Ophthalmological impairment in patients with congenital cytomegalovirus infection

Congenital CMV infection and central nervous system involvement: mechanisms, treatment, and long-term outcomes

Congenital Cytomegalovirus (cCMV) infection is the leading infectious cause of non-genetic sensorineural hearing loss and a significant cause of neurodevelopmental disability in infants. This narrative review aims to describe the mechanisms by which CMV disrupts fetal brain development in early gestation, the importance of neonatal neuroimaging in predicting prognosis, and the optimal intervention for preventing neurologic sequelae. We performed a literature search on PUBMED on this topic and selected the most relevant results, including studies describing neurologic outcomes, neuroimaging, hearing loss, treatment efficacy, or follow-up recommendations in infants with cCMV, prioritizing randomized controlled trials (RCTs), systematic reviews, and expert consensus guidelines. The pathogenesis of cCMV infection is the result of various mechanisms that the virus uses to replicate in the developing fetal central nervous system; the major cause of structural damage to the brain is aberrant migration of neuronal precursors. Recent literature stresses the importance of neuroimaging and the role of neuroradiologic scores to predict neurologic sequelae. The management of infants with isolated SNHL, especially those diagnosed after the neonatal period, remains controversial, though emerging evidence suggests a potential therapeutic window up to 12 weeks of age. Follow-up protocols should be tailored based on clinical presentation, with close audiologic and developmental surveillance.

CONCLUSIONS

Despite recent advances, key knowledge gaps persist regarding the mechanisms of CNS injury, optimal screening for vestibular dysfunction, neonatal biomarkers of prognosis, and treatment indications for isolated SNHL. Targeted research and standardized follow-up models are essential to improve outcomes in this vulnerable population.

WHAT IS KNOWN

• Congenital Cytomegalovirus infection is the leading infectious cause of non-genetic sensorineural hearing loss and a significant cause of neurodevelopmental disability in infants. • Neurological complications remain the most significant contributors to morbidity in cCMV infection.

WHAT IS NEW

• Beyond classical neurological manifestations, cCMV infected babies show a high prevalence of vestibular dysfunction; neurodevelopmental sequelae are frequent, including autism, attention deficit, and learning difficulties, and may occur even in asymptomatic cases. Neuroradiologic scoring systems proved to be predictive of developmental outcomes. • This review proposes a structured follow-up model tailored to clinical and imaging findings and discusses prognostic factors that may help identify children at increased risk for late-onset sequelae.

Can viral load predict a symptomatic congenital CMV infection? A systematic review and meta-analysis

Cytomegalovirus (CMV) is the most common cause of congenital infection. Although only 10% of infected newborns are symptomatic at birth, a clinical disease may develop later in infancy. An early diagnosis of symptomatic congenital CMV is important for successful treatment. The aim of this study was to evaluate if a higher viral load in different biological fluids at the time of diagnosis correlates with symptomatic disease. A systematic search of Medline, Embase, and SCOPUS from 1976 to August 2024 was performed. Studies were included if the viral load was clearly identifiable as median and mean. Two independent reviewers completed screening, full-text review, data extraction, and quality assessment. Study results were reported as median and interquartile range (IQR: Q1-Q3), with group comparisons based on median differences. Pooled estimates of median differences with 95% confidence intervals were obtained using a median-based meta-analysis approach. Of 4558 studies identified, 11 were used in the meta-analysis with a total of 796 patients (376 symptomatic and 420 asymptomatic babies) for blood determinations and 919 patients for urine (331 symptomatic and 588 asymptomatic babies). Symptomatic infants showed significant higher viral load in blood (pooled difference of median = 1.77 × 104, 0.82;2.72 IU/mL) and a trend in urine (pooled difference of median = 339.7 × 104, - 22.2;701.43 IU/mL).

CONCLUSION

In conclusions, we provide preliminary data that a high CMV load in blood and urine may be associated with symptomatic disease in newborns. Wider and more homogeneous evidence is warranted to confirm our conclusions and to identify a threshold for patients at risk of clinical disease.

WHAT IS KNOWN

• CMV is the most common cause of congenital infection and an early diagnosis of symptomatic disease is important for successful treatment. A higher viral load in blood was supposed to correlate with symptomatic disease but with non-unique results and data are lacking for different biological fluids.

WHAT IS NEW

• We provide preliminary data that a great CMV load in blood and urine may predict newborns at risk of symptoms. Wider and more homogeneous evidence is warranted to confirm our conclusions and to identify a specific viral load threshold for patients at risk of clinical disease.

Overview of Cytomegalovirus Ocular Diseases: Retinitis, Corneal Endotheliitis, and Iridocyclitis

Cytomegalovirus (CMV) infection is a significant clinical concern in newborns, immunocompromised patients with acquired immunodeficiency syndrome (AIDS), and patients undergoing immunosuppressive therapy or chemotherapy. CMV infection affects many organs, such as the lungs, digestive organs, the central nerve system, and eyes. In addition, CMV infection sometimes occurs in immunocompetent individuals. CMV ocular diseases includes retinitis, corneal endotheliitis, and iridocyclitis. CMV retinitis often develops in infected newborns and immunocompromised patients. CMV corneal endotheliitis and iridocyclitis sometimes develop in immunocompetent individuals. Systemic infections and CMV ocular diseases often require systemic treatment in addition to topical treatment.

Ophthalmic Complications, Diagnosis, and Treatment of Congenital Human Cytomegalovirus Infection

Background: Human cytomegalovirus (hCMV) is the most common etiological agent of congenital infections seen in newborns. Among the most commonly observed complications in children with congenital human cytomegalovirus infection are those affecting the visual system. Ocular complications of congenital CMV (cCMV) are a topic rarely addressed in the literature, which prompted the authors to update the available knowledge with the latest data. Methodology: English-language literature published between April 2000 and November 2023 (PubMed, NIH, Google Scholar) was analyzed for ocular complications of cCMV. The data obtained were categorized according to the ocular area involved and the incidence. A compilation of criteria for the symptomatic form of cCMV was also created. Results: The cCMV complications described in the literature affect all parts of the visual system: the anterior segment, the posterior segment, the posterior visual pathways, and the visual cortex. The most commonly described ocular complication of cCMV is choroidal and retinal scarring. Conclusions: Ophthalmic complications of cCMV can cause severe visual disturbances. Ophthalmic diagnosis in newborns should include hCMV PCR testing, which has the highest sensitivity and specificity. In the symptomatic form of cCMV, treatment should be instituted according to recommendations. A consensus should be established for screening of primary hCMV infection in pregnant women, the way in which to define the symptomatic form of cCMV, and the appropriateness and standards of treatment for primary hCMV infection in pregnant women.

Consensus recommendation for prenatal, neonatal and postnatal management of congenital cytomegalovirus infection from the European congenital infection initiative (ECCI)

Congenital cytomegalovirus (cCMV) infection carries a significant burden with a 0.64% global prevalence and a 17-20% chance of serious long-term effects in children. Since the last guidelines, our understanding, particularly regarding primary maternal infections, has improved. A cCMV guidelines group was convened under the patronage of the European Society of Clinical Virology in April 2023 to refine these insights. The quality and validity of selected studies were assessed for potential biases and the GRADE framework was employed to evaluate quality of evidence across key domains. The resulting recommendations address managing cCMV, spanning prevention to postnatal care. Emphasizing early and accurate maternal diagnosis through serological tests enhances risk management and prevention strategies, including using valaciclovir to prevent vertical transmission. The guidelines also strive to refine personalized postnatal care based on risk assessments, ensuring targeted interventions for affected families.