Cytomegalovirus infection - Symptoms

The incubation period of cytomegalovirus infection is 2-12 weeks.

[ 1 ], [ 2 ], [ 3 ], [ 4 ], [ 5 ], [ 6 ], [ 7 ]

The main symptoms of cytomegalovirus infection and the dynamics of their development

In congenital cytomegalovirus infection, the nature of the fetal damage depends on the period of infection. Acute cytomegalovirus infection in the mother in the first 20 weeks of pregnancy can lead to severe fetal pathology, which results in spontaneous abortion, intrauterine fetal death, stillbirth, defects, in most cases incompatible with life. In case of cytomegalovirus infection in the late stages of pregnancy, the prognosis for the life and normal development of the child is more favorable. Expressed symptoms of cytomegalovirus infection in the first weeks of life are observed in 10-15% of newborns infected with cytomegalovirus. The manifest form of congenital cytomegalovirus infection is characterized by hepatosplenomegaly, persistent jaundice, hemorrhagic or maculopapular rash, severe thrombocytopenia, increased ALT activity and direct bilirubin levels in the blood, and increased hemolysis of erythrocytes. Babies are often born prematurely, with low body weight, signs of intrauterine hypoxia. CNS pathology is typical in the form of microcephaly, less often hydrocephalus, encephaloventriculitis, convulsive syndrome, hearing loss. Cytomegalovirus infection is the main cause of congenital deafness. Enterocolitis, pancreatic fibrosis, interstitial nephritis, chronic sialadenitis with salivary gland fibrosis, interstitial pneumonia, optic nerve atrophy, congenital cataract, as well as generalized organ damage with the development of shock. DIC syndrome and death of the child. The risk of death in the first 6 weeks of life of newborns with clinically expressed cytomegalovirus infection is 12%. About 90% of surviving children who suffered from manifest cytomegalovirus infection have remote consequences of the disease in the form of decreased mental development, sensorineural deafness or bilateral hearing loss, speech perception disorders with preserved hearing, convulsive syndrome, paresis, and decreased vision. In case of intrauterine infection with cytomegalovirus, an asymptomatic form of infection with a low degree of activity is possible, when the virus is present only in urine or saliva, and a high degree of activity if the virus is detected in the blood. In 8-15% of cases, antenatal cytomegalovirus infection, without manifesting itself with bright clinical symptoms, leads to the formation of late complications in the form of hearing loss, decreased vision, convulsive disorders, delayed physical and mental development. A risk factor for the development of the disease with damage to the central nervous system is the persistent presence of cytomegalovirus DNA in whole blood in the period from the moment of birth to 3 months of life. Children with congenital cytomegalovirus infection should be under medical supervision for 3-5 years, since hearing impairment can progress in the first years of life, and clinically significant complications can persist even 5 years after birth.

In the absence of aggravating factors, intranatal or early postnatal cytomegalovirus infection is asymptomatic, manifesting clinically only in 2-10% of cases, most often as pneumonia. In premature weakened children with low birth weight, infected with cytomegalovirus during childbirth or in the first days of life by blood transfusions, by the 3rd-5th week of life a generalized disease develops, the manifestations of which are pneumonia, prolonged jaundice, hepatosplenomegaly, nephropathy, intestinal damage, anemia, thrombocytopenia. Cytomegalovirus infection is of a long-term recurrent nature. The maximum mortality from cytomegalovirus infection occurs at the age of 2-4 months.

Symptoms of acquired cytomegalovirus infection in older children and adults depend on the form of infection (primary infection, reinfection, reactivation of latent virus), routes of infection, presence and degree of immunosuppression. Primary infection with cytomegalovirus of immunocompetent individuals is usually asymptomatic and only in 5% of cases in the form of mononucleosis-like syndrome, the distinctive features of which are high fever, severe and prolonged asthenic syndrome, in the blood - relative lymphocytosis. atypical lymphocytes. Sore throat and enlarged lymph nodes are not typical. Infection with the virus through blood transfusions or during transplantation of an infected organ leads to the development of an acute form of the disease, including high fever, asthenia, sore throat, lymphadenopathy, myalgia. arthralgia, neutropenia, thrombocytopenia, interstitial pneumonia, hepatitis, nephritis and myocarditis. In the absence of pronounced immunological disorders, acute cytomegalovirus infection becomes latent with the lifelong presence of the virus in the human body. The development of immunosuppression leads to the resumption of cytomegalovirus replication, the appearance of the virus in the blood and the possible manifestation of the disease. Repeated entry of the virus into the human body against the background of an immunodeficiency state can also be the cause of viremia and the development of clinically expressed cytomegalovirus infection. During reinfection, the manifestation of cytomegalovirus infection occurs more often and is more severe than during reactivation of the virus.

Cytomegalovirus infection in immunosuppressive individuals is characterized by a gradual development of the disease over several weeks, symptoms of cytomegalovirus infection appear in the form of rapid fatigue, weakness, loss of appetite, significant weight loss, prolonged undulating fever of an irregular type with body temperature rises above 38.5 C, less often - sweating at night, arthralgia and myalgia. This complex of symptoms is called "CMV-associated syndrome". In young children, the onset of the disease may occur without pronounced initial toxicosis with normal or subfebrile temperature. A wide range of organ damage is associated with cytomegalovirus infection, the lungs are among the first to suffer. A gradually increasing dry or unproductive cough, moderate shortness of breath appear, symptoms of intoxication increase. Radiological signs of pulmonary pathology may be absent, but during the peak of the disease, bilateral small-focal and infiltrative shadows, located mainly in the middle and lower parts of the lungs, are often determined against the background of a deformed, enhanced pulmonary pattern. If the diagnosis is not made in a timely manner, respiratory failure, respiratory distress syndrome, and death may develop. The degree of lung damage in patients with cytomegalovirus infection varies from minimally expressed interstitial pneumonia to widespread fibrosing bronchiolitis and alveolitis with the formation of bilateral polysegmental pulmonary fibrosis.

The virus often affects the gastrointestinal tract. Cytomegalovirus is the main etiologic factor of ulcerative gastrointestinal tract defects in HIV-infected patients. Typical signs of cytomegalovirus esophagitis include fever, chest pain during passage of a food bolus, lack of effect of antifungal therapy, shallow round ulcers and/or erosions in the distal esophagus. Stomach damage is characterized by acute or subacute ulcers. The clinical picture of cytomegalovirus colitis or enterocolitis includes diarrhea, persistent abdominal pain, tenderness of the colon upon palpation, significant weight loss, severe weakness, and fever. Colonoscopy reveals erosions and ulcers of the intestinal mucosa.

Hepatitis is one of the main clinical forms of cytomegalovirus infection in transplacental infection of a child, in recipients after liver transplantation, and in patients infected with the virus during blood transfusions. A feature of liver damage in cytomegalovirus infection is the frequent involvement of the bile ducts in the pathological process. Cytomegalovirus hepatitis is characterized by a mild clinical course, but with the development of sclerosing cholangitis, pain in the upper abdomen, nausea, diarrhea, liver tenderness, increased activity of alkaline phosphatase and GGTT occur, and cholestasis is possible. Liver damage is characterized by granulomatous hepatitis, in rare cases, severe fibrosis and even cirrhosis of the liver are observed. Pathology of the pancreas in patients with cytomegalovirus infection is usually asymptomatic or with an erased clinical picture with an increase in the concentration of amylase in the blood. The epithelial cells of small salivary gland ducts, mainly parotid, are highly sensitive to cytomegalovirus. Specific changes in the salivary glands with cytomegalovirus infection in children occur in the vast majority of cases. Sialoadenitis is not typical for adults with cytomegalovirus infection.

Cytomegalovirus is one of the causes of adrenal pathology (often in patients with HIV infection) and the development of secondary adrenal insufficiency, manifested by persistent hypotension, weakness, weight loss, anorexia, bowel dysfunction, a number of mental disorders, and, less commonly, hyperpigmentation of the skin and mucous membranes. The presence of cytomegalovirus DNA in the patient's blood, as well as persistent hypotension, asthenia, and anorexia, requires determining the level of potassium, sodium, and chlorides in the blood, conducting hormonal studies to analyze the functional activity of the adrenal glands. Cytomegalovirus adrenalitis is characterized by an initial lesion of the medulla with the process moving to the deep layers, and then to all layers of the cortex.

Manifest cytomegalovirus infection often occurs with damage to the nervous system in the form of encephaloventriculitis, myelitis, polyradiculopathy, polyneuropathy of the lower extremities. For cytomegalovirus encephalitis in patients with HIV infection, scanty neurological symptoms are characteristic (intermittent headaches, dizziness, horizontal nystagmus, less often paresis of the oculomotor nerve, neuropathy of the facial nerve), but pronounced changes in mental status (personality changes, severe memory impairment, decreased ability for intellectual activity, a sharp weakening of mental and motor activity, impaired orientation in place and time, anosognosia, decreased control over the function of the pelvic organs). Mnestic-intellectual changes often reach the degree of dementia. In children who have suffered from cytomegalovirus encephalitis, a slowdown in mental and intellectual development is also detected. Cerebrospinal fluid studies show elevated protein levels, no inflammatory response, or mononuclear pleocytosis. Normal glucose and chloride levels. The clinical picture of polyneuropathy and polyradiculopathy is characterized by pain in the distal lower extremities, less often in the lumbar region, combined with numbness, paresthesia, hyperesthesia, causalgia. hyperpathy. Polyradiculopathy may be accompanied by flaccid paresis of the lower extremities, accompanied by decreased pain and tactile sensitivity in the distal legs. Increased protein levels and lymphocytic pleocytosis are found in the cerebrospinal fluid of patients with polyradiculopathy. Cytomegalovirus plays a leading role in the development of myelitis in HIV-infected patients. Spinal cord damage is diffuse and is a late manifestation of cytomegalovirus infection. At the onset, the disease has a clinical picture of polyneuropathy or polyradiculopathy. Later, in accordance with the predominant level of spinal cord damage, spastic tetraplegia or spastic paresis of the lower extremities develops, pyramidal signs appear, a significant decrease in all types of sensitivity, primarily in the distal parts of the legs; trophic disorders. All patients suffer from severe disorders of the pelvic organs, mainly of the central type. In the cerebrospinal fluid, a moderate increase in protein content and lymphocytic pleocytosis are determined.

Cytomegalovirus retinitis is the most common cause of vision loss in HIV-infected patients. This pathology has also been described in organ recipients, children with congenital cytomegalovirus infection, and in isolated cases in pregnant women. Patients note the following symptoms of cytomegalovirus infection: floating dots, spots, a veil before the gaze, decreased visual acuity and defects. Ophthalmoscopy reveals white foci with hemorrhages along the retinal vessels on the retina at the periphery of the fundus. Progression of the process leads to the formation of a diffuse extensive infiltrate with zones of retinal atrophy and foci of hemorrhage along the surface of the lesion. The initial pathology of one eye after 2-4 months becomes bilateral and in the absence of etiotropic therapy leads in most cases to vision loss. In patients with HIV infection who have a history of cytomegalovirus retinitis, uveitis may develop as a manifestation of immune reconstitution syndrome against the background of HAART.

Sensorineural deafness occurs in 60% of children with clinically expressed congenital cytomegalovirus infection. Hearing loss is also possible in adult HIV-infected individuals with manifest cytomegalovirus infection. Cytomegalovirus-related hearing defects are based on inflammatory and ischemic damage to the cochlea and auditory nerve.

A number of studies demonstrate the role of cytomegalovirus as an etiologic factor in the pathology of the heart (myocarditis, dilated cardiopathy), spleen, lymph nodes, kidneys, bone marrow with the development of pancytopenia. Interstitial nephritis caused by cytomegalovirus infection, as a rule, occurs without clinical manifestations. Microproteinuria, microhematuria, leukocyturia, rarely secondary nephrotic syndrome and renal failure are possible. Thrombocytopenia is often recorded in patients with cytomegalovirus infection, less often moderate anemia, leukopenia, lymphopenia and monocytosis.

Classification of cytomegalovirus infection

There is no generally accepted classification of cytomegalovirus infection. The following classification of the disease is advisable.

• Congenital cytomegalovirus infection:
  • asymptomatic form;
  • manifest form (cytomegalovirus disease).
• Acquired cytomegalovirus infection.
  • Acute cytomegalovirus infection.
    • asymptomatic form;
    • cytomegalovirus mononucleosis;
    • manifest form (cytomegalovirus disease).
  • Latent cytomegalovirus infection.
  • Active cytomegalovirus infection (reactivation, reinfection):
    • asymptomatic form;
    • cytomegalovirus-associated syndrome;
    • manifest form (cytomegalovirus disease).

[ 8 ], [ 9 ], [ 10 ], [ 11 ], [ 12 ], [ 13 ], [ 14 ]