Snapshot An 8-year-old boy is brought by his parents to the pediatrician with complaint of a fever and sore throat for the past few days. He says that he has felt tired and that his "neck is sore." Physical examination is notable for the finding seen in the image. A heterophile antibody test is negative. Introduction Overview cytomegalovirus (CMV) infection is widespread and general asymptomatic in healthy children can cause CMV mononucleosis in young adults major case of congenital infections that can lead to congenital defects, developmental delay, and neurologic sequelae Epidemiology Incidence adult seroprevalence approximately 50% by early adulthood in developed countries almost 100% by early adulthood in developing countries congenital infection about 1% of all births ETIOLOGY Pathophysiology CMV, also known as human herpesvirus type 5 (HHV-5), is in the family of human herpesviruses transmission sexual contact transplacental (congenital infection) breast milk respiratory droplets blood transfusions Presentation Symptoms congenital CMV infection 90% of babies will be asymptomatic petechial/purpuric rash hearing loss seizures acquired CMV infection fever malaise cervical lymphadenopathy Physical exam petechial or "blueberry muffin" rash (congenital infection) cervical lymphadenopathy Imaging Head CT scan indications required for infants with microcephaly or suspected congenital CMV infection findings presence of periventricular calcifications Studies Viral culture Viral PCR used to monitor status of CMV replication Differential Congenital toxoplasmosis key distinguishing factor intracranial calcifications are scattered diffusely and are not in a periventricular distribution EBV mononucleosis key distinguishing factor positive heterophile antibody test Treatment Medical antiviral agents ganciclovir cidofovir foscarnet Complications Sensorineural hearing loss incidence 10-15% of babies with congenital CMV infection Developmental and motor delay incidence 5% of babies with congenital CMV infection Chorioretinitis incidence 2% of babies with congenital CMV infection Microcephaly incidence 5% of babies with congenital CMV infection Prognosis Maternal seroconversion during the late 1st and early 2nd trimester of pregnancy is associated with more severe congenital CMV infection with CNS disease Asymptomatic congenital CMV infection has a better long-term prognosis than symptomatic infection