Congenital cytomegalovirus infection is associated with high maternal socio-economic status and corresponding low maternal cytomegalovirus seropositivity

Congenital infectious encephalopathies from the intrapartum period to postnatal life

Congenital infections are a common but often underrecognized cause of fetal brain abnormalities, as well as fetal-neonatal morbidity and mortality, that should be considered by all healthcare professionals providing neurological care to fetuses and newborns. Maternal infection with various pathogens (cytomegalovirus, Toxoplasmosis, Rubella virus, Parvovirus B19, lymphocytic choriomeningitis virus, syphilis, Zika virus, varicella zoster virus) during pregnancy can be transmitted to the developing fetus, which can cause multisystem dysfunction and destructive or malformative central nervous system lesions. These can be recognized on fetal and neonatal imaging, including ultrasound and MRI. Imaging and clinical features often overlap, but some distinguishing features can help identify specific pathogens and guide subsequent testing strategies. Some pathogens can be specifically treated, and others can be managed with targeted interventions or symptomatic therapy based on expected complications. Neurological and neurodevelopmental complications related to congenital infections vary widely and are likely driven by a combination of pathophysiologic factors, alone or in combination. These include direct invasion of the fetal central nervous system by pathogens, inflammation of the maternal-placental-fetal triad in response to infection, and long-term effects of immunogenic and epigenetic changes in the fetus in response to maternal-fetal infection. Congenital infections and their neurodevelopmental impacts should be seen as an issue of public health policy, given that infection and the associated complications disproportionately affect woman and children from low- and middle-income countries and those with lower socio-economic status in high-income countries. Congenital infections may be preventable and treatable, which can improve long-term neurodevelopmental outcomes in children.

Poly(I:C)-induced maternal immune activation causes elevated self-grooming in male rat offspring: Involvement of abnormal postpartum static nursing in dam

Introduction: Maternal immune activation (MIA) is closely related to the onset of autism-like behaviors in offspring, but the mechanism remains unclear. Maternal behaviors can influence offspring’s development and behaviors, as indicated in both human and animal studies. We hypothesized that abnormal maternal behaviors in MIA dams might be other factors leading to delayed development and abnormal behaviors in offspring.

Methods: To verify our hypothesis, we analyzed poly(I:C)-induced MIA dam’s postpartum maternal behavior and serum levels of several hormones related to maternal behavior. Pup’s developmental milestones and early social communication were recorded and evaluated in infancy. Other behavioral tests, including three-chamber test, self-grooming test, open field test, novel object recognition test, rotarod test and maximum grip test, were performed in adolescence of pups.

Results: Our results showed that MIA dams exhibit abnormal static nursing behavior but normal basic care and dynamic nursing behavior. The serum levels of testosterone and arginine vasopressin in MIA dams were significantly reduced compared with control dams. The developmental milestones, including pinna detachment, incisor eruption and eye opening, were significantly delayed in MIA offspring compared with control offspring, while the weight and early social communication showed no significant differences between the two groups. Behavioral tests performed in adolescence showed that only male MIA offspring display elevated self-grooming behaviors and reduced maximum grip.

Discussion: In conclusion, MIA dams display abnormal postpartum static nursing behavior concomitantly with reduced serum levels of testosterone and arginine vasopressin, possibly involving in the pathogenesis of delayed development and elevated self-grooming in male offspring. These findings hint that improving dam’s postpartum maternal behavior might be a potential regime to counteract delayed development and elevated self-grooming in male MIA offspring.

Thirty years of CMV seroprevalence-a longitudinal analysis in a German university hospital

Human cytomegalovirus (CMV) is a significant cause of morbidity and mortality in patient groups at risk. We have previously shown that the anti-CMV IgG seroprevalence in an urban region of Germany has changed over the last decades. Overall, a decline from 63.7 to 57.25% had been observed between 1988–1997 and 1998–2008 (p < 0,001). Here, we continuously follow the trends to the most recent decade 2009 to 2018. In a retrospective analysis, we determined the seroprevalence of CMV IgG antibodies in our patient cohort, stratified by gender and selected groups at risk (e.g., patients with HIV infection; women of childbearing age). The overall prevalence of anti-CMV IgG non-significantly declined further from 57.25% in 1998–2008 to 56.48% in 2009–2018 (p = 0.881). Looking at gender differences, overall CMV seroprevalence in males declined to 52.82% (from 55.54% in 1998–2008; p = 0.0254), while it non-significantly increased in females to 59.80%. The high seroprevalence in patients with a known HIV infection further increased from 87.46% in 1998–2008 to 92.93% in the current period (p = 0.9999). In women of childbearing age, no significant changes over the last three decades could be observed. The CMV seroprevalence in oncological patients was determined to be 60.64%. Overall, the former significant decline of CMV seroprevalence between the decades 1988–1997 and 1998–2008 in this urban region of Germany slowed down to a non-significant decrease of 0.77% (1998–2008 vs. 2009–2018). This might be an indicator that CMV seroprevalence has reached a plateau.

Seroprevalence of human cytomegalovirus among pregnant women who had undergone abortion(s) attending El-Damazin Hospital for Obstetrics and Gynecology, Sudan: A cross-sectional study

Background: Human cytomegalovirus (HCMV) is a major cause of congenital infections. It is more widespread in developing countries and communities with low socioeconomic status. The infection can cause pregnancy loss or spontaneous abortion. Tests are available for the detection of HCMV IgG and IgM antibodies. Many pregnant women in Blue Nile State, Sudan, have suffered from recurrent pregnancy loss, and currently there is no available data concerning the prevalence of HCMV in Blue Nile state. This study aimed to determine HCMV antibodies (IgG and IgM) among pregnant women, who had undergone abortion(s), attending El-Damazin Hospital for Obstetrics and Gynecology.   Methods: This was a descriptive, cross-sectional hospital-based study. 270 pregnant women, who had undergone abortion(s) and who attended El-Damazin Hospital for Obstetrics and Gynecology, were included in the study from September to December 2018. Personal and clinical data were collected directly from each participant into a predesigned questionnaire. Serum samples were separated and stored at -20˚C until used. Samples were analyzed for HCMV IgG and IgM using enzyme-linked immune-sorbent assay (ELISA). Results: Participants were categorized into three age groups: 15-25 years (33.7%; 91/270); 26-40 years (62.2%; 168/270); and >41 years (4.1%; 11/270). The majority of the participants had IgG antibodies to HCMV (74.8%; 202/270), while only 13.3% (36/270) had IgM antibodies to HCMV. Most abortion cases were documented in the first trimester (85.6%; 231/270) and this had a significant relationship with IgG level (P=0.003). Low socioeconomic status was recorded in 84.8% (229/270) of participants and showed significant correlation with IgG level (P=0.025), whereas illiteracy was reported in 41.9% (113/270) of participants and did not have a significant relationship.   Conclusions: Seroprevalence of HCMV in this study population was 74.8% for IgG antibodies. There was an association between HCMV IgG level and first trimester abortion and low socioeconomic status among the studied women.

Seroprevalence of Cytomegalovirus Infection Among HIV-Infected and HIV-Uninfected Pregnant Women Attending Antenatal Clinic in Harare, Zimbabwe

This study aimed to investigate the seroprevalence of cytomegalovirus (CMV) infection and risk factors associated with CMV acquisition among pregnant women in Zimbabwe. In a cross-sectional study, pregnant women were recruited in late gestation, seeking antenatal care at council clinics in three high-density suburbs in Harare, Zimbabwe. Anti-CMV IgM and IgG antibodies were quantified in serum using an enzyme-linked immunosorbent assay. Antibody avidity tests were used to distinguish active infection from viral reactivation in anti-CMV IgM-positive cases. Five hundred and twenty four women were recruited: 278 HIV infected and 246 HIV uninfected. Current or active CMV infection defined as IgM positive+low avidity was detected in 4.6% (24/524), 95% confidence interval (CI): 3-6.9 in all women, 5.8% (16/278) in the HIV infected and 3.3% (8/246), 95% CI: 1.4-6.3 in the HIV uninfected. IgG seroprevalence was 99.6% (522/524), 95% CI: 98.6-99.9 in all women. Notably, the difference in the prevalence of active CMV infection between the HIV-infected and HIV-uninfected women was not statistically significant (p = 0.173). The study shows a low prevalence of primary or active CMV infection among the pregnant women, but the IgG seroprevalence suggests high previous CMV exposure. Importantly, CMV seroprevalence was not associated with the HIV status of the women, perhaps due to the ubiquitous exposure of the population to CMV.

Cytomegalovirus (CMV) seroprevalence in the adult population of Germany

BACKGROUND

Infection with cytomegalovirus (CMV) remains asymptomatic in most immunocompetent hosts, but is the leading cause of congenital viral infection worldwide and can be life-threatening in immunocompromised individuals. We aimed to assess CMV seroprevalence in a nationally representative sample of adults in Germany and to identify sociodemographic factors associated with CMV seropositivity.

METHODS

Blood samples from 6552 participants (18-79 years) of the "German National Health Interview and Examination Survey 1998", a population-based sample of the adult population in Germany, were tested for the presence of CMV antibodies using an Ig-multiplex assay. Weighted seroprevalence was calculated and weighted binomial regression was used to identify factors associated with CMV seropositivity.

RESULTS

Overall CMV seroprevalence was 56.7% (95%CI: 54.8-58.7%), with a higher seroprevalence in women (62.3%) than in men (51.0%). Seroprevalence increased with age: from 31.8% to 63.7% in men and from 44.1% to 77.6% in women when comparing the 18-29 with the 70-79 year age-group, respectively. CMV seroprevalence in women of childbearing age (18-45 years) was 51.7%. Factors significantly associated with CMV seropositivity were age, country of birth, smoking status, education, living in northern Germany and number of household members. In addition, having attended child care was associated with seropositivity in men, and number of siblings and living in East Germany in women.

CONCLUSION

Our results indicate that half the women of childbearing age were susceptible for primary CMV infection during pregnancy. CMV screening during pregnancy and informing seronegative women about CMV risk reduction measures could prevent congenital CMV infections with its serious consequences.

Cyclophilin A as a target in the treatment of cytomegalovirus infections

BACKGROUND

Viruses are obligate parasites that depend on the cellular machinery of the host to regenerate and manufacture their proteins. Most antiviral drugs on the market today target viral proteins. However, the more recent strategies involve targeting the host cell proteins or pathways that mediate viral replication. This new approach would be effective for most viruses while minimizing drug resistance and toxicity.

METHODS

Cytomegalovirus replication, latency, and immune response are mediated by the intermediate early protein 2, the main protein that determines the effectiveness of drugs in cytomegalovirus inhibition. This review explains how intermediate early protein 2 can modify the action of cyclosporin A, an immunosuppressive, and antiviral drug. It also links all the pathways mediated by cyclosporin A, cytomegalovirus replication, and its encoded proteins.

RESULTS

Intermediate early protein 2 can influence the cellular cyclophilin A pathway, affecting cyclosporin A as a mediator of viral replication or anti-cytomegalovirus drug.

CONCLUSION

Cyclosporin A has a dual function in cytomegalovirus pathogenesis. It has the immunosuppressive effect that establishes virus replication through the inhibition of T-cell function. It also has an anti-cytomegalovirus effect mediated by intermediate early protein 2. Both of these functions involve cyclophilin A pathway.

Cohort study on maternal cytomegalovirus seroprevalence and prevalence and clinical manifestations of congenital infection in China

Congenital cytomegalovirus (CMV) infection is the leading viral cause of birth defects and developmental disabilities in developed countries. However, CMV seroprevalence and burden of congenital CMV infection are not well defined in China.Cohort of newborns from 5 birthing hospitals in 2 counties of Shandong Province, China, were enrolled from March 2011 to August 2013. Dried blood spots (DBS) and saliva were collected within 4 days after birth for IgG testing for maternal seroprevalence and real-time PCR testing for congenital CMV infection, respectively.Among 5020 newborns tested for CMV IgG, 4827 were seropositive, resulting in CMV maternal seroprevalence of 96.2% (95% confidence interval [CI]:95.6%-96.7%). Of the 10,933 newborns screened for congenital CMV infection, 75 had CMV detected, resulting in an overall prevalence of 0.7% (95% CI: 0.5%-0.9%), with prevalences of 0.4% (14/3995), 0.6% (66/10,857), and 0.7% (52/7761) for DBS, wet saliva, and dried saliva specimens screened, respectively. Prevalence of congenital CMV infection decreased with increasing maternal age (0.9%, 0.6%, and 0.3% among newborns delivered from mothers aged 16-25, 26-35, and >35 years, respectively; P = 0.03), and was higher among preterm infants than full term infants (1.3% vs 0.6%, P = 0.04), infants with intrauterine growth restriction (IUGR) than those without (1.8% vs 0.7%, P = 0.03), and twins or triplets than singleton pregnancies (2.8% vs 0.7%, P = 0.04). None of the 75 newborns exhibited symptomatic congenital CMV infection, and there was no difference in clinical characteristics and newborn hearing screening results between infants with and without congenital CMV infection at birth.Congenital CMV infection prevalence was lower and the clinical manifestations were milder in this relatively developed region of China compared to populations from other countries with similarly high maternal seroprevalence. Follow-up on children with congenital CMV infection will clarify the burden of disabilities from congenital CMV infection in China.

Awareness of cytomegalovirus and risk factors for susceptibility among pregnant women, in Montreal, Canada

BACKGROUND

Advances in diagnostic and therapeutic modalities for congenital cytomegalovirus (CMV) infection have generated a mounting interest in identifying mothers susceptible to CMV. The objectives of this study were to evaluate the prevalence and socio-demographic determinants of CMV susceptibility and CMV awareness, among pregnant women, in Montreal, Quebec.

METHODS

Between April and December 2012, women delivering at Centre Hospitalier Universitaire Sainte Justine were recruited for the study. Stored serum from the first trimester of pregnancy was tested for CMV IgG. Knowledge about CMV and socio-demographic characteristics were collected via standardized questionnaire.

RESULTS

Four hundred and ninety one women were enrolled in the study. Overall, 225 mothers (46%) were seronegative for CMV, and 85% (n = 415) were unaware of CMV or the associated risks in pregnancy. Significant risk factors for CMV seronegative status included Canadian vs. foreign born (aOR 6.88, 95% CI 4.33-10.94), and high vs. low family income (aOR 4.68, 95% CI 2.09-10.48). Maternal employment status was the only significant predictor of CMV unawareness, with unemployed mothers at the highest risk (aOR 85.6, 95% CI 17.3-421.3).

CONCLUSIONS

Nearly half of pregnant women studied were at risk of primary infection, and yet, the majority was unaware of potential risks associated with CMV. Canadian born mothers and those with a high socioeconomic status were more likely to be CMV seronegative. Increased education about CMV infection, through public health interventions and obstetrician/pediatric counseling, is needed for all pregnant women.

Awareness of Cytomegalovirus Infection among Pregnant Women in Geneva, Switzerland: A Cross-sectional Study

BACKGROUND

Cytomegalovirus (CMV) is the most frequent cause of congenital infection and commonly associated with sensorineural deficit. At present, there is neither prophylaxis nor treatment during pregnancy. The objective of this study was to evaluate the level of awareness regarding CMV infection and its consequences in women delivering at the University of Geneva Hospitals (Geneva, Switzerland).

METHODS

The study consisted of a validated questionnaire completed by women in the immediate postpartum period.

RESULTS

The questionnaire was completed by 59% (314/528) of delivering women. Only 39% (123/314) knew about CMV and 19.7% (62/314) had received information about preventive measures. Women were more aware about other congenital diseases, such as toxoplasmosis (87%); human immunodeficiency virus (99%); syphilis (85.5%); rubella (92.3%); and group B Streptococcus (63%). Factors associated with CMV awareness were Swiss nationality, high education level, employment in health care or with children, and being followed by an obstetrician. Regarding quality of information, few were aware of the main CMV complications (deafness, 25.2%; mental retardation, 34.5%). Among those informed about CMV, most (74.6%) knew about preventive measures. Among these, 82.5% thought that these were easily applicable.

CONCLUSIONS

Most women were unaware of CMV infection and its potential risks during pregnancy. It is crucial to improve CMV information given to pregnant women to prevent the risks for the fetus/newborn.

Cytomegalovirus-related childhood mortality in Australia 1999-2011

AIM

Cytomegalovirus (CMV) is an important cause of congenital infection, which can result in neonatal deaths or contribute to deaths in later childhood. Post-natally acquired CMV is a less common cause of disease and mortality, and only in preterm infants or immunocompromised children. Here we sought to describe CMV as a direct or secondary contributor to childhood mortality in Australia.

METHOD

We searched national mortality data sets between1999 and 2011 for cases <15 years with CMV recorded as an underlying or contributing cause of death.

RESULTS

Eighty-three CMV-associated deaths in children <15 years were identified (0.2 cases per 100 000 <15 years; 95% confidence interval 0.16-0.24). Childhood deaths associated with CMV were evenly distributed between males and females, and the majority (n = 57; 68%) occurred in children less than 12 months of age, with 22 cases <1 month of age. Over the 13-year study period, the mortality rate remained stable and CMV resulted in an estimated age-adjusted 5925 years of potential life lost.

CONCLUSIONS

CMV makes a small but important contribution to childhood mortality in Australia. Most CMV-related deaths occurred in infants <12 months of age. These infant deaths may be an indirect marker of the burden of severe intrauterine CMV disease given the natural history of this infection.

Cytomegalovirus infection and pathogenesis in the human placenta

Human cytomegalovirus (HCMV) is the most common cause of congenital viral infection. Affected children can have permanent neurological complications, including hearing loss, visual impairment and mental retardation1–3. In Australia, 57% of women are seronegative and at risk for primary infection and transmission of virus to the fetus during pregnancy4. Despite its public health significance, the specific molecular and cellular basis of HCMV replication in the human placenta and pathogenesis associated with poor clinical outcome are unknown. Direct fetal infection is involved in severe cases of neuropathology and infection of the placenta can impair its development and functions resulting in a hypoxic environment5–8 and stillbirth6,9,10. Gestational age at the time of infection is an important determinant of outcome. The rates of virus transmission increase from 30% in first trimester to over 70% in third trimester suggesting different mechanisms for overcoming the placental barrier2. Remarkable insights into viral pathogenesis factors that function in the tissue environment have been gained by studying congenitally infected placentas and explants infected by clinical strains ex vivo. Together these studies revealed that direct infection of specialised placental cells and paracrine factors contribute to impaired development and functional defects.

Clinical and epidemiological features of congenital cytomegalovirus infection globally

Human cytomegalovirus (CMV) is the most common non-genetic cause of congenital disability. As a herpesvirus that infects the majority of the population, CMV is able to establish a lifelong latent infection in the host. Any time during pregnancy, a primary CMV infection, reactivation of latent CMV or a new viral strain can infect the placenta and the developing foetus, resulting in congenital CMV infection. Each year, an estimated 2000 children are born with congenital CMV infection in Australia, leaving ~500 children with permanent disabilities such as hearing or vision loss, or mental disability. Despite the clinical importance of congenital CMV, there is limited awareness and knowledge in the medical and general community about congenital CMV infection. This article reviews the global epidemiology and clinical features of maternal and congenital CMV infections.

Congenital cytomegalovirus infection: Clinical presentation, epidemiology, diagnosis and prevention

Cytomegalovirus is the most common congenital infection causing serious disease in infants. It is the leading infectious cause of sensorineural hearing loss and neurodevelopmental disability in developed countries. Despite the clinical importance of congenital cytomegalovirus, surveys show there is limited awareness and knowledge in the medical and general community about congenital cytomegalovirus infection. This article reviews the clinical features, global epidemiology, transmission and risk factors for cytomegalovirus infections. It also highlights several major advances made in recent years in the diagnosis and prevention of cytomegalovirus infection during pregnancy. Although research is ongoing, no therapy is currently proven to prevent or treat maternal, fetal or neonatal cytomegalovirus infection. Education of women regarding hygiene measures can help prevent cytomegalovirus infection and are currently the best strategy to prevent congenital cytomegalovirus disease.