High perinatal seroprevalence of cytomegalovirus in northern Taiwan

Prevention and management of cytomegalovirus infection and disease in kidney transplant: A consensus statement of the Transplantation Society of Taiwan

Kidney transplant recipients have an increased risk of cytomegalovirus (CMV) infection and disease. A strategy for mitigating the risk of CMV infection in kidney transplant recipients has not yet been established in Taiwan. The Transplantation Society of Taiwan aimed to develop a consensus by expert opinion on the prevention and management of CMV infection. Based on the results of Consensus Conference, we suggested low-dose valganciclovir prophylaxis (450 mg once daily) for kidney transplant recipients. The prophylaxis duration was ≥6 months for high-risk (D+/R-) patients and 3 months for moderate-risk (R+) patients. Even for low-risk (D-/R-) patients, prophylaxis for at least 3 months is recommended because of the high seroprevalence of CMV in Taiwan. CMV prophylaxis was suggested after anti-thymocyte globulin treatment but not after methylprednisolone pulse therapy. Routine surveillance after prophylaxis, secondary prophylaxis after CMV disease treatment, and mTOR inhibitors for primary CMV prophylaxis were not recommended. Letermovir and marabavir are emerging CMV agents used for prophylaxis and refractory CMV disease. CMV immunoglobulins have been used to treat refractory CMV disease in Taiwan. We hope this consensus will help professionals manage patients with CMV in Taiwan to improve the quality of care.

Cytomegalovirus viral interleukin-10 (cmvIL-10) in patients with Aspergillus infection and effects on clinical outcome

BACKGROUND

Human cytomegalovirus (CMV) is associated with aspergillosis, but the simultaneous presence of cytomegalovirus viral interleukin-10 (cmvIL-10) and aspergillosis has never been investigated. CmvIL-10 is produced by CMV-infected cells and acts as an immune modulator during CMV infection. The aim of this study was to evaluate cmvIL-10 levels in peripheral blood and its influence on the clinical outcomes of Aspergillus infection.

METHODS

Patients who visited or were admitted to the hospital with suspected Aspergillus infection, including invasive aspergillosis (IA) and chronic pulmonary aspergillosis (CPA), were prospectively enrolled. The cmvIL-10, human IL-10 (hIL-10), IL-1B, IL-6, IL-8, IFN-γ, and TNF-α levels in peripheral blood were measured.

RESULTS

Patients with Aspergillus infection had a higher level of cmvIL-10 than the control group (158±305 vs. 27.9±30.4 pg/mL, p<0.05). The level of cmvIL-10 was not correlated with CMV viremia or end-organ disease. The cmvIL-10 but not hIL-10 level was positively correlated with the IFN-γ level (p<0.05) and marginally negatively correlated with IL-1B and IL-8 levels (p<0.1). In patients with CPA, a high level of cmvIL-10 (≥100 pg/mL) was a poor prognostic factor for long-term survival (p<0.05). In contrast, CMV viremia or end-organ disease was associated with poor survival in patients with IA (p=0.05).

CONCLUSIONS

Aspergillus infection was associated with CMV coinfection with cmvIL-10 in blood. A cmvIL-10 concentration ≥100 pg/mL was a predictor for unfavourable outcome in CPA patients.

Revisit of the Association between Cytomegalovirus Infection and Invasive Fungal Infection after Allogeneic Hematopoietic Stem Cell Transplantation: A Real-World Analysis from a High CMV Seroprevalence Area

Infection is a major complication after allogeneic hematopoietic stem cell transplantation (allo-HSCT) especially cytomegalovirus (CMV) infection and invasive fungal infection (IFI). Taiwan is a high CMV seroprevalence area. Our study aimed to evaluate the incidence, risk factors, the impact on survival of CMV infection (including reactivation and disease) and the association of CMV infection and IFI in recipients after allo-HSCT during the first 100 days after transplantation. This was a retrospective study including 180 recipients of allo-HSCT. A total of 99 patients had CMV reactivation, and nine patients had CMV diseases. There were more mismatched donors, more ATG usage and more transplantation from CMV IgG-negative donor in patients with CMV reactivation. There was no survival difference in patients with or without CMV reactivation. A total of 34 patients had IFIs, and IFI after allo-HSCT was associated with significantly inferior survival. Patients with CMV reactivation did not increase the incidence of overall IFI, but they did result in more late-onset (>40 days) IFI (p = 0.056). In this study, we demonstrated real-world data of CMV infection and IFI from a high CMV seroprevalence area.

Cytomegalovirus-Associated Autoantibody against TAF9 Protein in Patients with Systemic Lupus Erythematosus

Background: Evidence indicates a causal link between cytomegalovirus (CMV) infection and the triggering of systemic lupus erythematosus (SLE). Animal studies have revealed that CMV phosphoprotein 65 (pp65) induces autoantibodies against nuclear materials and causes the autoantibody attack of glomeruli. IgG eluted from the glomeruli of CMVpp65-peptide-immunized mice exhibited cross-reactivity against dsDNA and TATA-box-binding protein associated factor 9 (TAF9). Whether the elevation of anti-TAF9 IgG is associated with anti-CMV reactivity in human lupus remains unclear. Methods: The sera from patients with rheumatic diseases, including ankylosing spondylitis (AS), gout, rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and Sjögren syndrome (SS) were examined using ELISA for antibodies of CMV, CMVpp65, and TAF9. Results: In total, 83.8% of the rheumatic patients had acquired CMV infections. The SLE patients had a high prevalence of anti-CMV IgM. The highest seropositivity rates for anti-HCMVpp65 and anti-TAF9 IgG were observed in the SLE patients. Purified anti-CMVpp65 IgG from CMVpp65/TAF9 dual-positive SLE sera reacted to both TAF9 and dsDNA. An increased prevalence of proteinuria and low hemoglobin levels were found in CMV IgG- and CMVpp65 IgG-positive SLE patients. Conclusions: This observation suggests that immunity to CMVpp65 is associated with cross-reactivity with TAF9 and dsDNA and that it is involved in the development of clinical manifestations in SLE.

Prevalence of cytomegalovirus DNAemia and genotypic distribution among childbearing mothers and neonates in Taiwan

BACKGROUND

Congenital cytomegalovirus (CMV) infection is the leading cause of neurologic disabilities and sensorineural hearing loss in children. However, in Taiwan, there is limited information on the genotypic diversity and prevalence of perinatal CMV infection in both mothers and neonates. The aim of this study was to screen samples from both mothers and umbilical cord blood for CMV at the time of delivery and to determine the CMV genotypic distribution.

METHODS

Between June 2012 and July 2015, residual maternal and umbilical cord blood samples were collected from consenting participants admitted to the Chang Bing Show Chwan Memorial Hospital in central Taiwan. The blood samples were screened for CMV DNA using real-time PCR assay, and the genotypic classification of the CMV UL55, UL144, and US28 genes was determined by sequencing and phylogenetic analysis.

RESULTS

A total of 1282 mother-neonate paired samples were enrolled in the study, 95.3% of whom were Taiwanese. CMV DNA was detectable in 6.2% of the maternal blood samples, with a significantly higher rate noted in non-Taiwanese mothers (11.7%,p=0.027). For the 1,282 umbilical cord blood samples, CMV DNA was detectable in 5.3% of the samples. The presence of CMV DNA in maternal blood was positively associated with the presence of CMV DNA in umbilical cord blood (p=0.01). In addition, the UL55, UL144, and US28 genotypic distribution was similar between mothers and neonates.

CONCLUSION

The prevalence of CMV DNAemia in childbearing mothers and neonates is similar and their genotypic distribution implies potential CMV infection during pregnancy.

High level antibodies to TORCH in the IVIG preparation from Taiwanese

BACKGROUND

Congenital TORCH (toxoplasmosis, other viruses [varicella-zoster virus, VZV, etc.], rubella, cytomegalovirus [CMV], Herpes simplex virus [HSV]) infections are major causes of prenatal, perinatal, and postnatal morbidity and mortality. Although treatment or prevention strategies are available for these pathogens, all drugs may not be safe during the pregnancy. The aim of this study is to measure the antibodies (Abs) concentration in the intravenous immunoglobulin (IVIG) preparation to evaluate the therapeutic potential for TORCH infection.

METHODS

We tested the only one commercial IVIG preparation from Taiwanese for the presence of Abs against Toxoplasma gondii, VZV, Epstein-Barr virus (EBV), measles, mumps, rubella, CMV, HSV type 1 (HSV-1), and HSV type 2 (HSV-2) by using enzyme-linked immunosorbent assay or chemiluminescent microparticle immunoassay.

RESULTS

In our study, the median level (range) of anti-CMV immunoglobulin G (IgG) is > 250 (All > 250) (arbitrary unit, AU)/mL, anti-EBV > 200 (All > 200) (relative unit, RU)/mL, anti-HSV > 200 (152.75 to >200) RU/mL, anti-VZV > 5000 (All > 5000) IU/L, anti-measles > 5000 (All > 5000) IU/L, anti-mumps > 200 (156.5 to > 200) RU/mL, anti-rubella 209.8 IU/mL (192.7 to 238.5), and anti-Toxoplasma is 14.05 (12.3 to 16) IU/mL. There was not any immunoglobulin M (IgM) against HSV, VZV, mumps, measles, rubella, CMV, EBV, and Toxoplasma in the "Taiwan Blood Services Foundation" IVIG preparations.

CONCLUSION

There was high activity against T. gondii, VZV, EBV, measles, mumps, rubella, CMV, HSV-1, and HSV-2 in all IVIG batches. Further investigation is warranted to confirm the efficacy of IVIG from Taiwanese for congenital TORCH infections.

Epidemiology and clinical features of viral anterior uveitis in southern Taiwan-diagnosis with polymerase chain reaction

BACKGROUND

To report the epidemiology and clinical features of viral anterior uveitis in patients in southern Taiwan.

METHODS

A retrospective, case series study. HLA-B27 negative anterior uveitis patients with increased intraocular pressure or corneal edema seen at Kaohsiung Chang Gung Memorial Hospital from January 1, 2007 to January 31, 2018 had their aqueous sent for polymerase chain reaction analysis. Their records were reviewed for demographic data, ocular findings, and laboratory results.

RESULTS

In the aqueous samples obtained from 102 eligible eyes, 42 eyes were herpesviridae-positive, which included 9 with herpes simplex virus (8.8%), 5 with varicella-zoster virus (4.9%), 27 with cytomegalovirus (26.5%), and 1 with Epstein-Barr virus (1%). Herpesviridae-positive patients were more likely to be male, and have glaucoma. Glaucoma and pseudophakic eyes were significantly associated with CMV-positive eyes.

CONCLUSION

PCR analysis of the anterior chamber fluid is important for the confirmation of the diagnosis of viral anterior uveitis. Cytomegalovirus anterior uveitis is not uncommon in patients in southern Taiwan, and it may follow an uneventful cataract extraction in immunocompetent patients.

Concurrent Hearing, Genetic, and Cytomegalovirus Screening in Newborns, Taiwan

OBJECTIVE

To evaluate the feasibility and potential benefits of incorporating genetic and cytomegalovirus (CMV) screenings into the current newborn hearing screening (NHS) programs.

STUDY DESIGN

Newborns were recruited prospectively from a tertiary hospital and a maternity clinic between May 2016 and December 2016 and were subjected to hearing screening, CMV screening, and genetic screening for 4 common mutations in deafness genes (p.V37I and c.235delC of GJB2 gene, c.919-2A>G of SLC26A4 gene, and the mitochondrial m.1555A>G). Infants with homozygous nuclear mutations or homoplasmic/heteroplasmic mitochondrial mutation (referred to as "conclusively positive genotypes") and those who tested positive for CMV received diagnostic audiologic evaluations.

RESULTS

Of the total 1716 newborns enrolled, we identified 20 (1.2%) newborns with conclusively positive genotypes on genetic screening, comprising 15 newborns (0.9%) with GJB2 p.V37I/p.V37I and 5 newborns (0.3%) with m.1555A>G. Three (0.2%) newborns tested positive on CMV screening. Twelve of the 20 newborns (60%) with conclusively positive genotypes and all 3 newborns who tested positive for CMV (100%) passed NHS at birth. Diagnostic audiologic evaluations conducted at 3 months confirmed hearing impairment in 6 of the 20 infants (30%) with conclusively positive genotypes.

CONCLUSIONS

This study confirms the feasibility of performing hearing, genetic, and CMV screenings concurrently in newborns and provides evidence that the incorporation of these screening tests could potentially identify an additional subgroup of infants with impaired hearing that might not be detected by the NHS programs.

Seroepidemiology Study of Cytomegalovirus and Rubella among Pregnant Women at St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia

BACKGROUND

Maternal cytomegalovirus (CMV) and rubella infections have adverse neonatal outcomes. Both CMV and rubella are more widespread in developing countries and in communities with lower socioeconomic status. The aim of this study was to investigate sero-prevalence of CMV and rubella infection and associated possible risk factors.

METHOD

Using cross sectional study design a total of 200 pregnant women were consecutively recruited starting from June and July 2014. Blood samples were collected, and structured questions were used to gather socio-demographic and risk factor related data. ELISA was used to detect CMV (IgG, IgM) and rubella IgM. SPSS version 20 was used to analyze the data, and regression was also performed.

RESULTS

Out of 200 pregnant women, 88.5%, 30(15.5%) and 4(2.0%) were CMV-IgG, CMV-IgM, and rubella-IgM positive, respectively. Women who were immune/positive only for IgG were 73.5%. The second group was those with primary infection [IgG (+) plus IgM (+)] and this consisted of 15.0% participants. Eleven percent of the participants were at high risk for primary infection during their pregnancy. One pregnant woman was identified as having a recent primary infection. In this study, no statistically significant association was detected between CMV infection with idependent factors (p-value>0.05).

CONCLUSION

In addition to detection of high prevalence of CMV, detecting recent infection of rubella worsens the outcome of the disease. Rubella vaccine should be taken into consideration after large scale surveillance. However, screening of all pregnant women for CMV infection may not be cost-effective as in the countries with high seropositivity.

Clinical Features of CMV-Associated Anterior Uveitis

Cytomegalovirus (CMV) anterior uveitis is the most common ocular manifestation of CMV disease in immunocompetent individuals. It is thought to be due to a local reactivation of latent CMV and is usually unilateral. The acute form presents as Posner-Schlossman Syndrome, a recurrent hypertensive anterior uveitis with few granulomatous keratic precipitates. There are geographic differences in the chronic form of CMV anterior uveitis. Asian patients commonly present as Fuchs Uveitis Syndrome with diffuse stellate keratic precipitates, while the European patients present with a chronic hypertensive anterior uveitis with fewer keratic precipitates that are brown in color and located inferiorly. Characteristic features of CMV anterior uveitis include mild anterior chamber inflammation, elevated intraocular pressure, stromal iris atrophy. Synechiae, macular edema and retinitis are typically absent. CMV disease may also be associated with the development of corneal endotheliitis with a reduced endothelial cell count. Long-term complications include glaucomatous optic neuropathy and cataract formation.

Magnitude of the Cytomegalovirus infection among pregnant women attending antenatal clinics in the city of Mwanza, Tanzania

Background

Despite, Cytomegalovirus (CMV) infection being associated with a potential risk to the fetus, there is limited data from Tanzania and many other developing countries regarding the epidemiology and the impact of CMV infections. This cross-sectional study was conducted between December 2014 and June 2015 among pregnant women attending antenatal clinics in the city of Mwanza, Tanzania to investigate the magnitude and associated factors of CMV infection.

Methods

The specific CMV IgM and IgG antibodies were detected using indirect enzyme linked immunosorbent assay (ELISA). Demographic and clinical data were collected using pre-tested data collection tool. Data were analysed using STATA version 13.

Results

A total of 261 pregnant women with median age of 20 (IQR 19–25) years and mean gestation age of 17 ± 7.8 weeks were enrolled. The seroprevalence of CMV IgG antibodies was 193(73.9%; 95% CI 67.2–79.6) while that of CMV IgM antibodies was 0.4%. As the age increased by one unit the IgG seroprevalence was found to increase by 0.3% (95% CI 0.13–0.47, p = 0.001) whereas the risk of being IgG positive increased by 24%. On multivariable logistic regression analysis only urban residence (OR 6.329, 95% CI 2.885–13.887, p < 0.001) was found to independently predict CMV IgG seropositivity. Regarding the outcomes of previous pregnancies the history of miscarriage independently predicted IgG seropositivity (OR 5.6, 95% CI 1.29–24.178, p = 0.021). The IgM seropositive woman had fatal outcome of the term delivery of the baby with microcephaly and spinal-bifida.

Conclusion

Cytomegalovirus seroprevalence among pregnant women residing in urban areas of Mwanza city, Tanzania is high and is associated with poor pregnancy outcomes. There is a need to emphasize routine screening of CMV in order to establish the impact of CMV during pregnancy.

Detection of human cytomegalovirus in glioblastoma among Taiwanese subjects

The relationship between human cytomegalovirus (HCMV) and glioblastoma (GBM) has been debated for more than a decade. We investigated the presence of HCMV genes, RNA and protein in GBMs and their relationships with tumor progression. Results of quantitative PCR for HCMV UL73, nested PCR for HCMV UL144, in situ hybridization (ISH) for RNA transcript, and immunohistochemistry (IHC) for protein expression and their relationship to the prognosis of 116 patients with GBM were evaluated. Nine (7.8%) cases revealed a low concentration of HCMV UL73, and only 2 of the 9 (1.7%) cases showed consistent positivity on repeat PCR testing. HCMV UL144, ISH and IHC assays were all negative. The HCMV UL73 positive cases did not show significant difference in the clinicopathological characters including age, gender, Karnofsky performance status, extent of resection, bevacizumab treatment, isocitrate dehydrogenase 1 mutation, O⁶-methylguanine-DNA-methyltranferase status and Ki67 labeling index, and did not reveal prognostic significance. As only one HCMV gene was detected at low concentration in 7.8% of GBMs and there was no evidence of transcription, protein expression or prognostic impact, we cannot conclude a relationship between HCMV and GBM in Taiwanese patients.

Posner-Schlossman syndrome in Wenzhou, China: a retrospective review study

AIM

To describe the incidence of Posner-Schlossman syndrome (PSS) in Lucheng District, Wenzhou, China, over a 10-year period.

METHODS

We reviewed retrospectively the medical records of all inpatient and outpatient patients diagnosed with PSS during the years 2005-2014 in the Eye Hospital of Wenzhou Medical University. The keywords of 'glaucomatocyclitic crisis', 'Posner-Schlossman syndrome' and 'PSS' were used for the retrieval. Only patients with registered residing address in Lucheng District where the hospital located were finally selected. The cumulative incidence and annual incidence of PSS were calculated based on the sum of household registered population and temporary resident population in Lucheng District.

RESULTS

A total of 576 patients with PSS (339 men and 237 women) met the retrieval criteria. The mean age of these subjects at the first clinic visit was 40±15 years. Intraocular pressure (IOP) of the initial record was 31.91±15.37 mm Hg. The 10-year cumulative incidence of PSS in Lucheng District was 39.53 per 100 000 population, whereas the mean annual incidence of PSS in this area was 3.91 per 100 000 population. The majority of these patients were aged 20-59 years (83.9%). Men showed a significantly higher cumulative incidence of PSS than women (p=0.010). Higher rate of newly onset cases was found in spring (31%) than in other seasons (p=0.006).

CONCLUSIONS

Our results suggest a relatively high incidence of PSS in Wenzhou, a southeastern city in China. Young, male adults are prone to be affected in spring. However, the aetiology and other risk factors are still waited to be clarified.

Heart Transplantation in Asia

Heart transplantation (HTx) is the effective way to improve quality of life as well as survival in terminal heart failure (HF) patients. Since the first heart transplant in 1968 in Japan and in earnest in 1987 at Taiwan, HTx has been continuously increasing in Asia. Although the current percentage of heart transplants from Asia comprises only 5.7% of cases in the International Society of Heart and Lung Transplantation (ISHLT) registry, the values were under-reported and soon will be greatly increased. HTx in Asia shows comparable with or even better results compared with ISHLT registry data. Several endemic infections, including type B hepatitis, tuberculosis, and cytomegalovirus, are unique aspects of HTx in Asia, and need special attention in transplant care. Although cardiac allograft vasculopathy (CAV) is considered as a leading cause of death after HTx globally, multiple observations suggest less prevalence and benign nature of CAV among Asian populations. Although there are many obstacles such as religion, social taboo or legal process, Asian countries will keep overcoming obstacles and broaden the field of HTx.

TORCH Antibodies Among Pregnant Women and Their Newborns Receiving Care at Kilimanjaro Christian Medical Centre, Moshi, Tanzania

Background:

Toxoplasmosis, other (syphilis, varicella-zoster, parvovirus B19, and hepatitis B), rubella, cytomegalovirus (CMV), and herpes simplex virus type 1 and type 2 (HSV-1 and HSV-2) – known by the acronym TORCH – is a group of infections affecting both mothers and their unborn babies with adverse short- and long-term outcomes. The majority of infected mothers are asymptomatic, which leaves only speculation as to the probable cause of many congenital anomalies, stillbirths, prematurity, and death resulting from TORCH infections. The main objective of this study was to investigate previous exposure to TORCH infections by measuring the seroprevalence of TORCH antibodies in pregnant women and their newborns receiving care at Kilimanjaro Christian Medical Centre (KCMC), Moshi, Tanzania.

Methods:

This was a cross-sectional, hospital-based study conducted at KCMC from December 2013 to April 2014. Of 350 pregnant women enrolled in the study, we tested 347 pregnant women attending the antenatal clinic and who opted to deliver at KCMC. Cord blood was collected and analysed for 309 of their newborns. To identify immunoglobulin G (IgG) and immunoglobulin M (IgM) antibodies in mothers and IgM antibodies in newborns, we used enzyme-linked immunosorbent assay testing. A structured questionnaire was used to collect data of mothers and their newborns. Data analysis was done using SPSS version 20.

Results:

The seroprevalence of IgG antibodies to TORCH infections among pregnant women was 154 (44.4%) for toxoplasmosis, 311 (89.6%) for rubella, 343 (98.6%) for CMV, and 346 (99.7%) for HSV-1 and HSV-2; 141 (40.6%) had been exposed to all 4 infections. For HSV-1 and HSV-2, the IgM antibodies were found in 137 (39.5%) of the 347 pregnant women included in this study. Age above 35 years (OR 6.15; 95% CI, 1.22–31.1; P=.028) and multiparity (OR 1.63; 95% CI, 1.01–2.62; P=.045) were associated with higher risk of being exposed to all TORCH infections. A total of 11 newborns had IgM antibodies to HSV-1 and HSV-2 giving a seroprevalence of 3.6%, and one newborn had IgM antibodies to rubella, giving a seroprevalence of 0.3%. None of the newborns had antibodies to toxoplasmosis and CMV.

Conclusion:

Exposure to TORCH infections was high among pregnant women in our population. Older age and multi-parity were associated with a higher risk of being exposed to all TORCH infections. Seroprevalence to HSV-1 and HSV-2 was high in newborns. The higher IgM antibodies to HSV-1 and HSV-2 among pregnant mothers and their newborns may disturb maternal, fetal, and neonatal health, and therefore we recommend establishing treatment protocol to support management of pregnant women and newborns who are seropositive for IgM antibodies.

Prognostic Factors on the Graft-versus-Host Disease-Free and Relapse-Free Survival after Adult Allogeneic Hematopoietic Stem Cell Transplantation

The cure of hematologic disorders by allogeneic hematopoietic stem cell transplantation (HSCT) is often associated with major complications resulting in poor outcome, including graft-versus-host disease (GVHD), relapse, and death. A novel composite endpoint of GVHD-free/relapse-free survival (GRFS) in which events include grades 3-4 acute GVHD, chronic GVHD requiring systemic therapy, relapse, or death is censored to completely characterize the survival without mortality or ongoing morbidity. In this regard, studies attempting to identify the prognostic factors of GRFS are quite scarce. Thus, we reviewed 377 adult patients undergoing allogeneic HSCT between 2003 and 2013. The 1- and 2-year GRFS were 40.8% and 36.5%, respectively, significantly worse than overall survival and disease-free survival (log-rank p < 0.001). European Group for Blood and Marrow Transplantation (EBMT) risk score > 2 (p < 0.001) and hematologic malignancy (p = 0.033) were poor prognostic factors for 1-year GRFS. For 2-year GRFS, EBMT risk score > 2 (p < 0.001), being male (p = 0.028), and hematologic malignancy (p = 0.010) were significant for poor outcome. The events between 1-year GRFS and 2-year GRFS predominantly increased in relapsed patients. With prognostic factors of GRFS, we could evaluate the probability of real recovery following HSCT without ongoing morbidity.

A case report of scrub typhus-associated hemophagocytic syndrome and a review of literature

A 34-year-old woman presented with septic shock, disseminated intravascular coagulation (DIC), and multiorgan dysfunction with a 1-week history of fever, abdominal pain in the right upper quadrant, and dull pain in the right flank. Physical and laboratory data showed cytopenia (thrombocytopenia and anemia), splenomegaly, hyperferritinemia, hypofibrinogenemia, and an elevated level of interleukin-2 receptor (soluble CD25). Bone marrow examinations disclosed hypercellular marrow with increased infiltration of histiocytes with hemophagocytosis. This diagnosis was confirmed by positive Weil-Felix test results (Proteus mirabilis OX-K titer, 1:80), the presence of IgG and IgM antibodies, and positive PCR results for Orientia tsutsugamushi. The patient developed a severe intracranial hemorrhage 3 days after admission and expired due to systemic inflammatory response syndrome with DIC and multiorgan failure on the 13th day of hospitalization. Scrub typhus with hemophagocytic syndrome can be complicated by DIC and multiorgan failure. Patients with scrub typhus usually have an excellent response to treatment; therefore, early diagnosis and prompt administration of antimicrobial therapy may prevent the development of serious complications.

Cytomegalovirus seroprevalence in pregnant women and association with adverse pregnancy/neonatal outcomes in Jiangsu Province, China

Background

In this study, we aimed to determine the provincial population-based seroprevalence in pregnant women and to further explore the association of maternal CMV infection status and adverse pregnancy/neonatal/growth outcomes in Jiangsu, China.

Methods

In this case-control study, the sera from 527 pregnant women with adverse pregnancy/neonatal outcomes and 496 mothers of healthy infants in Jiangsu Province, collected at gestation age of 15–20 weeks, were tested for anti-CMV IgG, IgM and IgG avidity. Adverse pregnancy/neonatal outcomes were identified based on pregnancy/neonatal outcomes.

Results

The overall seroprevalence of anti-CMV IgG was 98.7%, with 99.4% and 98.0% in the case and control groups, respectively (P = 0.039). The prevalence of anti-CMV IgG+/IgM+, was higher in the case group than that in the control group (3.8% vs. 1.6%, P = 0.033). Anti-CMV IgG avidity assay showed that none in the control group were primarily infected, but five (0.9%) in the case group underwent primary infection (P = 0.084); all five infants of these women presented severe adverse neonatal/growth outcomes. Exact logistic regression analysis showed that anti-CMV IgG+/IgM+ was associated with adverse pregnancy/neonatal/growth outcomes (aOR = 2.44, 95% CI 1.01–6.48, P = 0.047). Maternal low education level and prior abnormal pregnancies also were risk factors for adverse pregnancy/neonatal outcomes.

Conclusions

In populations with very high prevalence of latent CMV infection, active maternal CMV infection during pregnancy might be a risk factor for adverse pregnancy/neonatal outcomes.

Presence of cytomegalovirus DNA in leucocytes is associated with increased oxidative stress and subclinical atherosclerosis in healthy adults

OBJECTIVE

Investigate the latent cytomegalovirus (CMV) infection as a biomarker of oxidative stress and atherosclerosis.

METHODS

Latent CMV infection was diagnosed in healthy individuals with PCR-evidence of CMV DNA in peripheral leucocytes. Oxidative stress and atherosclerosis were measured by mitochondrial DNA oxidative damage index (mtDNA(ΔCT)) and intima media thickness (IMT).

RESULTS

The CMV DNA positive subjects had a higher mean mtDNA(ΔCT) and greater IMT than subjects in the control group.

CONCLUSIONS

Presence of CMV DNA in leucocytes, as a marker of latent CMV infection, was associated with increased levels of oxidative stress and subclinical atherosclerosis in healthy adults.

Seroprevalence of Cytomegalovirus among pregnant women and hospitalized children in Palestine

Background

Human Cytomegalovirus (HCMV) is the most common cause of congenital infections. The maternal immune status plays a major role in the likelihood of congenital infection. The aim of this study is to shed light on the seroprevalence of HCMV in pregnant women, hospitalized children and newborns including cases of congenital infections in Palestine.

Methods

We analyzed HCMV IgG and IgM test results that had been ordered for pregnant women, hospitalized children and newborns in the years 2006–2012 at Al-Makassed Islamic Charitable Hospital (MICH) in East Jerusalem. Furthermore, we reviewed the medical charts of newborns and HCMV IgM-positive children.

Results

HCMV IgG was positive in 96.6% of pregnant women, in 88% of hospitalized children and in 98.4% of hospitalized newborns. HCMV IgM was positive in 11.5% of pregnant women, in 11.7% of hospitalized children and in 2% of hospitalized newborns respectively. The HCMV avidity assay revealed that 95% of IgM-positive pregnant women had high avidity (>60%) indicating that most Palestinian women were undergoing a recurrent HCMV infection. Real time PCR on limited number of cases indicated that 62.5% of infants, mostly born to IgM-positive mothers and 83.3% of HCMV IgM-positive children had detectable HCMV DNA in their urine. Out of the 249 newborns tested during this study period, four (1.6%) were subjected to Gancyclovir treatment because of symptomatic congenital HCMV infection.

Conclusions

This is the first report to provide an insight into HCMV seroprevalence in Palestine. Despite the high rate of seropositivity, the importance of HCMV testing during pregnancy should not be underestimated. A comprehensive study with a long term follow-up examination of offspring born to HCMV IgM-positive mothers would be required to provide estimates of an accurate percentage of symptomatic congenital HCMV infection in Palestine.

Kinetics of IgG antibody to cytomegalovirus (CMV) after birth and seroprevalence of anti-CMV IgG in Chinese children

Background

Prevalence of cytomegalovirus (CMV) infection is 90–100% in developing countries; however, the kinetics of anti-CMV IgG in infants remains elusive.

Methods

Sera from 112 mother-newborn pairs and longitudinal samples from 41 infants up to 2-year old were tested for anti-CMV IgG and IgM. Additionally, samples from 837 healthy children were included.

Results

Of 112 mothers, 108 (96.4%) were anti-CMV IgG positive; their 108 newborns were also seropositive. In a 2-year follow-up among 40 infants of positive mothers, anti-CMV IgG level in 8 individuals decreased with time and became undetectable by age of 3.5–8 months, and that in 32 others decreased at 1- and 3.5-month old, and then increased. Based on the positive IgM, rising IgG levels, and low anti-CMV IgG avidity index, 76.7% of the primary infections were demonstrated to occur during 1–3.5 months of age. The overall seroprevalence of anti-CMV in 837 children was 82.4%, which was generally constant from 2 to 8 years old (χ² = 3.150, p = 0.790).

Conclusions

The maternally acquired anti-CMV IgG in infants disappears before 8-month old. Primary CMV infection in Chinese children mostly occurs during 1–3.5 months of age. Whether the relatively lower seroprevalence of anti-CMV in Chinese children found in this survey may reflect the positive rate in child-bearing age women in the future remains to be further studied.

The Taiwan Birth Panel Study: a prospective cohort study for environmentally- related child health

BACKGROUND

The Taiwan Birth Panel Study (TBPS) is a prospective follow-up study to investigate the development of child health and disease in relation to in-utero and/or early childhood environmental exposures. The rationale behind the establishment of such a cohort includes the magnitude of potential environmental exposures, the timing of exposure window, fatal and children's susceptibility to toxicants, early exposure delayed effects, and low-level or unknown neurodevelopmental toxicants.

METHODS

A total of 486 mother-infant paired was enrolled from April 2004 to January 2005 in this study. Maternal blood before delivery, placenta and umbilical cord blood at birth, and mothers' urine after delivery were collected. The follow-up was scheduled at birth, 4, 6 months, and 1, 2, 3 and 5 years. The children's blood, urine, hair, and saliva were collected at 2 years of age and children's urine was collected at 5 years of age as well. The study has been approved by the ethical committee of National Taiwan University Hospital. All the subjects signed the inform consent on entering the study and each of the follow up.

RESULTS

Through this prospective birth cohort, the main health outcomes were focused on child growth, neurodevelopment, behaviour problem and atopic diseases. We investigated the main prenatal and postnatal factors including smoking, heavy metals, perfluorinated chemicals, and non-persistent pesticides under the consideration of interaction of the environment and genes.

CONCLUSIONS

This cohort study bridges knowledge gaps and answers unsolved issues in the low-level, prenatal or postnatal, and multiple exposures, genetic effect modification, and the initiation and progression of "environmentally-related childhood diseases."

Diagnosis and screening for cytomegalovirus infection in pregnant women in Cuba as prognostic markers of congenital infection in newborns: 2007-2008

BACKGROUND

Human cytomegalovirus (HCMV) has established itself as the most significant cause of congenital infection in the developed world. The objective of this research was prenatal identification of pregnant women at risk for developing active infection due to HCMV as well as to diagnose congenitally infected newborns.

METHODS

A diagnostic algorithm based on specific immunoglobulin G (IgG), IgM, and, IgG avidity was used to screen serum from 1131 pregnant women enrolled prospectively from 3 municipalities from Havana City, Cuba during 2007-2008. Qualitative multiplex nested PCR and quantitative real time-based PCR testing for HCMV DNA were performed on urine and saliva specimens from women detected with active infection and from their newborns.

RESULTS

Most women were seropositive to HCMV (92.7%), with 2.38% (27 women) having active infection. Primary infection was detected in 20 pregnant women (1.77%) while 7 patients (0.62%) had active nonprimary infection. HCMV DNA was detected in specimens from 9 of the 27 pregnant women by both PCR methods. HCMV congenital infection was diagnosed in 12 (1.06%) of the 26 live children born from 25 mothers with active infection, for a vertical transmission rate of 46.2%. Two fetal deaths were reported from 2 women with active infection; furthermore 2 newborns were symptomatic at birth and 2 showed sequelae during the follow-up done until 6 months age.

CONCLUSIONS

Mothers with active infection during the pregnancy and with HCMV excretion had significant risks, RR = 1.16 and RR = 1.35, respectively, to have congenitally infected children.

Review of cytomegalovirus seroprevalence and demographic characteristics associated with infection

Cytomegalovirus establishes a lifelong latent infection following primary infection that can periodically reactivate with shedding of infectious virus. Primary infection, reactivation and reinfection during pregnancy can all lead to in utero transmission to the developing fetus. Congenital CMV infections are a major cause of permanent hearing loss and neurological impairment. In this literature review, we found that CMV infection was relatively common among women of reproductive age, with seroprevalence ranging from 45 to 100%. CMV seroprevalence tended to be highest in South America, Africa and Asia and lowest in Western Europe and United States. Within the United States, CMV seroprevalence showed substantial geographic variation as well, differing by as much as 30 percentage points between states, though differences might be explained by variation in the types of populations sampled. Worldwide, seroprevalence among non-whites tended to be 20-30 percentage points higher than that of whites (summary prevalence ratio (PR) = 1.59, 95% confidence interval (CI) = 1.57-1.61). Females generally had higher seroprevalences than males, although in most studies the differences were small (summary PR = 1.13, 95% CI = 1.11-1.14). Persons of lower socioeconomic status were more likely to be CMV seropositive (summary PR = 1.33, 95% CI = 1.32-1.35). Despite high seroprevalences in some populations, a substantial percentage of women of reproductive age are CMV seronegative and thus at risk of primary CMV infection during pregnancy. Future vaccine or educational campaigns to prevent primary infection in pregnant women may need to be tailored to suit the needs of different populations.

Construct validity of the Comprehensive Developmental Inventory for Infants and Toddlers

BACKGROUND

The aim of this study was to investigate the construct validity of the diagnostic test, the Comprehensive Developmental Inventory for Infants and Toddlers (CDIIT).

METHODS

A total of 1085 children in four age groups (infant, 1-year-old, 2-year-old, preschool age) were enrolled. The Developmental Quotient of each subdomain of the five CDIIT subtests (Cognition, Language, Motor, Social, and Self-help) was used as the basic unit for factor analysis with the iterative principle factor method and promax rotation.

RESULTS

The two-factor solution in two younger age groups and 2- or 3-factor solutions in the 2-year-old and preschool groups provided superior factor structure in terms of interpretability and compatibility with existing child development theories.

CONCLUSION

Although five constructs were proposed in the original manual of CDIIT, two to three constructs were revealed in this empirical study.

Monitoring human cytomegalovirus infection with nested PCR: comparison of positive rates in plasma and leukocytes and with quantitative PCR

BACKGROUND

Human cytomegalovirus (HCMV) infection poses a significant health threat to immunocompromised individuals. Here we performed this study to set up a highly sensitive nested PCR method applicable for detecting HCMV infection in high-risk individuals. In this work, 106 blood specimens from 66 patients with potential HCMV infection were obtained. Total DNA was extracted separately from plasma and peripheral blood leukocytes (PBL) of each sample. HCMV DNA was detected in parallel by nested PCR and quantitative real-time PCR (qRT-PCR), and the results were compared.

RESULTS

Serial dilution test revealed that the detection limit of nested PCR was 180 copies/ml. The nested PCR showed a higher positive rate than qRT-PCR (34.9% vs. 12.3%, p < 0.001). The positive rate of nested PCR based on PBL DNA was significantly higher than that based on plasma DNA (34.9% vs. 18.9%, p = 0.002). Of the 14 patients with serial samples, 11 were positive for HCMV DNA in PBL while only 7 were positive in plasma. Moreover, for each patient, nested PCR using PBL DNA also detected more positive samples than that using plasma DNA.

CONCLUSION

Combined use of nested PCR with PBL DNA is highly sensitive in defining HCMV infection. This assay is particularly useful in the case of quantification not essential.

The influence of wakeful prone positioning on motor development during the early life

OBJECTIVE

The "Prone to Play" campaign was proposed and has been ongoing since 2001, but the causal and dosage effects of wakeful prone positioning on motor development are still unclear. The purpose of this longitudinal cohort study was to investigate the effects of prone wakeful positioning at 3 to 6 months of age on motor development during the 6 to 24 months age bracket.

METHODS

Two hundred eighty-eight full-term newborns were recruited at birth and followed up at 4, 6, 12, and 24 months of age respectively. Data on experience, duration, and preference of prone wakeful positioning were collected at 4 and 6 months of age. The acquisition ages of prone specific and nonprone milestones were collected and analyzed to evaluate the impact of wakeful prone positioning on motor development during early life. Gross motor developmental quotients (GMDQ) and fine motor developmental quotients (FMDQ) of the Comprehensive Developmental Inventory for Infants and Toddlers were assessed at ages 6 and 24 months.

RESULTS

The prone duration significantly affected the acquisition ages of 3 prone specific milestones (rolling, crawling-on-abdomen, crawling-on-all-fours) and sitting; without affecting the other 2 nonprone specific milestones (walking and transferring objects), GMDQs and FMDQs. The infants of prone preference achieved prone specific milestones earlier than those of nonprone preference. The prone experience affected the crawling-on-abdomen acquisition age, but not the other motor outcomes.

CONCLUSION

Wakeful prone positioning promotes prone-specific motor milestones in early infancy. "Prone to play for a certain amount of time in an interactive and supervised environment" might be advocated.