in vivo 18: 819-824 (2004)

Incidence and Outcome of Congenital Cytomegalovirus

Infection in Selected Groups of Preterm and Full-term
Neonates Under Intensive Care
ARANKA NAGY1, EMKE ENDREFFY1, KROLY STREITMAN1,
SNDOR PINTR1 and ROZLIA PUSZTAI2
1Department

of Paediatrics and 2Department of Medical Microbiology and Immunobiology, Faculty of Medicine,

Albert Szent-Gyrgyi Medical and Pharmaceutical Centre, University of Szeged, Hungary

Abstract. Congenital cytomegalovirus (CMV) infection is

the leading cause of mental retardation and hearing
impairment. Examination for the presence of CMV infection
was carried out in a selected population of 70 neonates.
Urine samples were tested for CMV by means of a nested
polymerase chain reaction. CMV was detected in 6 (16.7%)
of the 36 preterm newborns and in 5 (14.7%) of the 34 fullterm newborns. One preterm neonate died and the remaining
10 newborns were followed up. Two children born at full-term
did not excrete CMV at 2 years of age and were symptomfree. Of 8 CMV-excreting children (5 preterm and 3 fullterm), 2 were symptom-free (1 preterm and 1 term).
Symptomatic CMV disease developed in 6 children (4
preterm and 2 full-term), with mental retardation (n=4),
hearing loss (n=1), strabismus (n=2) or bronchial asthma
(n=1). Screening of such neonates is important; those
identified as congenitally CMV-infected can be monitored to
correct any sequelae immediately.
Human cytomegalovirus (CMV) is one of the eight
members of the Herpesviridae family. It is a doublestranded DNA virus that is restricted to humans. Epithelial
cells, endothelial cells and fibroblasts are the major targets
of CMV infection in vivo (1). In some instances, neurones
in the brain and retina, smooth muscle cells in the
gastrointestinal tract and hepatocytes can also be infected.
In the peripheral blood, the circulating leukocytes are
susceptible to CMV. In vitro, the virus replicates well only

Correspondence to: Rozlia Pusztai, Department of Medical

Microbiology and Immunobiology, University of Szeged, H-6720
Szeged, Dm tr 10, Hungary. Tel: 36-62-546112, Fax: 36-62545113, e-mail: pusztai@comser.szote.u-szeged.hu
Key Words: Cytomegalovirus, congenital infection, preterm
neonates, full-term neonates, intensive care.

0258-851X/2004 $2.00+.40

in human fibroblasts. CMV displays many of the

characteristics of the herpesvirus family, such as the ability
to cause primary infection, then evolve into a latent state
and subsequently undergo reactivation.
CMV is the most common pathogen of intrauterine
infections, affecting an estimated 1-2% of all live births.
However, the incidence of congenital infection among
different populations is quite variable (2). Maternal primary
CMV infection occurs in approximately 0.7% to 4% and is
usually asymptomatic. Subsequent vertical transmission to
the foetus has been demonstrated at rates of 24% to 75%
(2-4). The usual clinical manifestations of congenital
infection are intrauterine growth retardation (IUGR),
microcephaly, ventriculomegaly, intracranial calcification,
chorioretinitis, hepatosplenomegaly, jaundice, petechiae,
thrombocytopenia and elevated serum transaminase levels
(5). The seriously ill babies have a mortality rate of
approximately 30% (6,7). The most common long-term
sequelae in infancy and childhood are sensorineural hearing
deficits and learning disabilities. Many infants, who appear
normal at birth, will manifest a hearing loss and other
delayed neurological complications. A progressive
sensorineural hearing loss may develop in 13-15% of
asymptomatic newborns (8).
A substantial proportion of congenital CMV infections
occur in women with preconceptional immunity (9-11). A
majority of infants with congenital CMV, who are born to
women with preconceptional immunity acquire the virus as
a result of recurrent maternal infection: reactivation of
endogenous virus or reinfection with a new strain of CMV.
A number of studies have suggested that symptoms and
permanent neurological deficits are rare in the infants of
women with preconceptional immunity (3,4). However, such
a clinical outcome may, in fact, be more common than
previously thought (12-15).
In the present study, the incidence, clinical spectrum and
outcome of congenital CMV infection were investigated

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in vivo 18: 819-824 (2004)

among preterm and full-term newborns under intensive care
with suspected intrauterine infection. Paediatric, otologic,
ophthalmologic and neurological follow-ups were scheduled
for 1 to 4 years.

Table I. Clinical features in 11 newborn infants with congenital CMV

infection.
Infant Apgar scores at
1, 5 and 10 min

pH

Materials and Methods

1
2
3
4
5
6
7
8
9
10
11

7.17
7.20
7.10
7.23
7.20
7.12
7.30
7.32
7.22
7.52
7.26

Patients. Seventy newborns aged less than 2 weeks were admitted

to the Intensive Care Unit of the Department of Paediatrics,
University of Szeged, Hungary, with suspected intrauterine
infection (gestational age 25-40 weeks, weight 750-4500 g). Virus
infection was suspected in consequence of the detection of an
abnormality such as IUGR, non-immune hydrops foetalis (NIHF),
ascites, hydrothorax, congenital malformation, sepsis, hyperbilirubinaemia, seizure or pneumonitis. Clinical information was
obtained by review of the medical records of each subject. All
neonates with proven congenital CMV infection were followed-up
by the same paediatrician, ocular specialist, otologist and
neurologist. They were examined 2 weeks after birth and once or
twice annually up to 1-4 years of age.
The control group comprised 50 infants at no risk of foetal
CMV transmission.
The present study was approved by the Human Investigation
Review Board of the University of Szeged.
Detection of CMV in urine. Urine samples were collected from the
neonates in sterile urine-collecting bags within the first 2 weeks of
life, aliquoted into Eppendorf tubes and stored at -70C until
processed. CMV DNA was extracted from 200 l of the urine
sample by using the High Pure Viral Nucleic Acid Kit (Roche
Diagnostics GmbH, Mannheim, Germany) according to the
manufacturers instructions. Briefly, cell and virus lysis was
performed by incubation of the samples in a lysis/binding buffer
with proteinase K, and poly(A) carrier RNA and CMV DNA were
selectively bound to a glass fleece by centrifugation. Residual
impurities were removed in washing steps and the bound crude
CMV DNA was eluted in 50 l of nuclease-free sterile water. The
viral DNA target sequences derived from the envelope
glycoprotein B (gB) were amplified by nested polymerase chain
reaction (nPCR). The outer primer pair consisted of
oligonucleotide 5-GGA AAC GTG TCC GTC TTT GA-3 (gB
1246) and 5-GAG TAG CAG CGT CCT GGC GA-3 (gB 1724).
The inner primer pair consisted of the sense primer 5-TGG AAC
TGG AAC GTT TGG C-3 (gB 1319) and the antisense primer 5GAA ACG CGC GGC AAT CGG-3 (gB 1604).
Amplification was carried out in a final volume of 50 l
containing 50 pmol of primers, 200 M dNTPs (each), 1.5 mM
MgCl2 and 1.25 Units of Taq DNA polymerase in 50 mM KCl, 10 mM
Tris-HCl (pH 9.0), 0.1% Triton X-100 reaction buffer. Five l
aliquots of the crude DNA preparations were added to the first
PCR, and 3 ml aliquots from the previous PCR to the second one.
The thermal cycling profile was as follows: denaturation for 5 min
at 95C, 35 cycles of amplification (95C for 30 sec, 55C for 40
sec and 72C for 60 sec) and then holding at 72C for 10 min. A
positive control with DNA isolated from the Towne strain of CMV
was included in each experiment. In both the initial and nPCR
reactions, negative controls were also included in each experiment
(buffer, nucleotides, primers, magnesium and Taq DNA
polymerase, but no template). PCR products (approximately 285 bp)

820

6/5/5
5/7/9
0/1/2
2/5/5
6/7/8
2/3/4
1/4/7
9/9/10
8/6/7
9/10/10
7/8/9

Arterial blood
PaO2 (mm Hg) O2SAT (%)
43.7
50.0
52.6
45.0
55.0
62.3
57.0
80.0
43.7
79.0
55.2

91
92
80
90
91
90
93
95
85
96
70

were detected by electrophoresis in 2% agarose gel stained with

ethidium bromide.
As the primers for amplification were selected from a region of
high peptide variability in the gB gene, the gB genotype of CMV
DNA was also determined by restriction fragment length
polymorphism (16).

Results
Seventy ill neonates were enrolled in the CMV follow-up
study: 36 preterm newborn infants and 34 term newborn
infants.
The presence of CMV DNA in the urine of the neonates
was detected by means of nPCR, and the gB genotype of the
CMV was also determined. CMV was found in the urine
samples of 11 (15.7%) of the neonates under intensive care.
Of the 11 CMV DNA samples, 10 proved to be of gB1 and
1 of gB2 genotype (case 9). During the follow-up period,
specimens for CMV detection were available from 10
patients. The gB genotype of the CMV DNA was found to
be the same as indentified after birth. Urinary excretion of
CMV was not detected in any of the 50 healthy neonates.
In 4 of the CMV-infected neonates, hypoxaemia was
detected at birth. In these cases, the Apgar scores were less
than 4 at 1 minute (Table I). The pH of the arterial blood was
below 7.2 in 3 cases. The paO2 was below 50 mm Hg in 3
cases, but the O2 therapy applied resulted in a saturation
efficiency of 89-95% (Table I). In 2 cases, hyperbilirubinaemia
was detected, and in 2 cases also thrombocytopenia (Table II).
Following clinical admission, 7 neonates, of whom 3 were
preterm (cases 1, 2 and 4) and 4 were full-term (cases 3, 5,
6 and 9), required ventilatory support for 1 to 10 days.
Patient 4, a preterm infant, died of intracranial
haemorrhage, septic uraemia and prematurity at 9 days of
age. Ten CMV-infected neonates were followed up for 5

Nagy et al: Congenital CMV Infection in Selected Groups of Neonates

Table II. Laboratory findings in 11 newborn infants with congenital CMV infection at 2 weeks of age.
Infant

Thrombocyte
number (G/l)

1
2
3
4
5
6
7
8
9
10
11

240
204
191
128
56
237
103
199
268
132
238

Bilirubin
(M)

GOT
(U/l)

Blood serum
GPT
(U/l)

CN
(mM)

Creatine
(M)

154.4
87.8
42.1
133.6
NT*
27.1
236
239
NT
102
186

22
22
NT
45
NT
NT
54
18
15
25
24

17
16
NT
57
NT
NT
17
23
13
19
20

10.9
6.6
6.7
16.6
9.9
7.8
4.4
6.0
4.9
4.8
1.8

119
55
162
207
139
45
77
118
120
98
89

* NT: not tested

GOT: glutamate-oxalate-transaminase; GPT: glutamate-pyruvate-transaminase; CN: carbamic nitrogen

months to 4 years (Table III). Mental retardation was

observed in 4 cases, of whom 2 were preterm (cases 1 and 2)
and 2 were full-term neonates (cases 3 and 5). A
sensorineural hearing loss was detected in 1 neonate (case 3),
who was also growth-retarded. Bronchial asthma developed
in 1 preterm (case 10) and strabismus in 2 preterm cases
(cases 1 and 7). Five children born preterm (cases 1, 2, 7, 10
and 11) excreted CMV at their last visit and 1 was symptomfree. In the full-term group, 3 of the 5 patients excreted virus
and 1 was symptom-free. No virus was detected in the urine
of the 2 full-term patients (cases 6 and 9) during the follow
up period. They were clinically symptom-free, but intense
mechanical ventilation was required at birth in both cases.
Ophthalmologic examination did not reveal chorioretinitis in
any of the cases. Strabismus developed in 2 preterm infants
(cases 1 and 7). The results of audiometric testing were found
to be normal in all infants except case 3.

Discussion
The prevalence of congenital CMV infection in selected
newborns under intensive care with suspected intrauterine
infection proved to be high (15.7%). The frequency of CMV
infection in the preterm newborns (16.7%) was similar to
that observed in the full-term newborns (14.7%). Santos et
al. (17) detected congenital CMV infection in 6.8% (20 out
of 292) of non-selected newborns in a neonatal intensive
care unit. In Brazil, where the rate of CMV seropositivity
among pregnant women is 95%, Yamamoto et al. (18)
observed that the frequency of congenital CMV infection in
non-selected preterm newborns (2.1%) was similar to that
in full-term newborn infants (1.8%) and to that in another
high-immunity population (19,20).

The occurrence of severe manifestations of congenital

CMV infection has been reported in preterm infants
(19,21). In our study, 1 of the 6 preterm infants (case 4),
who was born with intracranial haemorrhage, sepsis and
RDS, died at 9 days of age. Another preterm infant (case 2)
was similarly born with intracranial haemorrhage. This
infant had pneumonitis at birth, too. An association
between congenital CMV infection and intracranial
haemorrhage has been described in two previous reports
(22,23). As 1-2% of babies are born with CMV infection, it
may be important to test for CMV in infants with
intracranial haemorrhage where there is no immediately
apparent cause. Necrotizing enterocolitis (NEC) was the
only clinical finding in 1 preterm infant (case 1) at birth, and
at 12 months of age mental retardation and strabismus were
detected. The association of NEC with congenital CMV
infection is rare. During the past 20 years, 6 cases of CMVassociated NEC have been reported in infants. The last
case, in a premature infant born to a mother with recurrent
maternal CMV infection, was published recently (24). Our
CMV-associated NEC case confirms the suggestion of
others that CMV should be added to the list of pathogens
potentially responsible for NEC (24,25). However, further
studies are needed, as full-term neonates with congenital
CMV infection-associated NEC have not been identified
(26). Strabismus occurs more frequently among children
who are symptomatic at birth than among those who are
initially asymptomatic (27,28). Although additional evidence
is needed, our data suggest that the incidence of strabismus
in the preterm population may be higher than in the fullterm population. The prolonged urinary excretion of CMV
was documented in both asymptomatic and symptomatic
patients in previous studies (29-31).

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in vivo 18: 819-824 (2004)

Table III. Clinical findings in neonatal period and outcome of congenital CMV infection in newborns under intensive care.
Infant Gestation Body weight
at
(g)
age
(weeks)

Clinical findings
in neonatal period and up to 48 months

32

1820

Prematurity, necrotizing enterocolitis

Mental retardation, Strabismus

30

1670

39

2760

25

1150

35

2800

36

3480

RDS, hypoxia, sepsis, pneumonia,

Mental retardation, hydrocephaly
intracranial haemorrhage
Intrauterine asphyxia and infection, prematurity,
Mental retardation, hearing loss
hypotonia, seizures, polytraumatization, azotaemia
RDS, sepsis, intracranial haemorrhage,
Died
polytraumatization
Intrauterine infection, microcephaly, seizures,
Mental retardation, cerebral atrophy
polytraumatization, eclampsia, perinatal cerebral lesion,
intrauterine infection, thrombocytopenia
NIHF
Symptom-free

33

2070

37

3000

Intrauterine infection and hypoxia,

thrombocytopenia
Intrauterine infection

Symptom-free

40

3300

Intrauterine hypoxia, PFC

Symptom-free

10

34

1310

RDS, icterus

Bronchial asthma

11

32

2400

Intrauterine infection, icterus

Symptom-free

RDS: respiratory distress syndrome;

* follow-up period

NIHF: non-immune hydrops foetalis;

In conclusion, our study has demonstrated that the

frequency of congenital CMV infection is high in preterm
(16.7%) and full-term (14.7%) newborn infants under
intensive care with suspected intrauterine infection. It seems
that the clinical findings and the gB genotype of CMV
detected at birth do not allow a prediction of the outcome
of congenital CMV infections. Intracranial haemorrhage and
NEC should be added to the possible sequelae of congenital
CMV infection, especially in preterm newborns. Screening
of this group of neonates for congenital CMV appears
important. Those identified as having congenital CMV
infection can be monitored to correct any sequelae
immediately. The compassionate use of ganciclovir in
newborns with life-threatening or vision-threatening
congenital CMV infection is probably justified (32).

Acknowledgements
This study was supported by the Hungarian Scientific Research
Fund (grant OTKA-T26442/1998), the Research Fund of the
Hungarian Ministry of Education (grant FKFP 113/2000), and
ICON-H3 Ltd.

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Strabismus, anaemia, chronic bronchitis

CMV excretion
(months)*

+
(12)
+
(5)
+
(48)

+
(9)
(36)
+
(36)
+
(24)
(24)
+
(36)
+
(36)

PFC: persistent foetal circulation.

We thank Mrs. Ildik Wellinger and Mrs. Csilla Szab for their
excellent technical assistance.

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Received July 30, 2004

Accepted October 20, 2004

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