How to treat cytomegalovirus in women

Cytomegalovirus (CMV) is a common virus that is present in the body most of the population. CMV belongs to the group of herpes viruses and is spread by close contact with body fluids. A high degree of destruction of the population of the infection is essentially invisible, because, despite the fact that the virus remains in the body permanently, in healthy people, the visible signs do not appear. Perhaps the only exception in healthy people is the formation of very dangerous CMV mononucleosis (see below).

On the other hand, CMV is very dangerous for people with impaired immunity, particularly for persons with AIDS and recipients of organ transplants taking immunosuppressant (medicines restraining the immune system). Besides, it is very dangerous for CMV infection of the developing fetus.

Cytomegalovirus infection in women and men remains one of the most important complications after hematopoietic stem cell transplantation. Despite advances in diagnosis and treatment, there are still many caused by CMV, the clinical situations that are very serious, therapeutically almost not solved. The article presents the standard approaches to prevention and how to treat the cytomegalovirus.

Form of CMV infection

Infection of a pregnant woman and the fetus. In that case, if a virus infects a pregnant woman or she comes to reactivation of virus already present, there is a risk of harm to the fetus, the development of congenital deformities and the formation of irreversible defects, including mental retardation.

Cytomegalovirus colitis. The first symptom of this disease mostly presented with fever and severe diarrhea. During a colonoscopy, is an inflammatory disease of the mucous membrane, sometimes with the formation of multiple ulcers. The disease is typical for people with impaired immunity.

Cytomegalovirus hepatitis. Can occur very quickly and lead to life-threatening acute liver failure. CMV hepatitis is also characteristic of people with impaired immunity.

Cytomegalovirus esophagitis. Inflammation of the esophagus is also typical for persons with impaired immunity, the first manifestation is represented by fever, difficulty swallowing and pain when swallowing. If you are performing a gastroscopy, in the mucosa of the esophagus are visible superficial erosion or ulcer.

Cytomegalovirus infection of the brain. CMV encephalitis, fortunately, is a rare disease and, again, occurs in people with weakened immune systems. Can have dramatic symptoms, including personality changes, confusion, aggression, and impaired consciousness. Without early initiation of treatment can have fatal consequences.

Cytomegalovirus mononucleosis. We are talking about an infection with symptoms similar to the manifestations of classical viral mononucleosis caused by EBV (Epstein-Barr) but the manifestations are less noticeable and usually do not include swollen lymph nodes and enlarged liver. The disease can occur in people with normal immune systems.

Pharmacological prevention

Under preventive drug means medical treatment of people with risk of CMV reactivation. A possible option is the introduction of Ganciclovir. The person in this case can be left without close monitoring of CMV PCR or antigenemia. The disadvantage is the effect of Ganciclovir toxicity (hematologic toxicity). The subsequent prolonged neutropenia leads to an increase in the number of cases of bacterial infections.

In addition, it is assumed a greater recovery of anti-CMV immunity in people without prevention, where before the introduction of pre-emptive therapy will be held, at least, reasonable CMV reactivation effect in case prevention is not expected.

An alternative may be prophylactic administration of Foscarnet.

Specific, but insufficient preventive effect also shows prevention of Acyclovir – this approach shouldcombined with strict monitoring using PCR or CMV PP65 antigenemia of any pre-emptive therapy.

A large randomized study showed the best prophylactic efficacy of high-dose Valaciclovir (4 times a day for 2 d) compared with Acyclovir. In this case, also decreased the need to start a proactive treatment. In addition, there is also a need for monitoring.

People receiving Alemtuzumab, the prevention effectiveness showed Valganciclovir, but the feasibility of this procedure has not yet been evaluated.

Prophylactic administration of intravenous immunoglobulin (IVIG) does not prevent the development of cytomegalovirus infection/reactivation, and is not recommended.

People who have had salivary gland disease, require prolonged treatment, if you plan to transplant, it should be deferred; may be introduced secondary anti-CMV prophylaxis with Valganciclovir. In the case of proactive approach, these people require careful monitoring and low threshold for starting treatment.

CMV in pregnancy

Most of us the presence of this virus in the body does not notice, because it creates almost no difficulties unless you have a weak immune system. The doctors calculated that CMV affects and causes birth defects in children than down syndrome. The most dangerous period is 20 weeks pregnant.

CMV belongs to the herpes viruses. Once infecting a person, it remains forever in the body and can reactiviate in the case of immunosuppression. According to experts, in developed countries, the virus has affected about 50% of the population, while in developing countries almost everyone due to the worst hygienic standards.

A high level of infection in the population

His omnipresence among the people, in fact, is a plus for human health, being once infected, the body creates antibodies and the next time, in case of an attack the virus, the person is already protected.

The virus is transmitted in bodily fluids – i.e., urine, saliva, breast milk, semen, vaginal secretions and so on. The first infection, which often takes place in childhood or adolescence healthy people mostly don't even notice. In some rare cases, the infected may experience fever, headache and inflammation of the Airways. However, as a rule, CMV infection is asymptomatic.

The occurrence of primary CMV infection in women during pregnancy can indicate possible problems, but there is no reason to panic. According to the magazine "Rev Med Virol" from the 2010 primary infection during pregnancy exposed to 1-7% of all pregnant women in 30-40% of cases comes to transmission of the infection to the fetus. It has been estimated that it subsequently appears, approximately 10-15% of infected newborns.

CMV infection in the fetus may, but shall not be manifested. Sometimes the signs are already visible after birth, when the child comes to the enlargement of the liver, spleen and symptoms of jaundice. These symptoms, however, may be confused with so-called neonatal jaundice, which does not have an infectious origin, and occurs in the first days after birth due to intrauterine degradation of hemoglobin and the child's adaptation to the external environment.

To remote consequences, which may occur in children who have postpartum infection is not, include a variety of neurological complications, visual disturbances.

Pregnant women, beware of diapers, nipples and spoons!

Cytomegalovirus in women during pregnancy usually is not diagnosed, but doctors recommend testing high-risk groups such as health workers, teachers and workers of other fields working with children. The greatest risks connected with infection before pregnancy or during first trimester.

In prevention particular attention is paid to hygiene, especially thorough hand washing. This is in particular true for women with young children. If someone from close people has an active CMV infection, pregnant women and those planning to conceive are advised to avoid contact with him. In pregnant women this in particular, refers to the 20th week of pregnancy, when risk to the fetus is highest.

CMV there is no vaccine and, in addition, neither pregnant women nor children are usually not tested for the virus. Therefore, according to experts, it is important that pregnant women were informed about possible ways of infection, for example, when changing diapers, use of common spoons, and, thus, could minimize the risk of infection themselves.

Therapeutic method

Standard treatment of CMV pneumonia

Previously a very frequent complication with high mortality, which, despite aggressive treatment 30-50%, remains a severe manifestation of CMV. Mortality is considerably increased, if necessary, artificial ventilation.

Intravenous therapy with Ganciclovir or Foscarnet, lasting at least 2 weeks later and 3-4 weeks in maintenance doses, in combination with IGW, remains the basis for resolving the question of how to treat CMV pneumonia, despite the ongoing debate on the necessity of administration of IVIG.

The effectiveness of IGW has never been proven in randomized trials, and data on the application based onstudying with those times when you have not used effective antiviral drugs.

The introduction of IVIG, however, because of the small risks associated with their admission, are still considered the standard approach.

As second drugs of choice to treat cytomegalovirus, indicated Cidofovir or the combination of Ganciclovir and Foscarnet.

Treatment of CMV colitis

Colitis is currently the most common location of the virus. This insidious infection is a possible process with a negative PCR findings in peripheral blood.

Gastrointestinal symptoms are no different from other infectious causes.

In cases of this infection the doctor may recommend the introduction of a full dose of Ganciclovir for 3-4 weeks and, subsequently, maintenance treatment with a reduced dose for several weeks.

In the case of neutropenia, mainly introduces the treatment Foscarnet. A shorter induction therapy (2 weeks) is not showing high efficiency.

Receiving IVIG is not provided. In the case of continued immunosuppression, approximately 30% of cases leads to recurrences whose frequency is an appropriate indication for secondary prophylaxis until cessation of immunosuppression.

Treatment of CMV retinitis

CMV retinitis is a relatively common manifestation of infection.

The therapy is based on the systematic introduction of Ganciclovir, Foscarnet or Cidofovir with or without intraocular injection of Ganciclovir.

Intraocular application should be considered, especially in people with risk of vision loss, as the penetration of systemic antiviral substances intraocular might not be sufficient.

The recurrence rate after intraocular injection of Ganciclovir significantly lower than with conventional systemic therapy.

Treatment of CMV infection of the Central nervous system

CMV encephalitis is a very serious manifestation of infection, but in the specialized literature describes a relatively rare. Analysis of 11 cases in the period from 1950 through 2009 shows that 10 of the 11 patients the infection led to a fatal outcome despite combined antiviral treatment; the efficacy of drugs restricts insufficient passage across the blood-brain barrier.

Clear guidelines for the selection of antiviral drugs available, due to the low frequency of cases.

The complexity of the treatment of congenital CMV infection

Treatment of congenital CMV infections is difficult. Its purpose is to reduce the incidence of life-threatening diseases and injuries of organs. The optimal solution does not exist yet. The defeat of organs occurs mainly during fetal development. Even if we manage to diagnose a pregnant woman with primary infection or reactivation, it is known that transmission to the fetus occurs only in some cases, to serious diseases of the fruit, again, comes from a small number of infections. To demonstrate ongoing intrauterine infection is currently possible, but it is impossible to determine the prognosis of these children, also today, is not available a reasonably safe medication that you can enter the child after birth.

A possible solution is to prevent infection in pregnant women, for example, by reducing the number of teenage mothers who have primary infection is a common restriction during pregnancy contact with young children and sexual activity. However, these measures are difficult to implement. Therefore, the best solution would be vaccination, a suitable agent for which are not yet available. To date, studies in this field, the results of which will be a very important moment in the development of an effective vaccine.

Prophylactic treatment of infected women during pregnancy is not possible, as antiviral agents for the treatment of CMV infections have various adverse effects, and pregnancy has not been tested. Prevention of cytomegalovirus infection, therefore, is highly desirable, especially in women of childbearing age who have not suffered.

Most risky to the fetus, there are situations when the mother undergoes primary infection.

Prevention with vaccination was first tested with a weakened strain of the town, but the vaccine is not recommended for pregnant women and its safety during pregnancy has not been tested. A safer alternative vaccines are still, using some of immunodominant proteins. One of them is represented recombinant vaccine derived from envelope glycoprotein B, the results of the introduction which presented 19. 03. 2009 American doctors in an article published in "NEJM".