Presented at the Neonatal Society 2004 Spring Meeting.
Cheong JLY, Cowan FM, Modi N
Division of Paediatrics, Obstetrics & Gynaecology, Faculty of Medicine, Imperial College, London
Background: Postnatal cytomegalovirus (CMV) infection has not attracted the attention received by congenital infection as it is often associated with low morbidity. However, the recognition of severe gastrointestinal symptoms in a number of preterm infants with postnatal CMV infection prompted a literature search and review of infants who were admitted to our neonatal unit over a 5-year period known to have postnatally acquired CMV.
Methods: Infants were identified as a result from CMV screening (using a urine DEAFF test) in the presence of symptoms e.g. prolonged jaundice, or signs of systemic sepsis in the absence of positive blood cultures. The diagnosis was made based on a previously negative CMV DEAFF test that became positive coincidentally with the onset of clinical symptoms.
Results: Sixteen infants were identified out of 2830 admissions over a five-year period. The median (interquartile range) gestational age was 25 weeks (24-29) and birth weight 801 g (705-978 g). One infant of 38 weeks gestational age had Rothmund-Thompson syndrome. Eleven of the infants had gastrointestinal signs at the time of presentation. These ranged from minor and transient (abdominal distension and enteral feed intolerance) to severe and life threatening (protein losing enteropathy, diarrhoea and hypernatraemic dehydration). An initial diagnosis of necrotising enterocolitis was common but no infant demonstrated intestinal or hepatic portal pneumatosis. All infants had received fresh maternal expressed breast milk prior to the onset of symptoms and at the time of diagnosis, were receiving a combination of fresh maternal expressed breast milk and banked donor breast milk. One infant received ganciclovir for 12 days.
Discussion: Gastrointestinal manifestations of CMV infection are well recognised in immunocompromised adults and older children (1), but not in the neonatal population. Our review reflects a predominance of extremely preterm infants, with a single mature infant with a known immunodeficiency syndrome. The true prevalence is likely to be much higher as DEAFF testing was selective and only when prompted by clinical signs. Hamprecht et al, in a prospective study (2) reported a mother-to-infant CMV transmission rate of 37%. Acquisition is likely to have been from fresh maternal breast milk (2) as our unit feeding policy was to commence enteral feeds as early as possible after birth, preferably with fresh maternal breast milk (stored at 40ºC) or alternatively frozen maternal or banked pasteurised donor milk (stored at -20ºC). Clarification of best practice with regards to maternal CMV testing and handling of expressed breast milk will require prospective evaluation. Treatment with ganciclovir is controversial and clinical improvement that could be attributable to antiviral treatment was unclear in our single case. We suggest that CMV enteritis is added to the spectrum of clinical manifestations of postnatal CMV infection. Signs suggestive of necrotising enterocolitis with atypical features should prompt investigations for CMV infection.
References
1. Ljungman P, et al. Clin Infect Dis 2002;34:1094-7
2. Hamprecht K, et al. Lancet 2001;357:513-8