Gastrointestinal manifestations of postnatal cytomegalovirus infection in infants admitted to a neonatal intensive care unit over a five year period

Abstract

Sixteen cases of postnatal cytomegalovirus (CMV) infection were identified in a neonatal intensive care unit population over a five year period. Eleven of these infants had gastrointestinal signs at the time of presentation. These ranged from minor and transient (abdominal distension and enteral feed intolerance) to severe and life threatening (protein losing enteropathy, diarrhoea, and hypernatraemic dehydration). An initial diagnosis of necrotising enterocolitis was common, but no infant showed intestinal or hepatic portal pneumatosis. The gestational age of the infants was 24-38 weeks. All had received fresh maternal breast milk. It is suggested that CMV enteritis is added to the spectrum of clinical manifestations of postnatal CMV infection. Signs suggestive of necrotising enterocolitis with atypical features should prompt investigations for CMV infection. P ostnatal cytomegalovirus (CMV) infection has not attracted the attention received by congenital infection as it is held to result in low morbidity. The recognition of severe gastrointestinal symptoms in a small number of preterm infants with postnatal CMV infection prompted a search of the literature and a review of infants admitted to our neonatal unit over a five year period who were known to have postnatally acquired CMV infection. METHODSInfants were identified as a result of CMV screening in the presence of symptoms such as prolonged jaundice, unexplained enteritis, or signs of systemic sepsis in the absence of positive blood cultures for bacterial sepsis. The standard screen test was the urine CMV DEAFF (detection of early antigen fluorescent foci) test. This is a rapid culture test whereby early CMV antigens are detected by immunofluorescence after the inoculum on a cell sheet is spun for two to four days. The diagnosis of CMV infection was based on the fact that a previously negative urine CMV DEAFF test became positive coincidentally with the onset of clinical symptoms. Urine CMV DEAFF screening of infants at admission was not performed routinely although many of the infants had early screening. However, all of our cases had negative urine CMV DEAFF tests before the positive tests. In cases where the symptomatology was severe, additional tests such as CMV blood IgM and antigen detection were carried out. As the infants were sick preterm babies, it was not feasible to obtain gastrointestinal biopsy samples to confirm the diagnosis of CMV gastrointestinal disease.Our unit feeding policy is to start enteral feeds early once the infant is clinically stable. The preference is for the mother's own breast milk. If not available, then with parental consent, banked breast milk is given. The mother's own milk is given fresh within 48 hours of expression. This milk would have been stored at 4˚C. If fresh mother's milk is unavailable or insufficient, frozen maternal breast milk or banked donor milk is used. Our unit has its own milk bank on site. Milk is obtained from donors who are screened for a panel of viruses (hepatitis B, hepatitis C, HIV-1 and HIV-2,...

Cytomegalovirus in Breast Milk: Reassessment of Pasteurization and Freeze-Thawing

“…Gastrointestinal signs ranging from minor and transient to severe and life-threatening and resembling necrotising enterocolitis were recently described in preterm infants with breast milk transmitted CMV infection (11 cases out of 2830 admissions to a neonatal unit (22) and a handful of case reports in the literature)-in one CMV was verified by immunohistopathology (23).…”

Neonatal gastrointestinal involvement and congenital cytomegalovirus

“…Most of the studies revealed a possible association between CMV infection and enteritis, 22 17,25,33,36,37,39,40,44,63,65 often with finding of CMV inclusions in histological intestinal samples. It is debatable whether the virus has a role in the pathogenesis of the diseases, either directly or as a secondary super-infection after the acute phase of the enterocolitis.…”

“…7,8,10,11,20 On the other hand, CMV gastrointestinal symptoms could be an important manifestation of postnatal infection in patients admitted to neonatal intensive care units 25 or a manifestation of CMV intestinal disease in immunocompromised patients or patients affected by inflammatory bowel disease. 22,[26][27][28][29][30][31][32][33] A rare presentation with intestinal polyps in immunocompetent healthy patients has also been described.…”

Incidence and Impact of CMV Infection in Very Low Birth Weight Infants

“…CMV-related gastrointestinal disease including perforation has been reported previously. 15,[26][27][28] A larger trial with prospective screening at regular intervals for acquired CMV would be needed to confirm or refute this potential association, especially because it is possible in our study that infants with gastrointestinal perforation presented with a constellation of symptoms that simply made them more likely to be tested for CMV.…”