i) CMV is an RNA virus

ii) It is the most common intra-uterine infection

iii) Congenital CMV can be caused by maternal primary infection or reactivation and both are of the same severity

iv) The incidence of primary CMV infection acquired during pregnancy is 5–10%

v) Primary CMV infection is associated with a 40% risk of congenital CMV infection

vi) At least 50% of infected infants will show clinical signs at birth

vii) There is a 20% mortality associated with symptomatic congenital CMV

viii) Infants can become infected by breast feeding if the mother is seropositive.

vii) What treatment options are available?

i) It is a large double stranded DNA virus

ii) It is a small single stranded DNA virus

iii) It replicates in rapidly dividing cells

iv) Approximately 25% of adults show evidence of a previous infection

v) A rash and arthralgia occur in the second phase of the illness. At this point, the child is still infectious

vi) The more severe the infection in a pregnant woman, the more severe the fetal infection

vii) If parvovirus B19 infection occurs during pregnancy, the majority of fetuses will be affected

viii) The outcome of the fetus depends on the point at which the infection occurred in pregnancy.

i) Congenital CMV

ii) Congenital toxoplasmosis

iii) Congenital Epstein–Barr virus

iv) Congenital varicella

v) Congenital rubella

vi) Congenital herpes

vii) Congenital TB.

i) The risk of congenital infection remains constant throughout pregnancy

ii) The risk of congenital infection is up to 90% in the third trimester

iii) Congenital infection is more severe if maternal infection is acquired in the third trimester

iv) In the UK, about 60% of women are sero-positive

v) Congenital infection occurs in 1 in 100 exposed babies

vi) Increasing gestational age at seroconversion is associated with an increased risk of mother-to-child transmission

vii) CSF will show a lymphocytosis

viii) Toxoplasmosis cannot be treated

ix) If diagnosed antenatally in the first trimester the mother can be treated with pyrimethamine and sulfadiazine to decrease the risk of fetal infection

x) If there are no eye signs within the first year of birth, the infant is unlikely to develop ocular problems.

vi) What do you do now?

vii) What does this result mean?

viii) Which of the following treatments would you consider?

i) Admit the baby to the NICU for observation

ii) Admit the baby to the NICU for observation and routine surface swabs

iii) Admit the baby to the NICU for a septic screen (blood cultures, FBC and CRP) and await results before considering antibiotics

iv) Admit the baby to NICU, perform septic screen and start antibiotics

v) Reassure and discharge home

vi) Allow to go home with instructions if the baby becomes unwell to seek medical advice

vii) Discuss with the mother and say that she must stay in and the baby must be observed for a further 24 hours

viii) Observe the baby for another 12 hours; allow to go home with instructions if the baby becomes unwell to seek medical advice.

i) Reassure the mother that no treatment is needed

ii) Reassure mother but isolate baby in side room

iii) Check the mother and baby’s immune status and then give VZIG to both

iv) Check the mother’s immune status and if negative give her VZIG

v) Check the baby’s immune status and if negative give the baby VZIG

vi) Give the baby and mother VZIG

vii) Give the baby VZIG and aciclovir.

i) Bacillus fragilis

ii) Bacillus cereus

iii) Bacteroides fragilis

iv) Campylobacter jejuni

v) Haemophilus influenzae

vi) Proteus mirabilis

vii) Salmonella typhi

viii) Group B streptococcus (GBS)

ix) Staphylococcus aureus

x) Klebsiella

xi) Serratia marcescens.

i) Mother is HBsAg negative and HBeAg negative

ii) Mother is HBsAg negative and HBeAg positive

iii) Mother is HBsAg positive and HBeAg negative

iv) Mother is HBsAg positive and HBeAg positive

v) Mother had acute hepatitis during pregnancy

vi) Mother where eAg and eAb status are unknown.

i) Describe the skin.

ii) What is the diagnosis?

Figure 10.1.

iii) What is the likely organism responsible?

iv) What is the treatment?

v) What is the prognosis?

i) It is a notifiable disease

ii) Causes hydrocephalus

iii) Causes thymic hypoplasia

iv) Causes corneal opacity

v) Causes bony abnormalities

vi) Causes IUGR

vii) Causes microphthalmia

viii) Causes conductive deafness

ix) Causes PDA

x) Causes aortic stenosis

xi) Infection during the first 12 weeks of pregnancy results in congenital infection and/or miscarriage in all cases

xii) Congenital infection can occur if mum is infected during the 2nd trimester

xiii) The infant is extremely infectious in the immediate postnatal period but this is no longer a risk after the first 4 weeks of life

xiv) Rubella is increasing in the immigrant population.

i) What do these test show?

ii) What test do you carry out to confirm this?

iii) What do you do now? Name two things.

iv) Which one test would confirm a diagnosis of congenital syphilis?

v) If the test is negative, what does this show?

vi) What information do you need from the mother?

vii) What other test might be helpful in assessing the risk to the baby?

viii) What do you do?

i) Infected infants should remain in the cots they currently occupy; all staff involved in the care of the baby should adopt barrier nursing procedures

ii) Wearing of sterile gloves avoids the need for repeated hand washing

iii) Infected babies may be nursed by the same member of staff as uninfected infants

iv) Regular skin disinfection is of established benefit in most cases

v) Topical antibiotic ointment should always be used

vi) Use of separate gowns for each baby is an extremely important element of infection control

vii) Screening of all babies and all staff may be implicated

viii) Staffing levels are closely related to the incidence of nosocomial infection, as is the availability of hand washing facilities

ix) Units should be closed to all admissions as soon as the possibility of an outbreak is considered

x) Environmental screening is of no value

xi) Meticulous attention to hand hygiene is by far the most important element in reducing the spread of infection

xii) There is good evidence that standards of hand hygiene are normally very high in neonatal intensive care units

xiii) Soap and water hand wash is more effective than the use of alcohol-based hand rub

xiv) Topical cord care at birth has a major role in reducing the incidence of infection.

i) False – CMV is a DNA virus of the herpes virus group.

ii) True – it affects up to 2.5% of live born infants a year worldwide. In the UK the incidence is approximately 0.2%.

iii) False – fetal infection is more likely to occur and is more severe after primary maternal infection than after reactivation of latent infection. The earlier the infection occurs in pregnancy the worse the outcome. ¹

iv) False – the incidence is thought to be 1–4%.

v) True.²

vi) False – overall, only 10–15% of infected infants show clinical signs at birth but up to 90% of these will develop long-term sequelae. ³

vii) True – reports state mortality ranges between 10% and 30% although much higher in premature infants.

viii) True – in the postpartum period, mother to infant transmission can occur as up to 88% of seropositive mothers shed the virus into their milk. Approximately 50% of these infants will become infected. CMV excretion is usually the result of reactivation in a seropositive mother; most infants will not develop clinical signs due to the presence of maternally derived transplacental antibodies. This is usually a benign and asymptomatic infection.

i) Echogenic bowel, intracranial calcification, cortical dysplasia.

ii) Answers a, b, c, e, g and h are correct. Hepatosplenomegaly and petechiae secondary to thrombocytopenia are relatively common manifestations of congenital CMV in the neonatal period. Jaundice is also common but this is usually a conjugated hyperbilirubinaemia as CMV hepatitis can cause both intrahepatic and extrahepatic bile duct destruction. ⁴ Intracranial manifestations of congenital CMV are microcephaly and periventricular calcification where the infection has caused brain necrosis. Lissencephaly and polymicrogyria can be present depending on the timing of the infection, lissencephaly occurring with an earlier infection. Defective enamelisation occurs in 40% of symptomatic infants at birth and 5% of asymptomatic infants. Inguinal hernias can occur with congenital CMV in male infants although the reason for this is unclear.

iii) Up to 80% of symptomatic newborns will develop sequelae such as mental retardation, cerebral palsy, visual defects and sensorineural hearing loss. Symptoms at birth are associated with a worse prognosis. ⁵

iv) Up to 15% of infants who are asymptomatic at birth will have neurodevelopmental problems and sensorineural (SN) deafness. SN deafness is the most common abnormality seen in congenital CMV infection, occurring in 30–65% of symptomatic infants and up to 15% of asymptomatic infants. It usually develops after the newborn period and tends to be progressive. Cochlear implants have been used successfully.

v) Answer c is correct.

vi) PCR testing on a urine sample needs to be done within the first 3 weeks after birth. If the test is carried out after 3 weeks it is difficult to distinguish between a congenital, perinatal or postnatal infection. Infants infected at birth after exposure to infected secretions during delivery may start shedding virus by 3 weeks of age.

vii) There are currently a few antiviral chemotherapeutic agents, such as ganciclovir and foscarnet, that are available for treatment of serious, life-threatening or sight-threatening CMV in the immunocompromised patients. Cidofovir is also licensed for CMV retinitis. A randomised, controlled multicentre clinical trial investigated the use of ganciclovir for the treatment of infants with congenital CMV infection with evidence of CNS involvement. ⁷