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

2. Objectives 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

3. 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)

4. CMV - Pathology 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

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

6. 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%)

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

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

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

10. 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

11. 10% 90% Disease manifestations – Congenital CMV

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

13. Clinical abnormalities in symptomatic congenital CMV Boppana SB et al, Pediatr Infect Dis J. 1992 Feb;11(2):93-9

14. Laboratory abnormalities in symptomatic congenital CMV Boppana SB et al, Pediatr Infect Dis J. 1992 Feb;11(2):93-9

15. Symptomatic Congenital CMV 10% die 45% - 90% will have CNS sequelae Sequelae – Sensorineural hearing loss – Developmental & cognitive deficits – Chorioretinitis

16. Congenital CMV Risk Factors 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.

17. Diagnosis of Congenital CMV 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

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

19. CMV viral testing 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

20. How many CMV urine tests are needed? Viral culture POSNEG ShellPOS13114 Sensitivity = 1 NEG0753 Specificity =.999 13754 PPV = 0.923 NPV = 1 Viral culture POSNEG ShellPOS16117 Sensitivity = 1 NEG01220 Specificity = 0.999 161221 PPV = 0.941 NPV = 1 Viral culture POSNEG ShellPOS20121 Sensitivity = 1 NEG01530 Specificity = 0.999 201531 PPV = 0.952 NPV = 1 1 st test 2 nd test 3 rd test Two CMV urine tests are adequate to screen for CMV infection Courtesy N. Srinivas, LPCH

21. Treatment of Congenital CMV Antiviral against CMV is available – Ganciclovir - IV Which patients do you treat? How long do you treat? How do you know if it worked?

22. 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

23. Kimberlin DW. J Pediatr 2003, 143:16;

24. 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;

25. Major caveats… 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

26. 1. Virus in the urine increases after treatment 2. Viral load in blood increases after treatment 3. CMV genome detected in perilymph 3 Reasons for Prolonged Ganciclovir Therapy 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

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

28. CASG 112

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

32. Asymptomatic congenital CMV 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

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

34. 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) A Randomized Trial to Prevent Congenital Cytomegalovirus (CMV) - NCT01376778

35. CMV Vaccine? 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

36. -recent phase 2 trial showed 50% vaccine efficacy at preventing CMV infection in CMV- seronegative 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 CMV glycoprotein B vaccine with MF59 Pass RF et al, N Engl J Med (2009) 360:1191

37. 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

38. 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