I. See Also

II. Epidemiology

  1. General Population
    1. Prior exposure in 40-100% of general population
    2. Many cases occur in childhood and adolescence
    3. May account for 2% of febrile adult cases
      1. Wreghitt (2003) Clin Infect Dis 37:1603-6
  2. HIV patients
    1. Infects 75-100% of HIV positive patients
    2. Active CMV disease occurs in 20% with CD4 Count <100
    3. CMV disease rarely occurs at CD4 Count > 50 cells

III. Pathophysiology

  1. Human Herpes Virus (Herpesviridae)
  2. Pathogenesis
    1. CMV remains latent after initial infection
    2. CMV reactivates in immunocompromised patients
  3. Infectivity
    1. Spread by close contact with body fluids
    2. Passed by Saliva, urine, blood, semen, Breast Milk
    3. Also passed by organ tissue transplants

IV. Risk factors for infection

  1. Pregnant day care workers (see TORCH Virus)
  2. Organ transplant recipients
  3. Immunocompromised patients (e.g. HIV Infection)

V. Symptoms and Signs

  1. Asymptomatic in most immunocompetent patients
  2. CMV-Induced Mononucleosis
    1. Identical to EBV-Induced Mononucleosis
    2. Accounts for up to 7% of Mononucleosis cases
    3. Classic Ampicillin rash also occurs with CMV
  3. Intrauterine adverse effects to fetus
    1. CMV is a TORCH Virus
    2. Risk of Intrauterine Growth Retardation

VI. Labs

  1. Complete Blood Count
    1. CMV-Induced Mononucleosis changes
      1. Lymphocytes increased >50%
      2. Atypical lymphocytes 10% of total Lymphocytes
    2. Uncommon findings
      1. Anemia
      2. Thrombocytopenia
  2. Liver Function Test abnormalities (in acute infection)
    1. Most common clinical factor to distinguish CMV
      1. Abnormal in 72% of cases
      2. Wreghitt (2003) Clin Infect Dis 37:1603-6
    2. Aspartate transaminase increased less than 5x normal
    3. Alanine Transaminase increased less than 5x normal
  3. Serology
    1. CMV IgM titer
      1. Best diagnostic test for CMV-Induced Mononucleosis
      2. Indicated if Heterophil Antibody Test negative
    2. CMV PCR
      1. Indications
        1. Immunocompromised patients
        2. Suspected CMV Encephalitis or polyradiculopathy
      2. Not useful in acute infection
        1. Positive test may be transient reactivation
  4. Histology of tissue biopsy (CMV organ involvement)
    1. Owls-eye inclusion body (highly specific for CMV)
  5. CMV-Induced false positive tests
    1. Rheumatoid Factor
    2. Direct Coombs
    3. Cryoglobulinemia
    4. Speckled pattern of Antinuclear Antibody test

VII. Differential Diagnosis

  1. Mononucleosis (nearly identical presentation)
  2. See Mononucleosis Differential Diagnosis

VIII. Diagnosis

IX. Complications in Immunocompromised patients

  1. CMV Chorioretinitis (occurs in 15-20% of HIV patients)
  2. Gastrointestinal tract infection (in 5-10% of HIV)
    1. Hepatitis
    2. Pancreatitis
    3. Colitis
  3. Less common or rare effects
    1. Guillain-Barre Syndrome
    2. Neurologic involvement
      1. Encephalitis
      2. Peripheral Neuropathy
    3. Interstitial Pneumonia
    4. Myocarditis
    5. Epididymitis
    6. Skin changes
      1. Nonspecific rash
      2. Perifollicular papulopustules
      3. Vesiculobullous lesions

X. Management: General

  1. No school or work restrictions in acute infection
    1. Children may continue to attend school or daycare
    2. Healthcare workers may continue to work

XI. Management: Immunocompromised patients (especially HIV)

  1. Highly Active Antiretroviral Therapy (HAART) in HIV
    1. Critical to prevent CMV organ involvement
    2. Risk in HIV highest when CD4 Count <50/mm3
  2. Indications for Viral DNA polymerase inhibitors
    1. CMV Retinitis (Urgent therapy)
    2. Clinically Significant colitis or other end-organ
    3. Treatment of asymptomatic CMV not indicated
  3. Preparations
    1. Ganciclovir
      1. Granulocytopenia and Anemia risk (25%)
    2. Foscarnet (Foscavir)
      1. Nephrotoxicity (33%)
      2. Neurotoxicity
      3. Electrolyte disturbance (Hypokalemia, Hypocalcemia)
    3. Cidofovir (Vistide)
      1. Nephrotoxicity
      2. Neutropenia
      3. Alopecia
  4. Efficacy
    1. CMV Retinitis responds to 14-21 day in 75-90% cases
    2. Patients failing one drug should move to the other
  5. Dosing
    1. Acute
      1. Cidofovir 5 mg/kg IV each week for 2 weeks
    2. Chronic maintenance (prevents relapse in 4-8 weeks)
      1. Cidofovir 5 mg/kg every other week

XIII. Resources

  1. CDC National Center for Infectious Diseases
    1. http://www.cdc.gov/ncidod/diseases/cmv.htm

Images: Related links to external sites (from Google)

Ontology: Cytomegalovirus Infections (C0010823)

Definition (MSHFRE) Infection à cytoméglovirus caractérisée par l'apparition de cellules volumineuses comportant des inclusions intranucléaires. L'infection peut toucher presque tous les organes mais elle atteint surtout les glandes salivaires chez l'enfant et les poumons chez l'adulte.
Definition (NCI) A herpesvirus infection caused by Cytomegalovirus. Healthy individuals generally do not produce symptoms. However, the infection may be life-threatening in affected immunocompromised patients. The virus may cause retinitis, esophagitis, gastritis, and colitis. Morphologically, it is characterized by the presence of intranuclear inclusion bodies.
Definition (MEDLINEPLUS)

Cytomegalovirus (CMV) is a virus found around the world. It is related to the viruses that cause chickenpox and infectious mononucleosis (mono). Between 50 percent and 80 percent of adults in the United States have had a CMV infection by age 40. Once CMV is in a person's body, it stays there for life.

Most people with CMV don't get sick. But infection with the virus can be very serious in babies and people with weak immune systems. If a woman gets CMV when she is pregnant, she can pass it on to her baby. CMV does not harm most babies. But some develop lifelong disabilities.

CMV is spread through close contact with body fluids. You should use good hygiene, including proper hand washing, to avoid catching or spreading the virus. Most people with CMV don't require treatment. If you have a weakened immune system, your doctor may prescribe antiviral medicine.

Centers for Disease Control and Prevention

Definition (MSH) Infection with CYTOMEGALOVIRUS, characterized by enlarged cells bearing intranuclear inclusions. Infection may be in almost any organ, but the salivary glands are the most common site in children, as are the lungs in adults.
Concepts Disease or Syndrome (T047)
MSH D003586
ICD9 078.5
ICD10 B25 , B25.9
SnomedCT 186699001, 187456009, 28944009, 243578002, 186695007, 154371005, 266203007
English Cytomegalovirus, Cytomegalic Inclusion Disease, Cytomegalic Inclusion Diseases, Cytomegalovirus Infection, Cytomegalovirus Infections, Diseases, Cytomegalic Inclusion, Inclusion Disease, Inclusion Disease, Cytomegalic, Inclusion Diseases, Inclusion Diseases, Cytomegalic, Infections, Cytomegalovirus, Salivary Gland Virus Disease, CMV INFECTION, CYTOMEGALIC INCLUSION DISEASE, CYTOMEGALOVIRUS INFECTION, Disease, Cytomegalic Inclusion, Infection, Cytomegalovirus, Cytomegalovirus infection, NOS, CMV - Cytomegalovirus infec, Cytomegaloviral dis,unspec, Cytomegaloviral disease, unspecified, [X]Cytomegaloviral dis,unspec, [X]Cytomegaloviral disease, unspecified, Cytomegaloviral Infection, CYTOMEGALUS VIRUS INFECTION, CYTOMEGALIC INCLUSION DIS, CYTOMEGALOVIRUS INFECT, INFECT CYTOMEGALOVIRUS, INCLUSION DIS, SALIVARY GLAND VIRUS DIS, cytomegalovirus infection, cytomegalovirus disease, cytomegalovirus disease (diagnosis), cmv infection, [X]Cytomegaloviral disease, unspecified (disorder), CMV Infections, CMV infection, Cytomegaloviral infections, Cytomegalus virus infection, Cytomegalovirus Infections [Disease/Finding], cmv cytomegalovirus infection, cytomegalovirus infections, cytomegaloviral infections, cytomegaloviral infection, cmv infections, cytomegalic inclusion disease, Cytomegalic inclusion disease, Salivary gland virus disease, CMV - Cytomegalovirus infection, Cytomegalovirus infection, Cytomegalovirus infection (disorder), Disease due to Cytomegalovirus, inclusion disease, cytomegaloviral disease, disease (or disorder); inclusion disease (cytomegaloviral), disease (or disorder); inclusion disease, salivary gland, inclusion disease; salivary gland, salivary gland; inclusion disease, Cytomagalovirus infection, Cytomegaloviral disease, cytomegalovirus
Italian Infezione da citomegalovirus, Malattia citomegalica, Infezione da Cytomegalovirus, Infezioni da Cytomegalovirus
Dutch cytomegalie-inclusieziekte, CMV-infectie, aandoening; inclusion disease (cytomegalie), aandoening; inclusion disease, speekselklier, inclusion disease; speekselklier, speekselklier; aandoening, insluitlichaampje, Ziekten door cytomegalovirus, niet gespecificeerd, cytomegalovirusinfecties, cytomegalovirusinfectie, Cytomegalovirusziekte, Cytomegalo-inclusieziekte, Cytomegalovirus-infectie, Cytomegalovirus-infecties, Inclusieziekte, Infectie, cytomegalovirus-, Infecties, cytomegalovirus-, Speekselklierziekte, virale, Virusinfectie, cytomegalo-, Virusinfecties, cytomegalo-
French Infection par CMV, Infection à cytomegalovirus, Maladie des inclusions cytomégaliques, INFECTION A CMV, Infection à Cytomégalovirus, Infections à Cytomégalovirus, Infections à cytomégalovirus, Infections à CMV
German Einschlusskoerperchenkrankheit, Cytomegalus-Virusinfektion, CMV Infektion, ZYTOMEGALOVIRUSINFEKTION, Zytomegalie, nicht naeher bezeichnet, Zytomegalievirus-Infektionen, Zytomegalievirus-Infektion, Zytomegalievirusinfektionen, Zytomegalie, Einschlußkörperchenkrankheit, Speicheldrüsenviruskrankheit
Portuguese Infecção por CMV, Doença de inclusão citomegálica, INFECCAO POR CITOMEGALOVIRUS, Infecção a citomegalovírus, Infecções a citomegalovírus, Doença de Inclusão Citomegálica, Doença de Inclusão, Doença Viral das Glândulas Salivares, Infecções por Citomegalovirus
Spanish Infección por CMV, Enfermedad citomegálica de inclusión, Cytomagalovirus infection, Cytomegalic inclusion disease, Cytomegalovirus infection, Salivary gland virus disease, [X]Cytomegaloviral disease, unspecified, [X]enfermedad por citomegalovirus, no especificada, [X]enfermedad por citomegalovirus, no especificada (trastorno), enfermedad por inclusión citomegálica, enfermedad virósica de las glándulas salivales, infección por CMV, infección por citomegalovirus (trastorno), infección por citomegalovirus, Infecciones por citomegalovirus, Infección por citomegalovirus, Enfermedad de Inclusión Citomegálica, Enfermedad de Inclusión, Enfermedad Viral de la Glándula Salival, Infecciones por Citomegalovirus, Enfermedad Viral de la Glandula Salival, Enfermedad de Inclusion Citomegalica, Enfermedad de Inclusion
Swedish Cytomegalovirusinfektioner
Japanese サイトメガロウイルスカンセン, キョサイボウフウニュウタイビョウ, サイトメガロウイルス感染症, Cytomegalovirus感染症, 唾液腺ウイルス疾患, 封入体病, 封入病, 巨細胞封入体病, 巨細胞性封入体病, サイトメガロウイルス感染, 巨細胞封入体症
Czech cytomegalie inkluzní, Cytomegalovirus - infekce, Infekce způsobené cytomegaloviry, Infekce způsobená cytomegaloviry, Cytomegalovirová infekce, Cytomegalovirová inkluzní nemoc, Infekce cytomegalovirem
Finnish Sytomegalovirusinfektiot
Russian INKLIUZIONNAIA BOLEZN', TSITOMEGALOVIRUSNYE INFEKTSII, SLIUNNYKH ZHELEZ VIRUSNAIA BOLEZN', TSITOMEGALIIA, TSITOMEGALIIA LOKALIZOVANNAIA, ИНКЛЮЗИОННАЯ БОЛЕЗНЬ, СЛЮННЫХ ЖЕЛЕЗ ВИРУСНАЯ БОЛЕЗНЬ, ЦИТОМЕГАЛИЯ, ЦИТОМЕГАЛИЯ ЛОКАЛИЗОВАННАЯ, ЦИТОМЕГАЛОВИРУСНЫЕ ИНФЕКЦИИ
Korean 상세불명의 거대세포바이러스병, 거대세포바이러스병
Croatian CITOMEGALOVIRUSNE INFEKCIJE
Polish Zakażenie cytomegaliawirusowe, Cytomegalia
Hungarian Cytomegaliás inclusiós betegség, Cytomegalovírus okozta fertőzések, Cytomegalovirus fertőzés, CMV fertőzés

Ontology: Cytomegalovirus (C0010825)

Definition (NCI) A genus of the family herpesviridae, subfamily betaherpesvirinae, infecting the salivary glands, liver, spleen, lungs, eyes, and other organs, in which they produce characteristically enlarged cells with intranuclear inclusions.
Definition (MSH) A genus of the family HERPESVIRIDAE, subfamily BETAHERPESVIRINAE, infecting the salivary glands, liver, spleen, lungs, eyes, and other organs, in which they produce characteristically enlarged cells with intranuclear inclusions. Infection with Cytomegalovirus is also seen as an opportunistic infection in AIDS.
Definition (CSP) widely occurring intracellular herpesvirus characterized by narrow host specificity and slow reproduction (latency); causes a variety of pathologies in mammals, including AIDS related oculopathy in humans.
Definition (NCI) A virus that may be carried in an inactive state for life by healthy individuals. It is a cause of severe pneumonia in people with a suppressed immune system, such as those undergoing bone marrow transplantation or those with leukemia or lymphoma.
Concepts Virus (T005)
MSH D003587
SnomedCT 407444007, 16609001, 243579005, 243578002, 243577007
English Cytomegalovirus, Cytomegaloviruses, Salivary Gland Viruses, Virus, Salivary Gland, Viruses, Salivary Gland, Salivary Gland Virus, Cytomegalovirus group, NOS, Cytomegalovirus, NOS, Salivary gland virus, NOS, cytomegalovirus, CMV, salivary gland virus, CMV - Cytomegalovirus, Cytomegalovirus group virus, Genus Cytomegalovirus, cytomegalovirus group, Cytomegalovirus (living organism) (organism), CMV, CYTOMEGALOVIRUS, salivary gland viruses, cmv cytomegalovirus, cytomegalovirus (CMV), Salivary gland virus, Genus Cytomegalovirus (organism), Cytomegalovirus (living organism) [Ambiguous], Cytomegalovirus group virus (organism), Cytomegalovirus group
French Cytomégalovirus, CMV, Cytomegalovirus, Virus cytomégalique
Swedish Cytomegalovirus
Spanish género Cytomegalovirus, Cytomegalovirus, citomegalovirus, CMV, citomegalovirus (concepto no activo), citomegalovirus (organismo vivo), grupo citomegalovirus, virus de la glándula salival, virus de las glándulas salivales, grupo Cytomegalovirus, virus del grupo de CMV, virus del grupo de citomegalovirus (organismo), virus del grupo de citomegalovirus, género Cytomegalovirus (organismo), Citomegalovirus, Virus de la Glandula Salival, Virus de la Glándula Salival
Czech Cytomegalovirus, CMV infekce
Finnish Sytomegalovirus
Italian Virus della ghiandola salivare, Cytomegalovirus
Russian GERPESVIRUS 5 (BETA) CHELOVEKA, TSITOMEGALOVIRUS, GERPESVIRUS 5 CHELOVEKA, SLIUNNYKH ZHELEZ BOLEZNI VIRUSY, ГЕРПЕСВИРУС 5 (БЕТА) ЧЕЛОВЕКА, ГЕРПЕСВИРУС 5 ЧЕЛОВЕКА, СЛЮННЫХ ЖЕЛЕЗ БОЛЕЗНИ ВИРУСЫ, ЦИТОМЕГАЛОВИРУС
Japanese ヒトヘルペスウイルス5(ベータ), ヒトヘルペスウイルス5型, ヒトヘルペスウイルス5, 唾液腺ウイルス, サイトメガロウイルス, ヘルペスウイルス5型-ヒト, サイトメガロウイルス
Portuguese CMV, Citomegalovirus, Cytomegalovirus, Vírus das Glândulas Salivares
German CMV, Zytomegalievirus, Speicheldrüsenviren
Dutch CMV, Cytomegalievirus, Cytomegalovirus, Virus, Cytomegalo-, Speekselkliervirus
Croatian CITOMEGALOVIRUS
Polish Cytomegaliavirus, Wirusy ślinianek, Wirusy cytomegalii, CMV, Cytomegalowirusy
Hungarian CMV