Pitfalls in the Serological Evaluation of Maternal Cytomegalovirus Infection as a Potential Cause of Fetal and Neonatal Involvements: A Narrative Literature Review

Cytomegalovirus (CMV) is the most common cause of intrauterine infection and serological assays are the primary tools for assessing CMV infections during pregnancy. CMV-specific immunoglobulin M (IgM) antibodies have been used as a diagnostic marker for primary CMV infection in pregnant women, although CMV-IgM has been detected in non-primary CMV infections. IgG avidity testing may aid the distinguishing of primary from non-primary CMV infection; however, there is no standardized assay for detecting this difference. Moreover, when maternal serology shows positive CMV-IgG with negative CMV-IgM findings, vertical transmission probability following primary CMV infection is often excluded. However, symptomatic congenital CMV infections in the context of negative findings for maternal CMV-IgM have been reported recently. The absence of CMV-IgM is recognized in both primary and non-primary CMV infections. Furthermore, maternal non-primary CMV infections during pregnancy may yield a greater proportion of symptomatic congenital CMV infections than previously thought. If universal prenatal screening is performed, ultrasonography for abnormal fetal findings should be conducted regardless of CMV-IgM antibody status. If not universally screened, CMV antibody screening should be performed whenever routine fetal ultrasound reveals abnormal findings. For suspected fetal CMV infection, amniotic fluid or postnatal infant urine CMV-DNA testing is required.

IgM Positivity for both EBV and CMV: A Clinical Conundrum

A review of 28 patients who tested positive for both Epstein-Barr virus and cytomegalovirus immunoglobulin M at an academic medical center revealed that dual positivity is more common than previously reported. These cases require careful review of the history and sometimes supplemental testing. This report highlights features of patients with dual positivity and provides recommendations on interpretation of the results.

False Positive COVID-19 Antibody Test in a Case of Granulomatosis With Polyangiitis

Collateral damage due to 2019 novel coronavirus disease (COVID-19) represents an emerging issue. Symptoms of COVID-19 are not disease-specific. Differential diagnosis is challenging and the exclusion of other life-threatening diseases has major caveats. In the era of this pandemic, diagnosis of other life-threatening diseases might delay treatment. The Food and Drug Administration has recently authorized the first antibody-based test for COVID-19; however, RT-PCR of nasopharyngeal or oropharyngeal swabs remains the recommended test for diagnosis. We present the first report of a false positive COVID-19 antibody test in a case of Granulomatosis with Polyangiitis (GPA). Specifically, the case concerns an 82-year-old female, never smoker, who was admitted to our hospital with symptoms of fever and general fatigue that had lasted 7 days. She already had a positive IgM test for COVID-19, yet multiple RT-PCR tests had returned as negative for SARS-CoV-2. In the following days, her renal function deteriorated, while hematuria and proteinuria with active urinary sediment developed. Based on high clinical suspicion for ANCA-associated vasculitis, we performed a complete immunologic profile which revealed positive c-ANCA with elevated titers of anti-PR3. Pulses of methylprednisolone along with cyclophosphamide were applied. At day 10, treatment response was noticed as indicated by respiratory and renal function improvement. This report highlights the need for meticulous patient evaluation in order to avoid misdiagnosis in the era of COVID-19.

Detection and Prevention of Perinatal Infection: Cytomegalovirus and Zika Virus

Congenital cytomegalovirus is the most common viral congenital infection, and affects up to 2% of neonates. Significant sequelae may develop after congenital cytomegalovirus, including hearing loss, cognitive defects, seizures, and death. Zika virus is an emerging virus with perinatal implications; a congenital Zika virus syndrome has been identified, and includes findings such as microcephaly, fetal nervous system abnormalities, and neurologic sequelae after birth. Screening, diagnosis, prevention, and treatment of these perinatal infections are reviewed in this article.

Association between false-positive TORCH and antiphospholipid antibodies in healthy pregnant women

The present study investigated: (a) the presence of antiphospholipid antibodies and (b) the obstetric outcome in healthy pregnant women showing false-positive TORCH-Toxoplasmosis, Other: syphilis, varicella-zoster, Rubella, Cytomegalovirus (CMV), and Herpes infections-results. Data from 23 singleton healthy pregnancies with false-positive TORCH results were collected. Each woman was systematically screened for TORCH IgG and IgM during the pre-conception assessment and/or at the beginning of pregnancy. In the presence of IgM positivity, when indicated (CMV, toxoplasmosis, rubella, herpes simplex virus), IgG avidity was evaluated and, if possible, polymerase chain reaction was performed on an amniotic fluid sample in order to distinguish between primary infection or false positivity. The antiphospholipid antibodies tests were: lupus anticoagulant, anticardiolipin antibodies IgG, IgM, and anti-β2glicoprotein I IgG, IgM. The antiphospholipid antibodies tests, if positive, were repeated after 12 weeks to confirm the results. In pregnant women with false-positive TORCH, the overall prevalence of positive antiphospholipid antibodies for one or more tests was 52.2%. To clarify the correlation of false-positive TORCH results with clinical practice, obstetric outcome was analyzed in terms of live births, week of delivery, neonatal birth weight, and neonatal birth weight percentile. A statistically significant lower neonatal birth weight and neonatal birth weight percentile were observed in women with false-positive TORCH associated with antiphospholipid antibodies positivity (Group A) in comparison with those in women with false-positive TORCH without antiphospholipid antibodies positivity (Group B). No statistically significant difference was found for the week of delivery between the two groups. It is hoped that future studies will verify the life-long persistence of antiphospholipid antibodies positivity by follow-up of these women and identify who will develop a classical antiphospholipid syndrome or other autoimmune disorders.

Dynamic relationship between infantile hepatitis syndrome and cytomegalovirus infection

We investigated the correlation between cytomegalovirus (CMV) infection and infantile hepatitis syndrome and the correlation between blood ammonia levels in children with CMV-induced hepatitis syndrome and liver function indicators. To analyze the relationship between the positive-negative attributes of CMV infection and the recurrence rate of infantile hepatitis syndrome, a total of 86 cases of children with hepatitis syndrome admitted to Xuzhou Children's Hospital from January 2014 to March 2015 were selected for the study group. Furthermore, 86 cases of healthy children who visited our hospital for a physical examination during the same period were selected as the control group. From the two groups, serum CMV-immunoglobulin M (IgM) levels were determined via enzyme-linked immunosorbent assay, and urinary CMV-deoxyribonucleic acid (DNA) was ascertained by fluorescent ratio polymerase chain reaction. These levels were then compared between the two groups and analyzed. A fully automatic biochemical analyzer was utilized to evaluate the blood ammonia and liver function indicators of the children with infantile hepatitis syndrome induced by CMV infection and to analyze the correlation of these factors. A mean follow-up of 12 months after the children's discharge was adopted to observe the relationship between the negative-positive attributes of CMV infection and the recurrence rate in the children upon cure. The positive detection rate for the serum CMV-IgM was 24.4%, and that for the urinary CMV-DNA was 34.9%; both values were significantly higher than that for the control group (P<0.05). The blood ammonia levels of the children with infantile hepatitis syndrome induced by CMV infection were not correlated with the liver function indicators, such as total bilirubin, direct bilirubin, alanine aminotransferase, aspartate aminotransferase, γ-glutamyltransferase, total bile acid, and cholinesterase (P>0.05), but they were negatively correlated with blood albumin (ALB) (P<0.05). The recurrence rate of hepatitis syndrome among the children with negative CMV infection was 3.8%, which was significantly lower than that among the children with positive CMV infection (62.5%, P<0.05). A significant correlation was found between CMV infection and infantile hepatitis syndrome, with the former being a risk factor for the latter. Changes in the conditions of infantile hepatitis syndrome may be reflected by blood ammonia and ALB indicators. Through improved monitoring, these indicators facilitate the early diagnosis and treatment of children with hepatitis syndrome induced by CMV infection. Sufficient attention should be paid to preventive measures to reduce the incidence rate of infantile hepatitis syndrome.

New diagnostics and methods of assessing pregnant women at risk of cytomegalovirus

Human cytomegalovirus (CMV) infection can occur in pregnant women by primary infection or by non-primary infection, namely by either reactivation of the latent virus or reinfection with a different strain1. In all cases the mother can transmit the virus to the fetus through the placenta2,3. In the diagnosis of primary CMV infection, the gold standard is maternal seroconversion to CMV-specific antibodies. Currently, women are not routinely screened for CMV before conception or during pregnancy, thus CMV seroconversion is infrequently documented1. Lastly, serological diagnosis of non-primary CMV infection is very difficult and very often unreliable since no optimal diagnostic methods are currently available. Today, the fetal compartment can be only studied by amniocentesis and ultrasound examination for the diagnosis and prognosis of CMV infection and generally, invasive diagnostic protocol can be only suggested to pregnant women with evidence of primary CMV infection acquired early in gestation and in case of abnormal findings suggestive of congenital infection1. Therefore, a correct maternal diagnosis makes so that invasive prenatal diagnosis is only offered in selected cases. This report points out how a CMV-screening program combined with an advanced diagnostic protocol performed on pregnant women could identify those at high risk of transmitting the virus to their fetus. Furthermore, we evaluated the possible role of soluble HLA-G (sHLA-G) molecules detected in maternal and fetal samples in order to more accurately assess a greater risk of CMV-transmission and fetal/neonatal injury.

Sero-epidemiological survey of human cytomegalovirus-infected children in Weifang (Eastern China) between 2009 and 2012

Background

To understand the prevalence and characteristics of human cytomegalovirus (HCMV) infection in children in the Weifang area, and to provide information for its prevention and treatment.

Methods

A comprehensive survey was performed from 2009 to 2012 in 7582 children from birth to 6 years of age hospitalized in the Maternity and Child Health Hospital of Weifang. ELISA HCMV serology results and survey data were analyzed by age group and socio-economic level. The infection rates were based on IgG and IgM serology.

Results and conclusions

The overall infection rate from IgG and IgM in the Weifang area from 2009 to 2012 was 42.5% (3496/7582), among which 34.2% were HCMV-IgG positive, suggesting past infection. Overall, the probability of active HCMV infection showed no gender difference in any age group (P >0.05). Recent infections centered on the first 6 months of life, presumably due to breastfeeding. Among the 654 children hospitalized for active HCMV infection, 379 (57.9%) were from rural areas and 275 (42.1%) from urban areas, showing that active infection in the countryside was higher than that in the city (χ² = 32.65, p <0.01).

The relationship between TORCH complex false positivity and obstetric outcome in patients with antiphospholipid syndrome

OBJECTIVE

The presence of TORCH IgM positivity is not a specific indicator of primary infection; the assessment of IgG avidity index has been shown to be useful in identifying or excluding primary infection in pregnant women with no pre-gestational TORCH serology. TORCH is an acronym for Toxoplasmosis, Others (HBV, syphilis, Varicella-Zoster virus, Epstein Barr virus, Coxsackie virus and Parvovirus), Rubella, Cytomegalovirus (CMV) and Herpes Simplex.

PATIENTS AND METHODS

Data from 54 pregnancies in women with antiphospholipid syndrome (APS) were assessed in comparison with data from 222 healthy pregnant women as controls. Each woman in both groups was systematically screened for TORCH IgG and IgM during pre-conceptional evaluation and/or at the beginning of pregnancy. The assessment of IgG avidity was also evaluated in order to identify primary infection or false positivity.

RESULTS

A significant increase of CMV IgM false positivity in APS in comparison with controls was detected. A worse pregnancy outcome was observed among APS patients having CMV IgM false positivity in comparison with APS patients without false positivity; in particular a statistically significant lower neonatal birth weight and a lower neonatal birth weight percentile were observed.

CONCLUSION

Our data suggest that the presence of CMV IgM false positivity could represent a novel prognostic factor for poor pregnancy outcome in APS patients.

Complementemia and obstetric outcome in pregnancy with antiphospholipid syndrome

Objective: To investigate the predictive value of serum C3 and C4 complement component levels in relation to pregnancy outcome in patients with antiphospholipid syndrome (APS).

Materials and methods: A prospective study of 47 pregnancies associated with APS was performed. Pregnancy outcome was analyzed in terms of: fetal loss, preterm delivery (≤34 gestational weeks), fetal intrauterine growth restriction (IUGR), birth weight <2500 g and preeclampsia. Week at delivery, neonatal birth weight and neonatal birth weight percentile were also investigated. Hypocomplementemia, positivity for anti-dsDNA and triple positivity for antiphospholipid antibodies (aPL) were related to pregnancy outcome.

Results: Forty-three pregnancies ended in live births with a fetal loss rate of 8.5%. Fetal death, preterm delivery and birth weight <2500 g were associated with hypocomplementemia ( p = 0.019, p = 0.0002, p < 0.0001 respectively). Lower neonatal birth weight, lower neonatal birth weight percentile and lower week at delivery were associated with hypocomplementemia ( p < 0.0001, p = 0.0003, p < 0.0001 respectively) and with triple aPL positivity ( p = 0.008, p = 0.014, p = 0.03 respectively). A poor pregnancy outcome was confirmed among primary APS (PAPS) pregnancies with hypocomplementemia. Multivariate analysis confirmed that hypocomplementemia was an independent predictor of lower neonatal birth weight ( p = 0.0001) and lower week at delivery ( p = 0.002).

Conclusion: Hypocomplementemia could be considered a novel prognostic factor for pregnancy outcome in APS patients.