Postnattaly Acquired Cytomégalovirus Infection in Term Infant: A Case Report

    

    

    Figure 1: Chest scanner.
    

Immune assessment

Weight determination of immunoglobulins IgG, IgA, IgM, IgE. Assay of serum complement, CH50, C2, C3.Lymphocyte typing. Lack of immune deficiency.

Treatment

Nasal oxygen thérapy.

Oral Valganciclovir at a dosage of 16 mg/kg twice daily during 2 weeks [4].

In total

Clinical picture of pneumonia and monocnucleosis syndrome with thrombocytopenia prompted testing for CMV in saliva and urine. PCR + and favorable pulmonary and hematologic evolution under antiviral treatment lead to a diagnosis.

Discussion

Human cytomegalovirus is the most common congenital infection. About 1 to 3% of newborns become infected during pregnancy. Around 10 to 15% of the infants born after maternal seroconversion are symptomatic, and less than 3% after reactivation. The main reason for prenatal CMV transmission is primary infection of mothers during pregnancy rather than recurrent infection. Of even higher epidemiological relevance, however, is postnatal mother-tochild transmission, with breastfeeding being the main reason. In different studies, virolactia, or viral DNA in breast milk, was detected in 13 to 70% of lactating mothers. Using highly sensitive methods like PCR to screen for viral DNA in breast milk or cell-free milk whey, it has been demonstrated that 40% to 96% of seropositive mothers shed the virus via their breast milk. The reason for DNA and viruses in breast milk was the réactivation of CMV infections of the mothers during lactation.

To date the only confirmed sites of CMV latency in humans are undifferentiated progenitor cells of monocytes/granulocytes/ dendritic cells in the bone marrow.

Systemic inflammation and stress are the two known mechanisms triggering CMV reactivation from latency

The human breast harbors latently infected cells or latently infected cells are transported very efficiently to the lactating breast.

In the lactating breast, bioactive substances can be produced or accumulated which induce or support the replication of the virus in its target cells. Using in vitro transfection and infection systems, we have recently been able to show that cell-free milk whey is indeed capable of stimulating the gene expression of the CMV IE1/2 enhancer/promoter in monocytic cells (a possible target cell type for CMV in breastfeeding mothers. Breast). This promoter is responsible for the initiation of viral replication and, moreover, determines the efficiency of replication.

CMV was present in the respiratory tract of all infected infants [5].

In addition, milk whey enhanced replication of CMV in permissive human embryonic lung fibroblasts [6].

Apart from congenital CMV infection, CMV infection can be passed to newborn babies through breast milk. Reactivation in CMVpositive women is localized and limited in the breast. The acquisition of CMV via breast milk follows a trans-mucosal pathway.

Postnatal infection can be serious in premature babies because they lack the IgGs from their mothers, which are not transmitted until after 28 weeks of gestation. Postnatal infection through breast milk is often asymptomatic. However, it can occur noisily, especially in the presence of congenital immune deficiency. Pasteurization of breast milk is the most reliable method of eliminating CMV, but it changes the nutritional qualities of the milk. It is recommended in France for premature GA babies of less than 32 weeks. Freezing milk reduces the risk without eliminating it completely, but it does not change the qualities of the milk [7].

In term newborns it is transmitted to the oropharyngeal or nasopharyngeal level while in premature babies who are supplied with enteral nutrition CMV is transferred directly through the lining of the small intestine [8].

It is favored by stress, stimulation of interleukin II-6. Macrophage cells in breast milk are responsible for reactivating CMV. Transmission is possible from the first week of lactation and peaks between 4 and 8 weeks and would end at 3 months of lactation [9].

In this case report, reactivation could be favored by infection of the breast by Staphylococcus Aureus and by the two surgical interventions required as well as by the continuation of breastfeeding during the two months which separated the two surgical interventions inflammation, dysimmunity, phenomena favoring excretion CMV.

Conclusion

This case report shows that the morbidity of postnatal transmission of CMV in the term newborn is not always minimal. It should be taken in consideration that CMV becomes reactivated in all latently infected mothers during lactation and is shed within the breast milk.

References

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