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ACQUIRED CYTOMEGALOVIRUS INFECTION

Case Report
A seven years old female child presented with swellings over both
axilla and in the neck since 1 month.
On examination, she had bilateral mobile axillary lymph nodes
(largest 3cm x 3cm) with multiple small mobile, non-tender cervical
and inguinal lymph nodes.
She also had a firm hepatosplenomegaly.
Her anthropometry was in the 50th percentiles ruling out chronic
malnutrition.
She had received antituberculous therapy 6 years back for 8
months in view of primary complex.
With the above clinical picture a differential diagnosis of infectious
mononucleosis, reactive lymphadenopathy, Kochs, HIV and
malignancy were considered.
Her hemoglobin was 7.4 gm% with WBC count of 12,600/cumm
with 61% polymorphs, 38% lymphocytes and 1% monocytes. ESR
was 5 mm after 1 hour.
Her ELISA for HIV was negative and X-ray chest was normal. Her
GL for AFB was negative. Peripheral smear did not show any
abnormal cells.
An ultrasound of the abdomen was suggestive of lymphomatous
deposits of 5 mm in inferior pole of spleen with splenomegaly.
Axillary lymph node biopsy was done which showed loss of
architecture with prominent lymphoid follicles, expanded centres
and active phagocytosis with mild blurring of follicles and reactive
sinusoidal change suggestive of a florid antigenic stimulation like a
recent viral or toxoplasma infection.
Her serology by EIA for toxoplasma, rubella and cytomegalovirus
was done which showed both increased CMV IgM [2.95 IU/ml
(Normal = 0.0 0.25 IU/ml)] and increased CMV IgG [1.88 IU/ml
(Normal = 0.0 1.0 IU/ml)].
Her titres for Rubella IgG & IgM and Toxoplasma IgM & IgG were
negative.
Thus a diagnosis of infectious mononucleosis due to CMV infection
was confirmed.
She was advised follow up after a period of 1 month.

Discussion
CMV is a member of the Herpes viridae family of DNA viruses.
Infection with CMV is common and usually unapparent.
Transmission: CMV transmission is highest in:
1. Early childhood
2. Adolescence
3. Child bearing years
1% of all newborns are born congenitally infected with CMV.
Acquired CMV usually occurs in 80% of children by 3 years of age in
patients from low socio-economic strata in developing countries.
Children excrete CMV in their saliva and urine and lead to a high
prevalence of horizontal spread. In adolescents, it is attributed to
intimate physical contact. Noscocomial transmission occurs with
blood product transfusion, BMT & organ transplantation.
Pathogenesis: CMV infection can involve virtually any organ of the
body leading to intranuclear inclusions and massive enlargement of
the affected cells.
Infection with CMV can be latent and non-productive, productive yet
asymptomatic, or productive and symptomatic. T cell immunity
especially cytotoxic T cells generation is the most important
parameter for effective immune response.

Clinical Manifestations:
Mononucleosis syndrome: Fever and severe malaise of about 1
to 4 weeks duration, lymphocytosis with atypical lymphocytes and
mild elevation of liver enzymes are the common manifestations.
It rarely causes pharyngitis, tonsillitis or significant splenomegaly as
in Epstein-Barr induced mononucleosis. It can cause a morbilliform
rash after ampicillin administration. Complications include
interstitial pneumonitis, myocarditis, pericarditis, hemolytic anemia,
thrombocytopenia, hemophagocytic syndrome, adrenal insufficiency,
GBS, meningoencephalitis and severe icteric hepatitis CMV retinitis
is seen in patients on immunosuppression or patients with AIDS.
Differential diagnosis
Mononucleosis seen by other viruses such as EBV, Hep A, Hep B and
HIV as well as acquired toxoplasmosis.
Diagnosis:
1. Isolation of virus Skin, urine, saliva, conjunctive stool,
cervicovaginal secretions.
2. CMV DNA PCR
3. Serology Seroconversion or a fourfold rise in CMV-IgG.
Positive IgM-CMV by RIA, IFA or ELISA. (IFA is most
reliable).In healthy adults, CMV IgM antibody usually persists
for 6 weeks and may be present up to 3 to 6 months after
primary infection occurs.
In an a typical case presenting with lymphadenopathy without fever,
sore-throat or splenomegaly, a lymph node biopsy may be required
to rule out malignant lymphoma. Microscopically there is
predominant sinusal distribution of the large lymphoid cells,
follicular hyperplasia with marked mitotic activity increase in plasma
cells and vascular proliferation. Though the nodal architecture
appears effected, the sinusoidal pattern remains intact.

Treatment
Ganciclovir For life threatening infections with CMV. It is
virostatic and so suppresses active CMV infection but does not
produce a cure. It is indicated for treatment of CMV retinitis,
pneumatosis.
Induction 5 mg/kg/dose IV bd for 2-3 weeks.
Following induction Maintenance of 5 mg/kg/day for 5-7 days
of the week.

Dr.kamel hassan. MD
Pediatrician Consultant
Gaza-Palestine
E-mail: kyh429161@yahoo.com
Kyh10557@hotmail.com
Kyh10557@gmail.com

kamel hassan

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