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Updated: Dec 23 2021

Cytomegalovirus (CMV)

Images retinitis.jpg
  • 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
    • Associated conditions
      • congenital CMV infection
  • 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
  • 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
  • Prognosis
    • Often self-limited in immunocompetent patients
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