Cytomegalovirus (CMV) Infections

Key Features

Essentials of Diagnosis

• Primary infection

  • Asymptomatic or minor illness in young children

  • Mononucleosis-like syndrome without pharyngitis in postpubertal individuals

• Congenital infection

  • Intrauterine growth retardation

  • Microcephaly with intracerebral calcifications and seizures

  • Retinitis and encephalitis

  • Hepatosplenomegaly with thrombocytopenia

  • "Blueberry muffin" rash

  • Sensorineural deafness

• In immunocompromised children

  • Retinitis and encephalitis

  • Pneumonitis

  • Enteritis and hepatitis

  • Bone marrow suppression

General Considerations

• Can be acquired in utero following maternal viremia or postpartum from birth canal secretions or maternal milk; in utero infection can be teratogenic

• Young children are infected by the saliva of playmates; older individuals are infected by sexual partners (eg, from saliva, vaginal secretions, or semen)

• Transfused blood products and transplanted organs can be a source of CMV infection

• Illness usually mild and self-limited in immunocompetent individuals

• CMV in immunocompromised children

  • Severe, progressive, often multiorgan disease can develop

  • Severity of the resulting disease is generally proportionate to the degree of immunosuppression

Clinical Findings

Symptoms and Signs

• Congenital CMV

  • Severely affected infants are born ill

    • Often small for gestational age, floppy, and lethargic

    • Feed poorly and have poor temperature control

    • Hepatosplenomegaly, jaundice, petechiae, seizures, and microcephaly are common

    • Characteristic signs are a distinctive chorioretinitis and periventricular calcification

    • A purpuric (so-called blueberry muffin) rash similar to that seen with congenital rubella may be present

    • Isolated hepatosplenomegaly or thrombocytopenia may occur

  • Even mildly affected children may subsequently manifest mental retardation and psychomotor delay

  • However, most infected infants (90%) are born to mothers with preexisting immunity who experienced a reactivation of latent CMV during pregnancy

    • These children have no clinical manifestations at birth

    • Of these, 10–15% develop sensorineural hearing loss, which is often bilateral and may appear several years after birth

• Perinatal CMV

  • Subclinical illness (ie, virus excretion only) or a minor illness develops within 1–3 months in 90% immunocompetent infants infected by their mothers at birth

  • An illness lasting several weeks characterized by hepatosplenomegaly, lymphadenopathy, and interstitial pneumonitis in various combinations develops in 10%

• CMV acquired in childhood and adolescence

  • Most young children are asymptomatic or have a minor febrile illness, occasionally with adenopathy

  • Prolonged fever with hepatosplenomegaly and adenopathy may be seen

• CMV in immunocompromised children

  • A mild febrile illness with myalgia, malaise, and arthralgia may occur, especially with reactivation disease

  • Severe disease often includes subacute onset of dyspnea and cyanosis as manifestations of interstitial pneumonitis

  • Auscultation reveals only coarse breath sounds and scattered rales

  • A rapid respiratory rate may precede clinical or radiographic evidence of pneumonia

  • Hepatitis without jaundice or hepatomegaly is common

  • Diarrhea, which can be severe, occurs with CMV colitis

  • CMV can cause esophagitis with symptoms of odynophagia or dysphagia

  • Retinitis that often progresses to blindness, encephalitis and polyradiculitis seen in patients with AIDS

Differential Diagnosis

• Toxoplasmosis

• Rubella

• Enteroviral infections

• Herpes simplex

• Syphilis

• Epstein-Barr virus

• Other mononucleosis syndromes, which ...