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

2. Cytolomegalovirus

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

4. 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

5. 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

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

7. 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

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

9. 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

10. 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

11. 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

13. 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

14. 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

15. Epstein-Barr Virus

16. 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

17. 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

18. 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

19. 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

20. Erythema Infectiosum

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

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

23. Erythema Infectiosum

24. 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

25. 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

26. Questions?