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Original Article

Congenital CMV Infection in Symptomatic Infants in Delhi

and Surrounding Areas
Inderjeet Gandhoke, Ramesh Aggarwal, Shiv Lal 1 and Shashi Khare
Department of Microbiology, 1Additional DG & Director, National Institute of Communicable Diseases, Directorate
General of Health Services, 22 Shamnath Marg, Delhi

ABSTRACT
Many viral infections are associated with significant maternal and fetal consequences during pregnancy among which
cytomegalovirus is one of the most important agent, globally. Both primary and recurrent infection due to this virus can result
in fetal infection. Samples from Congenital Anoammaled babies are referred to NICD from Delhi based Government hospitals
and surrounding areas for diagnosis of congenital infections like Toxoplasm, Rubella, CMV and Herpes. In the present study,
accumulated data is presented for the most common teratogenic virus - Cytomegalovirus prevalence as a causative agent for
congenital infection in New Born babies at Delhi and surrounding areas. 96 samples from symptomatic babies in the age group
of few days to 6 months exhibiting different congenital anomalies, were reported between 1 st Jan 04 to 30 th April/05. All the
blood samples were tested for the detection of CMV (IgM) antibodies using -capture ELISA technique. 18(18.75%) samples
from babies showed positive titres for CMV-IgM antibodies. None of the mothers of positive babies were found positive for CMVIgM antibodies but all were serologically exposed to CMV virus previously as their serum samples were positive for CMV -IgG
antibodies indicating primary infection in the past or reactivation/reinfection with a different strain of CMV in the early pregnancy.
[Indian J Pediatr 2006; 73(12) : 1095-1097] E-mail : shashikhare@hotmail.com

Key words : Cytomegalovirus; Congenital infection

Maternal infections are now being increasingly

recognized as a major cause of birth defects in newborn
babies. CMV infection in general is probably one of the
most common infections known to human being and is
characterized by mild, self limiting infection with fever in
healthy individuals. In pregnant women the virus can
cross placenta and result in fetal infection. The prevalence
of CMV infection varies from 0.3% to 2.4% and atleast
90% congenital infected infants have no clinical sign.1,2 The
disease causes illness ranging from no apparent clinical
signs to prematurity, encephalitis, deafness, hemolytic
disorders and death. 3,4 Congenital CMV infection is
described in 30000 to 40000 new borns each year in the
US, approximately 9000 of these children have permanent
neurological sequelae. 4 The death rate of symptomatic
CMV infection is approximately 30%.5
In India, serological surveys in different parts have
shown the prevalence of 80-90% seropositivity6,7,8,9 of
CMV antibodies (IgG) in women of child bearing age.
Studies regarding prevalence of birth defects due to

Correspondence and Reprint requests : Dr. Shashi Khare, National

Institute of Communicable Diseases, 22 Shamnath Marg, Delhi
110054.

Indian Journal of Pediatrics, Volume 73December, 2006

congenital CMV infection are limited in India. In the

present study, samples of babies with signs and
symptoms compatible with acute CMV infection and their
mothers were referred to this Institute between 1 st
Jan.2004 and 30th April 2005. They were assayed for CMV
-IgM antibodies to establish the evidence of congenital
CMV infection.
MATERIAL AND METHODS
During the period of present study (l st Jan 2004-30th April
2005), 96 serum samples from chil<h-en with various
congenital anomalies and their mothers samples were
referred to Virology laboratory of NICD from
Government hospitals of Delhi and adjoining areas.
Majority of the cases were reported from hospitals located
in the crowded zones of Delh like Sadar Pahar Ganj and
City zone.
The children were in the age group of few days to 6
months. The various clinical features in these children
reported were Hepatosplenomegaly, Convulsions,
Hydrocephaly, Microcephaly, NN cholestasis, Jaundice,
Anemia, Chorioretinitis etc. The referred samples
belonged to mixed population of Urban and Rural areas
but mostly from lower socio-economic strata.
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Inderjeet Gandhoke et al
Blood samples received from all the cases were clotted
and centrifuged for serum separation prior to testing. All
the sera were stored at -20C till tested.
The serum samples were tested for CMV-IgM
antibodies using commercially available -capture
enzyme immunoassay method (ELISA kits -RADIM in
this study) for qualitative detection. In this test system
Biotin-Streptaviridin Complex has been used to
increase the sensitivity of the procedure. The specificity of
the procedure used is also 100% with no non specific
binding due to rheumatoid or other herpatic viruses.
Mothers of positive babies were subjected to CMV-IgG
and IgM serology using commercial ELISA kits. Kit
instructions were strictly adhered to while processing the
samples.
Interpratation of the results was based on the controls
provided with the kit. Test sample was said to be positive
for IgM antibodies when it absorbance value was higher
than the absorbance value of the cut-off control. Positivity
of IgM antibodies against CMV in a sample indicates
active infection of CMV.
RESULTS
Eighteen (18.75%) out of 96 samples from children
showed presence of IgM antibodies giving serological
evidence of exposure to in-utero cytomegalovirus
infection.
None of the mothers from positive congenital CMV
infected babies were positive for CMV - IgM antibodies
but all showed IgG seropositivity against CMV virus
indicating primary infection in the past or reactivation or
reinfection with a different strain of the virus in early
pregnancy.
Congenital CMV related clinical manifestations when
compiled in the present study showed Hepato
splenomegaly as the most common clinical feature (Table
1) followed by bronchopneumonia, jaundice, anemia,
TABLE 1. Clinical Manifestations in Children with Serological
Evidence of Congenital CMV Infection (January 2004April 2005)
S. No.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

1096

Clinical sign

No. of affected
children (18)

Hepatosplenomegaly
Neonatal Jaundice
Neonatal Cholestasis
Cataract
Seizures
Congenital Nephrotic Syndrome
Ecchymaxia allover body, failure to thrive
Bleeding disorder
Microcephaly
Hydrocephaly
Bronchopneumonia
Aneamia
Chorioretinitis
Respiratory distress.

12
4
2
1
3
1
1
1
2
2
4
4
1
1

neonatal seizures, microcephaly, hydrocephaly, retinitis

etc.
DISCUSSION
High incidence ofCMV related congenital defects in
reported cases of New. Borns (18.75%) with congenital
anomalies can be seen in the present study, similar to few
other studies carried out in India.10, 11, 12 In the present
study false positivity for CMV IgM antibodies was ruled
out by using -capture ELISA system, which is highly
specific and sensitive.
The clinical presentation in the infants positive for
CMV -IgM antibodies was typical of congenitally
acquired CMV infection. Hepatosplenomegaly was the
commenest clinical feature(12 cases), next common
features was Neonatal jaundice, Bronchopneumonia and
Anemia (4 cases each). Other notable clinical symptoms
like neonatal seizures, microcephaly, hydrocephaly,
retinitis, cataract. etc. are compatible with Congenital
CMV infectionThis finding is in accordance with other
studies from India and abroad.12, 13
CMV is common in all socio-economic groups but
congenital infection with significant impairment is seen at
highest rate in population in which women in child
bearing age have highest risk of acquiring primary
infection.6, 8,11 In addition to the placental route, CMV can
be transmitted at delievery via the maternal genital tract,
during the post parturn period in breast milk and
transfused blood products.
Symptomatic cytomegalovirus infection in fetus can
occur after maternal recurrent infection but the incidence
of these cases is still not established. 14 Seropositive
women reinfected by a different strain of cytomegalovirus
can transmit the infection to the fetus and deliever a
symptomatic child.15, 16 High rate of seropositivity of CMV
IgG (80-90%) in child bearing age.8,9 delievering high no.
of symptomatic congenital CMV babies (present study)
support the above mentioned studies.
Antenatal screening for CMV infection has been
widely practiced in most developed countries which can
substantially reduce the incidence of congenital CMV
infection by advising MTP in case of intrauterine
symptomatic CMV infected fetus diagnosed by
amniocentasis or ultrasound16, 17 rather than giving birth to
infants having congenital infections with high sequele.
However, mandatory testing during antenatal period is
rudimentary in India due to various reasons. The
diagnosis is done most of the times after the mother gives
birth to a baby with congenital anomalies and that is why
the incidence of birth defects due to CMV virus is high in
India. Good hygine and general infection control practice
is, the best way to prevent transmission of CMV infection
in developing countries. Though the only drug currently
available for congenital CMV infection is Ganciclovir18, 19
yet the side effects due to this drug in most patients
Indian Journal of Pediatrics, Volume 73December, 2006

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Congenital CMV Infection in Symptomatic Infants in Delhi and Surrounding areas

during the course of therapy20 has limited its role.
CONCLUSION
The facts presented in the present study conclude beyond
doubt that maternal infection like CMV cause
considerable burden on society in terms of huge number
of babies with birth defects.
Good hygiene, antenatal screening, antiviral therapies,
development and introduction of good vaccine may
achieve the goal of controlling CMV related congenital
defects in the New Borns. The importance may primarily
be given to introduction of antenatal screening for CMV
infection in the developing countries like India as has
been implemented against HIV. Data generated will help
the health authorities to make policy against congenital
CMV infection prevailing in the country.
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