Cytomegalovirus infection and hepatitis
Ira Shah
Medical Sciences Department, Pediatric Oncall, Mumbai

Address for Correspondence: Dr Ira Shah, 1, B Saguna, 271, B St Francis Road, Vile Parle {W}, Mumbai 400056, India.

Clinical Problem :
A 4 month old boy, 2nd born of third degree consanguineous marriage presented with not gaining weight since birth. He was a full term normal delivery with birth weight of 3 kg. Mother had fever at 7-8 months of gestation and had received antibiotics orally for same. The child on Day 15 of life developed rash over body with fever which cleared off in 4 days. He was given IV antibiotics for 4 days. He had recurrent cough since 1½ months of age with regurgitation of food since 15 days for which he was advised propped up position. His milestones and immunization were normal. He was on breast feeds and started on formula feeds, a month back in view of poor weight gain. At 2 months of age, had hematemesis with malena and was given whole blood transfusion and fresh frozen plasma. An older male child had died at 1½ months of age due to failure to thrive. On examination, he was malnourished {weight = 2.75 kg, length = 56 cm}, had pallor, large eats and firm hepatomegaly. Other systems were normal. Investigations showed:
• Hemoglobin = 10.8 gm, dl
• WBC count = 27,300, cumm {78 percent polymorphs, 20 percent lymphocytes}
• Platelet count = 8,07,000, cumm
• Venous blood gas = pH = 7.362, bicarbonate = 21 mmol, L
• Urine = Normal
• CRP = Negative
• Bilirubin = 2.5 mg percent {direct = 1.3 mg percent}
• SGOT = 123 IU, L, SGPT = 66 IU, L {elevated}
• Total proteins = 6.7 gm percent, albumin = 2.3 gm percent
• S. creatinine, electrolytes, calcium, alkaline phosphatase = Normal
• VDRL, HIV ELISA = Negative
• Ultrasound abdomen = Normal
• Urine for reducing substance = Negative
• TORCH = Cytomegalovirus {CMV} IgG positive, Rest all IgM and IgG negative
• Blood culture = No growth
• CMV viral load = 3000 copies, ml
• Hearing and eye examination = Normal
• GER = Normal study

After 10 days, liver enzymes and bilirubin were normal and CBC was also normal and child’s regurgitation episodes also decreased.

Question :
Does the CMV infection require treatment_?

Expert Opinion :
This child has a cytomegalovirus {CMV} disease whether congenital or acquired {due to blood product transfusion} is not known. However, he had liver dysfunction which has recovered on its own. His hearing and eye evaluation are also normal. Also there is no pneumonia. Thus active CMV organ dysfunction is not found in the child. Though CMV viral load is 3000 copies, ml it is not that high to warrant treatment especially since child does not have symptomatic CMV disease. CMV is going to remain in the body for lifetime and will cause problems only when the immunity goes down and CMV flares up. The drugs available to treat CMV are all which will arrest the viral replication but will not cure the disease. Also the drugs for treating CMV such as ganciclovir, valganciclovir foscarnet are all toxic and can lead to severe adverse effects. Hence treatment is recommended only when there is symptomatic CMV disease and viral load is a method by which one can tailor the treatment. {Therapy to be continued till viral load becomes undetectable}.
This child needs annual hearing and fundus evaluation for early screening of CMV induced deafness and chorioretinitis respectively.

Correct Answers :  yes 69%
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