Successful treatment with oral valganciclovir in immunocompetent infant with gastrointestinal manifestations of cytomegalovirus infection

Cytomegalovirus enteritis with intractable diarrhea in infants from a tertiary care center in China

Background: Cytomegalovirus (CMV) is rarely thought to be the cause of significant gastrointestinal infection in immunocompetent children. CMV colitis is seldom observed in young infants. This study aims to examine the clinical features of CMV colitis in Chinese children.Methods: Patients with infantile onset CMV colitis diagnosed in intestinal tissue at Children's Hospital of Fudan University from 1st January 2017, to 31st January 2019 were enrolled. Clinical data were retrieved from medical records, and the literature on infant CMV colitis was also reviewed.Results: Ten patients were included with a median age of 2.5 months [interquartile range 2.0, 6.3 months]. All 10 patients had diarrhea, 10 patients had anemia, seven patients reported hematochezia, five patients had hypoalbuminemia, five patients had retinitis, two patients had hearing impairment, and one patient had perianal abscess and anal fistula. The patients had punched-out ulcerations, longitudinal ulcerations or irregular ulcerations on the rectum and/or colon. Typical histologic evaluation showed crypt distortion and inflammatory infiltration. CMV inclusion bodies were noted in four patients. Immunohistochemistry on intestinal tissue was performed to diagnose CMV, with all patients positive. After follow-up, all patients are clinically recovered or in remission; six patients received antiviral therapy, and five patients had healed ulcers on endoscopic examination.Conclusions: CMV colitis might be a rare cause of intractable diarrhea in immunocompetent children. Clinicians should be aware of the possibility of CMV colitis in patients with intractable diarrhea.

Cytomegalovirus Enterocolitis in Immunocompetent Young Children: A Report of Two Cases and Review of the Literature

Cytomegalovirus (CMV) causes significant morbidity and mortality in congenitally infected children and immunocompromised hosts. Among healthy individuals, CMV is generally thought to cause mild, self-limited illness. CMV enterocolitis, in particular, is rarely considered among immunocompetent children presenting with diarrhea. We describe 2 cases of invasive CMV colitis in immunocompetent infants presenting with diarrhea and review the literature to date on this topic. Although invasive CMV enterocolitis has been sporadically reported among immunocompetent children, it remains an underrecognized cause of infectious diarrhea in this population and indications for antiviral therapy are lacking. We propose that CMV should be included in the differential diagnosis of intractable diarrhea in immunocompetent children.

Cytomegalovirus infection in immunocompetent wheezy infants: the diagnostic value of CMV PCR in bronchoalveolar lavage fluid

WHAT IS KNOWN AND OBJECTIVE

Cytomegalovirus (CMV) pneumonitis in immunocompetent hosts is uncommon but is being recognized more frequently, particularly when presenting as severe viral pneumonia. The objective of this study was to examine lower respiratory tract CMV infection in immunocompetent wheezy infants, based on polymerase chain reaction (PCR) in bronchoalveolar lavage (BAL) fluid, to compare CMV PCR results in BAL and in blood samples and to evaluate the benefits of antiviral ganciclovir therapy in these patients.

METHODS

Retrospective review of the records of patients referred to our tertiary care hospital between January 2000 and July 2010 who had unexplained persistent wheezing and underwent fibreoptic flexible bronchoscopy (FFB).

RESULTS AND DISCUSSION

Fibreoptic flexible bronchoscopy was applied to 102 infants with persistent wheezing and diffuse interstitial infiltration on radiological investigations; so CMV PCR in BAL fluid was performed. CMV PCR in BAL fluid was positive in 51 patients. Retrospectively, we had access to the files of 25 of these patients. The mean CMV PCR in BAL fluid was 334 840 copies/mL. Only eight patients had CMV PCR positivity in their blood samples (mean: 2026·3 copies/mL). There was not a relationship between BAL and blood CMV PCR values based on Spearman's correlation analysis (r = -0·008). Fourteen patients had severe respiratory symptoms and received ganciclovir therapy. Twelve of them fully recovered.

WHAT IS NEW AND CONCLUSION

Bronchoalveolar lavage fluid CMV PCR was superior to blood CMV PCR in diagnosing lower respiratory tract infections caused by CMV in immunocompetent infants. Ganciclovir therapy may be effective in selected immunocompetent wheezy infants with CMV PCR positivity in BAL fluid.

Severe acquired cytomegalovirus infection in a full-term, formula-fed infant: case report

BACKGROUND

Cases of cytomegalovirus colitis are exceptionally reported in immuno-competent infant. The pathogenesis is uncertain but breast-feeding is considered as a main source of postnatal infection.

CASE PRESENTATION

Here we report a full-term, formula-fed infant who developed a severe cytomegalovirus anaemia and colitis when aged 2 months.

CONCLUSION

Even if the molecular identity between the cytomegalovirus-isolate of the infant and the maternal virus could not be demonstrated, we confirmed through laboratory investigation that cytomegalovirus infection was acquired postnatally. However, the source of cytomegalovirus infection remained unclear. Alternative modes of cytomegalovirus transmission are discussed.

Valganciclovir treatment of primary cytomegalovirus pneumonitis in an immunocompetent adult

Interstitial pneumonitis is a rare complication of cytomegalovirus (CMV) infection in the immunocompetent. There is a paucity of literature regarding treatment in these patients. A previously healthy, immunocompetent female patient presented with fever, shortness of breath, a dry non-productive cough and myalgia and was subsequently diagnosed with CMV interstitial pneumonitis. She was treated with valganciclovir and swiftly improved but experienced neutropenia, which resolved on treatment cessation.

Successful treatment with oral valganciclovir of primary CMV enterocolitis in a congenitally infected infant

Cytomegalovirus (CMV) is the most common congenitally acquired viral infection in the United States and is associated with significant morbidity and mortality. Primary CMV enterocolitis is well documented in immunocompromised patients, but remains rare in congenitally acquired infections. There are no universally accepted recommendations for the treatment of CMV enterocolitis in the pediatric population. Case reports show varied dosing and length of treatment of either intravenously administered ganciclovir, orally administered valganciclovir, or a combination of both. We present a congenitally infected infant with primary CMV enterocolitis who was successfully treated with orally administered valganciclovir.

[Review and guidelines on the prevention, diagnosis and treatment of post-natal cytomegalovirus infection]

Postnatal cytomegalovirus (CMV) infection in the newborn can occur from exposure to maternal cervical secretions during birth, ingestion of breast milk, transfusion of blood products or transmission by body fluids of infected people. Breast milk is the main source of infection, given the high rate of CMV-positive mothers excreting CMV in milk. Freezing reduces the risk of CMV transmission by breastfeeding, although it does not eliminate it completely. Pasteurisation prevents such transmission, but it can alter the immunological properties of breast milk. Postnatal CMV infection is usually asymptomatic, as it normally results from viral reactivation in the mother, and the neonate is born with protective antibodies. However, in the very low birth weight premature infant the amount of transferred antibodies is smaller and a symptomatic infection can occur. Symptomatic post-natal CMV infection in the newborn typically causes hepatitis, neutropenia, thrombocytopenia or sepsis-like syndrome. Pneumonitis and enteritis are less common, but very characteristic. Diagnosis is based on urine virus detection at the time of onset of symptoms. Postnatal CMV infection in the newborn generally resolves spontaneously without antiviral treatment. Ganciclovir should be reserved for severe cases. Unlike congenital CMV disease, post-natal CMV infection in the preterm infant does not seem to be associated with hearing loss or abnormal neuro-development in long term follow-up.

Antivirals for cytomegalovirus infection in neonates and infants: focus on pharmacokinetics, formulations, dosing, and adverse events

Cytomegalovirus (CMV) infection is very common throughout the world, and has become more of a pediatric clinical concern given the high incidence of congenital CMV infections as well as the increasing numbers of immunocompromised patients. Because of this, the need for antiviral therapies in infants and neonates is growing. Currently, there are four antivirals available that are active against CMV: ganciclovir, valganciclovir, foscarnet, and cidofovir. At this time, none have approved indications for use in children. Although there are limited data regarding the dose, pharmacokinetics (PK), safety, and adverse events for some of these antivirals, ganciclovir, and its oral prodrug valganciclovir, have been the best studied in the infant and neonate populations. In general, pharmaceutical PK studies in young children are limited by the constraints of sampling difficulties and blood volume requirements; fewer sampling times and studies may be available for drug evaluation. Given this caveat, ganciclovir and valganciclovir PK in children thus far appears to follow a monocompartmental model, contrary to what has been described in adults. However, when normalized for weight, the volume of distribution, clearance, and half-life of ganciclovir are similar to those found in adults. Given the findings that ganciclovir (and thus valganciclovir) clearance is directly proportionate to renal function, care must be taken when administering the drug to patients with impaired renal function. Recent studies evaluating valganciclovir PK in infants (at a dose of 16 mg/kg every 12 hours) have shown similar areas under the plasma concentration-time curve (AUCs) to intravenous ganciclovir (at a dose of 6 mg/kg every 12 hours), and that these AUCs remain quite stable over a number of weeks. As seen in adults, oral ganciclovir has a low bioavailability (4.8% in a pediatric analysis) and is therefore a poor alternative for treating serious CMV infections. Neutropenia is the most frequent toxicity associated with ganciclovir and valganciclovir therapy, whereas significant (and possibly irreversible) renal toxicity can be seen with cidofovir. Foscarnet administration can also result in renal toxicity as well as significant electrolyte imbalances. Several of these drugs have potential toxicities that are of concern, including carcinogenesis, teratogenesis, and azospermia (ganciclovir, valganciclovir, and cidofovir) and deposition into bone or dentition (foscarnet) that may have significant implications when treating an infant. Given these potential ill effects, careful consideration of the indications for the clinical use of these antivirals is necessary before using them for CMV infection in neonates and infants.

[Cytomegalovirus infection causing protracted diarrhea in an immunocompetent child]

Cytomegalovirus infection is a frequent cause of complications in immunodeficient patients. In healthy hosts, cytomegalovirus infection is usually asymptomatic. We describe a case of a 3 month old immunocompetent boy who suffered from protracted diarrhoea that required parenteral nutrition. After treatment with ganciclovir he recovered without any after effects.

Cytomegalovirus myopericarditis and hepatitis in an immunocompetent adult: successful treatment with oral valganciclovir

Primary infection by cytomegalovirus (CMV) commonly occurs subclinically or manifested by a self-limited mononucleosis-like syndrome in immunocompetent subjects. Severe clinical pictures are uncommon. We present a case of acute myopericarditis and hepatitis in a previously healthy 32-year-old man with primary CMV infection, assessed by serology and positive pp65 antigenemia. He was successfully treated with a course of oral valganciclovir therapy, with an immediate clinical response and normalization of laboratory tests. The literature on simultaneous presentation of CMV pericarditis and hepatitis in immunocompetent hosts, as well as the role of oral valganciclovir in this clinical setting, is reviewed.