Dilemmas in the management of congenital cytomegalovirus (CMV)

Abstract

<h3>Background</h3> Routine antenatal ultrasound screening revealed liver calcifications, and subsequent maternal serology (IgM and IgG) was shown to be positive for cytomegalovirus (CMV). Shortly after birth he was found to have hepatosplenomegaly, petechiae and visible jaundice. Bloods within the first few hours revealed marked conjugated jaundice, thrombocytopaenia and deranged coagulation. The baby was admitted to our neonatal unit for observation and treatment and congenital CMV infection was confirmed within 24 hours by positive CMV PCR from his urine. Further investigations revealed no intracranial abnormalities, no evidence of retinitis and normal newborn hearing. Abdominal ultrasound confirmed hepatic calcification and organomegaly. <h3>Management</h3> Following discussion between neonatal and paediatric infectious disease consultants, a decision was taken to treat the infant with IV ganciclovir for 2 weeks (necessitating insertion of a percutaneous long line), followed by oral valganciclovir for 4 weeks. Weekly Viral loads were checked, together with frequent monitoring for neutropaenia. <h3>Issues</h3> This case highlighted several dilemmas in the management of congenital CMV. CMV is the most frequent congenital infection and has a UK incidence of around 3-4/1000 live births. Around 10-15% of these infants will be symptomatic, of whom up to 90% will develop long term sequelae usually in the form of sensorineural hearing loss, visual impairment or developmental delay. Some 13% of asymptomatic infants also develop long term problems. In spite of such morbidity, decisions of whom to treat, and for how long, remain controversial. Whilst there is some support for treating infants with CNS symptoms, there is a paucity of high level evidence for treating infants with other organ involvement. In addition, the adverse effects of treatment - namely requirement of central venous access with its associated complications, and potential neutropaenia – are not inconsiderable. The controversies of treatment, and uncertainty regarding long term follow-up of symptomatic and asymptomatic babies, mean such cases provide difficult management problems.