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    Cytomegalovirus Infection: Dr. Hendra Purnasidha Bagaswoto, M.SC, Sp.A SMF Anak RSUP Dr. Soeradji Tirtonegoro Klaten

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    Donniehh Assassintilldeath Nothinglastforever
    Cytomegalovirus (CMV) is a common cause of congenital infection, occurring in 1-7% of pregnancies annually and can cause serious complications in the fetus, especially in the first and early second trimester. Symptoms of congenital CMV infection may include jaundice, hepatosplenomegaly, microcephaly, hearing loss, and neurological damage. Diagnosis is made through virus isolation from urine or saliva in the first few weeks of life, or detection of CMV DNA by PCR from body fluids.

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    Cytomegalovirus Infection: Dr. Hendra Purnasidha Bagaswoto, M.SC, Sp.A SMF Anak RSUP Dr. Soeradji Tirtonegoro Klaten

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    Donniehh Assassintilldeath Nothinglastforever
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    Cytomegalovirus (CMV) is a common cause of congenital infection, occurring in 1-7% of pregnancies annually and can cause serious complications in the fetus, especially in the first and early second trimester. Symptoms of congenital CMV infection may include jaundice, hepatosplenomegaly, microcephaly, hearing loss, and neurological damage. Diagnosis is made through virus isolation from urine or saliva in the first few weeks of life, or detection of CMV DNA by PCR from body fluids.

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    Askep pada anak cmv

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    Cmv

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    Cytomegalovirus (CMV) is a common cause of congenital infection, occurring in 1-7% of pregnancies annually and can cause serious complications in the fetus, especially in the first and early second trimester. Symptoms of congenital CMV infection may include jaundice, hepatosplenomegaly, microcephaly, hearing loss, and neurological damage. Diagnosis is made through virus isolation from urine or saliva in the first few weeks of life, or detection of CMV DNA by PCR from body fluids.

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    52 views40 pages

    Cytomegalovirus Infection: Dr. Hendra Purnasidha Bagaswoto, M.SC, Sp.A SMF Anak RSUP Dr. Soeradji Tirtonegoro Klaten

    Uploaded by

    Donniehh Assassintilldeath Nothinglastforever
    Cytomegalovirus (CMV) is a common cause of congenital infection, occurring in 1-7% of pregnancies annually and can cause serious complications in the fetus, especially in the first and early second trimester. Symptoms of congenital CMV infection may include jaundice, hepatosplenomegaly, microcephaly, hearing loss, and neurological damage. Diagnosis is made through virus isolation from urine or saliva in the first few weeks of life, or detection of CMV DNA by PCR from body fluids.

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    of 40

    CYTOMEGALOVIRUS INFECTION

    dr. Hendra Purnasidha Bagaswoto, M.Sc, Sp.A


    SMF Anak RSUP Dr. Soeradji Tirtonegoro Klaten
    Sekitar 1-7% wanita hamil
    Penyebab infeksi kongenital menderita infeksi CMV
    (yang melibatkan SSP) primer setiap tahunnya
    tersering
    Human
    cytomegalovirus
    (CMV)
    Komplikasi serius pada
    30-40% infeksi CMV pada janin terjadi terutama pada
    kehamilan ditransmisikan
    ke janin trimester pertama dan awal
    trimester kedua

    Clin Microbiol Infect 2011:1285 - 93


    CONGENITAL VS PERINATAL

    • CMV infection may be acquired in the


    newborn via congenital and perinatal
     secondary to exposure to CMV- infected cervical
    secretions during vaginal delivery or via ingestion of
    CMV-infected breast milk  rarely result in significant
    symtomps or sequele in term babies
     Premature babies appear to be at particularly high risk
    for CMV-associated disease  septic appearance
    CONGENITAL VS PERINATAL
     Congenital CMV occurs transplacentally and may result in
    symptomatic or asymptomatic infection in the neonate
     Difficult to differentiate whether CMV infection was
    acquired congenitally or perinatally in infants more than 3
    weeks of age  chorioretinitis, intracranial calcification,
    microcephaly and hearing loss, are present
    MANIFESTASI KLINIS

    Gestational Oligohidramnion, polihidramnion, prematuritas, IUGR


    Mukokutaneus Jaundice, ptekiae, purpura, rash, blueberry muffin spot

    Liver/ limpa Liver Jaundice, hepatomegali, splenomegali, hiperbilirubinemia

    Skeletal Osteochondritis, periostitis, destructive lesions (75-100%),


    pseudoparalysis parrot (12%)
    Hematologi Trombositopenia
    Neurologi Kalsifikasi periventrikular intrakranial, ventrikulomegali, mikrosefal,
    kejang, hiper/hipotoni, sensoryneural hearing loss, retardasi mental,
    gangguan motorik
    Okular  NeurologiKorioretinitis,
    dan Hepatosplenomegali
    strabismus, atrofiadalah
    optik gejala
    Gastrointestinal yang paling seringpancreatitis
    Enteritis, didapatkan pada CMV kongenital
    simtomatik
    Lain-lain Pneumonitis, dental defect, poor feeding
    Hepatomegali akan menghilang dalam 1 tahun
    l Antimicrob Chemot. 2009. 862-7
    Ann. N. Y. Acad. Sci. 2010. 144-7
    Buku Ajar Neurologi Anak. 2000
    OUTCOME CONGENITAL CMV

    • About 10-20% of all children with CCMV infection,


    symptomatic or not in the neonatal period will
    exhibit neurological damage when followed up

    • SNHL, mental retardation, seizures, psychomotor


    and speech delays, learning disabilities,
    chorioretini- tis, optic nerve atrophy, and defects
    in dentition are the most common long-term
    consequence
    PREVALENSI WANITA HAMIL ????
    HOW DO I GET
    Pencegahan infeksi CMV maternal saat
    kehamilan

    Kontak erat dengan anak < 2 thn dengan CMV, karena ekskresi
    CMV pada saliva & urin bisa bertahan berbulan2 sampai
    tahunan

    Anak dapat menularkan pada anak lain (termasuk di daycare).


    30% ibu serokonversi setelah anak berada 1 tahun di daycare

    Perlu hygienisitas dan perubahan perilaku


    (mis: sarung tangan, hindari co-sleeping)

    • Edukasi infeksi CMV congenital dan pencegahannya kepada tenaga


    medis (bidan, Sp.OG, Sp.A) dan seluruh ibu hamil (LoE 2b)
    Rawlinson WD, et al., 2017
    HOW DO I GET
    DIAGNOSIS

    VIRUS ISOLATION CMV-DNA BY PCR


    (URINE, SALIVA, (URINE, BLOOD, SALIVA
    BRONCHOALVEOLAR, AND CSF)
    BREAST MILK, CERVICAL
    SECRETION CYTOMEGALOVIRUS
    INFECTION

    HISTOPATHOLOGY DEAFF(Detection
    DETECTION of Early Antigen
    CMV IgM (OWL’S EYE) Fluorescent Foci)
    Virus can be isolated from urine, saliva, cervical
    and vaginal secretions, semen, breast milk, tears,
    blood products and transplanted organs.

    Urine and saliva are the best specimens for culture.


    Infants with congenital CMV infection may excrete
    CMV in the urine for several years.

    J Infect Dis 1975; 132: 472–3.


    N Engl J Med 1980; 302: 1073–6.
    Diagnosis pada neonatus

    Gold
    standard

     Diagnosis CMV kongenital juga dapat ditegakkan


    dengan mendeteksi IgM spesifik CMV pada neonatus
    dengan usia < 3 minggu namun
     Ig M spesifik CMV hanya terdeteksi pada 70%
    neonatus terinfeksi CMV

    Clin Microbiol Infect. 2011. 1285-93


    Ann. N. Y. Acad Sci. 2010. 144-7
    Diagnosis

     Infeksi CMV kongenital dan didapat pada awal kehidupan


    tidak dapat dibedakan kecuali virus terdeteksi pada 3
    minggu setelah lahir

     IgM pada infeksi aktif dapat bertahan selama 4-12 minggu


    → IgM pasien terdeteksi pada usia 12 minggu, masih
    mungkin infeksi didapat pasca lahir namun infeksi
    didapat pada neonatus biasanya asimtomatik
    Diagnosis of CMV maternal infection

     A primary infection is confirmed by seroconversion or the


    simultaneous detection of immunoglobulin M (IgM) and IgG
    antibodies with low functional avidity.

     IgG antibodies persist for life. For the 1st weeks after primary
    infection, the functional avidity of IgG class antibodies is very low
    and rises to a peak in 4–5 mo.

     Testing for CMV is not routinely recommended for all women during
    pregnancy or for newborn babies.

     CMV testing is currently recommended for pregnant women who


    develop an acute viral illness or when ultrasound reveals a foetal
    abnormality.

     Work in high risk settings (e.g. in child care centres) or have very
    young children at home.

    Nelson 18th , Textbook of Pediatrics


    LABORATORIUM
     Gold standard  isolation virus CMV pada urin / saliva
    dalam minggu 1st – 3 rd
    dalam kehidupan (Ross et al., 2011)
     PCR  sensitifitas 93% dan spesifisitas 100 % (Ross et al,
    2011)
     SEROLOGI (ELISA) IgM sensitifitas 72,95 % dan
    spesifisitas 62,06 % (Bathia, 2004)
     ANTIGENEMIA pp65:
    - sensitifitas > 90% dan spesifisitas >90%. (Bij et al, 1988)
    - sensitifitas 89,18% dan spesifisitas 100%. (Bathia, 2004)
    Tata laksana infeksi CMV

    Foscarne
    Gancyclovir t
    (prodrug:
    Valgancyclovir) Cidofovir

    3
    Terbukti efektif untuk
    antiviral
    Terbukti efektif untuk
    CMV kongenital
    CMV kongenital
    sistemik
    Ann. N. Y. Acad Sci. 2010. 144-7
    Hasil penelitian

    Gancyclovir Plasebo

    Perbaikan gangguan 21 dari 25 (84%) 10 dari 17 (59%)


    pendengaran atau
    tetap normal
    (baseline-6 bulan)
    Perburukan gangguan 5 dari 24 (21%) 13 dari 19 (68%)
    pendengaran
    (baseline-1 tahun)
    Netropenia 29 dari 46 (63%) 9 dari 43 (21%)

    Kesimpulan:
    Terapi gancyclovir yang dimulai pada saat neonatus pada CMV
    kongenital simtomatik dengan gangguan SSP terbukti mencegah
    gangguan pendengaran yang signifikan sampai dengan 1 tahun
    pasca terapi
    Company Logo
    Pencegahan transmisi vertikal infeksi
    CMV

    • Pemberian Hiperimunoglobulin tidak


    direkomendasikan secara rutin pada ibu
    hamil dengan infeksi CMV primer untuk
    pencegahan infeksi CMV kongenital,
    karena bukti belum adekuat (LoE 2C)

    • Pemberian rutin terapi antiviral tidak


    direkomendasikan untuk mencegah infeksi CMV
    kongenital, pada saat kehamilan (LoE3)

    Rawlinson WD, et al., 2017


    Tatalaksana infeksi CMV fetal selama masa
    kehamilan
    • Pemberian Hiperimunoglobulin tidak
    direkomendasikan secara rutin pada ibu hamil dengan
    infeksi CMV primer untuk pengobatan infeksi CMV
    fetal, karena bukti belum adekuat (LoE 2B)

    • Pemberian rutin terapi antiviral


    tidak direkomendasikan untuk
    mencegah/mengobati infeksi CMV
    Ganciclovir, valganciclovir, kongenital, pada saat kehamilan.
    foscarnet, cidofovir
     kategori C • Karena bukti keamanan dan
    Aciclovir, valaciclovir, efektivitas belum adekuat (LoE 2C)
    famciclovir
     kategori B Rawlinson WD, et al., 2017
    • Maternal CMV shedding in breast milk (BM) of seropositive
    mothers can be detected in colostrum and ends about 3
    months after birth
    • Yasuda et al. showed that 21 of the 24 seropositive mothers
    (87.5%) had detectable CMV DNA in their BM & most of the
    BM samples became positive for CMV DNA 2 weeks after
    delivery.
    • Several other studies, rates of CMV virolactia among
    seropositive women have been reported to be between 6.2%
    and 80%
    • In our study, 85 of the 200 BM samples (42.5%) and 80
    of the total 178 BM samples (44.9%) from mothers of
    CMV-IgG seropositive infants were CMV PCR positive
    • Breastfeeding is not contra-indicated for infants born to
    mothers who are who are seropositive carriers of
    cytomegalovirus (CMV) (if the infant is term)

    • Decisions about breastfeeding of very low birth weight


    infants (birth weight 1500 g) by mothers known to be CMV-
    seropositive should be made with consideration of the
    potential benefits of human milk versus the risk of CMV
    transmission

    • Freezing and pasteurization can significantly de- crease the


    CMV viral load in milk
    • Heating at 62.5°C for 30 minutes or 72°C for 5
    seconds (in thin film) destroyed viral infectivity
    and late viral RNA  Unfortunately, destroyed
    some of the biochemical and immunological
    qualities of the milk

    • Freezing at 20°C for 4–10 days did not effectively


    destroy infectivity
    TERIMA KASIH

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