Clin Med II Infectious Disease

1. Clin Med II Infectious Disease Lecture II—Viral Diseases, part 1/3

2. Cytolomegalovirus

3. Cytomegalovirus • Usually asymptomatic • Seroprevalence 60-80% in Western countries • Transmission • sexual contact • breast feeding • blood products • transplantation • person-to-person • congenital

4. Congenital CMV • Most common congenital infection in developed countries—0.2%-2% of all live births • 10% of infected newborns will be symptomatic with CMV inclusion disease

5. CMV in Immunocompetent • Most common cause of acute mononucleosis-like syndrome with negative heterophil antibodies • Critically ill—reactivated • Associated with multiple diseases but link is unclear • IBD • Atherosclerosis • Cognitive decline

6. CMV in Immunocompromised • Tissue and bone marrow transplant patients • CMV is immunosuppressive • Can contribute to transplanted organ dysfunction • HIV patients

7. Perinatal and CMV Inclusion • Jaundice and HSM • Thrombocytopenia and purpura • Microcephaly, periventricular CNS calcifications, mental retardation and motor disability • Hearing loss in > 50% symptomatic at birth • Most infected are asymptomatic but develop neurological deficits later on

8. CMV in Immunocompetent • Fever, malaise, myalgias, arthralgias, splenomegaly • Cutaneous rashes • Complications—mucosal GI damage, encephalitis, hepatitis, thrombocytopenia, Guillain-Barré, pericarditis, myocarditis

9. CMV in Immunocompromised • Distinguish between CMV infection and CMV disease • Patients at risk—HIV, organ transplant, stem cell transplant • CMV viral loads correlate with prognosis after transplantation

10. CMV in Immunocompromised • Retinitis—neovascular, proliferative lesions • GI/Hepatobiliary—odynophagia, gastritis, small bowel disease, colonic disease, liver transplant complications • Respiratory—pneumonitis • Neurologic—polyradiculopathy, transverse myelitis, ventriculoencephalitis, focal encephalitis

11. Cytomegalovirus • Mothers and Newborns—pregnant women tested for IgM CMV antibodies q 3 mo if positive assay in 1sttrimiester • PCR assays of dried blood samples from newborns and micro-ELISA on urine, saliva or blood specimens during 1st 3 weeks of life to diagnose congenital CMV • Immunocompetent—initial leukopenia followed by absolute lymphocytosis with atypical lymphocytes • abnormal LFTs • CMV specific IgM or 4x increase in specific IgG • Immunocompromised—serology, cultures, PCR, pp65 antigen and viral load; rapid shell-viral cultures • CXR—consistent with interstitial pneumonia • Biopsy—especially useful in pneumonitis and GI disease

13. Cytomegalovirus • Retinitis—IV ganciclovir if sight-threatening; less severe disease, oral valganciclovir • Other infections—same antivirals; length of therapy depends on how immunosuppressed the pt is • CMV from transplant—ganciclovir (at same doses as retinis) for 2-3 weeks • Pregnancy—passive immunization with hyperimmune globulin • Prevention—no current vaccine; HAART prevents in HIV-infected patients

14. Cytomegalovirus • Refer • neonatal infections consistent with CMV inclusion disease • AIDS + retinitis, esophagitis, colitis, encephalitis • AIDS + hepatobiliary disease • Organ or hematopoietic stem cell transplants with suspected CMV reactivation • Admit • Risk of colonic perforation • Unexplained, advancing encephalopathy • Biopsy of tissues • Initiation of IV anti-CMV agents

15. Epstein-Barr Virus

16. Epstein-Barr Virus • Also known as human herpesvirus type 4 • Infects >90% of population worldwide and persists for lifetime of host • Mainly transmitted by saliva but can also be recovered from genital secretions

17. Epstein-Barr Virus • Early—fever, sore throat, fatigue, malaise, anorexia, myalgia • Lymphadenopathy, splenomegaly, rash • Conjunctival hemorrhage, pharyngitis, tonsillitis, gingivitis, soft palate petechiae • Can see other organ system involvement as well

18. Epstein-Barr Virus • Labs—granulocytopenia followed within 1 week by a lymphocytic leukocytosis with atypical lymphocytes comprising over 10% of leukocyte count • May see hemolytic anemia or thrombocytopenia • Monospot test, IgM and IgG titers • PCR – useful for malignancies associated with EBV

19. Epstein-Barr Virus • Over 95% of patients with acute disease recover without specific antiretroviral therapy • Symptomatic—acetaminophen or NSAIDs, warm salt-water gargles TID-QID • Hepatitis, myocarditis, and encephalitis—symptomatic • Splenic rupture—splenectomy • Avoid contact sports for at least 4 weeks • Prognosis good in uncomplicated cases • fever resolves in 10 days • lymphadenopathy and splenomegaly resolve in 4 weeks • debility can linger for 2-3 months

20. ErythemaInfectiosum

21. Erythrovirus Infections • Parvovirus B19 • Widespread • Respiratory secretions, saliva, placenta, blood products • Incubation 4-14 days

22. ErythemaInfectiosum • Children—exanthematous illness, erythemainfectiosum • Fiery red cheeks • Circumoral pallor • Lacy maculopapular rash on extremities • Malaise, headache, and pruritis

23. ErythemaInfectiosum

24. Erythrovirus Infections • Immunocompromised—transient aplastic crisis and pure red blood cell aplasia • Adults—limited nonerosive symmetric polyarthritis • Chloroquine—exacerbates erythrovirus-related anemia • Pregnancy—premature labor, hydropsfetalis, fetal loss

25. Erythrovirus Infections • Clinical diagnosis may be confirmed by elevated anti-erythrovirusIgM (serum) or with PCR (serum or marrow) • Complications—rare • Treatment is symptomatic in healthy patients • Immunosuppressed patients—IVIG • Intrauterine transfusion—severe fetal anemia • Prevention—screening donated blood, standard containment guidelines in nosocomial outbreaks • Prognosis—excellent in immunocompetent patients

26. Questions?