Description

• CMV is a DNA virus in the Herpesvirus family. It is a member of the β-herpesvirus subfamily, which also includes HHV-6 and -7.
• Primary infection: Often asymptomatic; may remain latent throughout a person’s life if not immunocompromised
• Severe disease can result from primary infection of the fetus and newborn or reactivation in setting of immunocompromise or organ transplantation.
• Name derives from the infected cells, which are large and contain intranuclear inclusions, described as “owl’s eye” inclusions
• Not highly contagious:
  • Spread via close contact with persons shedding virus from saliva, urine, blood, breast milk, or semen
  • Also acquired via infected transplant organs
  • Any organ can be affected.
• Categories of CMV infections:
  • Congenital
  • Perinatal
  • Acute infection in a normal host
  • Latent infection
  • Infection in bone marrow and solid organ transplant patients:
    • Heart, lung, bone marrow, liver, and kidney transplants
  • Infection in patients with AIDS
  • Infections in other immunocompromised patients
• System(s) affected: Ophthalmic; Pulmonary; GI; Neurologic; Renal; Skin/Exocrine
• Synonym(s): Giant cell inclusion disease; CID CMV

• CMV infection in pregnancy may cause illness in the newborn ranging from asymptomatic infection to severe disease or even death.
• Infection may occur in utero, intrapartum, or postnatally.
• Pre-existing maternal CMV seropositivity substantially decreases, but does not completely eliminate fetal infection.

Pediatric Considerations
Breastfeeding can transmit virus to high-risk preterm infants. However, there is low risk of symptomatic disease and no evidence of long-term sequelae from transmission from breastfeeding. Currently, there are no recommendations for avoidance or treated breast milk (1).

Epidemiology

• Common, but frequently asymptomatic
• <2–3 cases of end-organ disease per 100 person-years in HIV patients
• CMV infection is even more prevalent in populations at higher risk for HIV infection (IV drug users, 75%; homosexual males, 90%).
• Predominant age: All ages, peaks at <3 months, 16–40 years, and 40–75 years
• Predominant sex: Male > Female

• Occurs worldwide
• 40–100% of the general US population is seropositive from prior exposure during childhood or early adulthood (2).
• 20% of children in the US are seropositive before reaching puberty (2).
• Most common perinatally transmitted infection: 0.2–2.2% of births in the US (1)

Risk Factors

• HIV infection with specific risks, including:
  • CD4 count <50 cells/μL (3)[B]
  • Absence of treatment with or failure to respond to ART (3)[B]
  • Previous opportunistic infections (3)[B]
  • HIV viral load >100,000 (3)[B]
• Organ transplantation
• Blood transfusion
• Immunocompromise
• Living in closed population
• Corticosteroid therapy
• Daycare environment, infant, or geriatric
• For congenital infection, maternal infection during pregnancy
• Low socioeconomic status (1)[C]
• Critically ill immunocompetent adults in ICU settings (up to 1/3 develop CMV, primarily between days 4 and 12 after admission) (4)[A]
• Inflammatory bowel disease (5)[A]

General Prevention

• Hand washing/basic hygiene
• Avoid immunosuppression.
• Highly active antiretroviral therapy (HAART) is the best method for high-risk HIV patients (2)[A].
• Chronic maintenance therapy for life in HIV patients with CMV end-organ disease unless successfully treated with ART (6)[A]
• Options include:
  • Parenteral or oral ganciclovir (6)[A]
  • Parenteral foscarnet (6)[A]
  • Combined parenteral ganciclovir and foscarnet (6)[A]
  • Parenteral cidofovir (6)[A]
  • Ganciclovir via intraocular implant or repetitive intravitreous injection of fomivirsen (6)[A]
• CMV antibody+, HIV+ children who are severely immunosuppressed require PO ganciclovir 30 mg/kg t.i.d.
• Antiviral suppression of CMV reactivation in CMV+ transplant recipients or recipients of CMV+ organs:
  • Solid organ transplant: Prophylactic or preemptive treatment with oral ganciclovir, valganciclovir (7)[A]
  • Bone marrow transplant: IV ganciclovir
• CMV immunoglobulins decrease rate of severe disease after liver transplant (8)[A] and decrease incidence of disease after renal transplant.

Etiology

• Primary infection
• Reinfection with different CMV strains
• Reactivation of latent virus in patients who are immunosuppressed

Commonly Associated Conditions

AIDS, corticosteroid therapy, transplantation, or immunosuppression