Chorioretinal scars and visual deprivation are common in children with cochlear implants after congenital cytomegalovirus infection.

AIM: The aim of this study was to compare visual function and ocular characteristics in children with cochlear implants, due to severe hearing impairment caused by the congenital cytomegalovirus (CMV) infection, with control children fitted with cochlear implants due to connexin 26 mutations (Cx26), a genetic cause of hearing impairment. METHODS: We carried out ophthalmological assessments, including visual acuity, ocular alignment, Ocular Motor Score, biomicroscopy and fundus photography, on 26 children with congenital CMV (median age 8.3 years, range 1.4-16.7) and 13 Cx26 controls (median age 5.6 years, range 1.7-12.5). RESULTS: We found unilateral chorioretinal macular scars that reduced best-corrected visual acuity ≤0.3 in five (19%) of the children with congenital CMV, but in none of the children with Cx26 (p = 0.15). Ocular motility problems were more common among children with congenital CMV, but the difference was not significant (p = 0.20). The vestibulo-ocular reflex was more frequently pathological in children with congenital CMV (p = 0.011). CONCLUSION: Ocular complications with central chorioretinal scars and ocular motility disturbances were common in children treated with cochlear implants due to severe hearing impairment caused by the congenital CMV infection. Ophthalmological assessments are advisable in such children for early identification, intervention and follow-up.

Prenatal acquired cytomegalovirus infection should be considered in children with autism.

AIM: The aim of the study was to evaluate the prevalence of congenital cytomegalovirus infection (CMV) in a representative sample of children with autism spectrum disorder. METHODS: In a representative group of 115 preschool children with autism spectrum disorder, of whom 33 also had intellectual disability, the dried blood spots from the newborn metabolic screening were analysed for CMV DNA using TaqMan polymerase chain reaction. RESULTS: One of the 33 children with autism spectrum disorder and intellectual disability - 3% of that group - had congenital CMV infection. The corresponding prevalence in newborn infants in Sweden is 0.2%. None of the 82 children without intellectual disability had congenital CMV. CONCLUSION: The finding lends some further support for congenital CMV being one of the many aetiologies underlying autism spectrum disorder with intellectual disability. The rate of 3% of congenital CMV in children with autism spectrum disorder with intellectual disability has implications for the medical work-up. The finding of congenital CMV also indicates the need for repeated hearing assessments in the child. There is a need for similar studies with much larger samples.

Impaired balance and neurodevelopmental disabilities among children with congenital cytomegalovirus infection.

AIM: Although cytomegalovirus (CMV) is the most common congenital infection, existing research has not provided us with a full picture of how this can affect children in the future. The aim of this case-control study was to evaluate disabilities in a well-defined group of children with congenital cytomegalovirus (CMV) infection, who had been fitted with cochlear implants because of severe hearing impairment. METHODS: A multidisciplinary team assessed 26 children with congenital CMV infection for balance difficulties, neurodevelopmental disabilities and language and visual impairment. We also included a control group of 13 children with severe hearing impairment due to connexin 26 mutations. RESULTS: The majority of the children with congenital CMV infection (88%) displayed balance disturbances, including walking at a later age, but there were no cases in the control group. The CMV group also displayed frequent neurodevelopmental disabilities and feeding difficulties. CONCLUSION: Congenital CMV infection affects the general development of the brain and gives rise to a complex pattern of difficulties. Identifying comorbid conditions is very important, as children with associated difficulties and disabilities need more support than children with just hearing impairment. Congenital CMV infection needs to be considered in children with hearing impairment and/or balance disturbance and/or neurodevelopmental disabilities.

Congenital cytomegalovirus infection - a common cause of hearing loss of unknown aetiology.

AIM: The aim of this study was to investigate the role of congenital cytomegalovirus (CMV) infection as a cause of various types of sensorineural hearing loss (SNHL) in a group of nonsyndromic children with otherwise unknown aetiology of hearing loss. Furthermore, the occurrence of combined congenital CMV infection and connexin 26 (Cx26) mutations was investigated. METHODS: The dried blood spot (DBS) cards of 45 children with various degrees of hearing deficits and 46 children with severe/profound hearing loss were tested for CMV DNA with polymerase chain reaction (PCR) technique. The DBS cards of the 46 children with severe/profound hearing loss were also analysed for Cx26 mutations. RESULTS: Of the 45 children with various degrees of hearing loss, nine were positive for CMV DNA (20%). The nine children represented severe/profound, mild and unilateral hearing loss. From the 46 children with severe/profound hearing loss, nine of 46 (20%) were positive for CMV DNA. In addition, three of the CMV DNA-positive children were carriers of mutations of Cx26. CONCLUSION: Congenital CMV infection is a high risk factor in hearing impairment among children.

Neuropsychologic outcomes in children with neonatal herpes encephalitis.

Neonatal herpes simplex virus infection with involvement of the central nervous system is a serious disease with high morbidity, even with acyclovir therapy. The disability includes cerebral palsy and different aspects of cognitive dysfunction which are of utmost importance for the child's future habilitation. We conducted a descriptive cohort study to define neuropsychologic outcomes and determine the relationship between neonatal neuroimaging and neuropsychologic outcomes. Among 267,690 children born in the Stockholm area over 12 years (1989-2000), 14 were diagnosed with neonatal herpes including central nervous system involvement. Nine children were neuropsychologically evaluated. Neonatal herpes virus infection had an even greater impact on cognitive function, speech ability, and attention deficit than anticipated. Relapse leading to deterioration was demonstrated in one child. Social skills were influenced to a lesser degree. Neurodevelopmental outcomes of the children were not well-correlated with extent of cerebral damage as visualized by computed tomography at 7-28 days after onset of signs. Neuropsychologic assessment is essential in the habilitation of the child, and a prerequisite for the evaluation of new treatments and for the assessment of deterioration of cerebral function related to relapses.

Molecular and virological studies on a rare case of biliary papillomatosis.

In a recurrence of a rare case of biliary papillomatosis, a disease that often becomes malignant, the presence of human papillomavirus (HPV), Cytomegalovirus (CMV) and Epstein-Barr virus (EBV), as well as DNA ploidy and markers of proliferation and invasion, were examined. No such viruses were identified by polymerase chain reactions. Moreover, markers of invasion, such as laminin, and of proliferation, MIB1 and cyclin A, were absent or at normal levels despite progressive superficial growth of the tumour. The tumour was aneuploid, but the p53-p21 tumour growth suppressor system was not mutated. It was concluded that the presented case of tumour relapse, despite an anamnesis of seven years and its expanding but non-invasive growth, did not contain the viruses that were examined for, and had not become malignant.

Detection of herpes simplex virus DNA in dried blood spots making a retrospective diagnosis possible.

BACKGROUND: Herpes simplex virus (HSV) infections in neonates are associated with life-threatening disease. Early diagnosis and treatment with antiviral therapy has decreased the morbidity, mortality and long-term sequelae in surviving children. The aim of the study was to investigate if herpes simplex virus DNA detection in dried blood spots on filter papers (Guthrie cards) sampled for screening of metabolic diseases may contribute to early diagnosis of neonatal HSV infection and enable pre-emptive therapy. METHODS: For detection of HSV-1 and -2 DNA, two different DNA extraction methods were evaluated. A minimal essential medium (MEM) extraction method was found superior and was used in combination with detection of HSV-1 and -2 DNA by PCR in dried blood spots from children with verified neonatal HSV infection. Cards from 28 children were included. The onset of illness varied from day 0 to 42 days and was the result of different types of maternal infection (27 cases) and an external source (one case). RESULTS: HSV DNA was detected in seven of the 28 Guthrie cards, two were HSV-1 and five were HSV-2 DNA positive. Positive dried blood spot cards were sampled within the interval 5 days before, to 6 days after onset of neonatal herpes. In cases of late onset CNS disease, viremia, was not demonstrable at the age of 3-5 days, the time period when the blood spot cards are normally sampled. CONCLUSION: Viremia, the prerequisite for demonstrating HSV DNA in dried blood spot cards preceded the onset of illness by up to 5 days and lasted at least up to 6 days thereafter. Analysis of HSV DNA in dried blood spot cards may be of value in the diagnostic arsenal for early onset of neonatal herpes and also have a role in the follow up of a child exposed at delivery. As the majority of the later onset neonatal herpes encephalitis cases are missed, a large-scale neonatal screening does not seem appropriate.

A real-time TaqMan PCR for routine quantitation of cytomegalovirus DNA in crude leukocyte lysates from stem cell transplant patients.

A real-time TaqMan PCR based on the cytomegalovirus (CMV) polymerase (pol) gene was developed for quantitation of CMV DNA in crude peripheral blood leukocyte (PBL) lysate from stem cell transplantation (SCT) patients. The dynamic range of the assay was between 10 and 4x10(6) copies. Both intra- and inter-assay variability were well within +/-0.25 log10 S.D. Thus, a pooled PBL sample that was used as positive control in 57 consecutive TaqMan PCR runs over 7 months showed a stable CMV quantity (4.12+/-0.13, log10 mean+/-S.D.). The sensitivity of the pol TaqMan PCR was validated by parallel analysis of 177 PBL samples with a nested PCR. The use of crude PBL lysate as PCR input did not cause PCR inhibition. We demonstrated further the clinical utility of the newly developed TaqMan PCR by monitoring changes in CMV levels in eight patients receiving antiviral therapy. This TaqMan PCR was highly sensitive, reproducible, and stable and has served a useful tool for monitoring CMV DNA levels in large number of clinical samples in a routine diagnostic setting for over 1 year.

Serum levels of rubella-specific antibodies in Swedish women following three decades of vaccination programmes.

In Sweden, more than 30 years after the introduction of vaccination for 12-year-old girls and post-partum mothers against rubella and 22 years after the introduction of routine MMR vaccination for all children at the ages of 18 months and 12 years, we have evaluated the rubella IgG activity in antenatal sera. 95.8% (39,890/41,637) of all women had anti-rubella IgG levels >or=10IU/mL. Levels <10IU/mL were more frequent in certain subcohorts: 8.2% (153/1870) of the Swedish women born after the introduction of the programme of childhood vaccination, 7.7% (616/8025) of women born outside the Nordic countries and 10.2% (118/1155) of recent immigrants and refugees to Sweden. In order to attain the goal of protecting the unborn, we propose alternative strategies to be evaluated: routine screening for rubella immunity prior to the first pregnancy, offering individuals with uncertain immunity a booster dose, and/or routine administration of an additional dose of MMR vaccine to all young adults before they leave the educational system.

Congenital CMV infection: prevalence in newborns and the impact on hearing deficit.

Congenital cytomegalovirus (CMV) infection is asymptomatic in 90% of infected newborns but approximately 10-20% of these infants are at risk of developing sequelae later, mostly hearing deficit. The aims of the study were to investigate the prevalence of congenital CMV infection in a Swedish population of newborns and investigate the relative risk of hearing deficit in newborns with congenital CMV infection. The dried blood spot (DBS) samples of 6060 newborns in southern Stockholm during 12 months (October 2003-June 2004; August 2004-October 2004) were analysed for CMV DNA by TaqMan based real-time PCR. Hearing deficit was assessed by otoacoustic emission (OAE) within a newborn screening programme. 12 infants out of 6060 or 0.2% (95% CI 0.1-0.3%) had congenital CMV infection. One boy among the 12 infected infants had unilateral hearing loss, indicating that the risk of hearing loss is greatly increased (about 20 times) in CMV infected infants. No child developed ocular complications such as chorioretinopathy during 3 y of follow-up. Congenital CMV has an impact on child health but can easily be overlooked due to lack of signs in the neonatal period. Surveillance for congenital CMV is important in addition to programmes for prevention and treatment.

The value of CMV and fungal PCR for monitoring for acute leukaemia and autologous stem cell transplant patients.

Both CMV and fungal infections have been suggested to be causes of fever of unknown origin (FUO) in neutropenic patients. The aim of this prospective, blinded study was to use nucleic acid techniques for monitoring of 20 acute leukemia and 15 autologous stem cell transplant (SCT) patients. Blood samples were taken weekly and examined for fungal and CMV DNA by PCR and CMV mRNA by NASBA. 387 samples were analysed. Fungal DNA was detected in 9 samples. Four samples were positive for Aspergillus and 6 for Candida DNA (1 sample positive for both). Candida PCR was positive in 2 patients with FUO, 1 patient with a bacterial infection, 1 patient with fungaemia, and in 1 afebrile patient. Three patients had verified Candida infections. One was PCR positive and 2 were negative. Three patients with positive Aspergillus PCR had pneumonias and 1 patient had a FUO. CMV DNA was found in 19 samples from 15 CMV seropositive patients. CMV mRNA was detected in 1 sample. Two patients had infections possibly caused by CMV. No antiviral therapy was give and both recovered. PCR for Aspergillus might be helpful for the diagnosis of pneumonia while neither CMV nor Candida PCR conferred diagnostic benefits in this study.

Visually impaired children with posterior ocular malformations: pre- and neonatal data and visual functions.

AIM: To analyse pre- and neonatal data and ocular findings in children with visual impairment caused by posterior ocular malformations. METHODS: Medical records were scrutinized, dried blood spot cards were analysed for virus DNA and ophthalmological assessments were performed in 28 children with optic nerve hypoplasia (ONH) and 10 with optic/chorio-retinal coloboma. RESULTS: Prenatal exposure to possible teratogens was documented in 5/28, herpes simplex virus type 1 DNA was identified in the dried blood spot cards of 1/26 children and neonatal hypoglycaemia in 12/28 children with ONH. The time delay from ocular to endocrinological diagnosis and treatment was 3 years. Children with ONH and severe visual impairment had endocrinopathy more often (11/13) than ONH children with better visual functions (5/15). Prenatal exposure to teratogens or neonatal hypoglycaemia was not identified in any of the children with coloboma. CONCLUSION: Neonatal hypoglycaemia was common in children with ONH. Severe visual impairment predicted endocrinopathy. Analysis of dried blood spot cards could serve as an additional diagnostic tool in children with ocular malformations.

Human polyomavirus DNA is not detected in Guthrie cards (dried blood spots) from children who developed acute lymphoblastic leukemia.

BACKGROUND: Epidemiological evidence has suggested that some childhood acute lymphoblastic leukemia (ALL) may be initiated in utero and may have an infectious etiology. The human polyomavirus JC virus (JCV) has been discussed as a candidate virus, but its presence has not been demonstrated in leukemia cells from children with ALL. The aim of this study was, therefore, to investigate if prenatal human polyomavirus infection could still indirectly be correlated to the development of childhood ALL. PROCEDURE: Fifty-four Guthrie cards (stored, dried blood spots filter papers, routinely collected from newborns for different screening analyses), collected at 3-5 days of age, from Swedish children who subsequently developed ALL, as well as from 37 healthy controls, were investigated by nested PCR for the presence of human polyomaviruses JCV and BK virus (BKV). RESULTS: JCV and BKV DNA were not detected in any of the Guthrie cards from ALL patients or from healthy controls, although all tested samples had amplifiable DNA as confirmed by an HLA DQ PCR. CONCLUSIONS: JCV or BKV were not found in any of the dried blood spots of children who later developed ALL or in the healthy controls. These findings suggest that it is unlikely that childhood ALL is associated with an in utero infection with JCV or BKV, although it is not possible to exclude an association with an in utero infection that has become latent in the kidneys with very low levels of circulating virus at birth.

Determination of cytomegalovirus DNA load for monitoring of cytomegalovirus disease and antiviral treatment in solid organ transplant patients, comparing limiting-dilution PCR and hybrid capture assay with cytomegalovirus isolation.

OBJECTIVE: To improve the identification of patients at risk of developing cytomegalovirus (CMV) disease. MATERIALS AND METHODS: In a prospective study of 50 kidney or liver transplant patients who developed fever, 133 EDTA blood samples were analyzed, using two tests to measure CMV DNA: a 10-fold limiting dilution of an extract of 2 million leukocytes for CMV PCR, and a CMV hybrid capture assay. Both tests were compared with virus isolation, using an equivalent amount of leukocytes as a base for all three tests. RESULTS: The limiting-dilution CMV PCR and the hybrid capture assay presented relatively similar changes of sensitivity and specificity at different CMV DNA concentrations. The kinetics of the positive and negative predictive values were also comparable. A higher CMV DNA load corresponded to an increased risk of developing CMV disease. Furthermore, an increase in the endpoint dilution of a positive CMV PCR also corresponded to more severe disease. After antiviral treatment, the CMV PCR decreased by at least 100-fold (2 log10) in 10 cases and by 10-fold (1 log10) in five cases. Thus, there was a decrease in 15 of 18 (83%) patients. Similarly, with the hybrid capture assay, the amount of CMV DNA decreased about 100-fold in five patients and decreased by about 0.5 genome equivalents in five cases, i.e. in 10 of 12 (83%) patients. CONCLUSION: Both methods proved clinically useful for detecting patients at risk of developing CMV disease and for monitoring antiviral treatment in solid organ transplant patients.

Leukocyte depleted, unscreened blood products give a low risk for CMV infection and disease in CMV seronegative allogeneic stem cell transplant recipients with seronegative stem cell donors.

Leukocyte depletion (LD) by blood product filtration has been shown to be similarly effective to the use of screened, CMV seronegative blood products to prevent CMV disease in CMV seronegative allogeneic stem cell transplant (SCT) patients with CMV seronegative donors. The aim of this retrospective study was to determine the risk for development of CMV infection requiring preemptive therapy and for CMV disease if unscreened products treated by prestorage LD is used. Forty-nine consecutive patients transplanted after June 1995 were included. As a control group, 33 patients transplanted from January 1992 to June 1995 in whom a combination of CMV seronegative and LD blood products were given. All patients were monitored weekly by a leukocyte-based PCR for CMV DNA detection. Preemptive therapy was initiated after two consecutively positive tests. No patient developed CMV disease in either group. CMV DNA was detected in 6/49 (p = NS) in the study group and in 3/33 patients in the historical control group. Two patients in the study group were given preemptive therapy compared to one patient in the control group. This study suggests that the risk for CMV disease and the need for preemptive therapy against CMV is low in CMV seronegative allogeneic SCT patients receiving grafts from CMV seronegative stem cell donors receiving LD blood products. Thus, this strategy can be safely used together with PCR monitoring and preemptive therapy.