Cytomegalovirus infection

Cytomegalovirus infection can establish long-lasting latent infections. Most infections are asymptomatic, but some are mononucleosis-like. It is transmitted by intimate mucosal exposure, blood transfusion, and soiled diapers of infants. Immunocompromised patients may develop disseminated disease.

CASES/YEAR
9,200,000 (US); 210,600,000 (Global)
CATEGORY
Childhood Infections
AGENT TYPE
Viruses
OTHER NAMES
CMV infection, Cytomegalic inclusion disease;
ACUITY
Acute-Moderate
INCUBATION
For horizontally transmitted infections: not known; 3-12 weeks after birth for perinatal infections; [CCDM, p. 142]
INITIAL SYMPTOMS
CMV can establish long-lasting latent infections. Most infections are asymptomatic, but some are mononucleosis-like illnesses. [Cecil, p. 2174] Reactivation syndromes develop if T lymphocyte-mediated immunity is compromised. [Harrison ID, p. 757]
PRECAUTIONS
Standard; "No additional precautions for pregnant HCWs." [CDC 2007 Guideline for Isolation Precautions] "Virus is excreted in urine and saliva for many months and may persist or be episodic for several years following primary infection." [CCDM, p. 142]
COMMENTS
FINDINGS:
About 10% infants infected in utero will develop the most severe form of this disease. Neonatal CMV infection damages the central nervous system; survivors have mental retardation and chronic liver disease. CMV infection in adults may be unapparent or cause a mononucleosis-like disease. CMV is transmitted by intimate mucosal exposure, by blood transfusion, and by soiled diapers of infants. Immunocompromised patients may develop disseminated disease (pneumonitis, retinitis, enteritis, and hepatitis). [CCDM, p. 141] Leukopenia occurs in infected transplant patients. In the normal host, infrequent to rare complications include leukopenia, Bell's palsy, Guillain-Barre syndrome, interstitial pneumonia, colitis, and encephalitis. The "deadly triad" after transplantation are hepatitis, leukopenia, and pneumonitis. [ID, p. 1545]

CMV MONONUCLOSIS:
Approximately 60% to 90% of adults have antibodies from a previous infection. [Merck Manual, p. 1620] Most cases involve sexually active young adults. Laboratory abnormalities in CMV mononucleosis include atypical lymphocytosis and transaminitis. Hemolytic anemia, thrombocytopenia, and granulocytopenia are rare complications. [Harrison ID, p. 757, 759] Splenomegaly is not a common feature of CMV mononucleosis. Patients with CMV mononucleosis are older (median age 29 years), and they may have fever for 9-35 days (mean of 19 days). Severe hepatitis with jaundice is rare in CMV mononucleosis. Most patients have elevated liver function tests and atypical lymphocytes. Pharyngitis and lymphadenopathy are less common in CMV mononucleosis than in EBV mononucleosis. [ID, p. 1545] Conjunctivitis is associated with a mononucleosis-like syndrome. [Guerrant, p. 994]

CMV IN AIDS PATIENTS:
CMV can cause a progressive weakness and flaccid paralysis in AIDS patients. CMV retinitis in AIDS patients leads to blindness within 4-6 months. Another syndrome in AIDS patients is colitis with explosive watery diarrhea. [PPID, 8th Ed, p. 1743] CMV causes GI tract ulceration in AIDS patients. Dysphagia is the main finding of esophagitis. Colitis usually presents with abdominal pain, diarrhea, and weight loss. [Cohen, p. 852] CMV is a common cause of retinitis and ulcerations of the GI tract in AIDS patients. [Merck Manual, p. 1620] CMV, as an opportunistic infection, can cause pneumonia with dyspnea, dry cough, and infiltrates on chest x-ray. [Cohen, p. 853] CMV infections usually resolve when the CD4 count exceeds 100/mm3. [Cecil, 24th Ed, p. 2133]
DIAGNOSTIC
"Viral load or quantitative nucleic acid amplification testing (QNAT) preferred for diagnosis, initation of pre-emptive tx, and monitoring response to tx." [ABX Guide]
SCOPE
Global
SIGNS & SYMPTOMS
  • >arthralgia
  • >fatigue, weakness
  • >fever
  • >myalgia
  • E dysphagia
  • E pharyngitis
  • G abdominal pain
  • G blood in stool
  • G diarrhea
  • G hepatomegaly
  • G jaundice
  • G liver function test, abnormal
  • G nausea, vomiting
  • H anemia
  • H hemolysis
  • H leukopenia
  • H lymphadenopathy
  • H splenomegaly
  • H thrombocytopenia
  • N confusion, delirium
  • N headache
  • N muscle weakness
  • O conjunctivitis, acute
  • R cough
  • R dyspnea
  • S lymphadenitis, acute
  • S papules or plaques
  • S petechiae and ecchymoses
  • S rash (exanthem)
  • X lung infiltrates
  • *arthritis
  • *blindness
  • *bowel obstruction
  • *cranial neuropathy
  • *encephalitis
  • *erythema nodosum
  • *glomerulonephritis
  • *hepatitis
  • *meningitis
  • *myelitis
  • *myocarditis
  • *pancreatitis
  • *paralysis
  • *parotitis
  • *pericarditis
  • *peripheral neuropathy
  • *pneumonia
  • *pneumonitis
  • *stupor, coma
  • *uveitis
  • *weight loss
ANTIMICROBIC

Yes

VACCINE

No

ENTRY
Ingestion, Needle (Includes Drug Abuse), Scalpel or Transfusion, Skin or Mucous Membranes (Includes Conjunctiva), Sexual Contact
SOURCE
Person-to-Person, Human Fecal-Oral
RESERVOIR
Human
RISK FACTORS
  • AIDS patients
  • Cancer patients
  • Care for patients (fecal-oral pathogens)
  • Have a blood transfusion
DRUG LINK
Merck Manual: Cytomegalovirus (CMV) Infection
REFERENCES FOR CASES/YEAR
1. (US) 1% of newborns are infected with CMV; the percentage is higher in poor countries; CMV is detectable in high percentage of sexually active men and women. About 1/2 of adults are seropositive in the US. [Harrison ID, p. 757] 50% of US population is antibody positive by age 35. Up to 90% of population is antibody positive by age 2 in developing countries. [Cecil, 24th Ed, p. 2131] Calculate: 4 million/year born in US; 4 million X 15 years = 60 million; 60 million X 20% = 12 million; 12 million/15 = 800,000; 1/2 of US population = 150 million; 150 million - 12 million = 138 million; 138 million/20 years = 6,900,000; 150 million X 1% = 1,500,000; 800,000 + 6,900,000 + 1,500,000 = 9,200,000 cases/year;
2. (Global) Seroprevalence is about 60% after the age of 6 years and over 90% after the age of 80 years; [Gorbach, p. 148] In developing countries, 90% are seropositive by age 2; [Cecil, p. 2131] Guesstimate: Assume 1/2 of world has US rate of about 9 million/300 million per year (0.03); Then 3 billion X 0.03 = 90 million; Assume the other 1/2 has rate of 90% by age of 2; 134 million people born every year or 67 million/year in 1/2 of world; In 2 years 134 million born and 90% seropositive = 120.6 million; 90 million + 120.6 million = 210.6 million;