Clin Med II Infectious Disease Lecture II—Viral Diseases, part 1/3

Cytolomegalovirus

Cytomegalovirus Usually asymptomatic Seroprevalence 60-80% in Western countries Transmission sexual contact breast feeding blood products transplantation person-to-person congenital

Congenital CMV Most common congenital infection in developed countries—0.2%-2% of all live births 10% of infected newborns will be symptomatic with CMV inclusion disease

CMV in Immunocompetent Most common cause of acute mononucleosis-like syndrome with negative heterophil antibodies Critically ill—reactivated Associated with multiple diseases but link is unclear IBD Atherosclerosis Cognitive decline

CMV in Immunocompromised Tissue and bone marrow transplant patients CMV is immunosuppressive Can contribute to transplanted organ dysfunction HIV patients

Perinatal and CMV Inclusion Jaundice and HSM Thrombocytopenia and purpura Microcephaly, periventricular CNS calcifications, mental retardation and motor disability Hearing loss in > 50% symptomatic at birth Most infected are asymptomatic but develop neurological deficits later on

CMV in Immunocompetent Fever, malaise, myalgias, arthralgias, splenomegaly Cutaneous rashes Complications—mucosal GI damage, encephalitis, hepatitis, thrombocytopenia, Guillain-Barré, pericarditis, myocarditis

CMV in Immunocompromised Distinguish between CMV infection and CMV disease Patients at risk—HIV, organ transplant, stem cell transplant CMV viral loads correlate with prognosis after transplantation

CMV in Immunocompromised Retinitis—neovascular, proliferative lesions GI/Hepatobiliary—odynophagia, gastritis, small bowel disease, colonic disease, liver transplant complications Respiratory—pneumonitis Neurologic—polyradiculopathy, transverse myelitis, ventriculoencephalitis, focal encephalitis

Cytomegalovirus Mothers and Newborns—pregnant women tested for IgM CMV antibodies q 3 mo if positive assay in 1st trimiester PCR assays of dried blood samples from newborns and micro-ELISA on urine, saliva or blood specimens during 1st 3 weeks of life to diagnose congenital CMV Immunocompetent—initial leukopenia followed by absolute lymphocytosis with atypical lymphocytes abnormal LFTs CMV specific IgM or 4x increase in specific IgG Immunocompromised—serology, cultures, PCR, pp65 antigen and viral load; rapid shell-viral cultures CXR—consistent with interstitial pneumonia Biopsy—especially useful in pneumonitis and GI disease

Cytomegalovirus Retinitis—IV ganciclovir if sight-threatening; less severe disease, oral valganciclovir Other infections—same antivirals; length of therapy depends on how immunosuppressed the pt is CMV from transplant—ganciclovir (at same doses as retinis) for 2-3 weeks Pregnancy—passive immunization with hyperimmune globulin Prevention—no current vaccine; HAART prevents in HIV- infected patients

Cytomegalovirus Refer Admit neonatal infections consistent with CMV inclusion disease AIDS + retinitis, esophagitis, colitis, encephalitis AIDS + hepatobiliary disease Organ or hematopoietic stem cell transplants with suspected CMV reactivation Admit Risk of colonic perforation Unexplained, advancing encephalopathy Biopsy of tissues Initiation of IV anti-CMV agents

Epstein-Barr Virus

Epstein-Barr Virus Also known as human herpesvirus type 4 Infects >90% of population worldwide and persists for lifetime of host Mainly transmitted by saliva but can also be recovered from genital secretions

Epstein-Barr Virus Early—fever, sore throat, fatigue, malaise, anorexia, myalgia Lymphadenopathy, splenomegaly, rash Conjunctival hemorrhage, pharyngitis, tonsillitis, gingivitis, soft palate petechiae Can see other organ system involvement as well

Epstein-Barr Virus Labs—granulocytopenia followed within 1 week by a lymphocytic leukocytosis with atypical lymphocytes comprising over 10% of leukocyte count May see hemolytic anemia or thrombocytopenia Monospot test, IgM and IgG titers PCR – useful for malignancies associated with EBV

Epstein-Barr Virus Over 95% of patients with acute disease recover without specific antiretroviral therapy Symptomatic—acetaminophen or NSAIDs, warm salt- water gargles TID-QID Hepatitis, myocarditis, and encephalitis—symptomatic Splenic rupture—splenectomy Avoid contact sports for at least 4 weeks Prognosis good in uncomplicated cases fever resolves in 10 days lymphadenopathy and splenomegaly resolve in 4 weeks debility can linger for 2-3 months

Erythema Infectiosum

Erythrovirus Infections Parvovirus B19 Widespread Respiratory secretions, saliva, placenta, blood products Incubation 4-14 days

Erythema Infectiosum Children—exanthematous illness, erythema infectiosum Fiery red cheeks Circumoral pallor Lacy maculopapular rash on extremities Malaise, headache, and pruritis

Erythema Infectiosum

Erythrovirus Infections Immunocompromised— transient aplastic crisis and pure red blood cell aplasia Adults—limited nonerosive symmetric polyarthritis Chloroquine— exacerbates erythrovirus-related anemia Pregnancy—premature labor, hydrops fetalis, fetal loss

Erythrovirus Infections Clinical diagnosis may be confirmed by elevated anti- erythrovirus IgM (serum) or with PCR (serum or marrow) Complications—rare Treatment is symptomatic in healthy patients Immunosuppressed patients—IVIG Intrauterine transfusion—severe fetal anemia Prevention—screening donated blood, standard containment guidelines in nosocomial outbreaks Prognosis—excellent in immunocompetent patients

Questions?