Cytomegalovirus DR.K.RAJA GHTM CHENNAI

LEARNING OBJECTIVES CMV IN IMMUNO COMPETENT PATIENTS CMV IN IMMUNO COMPROMISED PATIENTS CMV IN PREGNANT WOMEN

KEY POINTS IN 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 Structure Enveloped, slightly pleomorphic Spherical 120 – 200 nm in diameter Capsid Envelope 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 Transmission can also occur – congenitally - by sexual contact - through blood transfusion

CMV may be shed in the bodily fluids urine saliva blood semen 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 hemodialysis d) patients with cancer

CMV IN IMMUNO COMPETENT PERSONS The primary infection presents as mononucleosis-like syndrome which soon resolves. Most of them asymptomatic for life.

IN PREGNANCY 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

NEONATES 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.

INFANTS AND CHILDREN WHO ACQUIRE CMV AFTER BIRTH HAVE FEW, IF ANY, SYMPTOMS OR COMPLICATIONS.

CMV IN HIV INFECTION Primary infection - rare in HIV as most have been exposed to CMV Latent CMV infection is activated in advanced HIV disease.

CMV IN HIV retinitis oesophagitis encephalitis myelitis radiculopathy colitis pneumonitis adrenalitis pancreatitis

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.

Laboratory tests CMV antibody - paired serum samples 1) ELISA 2)fluorescence assays 3)indirect hemagglutination 4)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 ml Adults: 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 vial Adults: 5 mg/kg i.v daily Third line: foscarnet, solution for injection, 24 mg/ml 250 ml, 500 ml Adults: 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.