Updated: 8/7/2020

Cytomegalovirus (CMV)

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Snapshot
  • A 25-year-old woman presents to the clinic for routine check-up. She reports that about a month ago, she had what she thought was mononucleosis. She had fevers, chills, a red rash, muscle pain, and joint pains. She works in a daycare center, and some of her colleagues had similar symptoms. This resolved in 1 week. Today, there are no significant findings on physical exam. Laboratory evaluation reveals that she is positive for CMV-specific immunoglobulin M. Other laboratory tests are negative.
Introduction
  • Classification
    • cytomegalovirus (CMV) or human herpesvirus-5 (HHV-5)
      • double-stranded DNA virus
      • largest virus that causes human infections
      • transmission via body fluids or vertical transmission
  • Epidemiology
    • incidence
      • very common
    • risk factors
      • immunosuppression
      • men who have sex with other men
      • poor socioeconomic status
      • working in childcare
      • transplant recipients
        • prone to CMV pneumonia
  • Pathogenesis
    • CMV-caused diseases can either result from a primary infection or reactivation of a latent infection
    • replication of host cells (including epithelial cells, macrophages, and neurons) results in viremia and symptoms from primary infection
    • cellular immunity is crucial in clearing this virus
  • Associated conditions
    • congenital CMV infection
  • Prognosis
    • often self-limited in immunocompetent patients
Presentation
  • Symptoms
    • immunocompetent patients
      • most cases are asymptomatic
      • if symptomatic, CMV infections often result in a mononucleosis syndrome with fevers, myalgias, arthralgias, and cough
    • immunocompromised patients
      • esophagitis
      • colitis (most common) 
      • encephalitis
      • hepatitis
      • pneumonia
      • retinitis 
      • congenital CMV
      • hemolytic anemia
  • Physical exam
    • fever
    • cervical lymphadenopathy
    • hepatosplenomegaly
    • maculopapular rash
Studies
  • Labs
    • lymphocytosis with atypical lymphocytes
    • thrombocytopenia
    • transaminitis
    • negative heterophile antibody
    • CMV-specific immunoglobulin G (persists for 4-6 months) 
    • CMV-specific immunoglobulin M (2-3 weeks)
      • active infection
    • viral load 
      • does not distinguish active vs past infection
  • Histology  
    • if warranted, may reveal CMV on immunohistochemistry
  • Making the diagnosis
    • based on clinical presentation and laboratory studies
Differential
  • Epstein-Barr viral (EBV) mononucleosis
    • distinguishing factors
      • CMV mononucleosis often includes more myalgias, arthralgias, and cough than EBV infection
      • CMV infection also does not typically present with sore throat or lymphadenopathy 
Treatment
  • Management approach
    • mainstay of treatment is supportive care
  • Conservative
    • supportive care
      • indication
        • all patients
      • modalities
        • hydration
  • Medical
    • antiviral medications
      • indications
        • immunocompromised patients
        • severe disease or organ damage
      • drugs
        • ganciclovir  
        • valganciclovir
Complications
  • Thrombosis
  • Colitis
  • Permanent vision changes

 

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