Clin Med II Infectious DiseaseLecture II—Viral Diseases, part 1/3

Cytolomegalovirus

Cytomegalovirus

Usually asymptomatic Seroprevalence 60-80% in

Western countries Transmission

sexual contact breast feeding blood products transplantation person-to-person congenital

Congenital CMV

Most common congenital infection in developed countries—0.2%-2% of all live births

10% of infected newborns will be symptomatic with CMV inclusion disease

CMV in Immunocompetent

Most common cause of acute mononucleosis-like syndrome with negative heterophil antibodies

Critically ill—reactivated Associated with multiple diseases but link is unclear

IBD Atherosclerosis Cognitive decline

CMV in Immunocompromised

Tissue and bone marrow transplant patients

CMV is immunosuppressive

Can contribute to transplanted organ dysfunction

HIV patients

Perinatal and CMV Inclusion

Jaundice and HSM Thrombocytopenia and purpura Microcephaly, periventricular

CNS calcifications, mental retardation and motor disability

Hearing loss in > 50% symptomatic at birth

Most infected are asymptomatic but develop neurological deficits later on

CMV in Immunocompetent

Fever, malaise, myalgias, arthralgias, splenomegaly

Cutaneous rashes Complications—mucosal GI

damage, encephalitis, hepatitis, thrombocytopenia, Guillain-Barré, pericarditis, myocarditis

CMV in Immunocompromised

Distinguish between CMV infection and CMV disease

Patients at risk—HIV, organ transplant, stem cell transplant

CMV viral loads correlate with prognosis after transplantation

CMV in Immunocompromised

Retinitis—neovascular, proliferative lesions

GI/Hepatobiliary—odynophagia, gastritis, small bowel disease, colonic disease, liver transplant complications

Respiratory—pneumonitis

Neurologic—polyradiculopathy, transverse myelitis, ventriculoencephalitis, focal encephalitis

Cytomegalovirus Mothers and Newborns—pregnant women tested for IgM

CMV antibodies q 3 mo if positive assay in 1st trimiester PCR assays of dried blood samples from newborns and

micro-ELISA on urine, saliva or blood specimens during 1st 3 weeks of life to diagnose congenital CMV

Immunocompetent—initial leukopenia followed by absolute lymphocytosis with atypical lymphocytes abnormal LFTs CMV specific IgM or 4x increase in specific IgG

Immunocompromised—serology, cultures, PCR, pp65 antigen and viral load; rapid shell-viral cultures

CXR—consistent with interstitial pneumonia Biopsy—especially useful in pneumonitis and GI disease

Cytomegalovirus

Retinitis—IV ganciclovir if sight-threatening; less severe disease, oral valganciclovir

Other infections—same antivirals; length of therapy depends on how immunosuppressed the pt is

CMV from transplant—ganciclovir (at same doses as retinis) for 2-3 weeks

Pregnancy—passive immunization with hyperimmune globulin

Prevention—no current vaccine; HAART prevents in HIV-infected patients

Cytomegalovirus

Refer neonatal infections consistent with CMV inclusion disease AIDS + retinitis, esophagitis, colitis, encephalitis AIDS + hepatobiliary disease Organ or hematopoietic stem cell transplants with suspected CMV

reactivation

Admit Risk of colonic perforation Unexplained, advancing encephalopathy Biopsy of tissues Initiation of IV anti-CMV agents

Epstein-Barr Virus

Epstein-Barr Virus

Also known as human herpesvirus type 4

Infects >90% of population worldwide and persists for lifetime of host

Mainly transmitted by saliva but can also be recovered from genital secretions

Epstein-Barr Virus

Early—fever, sore throat, fatigue, malaise, anorexia, myalgia

Lymphadenopathy, splenomegaly, rash

Conjunctival hemorrhage, pharyngitis, tonsillitis, gingivitis, soft palate petechiae

Can see other organ system involvement as well

Epstein-Barr Virus

Labs—granulocytopenia followed within 1 week by a lymphocytic leukocytosis with atypical lymphocytes comprising over 10% of leukocyte count

May see hemolytic anemia or thrombocytopenia Monospot test, IgM and IgG titers PCR – useful for malignancies associated with EBV

Epstein-Barr Virus

Over 95% of patients with acute disease recover without specific antiretroviral therapy

Symptomatic—acetaminophen or NSAIDs, warm salt-water gargles TID-QID

Hepatitis, myocarditis, and encephalitis—symptomatic Splenic rupture—splenectomy

Avoid contact sports for at least 4 weeks Prognosis good in uncomplicated cases

fever resolves in 10 days lymphadenopathy and splenomegaly resolve in 4 weeks debility can linger for 2-3 months

Erythema Infectiosum

Erythrovirus Infections

Parvovirus B19 Widespread Respiratory secretions,

saliva, placenta, blood products

Incubation 4-14 days

Erythema Infectiosum

Children—exanthematous illness, erythema infectiosum Fiery red cheeks Circumoral pallor Lacy maculopapular rash on extremities Malaise, headache, and pruritis

Erythema Infectiosum

Erythrovirus Infections Immunocompromised—

transient aplastic crisis and pure red blood cell aplasia

Adults—limited nonerosive symmetric polyarthritis

Chloroquine—exacerbates erythrovirus-related anemia

Pregnancy—premature labor, hydrops fetalis, fetal loss

Erythrovirus Infections

Clinical diagnosis may be confirmed by elevated anti-erythrovirus IgM (serum) or with PCR (serum or marrow)

Complications—rare Treatment is symptomatic in healthy patients Immunosuppressed patients—IVIG Intrauterine transfusion—severe fetal anemia Prevention—screening donated blood, standard

containment guidelines in nosocomial outbreaks Prognosis—excellent in immunocompetent patients

Questions?