Presence of cytomegalovirus and herpes simplex virus in middle ear fluids from children with acute otitis media

Cytomegalovirus-induced pathology in human temporal bones with congenital and acquired infection

OBJECTIVE

Publications on histopathology of human temporal bones with cytomegalovirus (CMV) infection are limited. We aim to determine histopathology of the inner ears and the middle ears in human temporal bones with congenital and acquired CMV infections.

METHODS

Temporal bones from 2 infants with congenital and 2 adults with acquired CMV infection were evaluated by light microscopy.

RESULTS

Two infants with congenital CMV infection showed striking pathological changes in the inner ear. There was a hypervascularization of the stria vascularis in the cochlea of the first infant, but no obvious loss of outer and inner hair cells was seen in the organ of Corti. However, cytomegalic cells and a loss of outer hair cells were found in the cochlea of the second infant. The vestibular organs of both infants showed cytomegalic cells, mostly located on dark cells. There was a loss of type I and type II hair cells in the macula of the saccule and utricle. Loss of hair cells and degeneration of nerve fibers was also seen in the semicircular canals. Both infants with congenital infection showed abundant inflammatory cells and fibrous structures in the middle ear cavity. No evidence of cytomegalic cells and hair cell loss was found in the cochlea or vestibular labyrinth in acquired CMV infection.

CONCLUSIONS

In two infants with congenital CMV infection, the cochlea, vestibule, and middle ear were highly affected. Temporal bones of adult donors with acquired viral infection showed histological findings similar to donors of the same age without ear disease.

Acute otitis media associated with cytomegalovirus infection in infants and children

OBJECTIVE

Acute otitis media (AOM) is one of the most common complications of viral respiratory tract infections in children, but the role of each virus is still to be elucidated. We analyzed AOM associated with infection by cytomegalovirus (CMV), which is known as one of the major causes of viral respiratory tract infection.

METHODS

Four hundred and ninety-five children (292 boys and 203 girls) diagnosed as having AOM in 2002 were studied. All of the children were under 6 years old, with the average age being 1.31+/-1.36 years. Bacterial and viral culture of both nasopharyngeal secretions (NPS) and middle ear fluid (MEF) was performed in all 495 children. The levels of glutamyl pyruvic transaminase (GPT) and the serum IgM antibody for CMV were measured. CMV infection was defined on the basis of isolation of this virus by culture and/or positive anti-CMV IgM antibody. NPS and MEF specimens of the subjects diagnosed as having CMV infection were tested for the virus by nested PCR.

RESULTS

Twelve of the 495 children were found to have CMV infection. They included 6 boys and 6 girls aged from 3 to 25 months, with the average age being 11+/-7 months. Among 10 children in whom CMV infection was diagnosed by viral culture, CMV was isolated from NPS alone in nine cases and from both NPS and MEF in one case. Nested PCR was performed in all 12 subjects diagnosed as having CMV infection, and all NPS samples were positive, as were 8 MEF samples. We obtained serum samples from 205 children under 2 years of age, including 9 with CMV infection. The mean serum GPT level of 124 children in whom no viruses were detected was 20.7+/-14.4 IU/L. While, the serum GPT levels of 9 children with CMV infection ranged from 10 to 280 IU/L with the average titer being 78.4+/-81.9 IU/L, and the GPT levels of the children with CMV infection were significantly higher than those of the children in whom no viruses were detected (p<0.05).

CONCLUSION

Our results suggested that CMV is a causative pathogen of AOM, and that CMV infection should be suspected in patients with AOM and liver dysfunction.

Inner ear and facial nerve complications of acute otitis media with focus on bacteriology and virology

CONCLUSION

Among 20 patients with inner ear complications and/or peripheral facial palsy secondary to acute otitis media (AOM) a proven or probable bacteriological cause was found in 13 (65%). In seven patients (35%), a proven or probable viral cause was found. Only two of the patients (10%), with a proven bacterial AOM and a clinical picture of a purulent labyrinthitis in both, together with a facial palsy in one, had a substantial degree of dysfunction. Although the number of patients in this study is relatively low our findings show that inner ear complications and facial palsy due to AOM can be of both bacterial and viral origin. Severe sequelae were found only where a bacterial origin was proven.

OBJECTIVES

Inner ear complications and/or peripheral facial palsy secondary to AOM are rare. The general understanding is that they are due to bacterial infections. However, in some of these patients there are no clinical or laboratory signs of bacterial infections and they have negative bacterial cultures. During recent years different viruses have been isolated from the middle ear or serologically proven in AOM patients and are thought to play a pathogenetic role. We suggest that in some cases of AOM complications from the inner ear and the facial nerve can be caused by viruses. The purpose of our study was to analyze infectious agents present in patients with inner ear complications and/or facial palsy arising from AOM.

PATIENTS AND METHODS

The medical records of 20 patients who had inner ear complications and/or facial palsy following AOM ( unilateral in 18, bilateral in 2) between January 1989 and March 2003 were evaluated. Bacterial cultures were carried out for all patients. Sera from 12 of the patients were stored and tested for a battery of specific viral antibodies. In three patients, investigated between November 2002 and March 2003, viral cultures were also performed on samples from the middle ear and nasopharynx.

RESULTS

Nineteen patients had inner ear symptoms. Eight of them had a unilateral sensorineural hearing loss and vertigo, three had vertigo as an isolated symptom and one, with bilateral AOM, had bilateral sensorineural hearing loss. Seven patients had a combination of facial palsy and inner ear symptoms (unilateral sensorineural hearing loss in three, unilateral sensorineural hearing loss and vertigo in two, bilateral sensorineural hearing loss and vertigo in one, with bilateral AOM, and vertigo alone in one). One patient had an isolated facial palsy. Healing was complete in 11 of the 20 patients. In seven patients a minor defect remained at follow-up (a sensorineural hearing loss at higher frequencies in all). Only two patients had obvious defects (a pronounced hearing loss in combination with a moderate to severe facial palsy (House-Brackman grade 4) in one, distinct vestibular symptoms and a total caloric loss in combination with a high-frequency loss in the other. Eight patients had positive bacteriological cultures from middle ear contents: Streptococcus pneumoniae in two, beta-hemolytic Streptococcus group A in two, beta-hemolytic Streptococcus group A together with Staphylococcus aureus in one, Staph. aureus alone in one and coagulase-negative staphylococci (interpreted as pathogens) in two. In the 12 patients with negative cultures, there was a probable bacteriological cause due to the outcome in SR/CRP and leukocyte count in five. In four patients serological testing showed a concomitant viral infection that was interpreted to be the cause (varicella zoster virus in two, herpes simplex virus in one and adenovirus in one.) In three there was a probable viral cause despite negative viral antibody test due to normal outcome in SR/CRP, normal leukocyte count, serous fluid at myringotomy and a relatively short pre-complication antibiotic treatment period.

Chinchilla and murine models of upper respiratory tract infections with respiratory syncytial virus

Respiratory syncytial virus (RSV) is a major cause of lower respiratory tract infections in infants and the elderly. While the primary infection is the most serious, reinfection of the upper airway throughout life is the rule. Although relatively little is known about either RSV infection of the upper respiratory tract or host mucosal immunity to RSV, recent literature suggests that RSV is the predominant viral pathogen predisposing to bacterial otitis media (OM). Herein, we describe mouse and chinchilla models of RSV infection of the nasopharynx and Eustachian tube. Both rodent hosts were susceptible to RSV infection of the upper airway following intranasal challenge; however, the chinchilla proved to be more permissive than the mouse. The chinchilla model will likely be extremely useful to test the role of RSV in bacterial OM and the efficacy of RSV vaccine candidates designed to provide mucosal and cytotoxic T-lymphocyte immunity. Ultimately, we hope to investigate the relative ability of these candidates to potentially protect against viral predisposal to bacterial OM.

The occurrence of Chlamydia pneumoniae, Mycoplasma pneumoniae, and herpesviruses in otitis media with effusion

In a previous report we found Chlamydia (C.) pneumoniae to be present in middle ear fluids (MEE) from older children with otitis media with effusion (OME). However, OME is a disease of younger children the present study was conducted in toddlers. MEEs (n = 150) and nasopharynx samples (n = 83) from children with OME was analyzed by PCR for the presence of C. pneumoniae and Mycoplasma (M.) pneumoniae. C. pneumoniae was not present in any and M. pneumoniae only in one of the MEEs, and these pathogens could be demonstrated in one and two nasopharynx samples, respectively. Further, 133 MEEs were analyzed by PCR for the presence of the 8 human herpesviruses, and all samples were found to be negative. We conclude that neither C. pneumoniae or M. pneumoniae, or any of the 8 human herpesviruses seems to play a major role in the pathogenesis of OME in early childhood OME.

Presence of human herpesviruses in young children with acute otitis media

Some herpesviruses have been detected in middle ear fluid (MEF) of patients with acute otitis media (AOM), but their role in middle ear disease is unknown. We examined 73 middle ear fluid samples from 73 children with acute otitis media for the presence of four major herpesviral DNA, respiratory viral genomes, and bacterial DNA by multiplex polymerase chain reaction (PCR). Herpesviruses were detected in 16 specimens (22%), with 18 viral infections were identified overall. Respiratory viruses were detected in 35 specimens (48%), 39 viral infections overall. Bacterial DNA was detected in 51 specimens (70%), 60 bacterial infections overall. Clinical outcome was compared in patients with and without herpesvirus DNA, respiratory viral genomes, or bacterial DNA. Progression to otitis media with effusion (OME) was more common when herpesviral DNA was present. Presence of herpesvirus DNA may reflect an immunocompromised state that may make it difficult to eliminate bacteria from the middle ear after infection.

Importance of respiratory viruses in acute otitis media

Acute otitis media is usually considered a simple bacterial infection that is treated with antibiotics. However, ample evidence derived from studies ranging from animal experiments to extensive clinical trials supports a crucial role for respiratory viruses in the etiology and pathogenesis of acute otitis media. Viral infection of the upper respiratory mucosa initiates the whole cascade of events that finally leads to the development of acute otitis media as a complication. The pathogenesis of acute otitis media involves a complex interplay between viruses, bacteria, and the host's inflammatory response. In a substantial number of children, viruses can be found in the middle-ear fluid either alone or together with bacteria, and recent studies indicate that at least some viruses actively invade the middle ear. Viruses appear to enhance the inflammatory process in the middle ear, and they may significantly impair the resolution of otitis media. Prevention of the predisposing viral infection by vaccination against the major viruses would probably be the most effective way to prevent acute otitis media. Alternatively, early treatment of the viral infection with specific antiviral agents would also be effective in reducing the occurrence of acute otitis media.

Cytomegalovirus periodontal presence is associated with subgingival Dialister pneumosintes and alveolar bone loss

Destructive periodontal disease is associated with human cytomegalovirus (HCMV), Epstein-Barr type 1 virus (EBV-1) and other members of the Herpesviridae family as well as with various gram-negative anaerobic bacteria, including the Dialister pneumosintes species. This study aimed to determine possible interrelationships between periodontal HCMV, EBV-1, herpes simplex virus and D. pneumosintes, and relate the microbiological findings to periodontitis clinical status. Sixteen subjects each contributed paper point samples from two progressing and two stable periodontitis lesions, as determined by ongoing loss of probing attachment. Polymerase chain reaction methodology was used to identify the study herpesviruses and D. pneumosintes. Chi-squared tests, Fisher exact tests and multivariate logistic regression were employed to identify statistical associations among herpesviruses, bacteria and clinical variables. HCMV, and no other virus or combination of viruses, was positively associated with the presence of D. pneumosintes, and the relationship was specific for individual periodontitis sites with no detectable subject effect. D. pneumosintes was in turn positively associated with periodontal pocket depth and disease-active periodontitis. When the average percentage of alveolar bone loss in all teeth was treated as a response, HCMV remained significant even after D. pneumosintes was included in the model, suggesting that both HCMV and D. pneumosintes affected bone loss or, alternatively, HCMV affected factors not studied that themselves can induce bone loss. We hypothesize that periodontal HCMV sets the stage for subgingival proliferation of D. pneumosintes and subsequent periodontal disease progression. Studies on herpesviral-bacterial interactions may hold great promise for delineating important etio-pathogenic aspects of destructive periodontal disease.

Performance of two commercial glycoprotein G-based enzyme immunoassays for detecting antibodies to herpes simplex viruses 1 and 2 in children and young adolescents

In 61 patients 1 to 14 years of age, the Gull/Meridian enzyme-linked immunosorbent assay (ELISA) had a sensitivity of 100% for herpes simplex virus type 1 (HSV-1) and specificities of 74% for HSV-1 and 48% for HSV-2. In 128 similarly aged patients, the HerpeSelect ELISA (Focus Technologies) showed sensitivities of 80% for HSV-1 and 88% for HSV-2, and specificities of 97% for HSV-1 and 100% for HSV-2.

Resistance to antimicrobials used for therapy of otitis media and sinusitis: effect of previous antimicrobial therapy and smoking

We undertook to identify the antimicrobial susceptibility of the pathogens isolated from patients with otitis media or maxillary sinusitis who failed to respond to antimicrobial therapy, and correlate it with previous antimicrobial therapy and smoking. We analyzed isolates recovered from 2 consecutive cultures obtained from middle ear aspirate obtained through an open perforation in 22 children with otitis, and maxillary sinus aspirate collected by endoscopy from 20 patients. Forty-seven isolates were repeatedly recovered from 42 culture-positive individuals. The organisms isolated were Streptococcus pneumoniae (15 isolates), Haemophilus influenzae (14), Staphylococcus aureus (7), Moraxella catarrhalis (6), and Streptococcus pyogenes (5). Resistance of at least 2 tube dilutions to the antimicrobial agents used was found in 23 of the 47 (49%) isolates that were found in 20 (48%) of the patients. These included 10 of 15 (67%) isolates of S pneumoniae, 4 of 14 (29%) H influenzae (all were beta-lactamase producers), 4 of 7 (57%) S aureus (all beta-lactamase producers), 5 of 6 (83%) M catarrhalis (all beta-lactamase producers), and none of 5 S pyogenes. In the 21 patients who failed to respond to amoxicillin, H influenzae and S pneumoniae predominated. Streptococcus pneumoniae was recovered from 4 of the 11 (36%) after trimethoprim-sulfamethoxazole, 4 of 21 (19%) after amoxicillin, 2 of 3 (67%) after azithromycin dihydrate, and 1 of 4 (25%) after cefixime. A statistically significant higher recovery of resistant organisms was noted in those treated 2 to 6 months previously, and in those with sinusitis who smoked. The data illustrate the relationship between resistance to antimicrobials and failure of patients with otitis media and sinusitis to improve.

Prevalence of various respiratory viruses in the middle ear during acute otitis media

BACKGROUND

Vaccines against respiratory viruses may be able to reduce the frequency of acute otitis media. Although the role of respiratory viruses in the pathogenesis of acute otitis media is well established, the relative importance of various viruses is unknown.

METHODS

We determined the prevalence of various respiratory viruses in the middle-ear fluid in 456 children (age, two months to seven years) with acute otitis media. At enrollment and after two to five days of antibiotic therapy, specimens of middle-ear fluid and nasal-wash specimens were obtained for viral and bacterial cultures and the detection of viral antigens. The viral cause of the infections was also assessed by serologic studies of serum samples obtained during the acute illness and convalescence.

RESULTS

A specific viral cause of the respiratory tract infections was identified in 186 of the 456 children (41 percent). Respiratory syncytial virus was the most common virus identified in middle-ear fluid: it was detected in the middle-ear fluid of 48 of the 65 children (74 percent) infected by this virus (P< or =0.04 for the comparison with any other virus). Parainfluenza viruses (15 of 29 children [52 percent]) and influenzaviruses (10 of 24 children [42 percent]) were detected in the middle-ear fluid significantly more often than enteroviruses (3 of 27 children [11 percent]) or adenoviruses (1 of 23 children [4 percent]) (P< or =0.01 for all comparisons).

CONCLUSION

Respiratory syncytial virus is the principal virus invading the middle ear during acute otitis media. An effective vaccine against upper respiratory tract infections caused by respiratory syncytial virus may reduce the incidence of acute otitis media in children.

Blinded multiplex PCR analyses of middle ear and nasopharyngeal fluids from chinchilla models of single- and mixed-pathogen-induced otitis media

Multiplex PCR analyses for both bacterial and viral pathogens were conducted in a blinded manner on 33 archival specimens, of known culture status, procured from chinchilla models of both single- and mixed-pathogen-induced otitis media and from a pediatric patient. These specimens had been maintained at -70 degrees C for up to 6 years. Experimental specimens evaluated included middle-ear effusions, nasopharyngeal lavage fluids and middle-ear lavage fluids from animals which were immunologically naive, sham-immunized or actively immunized with nontypeable Haemophilus influenzae antigens. Sampling times used ranged from the day of bacterial or viral challenge to 42 days after challenge. Initial PCR analyses of the 33 specimens matched the traditional culture data in 24 instances (73%), correctly identifying nontypeable H. influenzae, Moraxella catarrhalis, Streptococcus pneumoniae, or adenovirus as the causative agent. A PCR-positive signal for the microbe(s) inoculated was also obtained in four animal model specimens (12%) which were culture negative. One of two culture-negative human effusions was also PCR positive. Thus, overall, results obtained by blinded PCR were 85% concordant with traditional culture methods or correctly indicated the specific pathogen introduced in four specimens that were sterile. In no instance was a false-positive signal obtained for any of the five etiologic agents being evaluated. We conclude that the multiplex PCR analyses are rapid and accurate methodologies when they are used to retrospectively evaluate diverse archival specimens of limited volume from experimental models of otitis media.

Role of viruses in middle-ear disease

Taken together, there is ample evidence suggesting a role for viruses in the pathogenesis of OM. This evidence comes from numerous studies performed in animals and in vitro cell cultures, as well as in adults and children with URI and OM. Viruses induce host immune and inflammatory responses that result in pathology of the ET and the middle ear, and predispose the host in various ways to secondary bacterial infection. A suggested mechanism for the pathogenesis of OM following respiratory viral infection is presented in Figure 1.