2 congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment Which one is a common clinical feature of acute CMV infection in the neonate? Petechiae Unconjugated hyperbilirubinaemia (jaundice) “Blueberry muffin” rash Retinitis

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Self Assessment Question 2 congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment Which one is a common clinical feature of acute CMV infection in the neonate? Petechiae Unconjugated hyperbilirubinaemia (jaundice) “Blueberry muffin” rash Retinitis A. CORRECT Click here to move onto the next question

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Self Assessment Question 2 congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment Which one is a common clinical feature of acute CMV infection in the neonate? Petechiae Unconjugated hyperbilirubinaemia (jaundice) “Blueberry muffin” rash Retinitis B. INCORRECT Please choose another option.

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Self Assessment Question 2 congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment Which one is a common clinical feature of acute CMV infection in the neonate? Petechiae Unconjugated hyperbilirubinaemia (jaundice) “Blueberry muffin” rash Retinitis C. INCORRECT Please choose another option.

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Self Assessment Question 2 congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment Which one is a common clinical feature of acute CMV infection in the neonate? Petechiae Unconjugated hyperbilirubinaemia (jaundice) “Blueberry muffin” rash Retinitis D. INCORRECT Please choose another option.

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Self Assessment Question 3 congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment Which of the following is not a recognised method of diagnosing CMV infection? Virus isolation from saliva CMV-specific IgM Antenatal ultrasound Virus isolation from peripheral blood

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Self Assessment Question 3 congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment Which of the following is not a recognised method of diagnosing CMV infection? Virus isolation from saliva CMV-specific IgM Antenatal ultrasound Virus isolation from peripheral blood A. INCORRECT Please choose another option.

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Self Assessment Question 3 congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment Which of the following is not a recognised method of diagnosing CMV infection? Virus isolation from saliva CMV-specific IgM Antenatal ultrasound Virus isolation from peripheral blood B. INCORRECT Please choose another option.

45 congenital cytomegalovirus
Self Assessment Question 3 congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment Which of the following is not a recognised method of diagnosing CMV infection? Virus isolation from saliva CMV-specific IgM Antenatal ultrasound Virus isolation from peripheral blood C. INCORRECT Please choose another option.

46 congenital cytomegalovirus
Self Assessment Question 3 congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment Which of the following is not a recognised method of diagnosing CMV infection? Virus isolation from saliva CMV-specific IgM Antenatal ultrasound Virus isolation from peripheral blood D. CORRECT Click here to move onto the next question

47 congenital cytomegalovirus
Self Assessment Question 4 congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment Which of the following statements related to the treatment of CMV is true? Aciclovir is the recognised first-line treatment in the UK Aciclovir is a pro-drug of valganciclovir CMV human immunoglobulin is indicated in CMV-positive mothers Gonadal toxicity is a recognised side-effect of valganciclovir use.

48 congenital cytomegalovirus
Self Assessment Question 4 congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment Which of the following statements related to the treatment of CMV is true? Aciclovir is the recognised first-line treatment in the UK Aciclovir is a pro-drug of valganciclovir CMV human immunoglobulin is indicated in CMV-positive mothers Gonadal toxicity is a recognised side-effect of valganciclovir use. A. INCORRECT Please choose another option.

49 congenital cytomegalovirus
Self Assessment Question 4 congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment Which of the following statements related to the treatment of CMV is true? Aciclovir is the recognised first-line treatment in the UK Aciclovir is a pro-drug of valganciclovir CMV human immunoglobulin is indicated in CMV-positive mothers Gonadal toxicity is a recognised side-effect of valganciclovir use. B. INCORRECT Please choose another option.

50 congenital cytomegalovirus
Self Assessment Question 4 congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment Which of the following statements related to the treatment of CMV is true? Aciclovir is the recognised first-line treatment in the UK Aciclovir is a pro-drug of valganciclovir CMV human immunoglobulin is indicated in CMV-positive mothers Gonadal toxicity is a recognised side-effect of valganciclovir use. C. INCORRECT Please choose another option.

51 congenital cytomegalovirus
Self Assessment Question 4 congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment Which of the following statements related to the treatment of CMV is true? Aciclovir is the recognised first-line treatment in the UK Aciclovir is a pro-drug of valganciclovir CMV human immunoglobulin is indicated in CMV-positive mothers Gonadal toxicity is a recognised side-effect of valganciclovir use. D. CORRECT Click here to move onto the next question

52 congenital cytomegalovirus
Self Assessment Question 5 congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment Which of the following statements related to the treatment of CMV is not true? There is a licensed vaccine for CMV Could potentially reduce paediatric neuro-disability Vaccine based on adjuvant protein B appear most promising Immune evasion makes herpes virus vaccines challenging to develop

53 congenital cytomegalovirus
Self Assessment Question 5 congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment Which of the following statements related to the treatment of CMV is not true? There is a licensed vaccine for CMV Could potentially reduce paediatric neuro-disability Vaccine based on adjuvant protein B appear most promising Immune evasion makes herpes virus vaccines challenging to develop A. CORRECT Click here to finish the session

54 congenital cytomegalovirus
Self Assessment Question 5 congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment Which of the following statements related to the treatment of CMV is not true? There is a licensed vaccine for CMV Could potentially reduce paediatric neuro-disability Vaccine based on adjuvant protein B appear most promising Immune evasion makes herpes virus vaccines challenging to develop B. INCORRECT Please choose another option.

55 congenital cytomegalovirus
Self Assessment Question 5 congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment Which of the following statements related to the treatment of CMV is not true? There is a licensed vaccine for CMV Could potentially reduce paediatric neuro-disability Vaccine based on adjuvant protein B appear most promising Immune evasion makes herpes virus vaccines challenging to develop C. INCORRECT Please choose another option.

56 congenital cytomegalovirus
Self Assessment Question 5 congenital cytomegalovirus Learning Objectives Introduction Congenital Infections Microbiology Epidemiology Clinical Features Clinical Findings and Deficits Sensorineural Deafness Long term Sequelae Diagnosis Neuro-Imaging Treatment Vaccines Key Points Summary Further reading Self Assessment Which of the following statements related to the treatment of CMV is not true? There is a licensed vaccine for CMV Could potentially reduce paediatric neuro-disability Vaccine based on adjuvant protein B appear most promising Immune evasion makes herpes virus vaccines challenging to develop D. INCORRECT Please choose another option.

57 Congratulations on completing this module and thank you for using NeuroID: elearning.
We hope to see you at a NeuroID: Liverpool Neurological Infectious Diseases Course soon. Download a certificate and then to finish the session CLICK HERE.

58 NeuroID 2013: Liverpool Neurological Infectious Diseases Course
To learn more about neurological infectious diseases… NeuroID 2013: Liverpool Neurological Infectious Diseases Course Liverpool Medical Institution, UK Provisional date: May 2013 Ever struggled with a patient with meningitis or encephalitis, and not known quite what to do? Then the  Liverpool Neurological infectious Diseases Course is for you! For Trainees and Consultants in Adult and Paediatric Neurology, Infectious Diseases, Acute Medicine, Emergency Medicine and Medical Microbiology who want to update their knowledge, and improve their skills. Presented by Leaders in the Field Commonly Encountered Clinical Problems Practical Management Approaches Rarities for Reference Interactive Case Presentations State of the Art Updates Pitfalls to Avoid Controversies in Neurological Infections Feedback from previous course: “Would unreservedly recommend to others” “An excellent 2 days!! The best course for a long time” Convenors: Prof Tom Solomon, Dr Enitan Carrol, Dr Rachel Kneen, Dr Nick Beeching, Dr Benedict Michael For more information and to REGISTER NOW VISIT:


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