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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 ...

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