Cytomegalovirus in a child - symptoms and treatment, what the consequences of CMV infection may be. Cytomegalovirus in children: general characteristics of this infectious pathology Cytomegalovirus in the saliva of a child

Cytomegalovirus (CMV) is discovered completely accidentally in children. Very often, after examining a child for infections, the mother hears a mysterious phrase from the doctor: Antibodies to cytomegalovirus were detected in the blood.

Most children are infected with it, but the infection behaves secretly and does not manifest itself until a certain moment.

Infection in children becomes more active due to decreased immunity and its consequences can be very sad: loss of vision, hearing, intellectual impairment and even death. What are the symptoms of cytomegaly and why is the disease considered so dangerous?

Causes of pathology - DNA virus, one of the family. Once the pathogen has entered the body, it remains there for life. If there are no manifestations of the disease, then this form of infection is called carriage. According to statistics, 80-90% of adults are infected with cytomegalovirus, and the first encounter with the pathogen occurs in childhood.

Once in the bloodstream, the virus seeks to penetrate the cells of the salivary glands - this is the favorite localization of the pathogen.

The virus affects the respiratory tract, liver, spleen, brain, gastrointestinal tract, and kidneys.

In cells it inserts its DNA into the nucleus, after which the production of new viral particles begins. The infected cell greatly increases in size, which gives the pathogen its name: translated from Latin it means “giant cells.”

Typically cytomegalovirus in children Not causes vivid symptoms and proceeds covertly. The disease causes serious damage when the immune defense is weakened, which occurs in the following groups of babies:

• premature and weakened;
• In children with congenital defects;
• HIV-infected;
• with disorders of the immune system;
• with chronic diseases (diabetes mellitus, glomerulonephritis).

How is it transmitted?

A carrier or sick person releases the virus into the external environment with saliva, breast milk, urine, and mucus from the genital tract.

Infection of a child can occur in the following ways:

• Vertical - occurs during intrauterine development. The virus is able to penetrate through the placenta into the bloodstream of the fetus from the mother's body. The risk of infection is especially high if a woman has suffered an acute form of infection during pregnancy.
• With mother's milk - if a woman suffers from an acute form of infection or became infected during lactation.
• Contact, airborne droplets - when passing through the birth canal and at an older age, when the baby communicates with infected people.

Kinds

There is no generally accepted classification of cytomegalovirus infection. Doctors divide the disease both by time of infection (congenital, acquired) and by prevalence (generalized, localized). Infection in HIV-infected children is classified into a separate group.

Congenital

A congenital infection is an infection that a child received from mother during pregnancy. If infection occurs in the first trimester, the pregnancy is terminated or a baby is born with severe developmental defects. Infection in later stages occurs in a milder form.

Along the way, congenital cytomegalovirus infection can be:

• acute;
• chronic.

The acute form appears immediately after birth, while the chronic form develops gradually during the first months of life.

Acquired

Child with acquired cytomegalovirus infection becomes infected during breastfeeding from the mother or through contact with a sick person. In infants, the disease can be severe; in children of preschool and school age, it can be an acute respiratory viral infection.

Along the way, the disease can be:

• latent – ​​localized form (the virus lives in the salivary glands);
• acute – like ARVI with increased temperature;
• generalized - a severe form with damage to many organ systems.

Symptoms

Symptoms will depend on the form of the disease, age and immune status of the child.

In a newborn

Cytomegalovirus in children in the first days of life affects the liver, which manifests itself as icteric discoloration of the skin and eyes. Normally, jaundice in newborns goes away within a month, but in infected children it lasts up to six months. May be digestion is disturbed, the child is not gaining weight well and is worried.

Damage to the hematopoietic system leads to a decrease in platelet count– blood cells responsible for clotting. As a result, it is easy on the baby's skin bruises appear, may be pinpoint hemorrhagic rash. Possible symptoms include: bleeding from the navel, blood in the stool and vomit.

Infection in newborns causes inflammation of brain tissue(encephalitis) with subsequent formation of dense calcified inclusions in the lesions. Your baby may have symptoms such as seizures, loss of consciousness, neurological disorders.

An increase in head size is the result of dropsy of the brain due to increased production of cerebrospinal fluid against the background of an inflammatory reaction.

Damage to the central nervous system is usually combined with visual impairment. The virus penetrates the structures of the eye and damages them, causing the baby to the lens may become cloudy, the shape and color of the iris and pupil may change. Often the consequences of cytomegaly are permanent visual impairment.

Cough, shortness of breath, bluish skin color newborn - symptoms of cytomegalovirus pneumonia. Decreased urine output, unusual color, or strong odor talk about kidney damage due to an acute form of infection.

Congenital infection leads to very serious consequences, including severe disability and death of the child. Treatment with folk remedies will not help here; serious drug therapy is required.

For a one-year-old child and older

In children aged one year and older, the infection is usually acquired. The disease manifests itself as inflammation of the upper respiratory tract. The baby is worried cough, pain when swallowing, fever bodies. May join rash all over the body in the form of red spots.

The child has enlarged lymph nodes in the neck, under the lower jaw, in the armpits, and groin. Swollen lymph nodes are painless, the surface of the skin is of normal color.

Sometimes the child complains about abdominal pain, in its right half or on both sides. The causes of pain are an increase in the size of the liver and spleen. There may be a slight yellowness of the skin and eyes– symptoms of liver damage.

Although the disease is similar to a regular ARVI, treatment with folk remedies will not cure the child completely.

Diagnostics

Diagnosing such a disease in children is not easy, since the manifestations are nonspecific and resemble the course of many other diseases. The doctor will examine the child and then prescribe the necessary tests and studies to confirm cytomegaly.

Analyzes

The following tests will help detect an infection in a child:

• Blood tests for antibodies to the pathogen - the protective protein Ig M indicates an acute infection, and IgG indicates a chronic or latent form.
• PCR of urine and saliva - allows you to detect the pathogen itself in the material.
• Complete blood count - the child has a reduced number of red blood cells (anemia), platelets and leukocytes.
• Biochemical blood tests - liver enzymes ALT and AST increase; with kidney damage, the concentration of urea and creatinine will increase.

The urine sediment must be examined under a microscope for the presence of giant cells with an owl's eye shaped nucleus will allow you to confirm the diagnosis of cytomegaly.

Instrumental methods

They are prescribed depending on which system is affected in the child:

• chest x-ray – if the lungs are damaged, the image will show signs of pneumonia;
• Ultrasound of the abdominal cavity - will reveal an enlargement of the liver and spleen, possible hemorrhages in them;
• Ultrasound or MRI of the brain will detect foci of inflammation or calcifications.

For a generalized infection, the doctor will order a fundus examination by an ophthalmologist. This will allow timely detection of damage to the structures of the eye and, possibly, preserve vision, subject to proper treatment.

Treatment

How and with what to treat the disease? Treatment is carried out by an infectious disease specialist together with a pediatrician. If necessary, the child will be observed by a neurologist, ophthalmologist, nephrologist or urologist.

Drugs

A medicine that completely eliminates cytomegalovirus from the body has not been developed. Initially, there were attempts to treat it with antiherpetic drugs, but this regimen was not very successful.

The doctor may prescribe ganciclovir, although in children it is used only in desperate situations due to its high toxicity. The medicine can only be used in older children in case of severe infection.

In case of severe infection, the child is given intravenous human immunoglobulin - protective antibodies that will help prevent the negative consequences of the disease.

If a child’s cytomegalovirus occurs as an acute respiratory viral infection, the doctor will prescribe medications that will alleviate the symptoms of the disease:

• antipyretics - at temperatures above 38 degrees C;
• expectorants - for coughing with viscous sputum;
• immunomodulatory - for children over 5 years old to accelerate the production of protective antibodies;
• vitamin and mineral – to increase the body’s resistance to disease.

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During an acute infection, the doctor will prescribe bed rest, plenty of warm liquids(tea with honey, fruit juice, compote), treatment with folk remedies: gargling with antiseptics(chamomile, soda, iodine) - this will not eliminate the causes of the disease, but will significantly alleviate the symptoms.

Prevention

Prevention of infection includes the child observing the rules of personal hygiene, since the virus is transmitted by contact. Walks in the fresh air, a varied menu, a rational daily routine - all this will strengthen the baby’s immunity and make it easy to survive the attack of the virus.

To protect the child from congenital cytomegaly, When planning a pregnancy, a woman should be tested for antibodies. If antibodies are not detected, the doctor will prescribe a preventive vaccination for the expectant mother.

The vaccination will form immunity to the pathogen and protect the woman during pregnancy from infection.

Treatment with folk remedies for acute infection during pregnancy is ineffective, you should definitely consult a doctor if you have any symptoms of ARVI. The consequences of congenital cytomegaly are too serious to neglect the possible danger.

It is not always possible to detect signs of a cytomegalovirus infection in a child’s body, since it does not have a negative effect on the baby. This infectious agent is usually detected completely by accident during an examination. Cytomegalovirus is diagnosed in a child by a positive blood test for igg antibodies. Primary infection does not show any symptoms until a certain point. Cytomegalovirus (CMV) is activated against the background of decreased immunity, and the consequences of the disease can be very sad.

What is cytomegalovirus in a child?

CMV is the most common infectious agent among children. At different ages, it occurs in more than half of children around the world. The specific causative agent of the infection is Human betaherpesvirus (human herpes virus). The penetration of CMV into a child’s body does not pose a particular health risk, since the pathology is mostly asymptomatic and does not require treatment. The danger arises if intrauterine infection of the fetus occurs or cytomegalovirus is detected in newborns, because infants still have low activity of the immune system.

Causes

Cytomegalovirus infection activates in children against the background of reduced immunity. The pathogen initially enters the digestive system, genital or respiratory organs through the mucous membranes of the nose or mouth. There are no changes in the introduction of infectious agents into children. Once in the body, the virus continues to exist there for life. CMV in children is in a latent phase until immunodeficiency appears. The cause of reduced immunity in a child can be:

• frequent colds (sore throat, acute respiratory viral infections, acute respiratory infections);
• chemotherapy;
• AIDS, HIV;
• long-term use of cytostatics and antibiotics.

How is it transmitted?

Only a virus carrier can become a source of infection for a child. Several options for transmitting cytomegalovirus to a child:

1. Transplacental. The virus is transmitted by crossing the placenta from an infected mother to the fetus.
2. Contact. With the help of saliva during kissing, the infection enters the respiratory system through the mucous membranes and larynx.
3. Domestic. The route of transmission is through the common use of household items.
4. Airborne. When someone who has the virus coughs or sneezes, or through saliva from close contact.

Symptoms of cytomegalovirus in children

Clinical manifestations of CMV are nonspecific. The first symptoms appear only after a decrease in immunity and are easily confused with other diseases:

• suppressed mononucleosis symptoms due to vitamin deficiency;
• fever that occurs for no apparent reason;
• pain syndrome in the limbs;
• signs of tonsillitis;
• swollen lymph nodes;
• increased body temperature up to 39 degrees;
• small rash all over the body.

In newborns

Cytomegalovirus manifests itself completely differently in children under one year of age. If a baby becomes infected through breast milk or during passage through the birth canal, then in 90% of cases the disease is asymptomatic. Clinical manifestations of congenital cytomegalovirus in a child:

• hemorrhagic or cavityless swelling, in 80% of cases minor hemorrhages;
• persistent jaundice in combination with an enlarged spleen and liver is observed in 75% of babies;
• the body weight of the newborn is much less than WHO indicators;
• pathology of peripheral nerves (polyneuropathy);
• small skull size;
• microcephaly with areas of calcified tissue in the brain in 50% of babies;
• inflammation of the retina;
• pneumonia;
• hydrocephalus.

Kinds

There are several forms of the virus:

1. Congenital. Jaundice and internal bleeding may develop. The disease can lead to damage to the nervous system even during a woman’s pregnancy. Congenital cytomegalovirus infection can cause miscarriage or ectopic fertilization.
2. Spicy. More often, infection occurs through sexual contact, and a child becomes infected from an adult during a blood transfusion. The symptoms are similar to those of a cold with the addition of enlarged salivary glands.
3. Generalized. Inflammatory foci form in the kidneys, spleen, and pancreas. Symptoms appear after a decrease in immunity and are often accompanied by a bacterial infection.

How dangerous is cytomegalovirus for a child?

Healthy children tolerate the infection normally. The pathology occurs without symptoms or with the onset of a cold, but goes away after 2-3 days. In weakened children, CMV occurs with complications that appear either immediately or after illness. In the future, the virus may cause a child to have mental retardation, visual impairment, or liver damage.

Over time, infected children experience neurological abnormalities and hearing problems. If a positive blood test for igg antibodies is detected during an examination of a pregnant woman, then after infection of the fetus the virus exhibits a teratogenic effect: the child experiences a disruption in the development of visceral organs, the brain, the organs of vision and hearing.

Antibodies to cytomegalovirus

The human body uses the same strategy to fight the disease - it produces antibodies that attack only viruses and do not affect healthy cells. Once it has fought an infectious agent, the specific immune system remembers it forever. Antibodies are produced in the body not only after an encounter with a “familiar” virus, but also when a vaccine is administered. A blood test for CMV shows either a negative or a positive result for igg class antibodies. This means the presence or absence of cytomegalovirus in the body.

Diagnostics

Since the manifestations of CMV are nonspecific, diagnosing the pathology in a child is not an easy task. To confirm cytomegaly, the doctor after examination prescribes the following tests:

• blood for the presence of antibodies to the pathogen: the igm protein indicates an acute infection, and the igg protein indicates a latent or acute form of the disease;
• PCR of saliva and urine to detect cytomegalovirus DNA;
• general blood test to determine the number of leukocytes, platelets, red blood cells;
• biochemical blood test to detect elevated levels of liver enzymes AST and ALT (the concentration of creatinine and urea increases with kidney damage);
• MRI or ultrasound of the brain to detect calcifications or areas of inflammation;
• Abdominal ultrasound to detect an enlarged spleen or liver;
• chest x-ray to determine pneumonia.

Treatment

Depending on the form and severity of the disease, treatment of cytomegalovirus in children occurs. The latent form does not require any therapy. Children with an acute form of cytogelovirus need treatment. For severe manifest infections and intrauterine infection, complex therapy is carried out in a hospital. The CMV treatment regimen includes:

• antiviral treatment (Foscarnet, Ganciclovir);
• interferons (Viferon, Altevir);
• immunoglobulin preparations (Cytotect, Rebinolin);
• antibiotics for secondary infections (Sumamed, Klacid);
• vitamin and mineral complexes (Immunokind, Pikovit);
• immunomodulators (Tactivin, Mercurid);
• in severe cases of cytomegalovirus, corticosteroids (Prednisolone, Kenacort) are used.

Folk remedies

Herbal infusions and decoctions help strengthen the immune system and strengthen the body. In case of infection with cytomegalovirus, traditional medicine offers the following recipes:

1. It is necessary to mix the components in equal parts: succession grass, chamomile flowers, alder fruits, roots of Leuzea, licorice, kopeck. Pour 2 tbsp into a thermos. l. herbal mixture, pour 500 ml of boiling water, let it brew overnight. Drink the finished infusion 1/3 cup 3-4 times a day until the condition improves.
2. You should mix equal parts of yarrow and thyme herbs, burnet roots, birch buds, and wild rosemary leaves. Then 2 tbsp. l. pour 2 cups of boiling water over the herbal mixture and leave in a thermos for 12 hours. In the morning, the infusion must be filtered and taken 100 ml 2 times a day daily for 3 weeks.

Consequences

You need to worry more about newborns and babies under 5 years old. After all, at this age children have a low immune status, so the virus can cause undesirable health consequences:

• with intrauterine infection, there is a risk that the baby will be born with problems with internal organs and heart defects;
• if the infection occurs late in pregnancy, pneumonia and jaundice occur after childbirth;
• When infected, periodic convulsions are observed at one year of age, and the salivary glands swell.

Prevention

To prevent infection with cytomegalovirus, it is necessary to strengthen the child’s immunity. Prevention consists of the following:

• taking antiviral drugs (Acyclovir, Foscarnet);
• balanced diet;
• regular walks in the fresh air;
• hardening;
• avoiding contact with infected people;
• strict adherence to personal hygiene rules.

Video

The disease, which is caused by the Herpesviridae virus, is similar to the herpes simplex virus. When multiplying in a cell, the cytomegalovirus virus in children leads to the formation of huge cells due to an increase in the nucleus and cytoplasm. This is a disease with polymorphic symptoms.

In general, CMV infection in children is transmitted without obvious signs. Viruses are resistant to antibiotics. Transmission occurs mainly by contact, less often by airborne droplets. Placental and parenteral (through blood) routes of transmission are possible. Fetuses and newborns are especially susceptible to the disease. Newborns can become infected through breastfeeding from their mother. The CMV virus in children is detected in saliva, cerebrospinal fluid, urine and organs.

CMV infection in children can occur due to the penetration of viruses through the placenta or during childbirth. However, not all infected children may be born with severe signs of the disease. Most often it occurs latently. Only in the salivary glands can cell changes occur (giant cell metamorphosis).

If a child is diagnosed with cytomegalovirus, but there are no symptoms, it is possible that parents should not worry. With good immunity, the virus does not pose a danger. If the disease is latent, the child will develop immunity, and the body itself will cope with the infection without consequences. But sometimes a latent infection can lead to some disorders of the central nervous system. The child develops headaches, mental retardation, insomnia, and fatigue.

Sometimes exposure to infection can cause serious complications. If the immune system is weakened and cytomegalovirus is found in the child, this is a signal to begin active therapeutic measures. With severe immune deficiency, infection leads to an unfavorable outcome.

At what age can cytomegalovirus appear in children?

Congenital cytomegalovirus in a child occurs when the placenta is damaged and the infection is generalized. If infection occurs in the first months of intrauterine development, developmental defects are possible. The child may have hydrocephalus, microcephaly, or a disorder of the structure of the brain substance. From the side of the cardiovascular system, there may be non-closure of the septum of the heart, endocardial fibroelastosis, and heart defects. Sometimes defects of the kidneys, genitals and gastrointestinal tract may appear.

If infection occurs late in life, cytomegalovirus in newborns shows symptoms after birth. The child develops jaundice, damage to the lungs and gastrointestinal tract, and hepatoleanal syndrome are detected. Sometimes the disease can manifest as hemorrhagic rashes. With CMV, newborns experience lethargy, frequent regurgitation and diarrhea. Because of this, children do not gain weight well, they have decreased tissue turgor, and increased temperature.

Jaundice may appear during the first two days. Most often it is pronounced, since there is a very high concentration of bile pigments in the blood. The child's feces are partially discolored, the spleen is enlarged, and the liver protrudes 37 cm from under the costal arch. Hemorrhagic syndrome can manifest as petechiae and vomiting. In children, hypotonia and hyporeflexia are determined. In severe cases, intoxication develops, leading to death.

Cytomegalovirus infection in an infant can be congenital or acquired. The disease in its congenital form is much more severe, since the virus manages to cause significant harm to the child’s body while still in the womb. But even when the virus is transmitted to the fetus, only 10% of children are born with obvious signs of the disease. Often cytomegalovirus does not appear in infants.

The nature of the development of the disease depends on the maturity of the fetus at the time of intrauterine infection, the mother’s immunity and the child’s immune reactivity. Symptoms of congenital CMV in an infant may include: jaundice, convulsions, abnormal development of organs and systems. Doctors can diagnose deafness and blindness.

Acquired cytomegalovirus in children under one year of age can manifest itself as damage only to the salivary glands. In response to the introduction of the virus into cells, a pronounced dysfunction of the affected organ may occur. In severe cases, cytomegalovirus in an infant can cause adrenal insufficiency, and in case of immunosuppression, damage to all organs.

Acquired cytomegalovirus in a 1-year-old child can manifest itself as a delay in physical development. In this case, disturbances in motor activity and convulsions are observed. Depending on the state of the child’s immunity, various signs may appear: swelling of the salivary glands, hemorrhages, blurred vision, damage to the gastrointestinal tract. But more often the acquired disease can be asymptomatic.

Cytomegalovirus in a 2-year-old child can lead to either isolated damage to the salivary glands or organ damage. However, unlike the congenital form, the disease more often manifests itself as mononucleosis. The child may experience a gradual increase in temperature, sore throat, enlarged lymph nodes, hepatosplenomegaly, swelling of the throat mucosa, and abdominal pain.

The immune system of children under 5 years of age is not yet capable of providing an adequate response to infection. Cytomegalovirus in children 3 years of age may present with symptoms of interstitial pneumonia. The child develops shortness of breath, whooping cough-like persistent cough, and cyanosis. Possible addition of dysfunctions of the gastrointestinal tract and liver. Temperatures can reach 40 degrees. This condition can last from 2 to 4 weeks.

In the generalized form, almost all organs can be involved in the process. The disease is manifested by sepsis, prolonged fever, disorders of the gastrointestinal tract and cardiovascular system, parenchymal hepatitis and encephalitis. For complications of CMV in children aged five years, treatment includes the administration of immunoglobulins (Interferon) in the complex of measures. After five years, the child’s body is able to cope with the infection on its own without serious consequences.

What are the symptoms and signs of infection in children?

If cytomegalovirus affects, symptoms in children may appear depending on age and immune status. The older the child, the easier the disease will be tolerated. At the first encounter with the virus, children under 7 years of age with normal immunity develop typical symptoms:

• Hyperthermia
• Swelling of the larynx, inflammation
• Muscle weakness, malaise
• Headache

Sometimes there may be rashes on the body. If children have symptoms of cytomegalovirus, treatment is carried out with antiviral drugs, which transfer the disease to a passive form.

In case of decreased immunity, symptoms of CMV in children may appear depending on the organ damage or the form of the disease. The virus affects the intestinal glands, bile ducts, kidney capsules, etc. This leads to the occurrence of focal inflammation. Pneumonia, bronchitis, inflammation of the spleen, adrenal glands, and liver may develop. In the generalized form, all organs can be affected. In this case, the symptoms of CMV infection in children are polymorphic. The generalized form is severe and can be fatal in the first 2 weeks of life. In isolated forms of damage to any organ, it can be asymptomatic.

When is treatment for a disease necessary?

Treatment of cytomegalovirus in children involves the use of a complex of drugs depending on the affected systems. In the generalized form, the administration of corticosteroids, antiviral (Ganciclovir) and specific Cytotect is indicated. In order to restore the basic functions of the immune system (primarily the production of interferon), a course of treatment is carried out with interferon inducers (amixin, Cycloferon). These drugs activate humoral and cellular immunity. Thanks to interferons, the immune system begins to work effectively and contributes to the death of the virus.

Most often, treatment of CMV in children is carried out with the prescription of human immunoglobulin (Megalotect, Cytotect). These drugs are non-toxic and can be used to treat children of any age. In exceptional cases, more toxic antiviral drugs are prescribed for the treatment of newborns - Ganciclovir, Cidofovir. This therapy is carried out in cases of severe damage to visceral organs. However, before treating cytomegalovirus in a child with toxic drugs, the degree of complications caused by the virus should be assessed. The therapy itself and the set of drugs used for treatment must correspond to the child’s immune status.

Virus carriage itself or a mild disease (mononucleosis syndrome) in children with normal immunity does not require therapy. It is enough to use vitamins and restorative drugs to strengthen the immune system. During periods when outbreaks of infectious diseases (flu or acute respiratory infections) occur, the use of multivitamin complexes will protect the child from the virus.

How dangerous is cytomegalovirus in a child?

Usually healthy children tolerate this infection normally. The disease can be asymptomatic or with symptoms of a cold that disappear after a few days. However, in weakened children, this infection can occur with complications. The consequences of cytomegalovirus in a child can appear either immediately after birth or after previous illnesses. Asymptomatic progression may in the future cause visual impairment or mental retardation. Hearing problems or neurological abnormalities may develop over time.

Scientific studies have established the danger of fetal infection in the first half of pregnancy. Having penetrated the body, the virus exhibits a teratogenic effect. As a result, there is a disruption in the development of the brain, organs of hearing and vision, and visceral organs.

Analysis for cytomegalovirus in a child

In order to make an accurate diagnosis, you should be tested for cytomegalovirus. Several methods are used for diagnosis:

1. Virological (cytological).
2. Serological. The most accessible ELISA method is the isolation of immunoglobulins G and M.
3. Molecular biological (PCR).

The most informative test for CMV in a child is the PCR method. It is possible to detect not only CMV DNA using PCR in children, but also the activity of the virus. However, this method is one of the most expensive. Another method is used that allows one to establish antibodies to cytomegalovirus in a child - serological (ELISA). The analysis determines several types of antibodies and the stage of the disease.

There are some differences in antibodies to understand. Class M immunoglobulins are produced in response to the virus. They cannot form immunological memory, so when they disappear, protection against the virus disappears. Immunoglobulins G are produced after suppression of infection throughout life, developing stable immunity to the disease.

If anti-CMV IgG is detected in a child, but anti-CMV IgM is not detected, this indicates that the body has developed lifelong immunity to the virus. That is, this is the norm for CMV in children, which does not require treatment. If cytomegalovirus igg is positive in children, but anti cmv ​​IgG antibodies are not detected, the analysis shows that the body does not have stable immunity to the virus. Antibodies suppress the development of the virus and help transmit the disease without symptoms. If a child does not have antibodies to cytomegalovirus (cmv g), this is explained by the absence of the disease or high susceptibility to infection.

Cytomegalovirus (cmv, CMV) igg positive in a child indicates that he is infected either before birth or after. If a child has a very high titer, this is evidence of activation of the infection. This usually increases the concentration of iGM antibodies.

Antibodies to cytomegalovirus igg are positive in the child - this means that the disease is either in an inactive stage or in the reactivation stage. The readings of class M antibodies help to give an accurate analysis. If anti CMV igg is positive in a child and Anti CMV IgM is positive, this means that the end of the primary infection is occurring in the body, and immunity has already formed. If IgM is negative, the disease is in an inactive stage.

A positive cytomegalovirus igM in a child with a negative Anti-CMV IgG indicates a primary disease in the acute stage. If the tests do not detect antibodies of both classes, it means either the disease is absent or it is at an early stage and antibodies have not had time to develop.

Cytomegaly is a fairly common viral disease. Cytomegalovirus in children can cause serious problems, especially if infected before birth. Fortunately, in most healthy people the disease is asymptomatic and the patient is not even aware of accidental contact with the virus. The symptoms and treatment of cytomegalovirus themselves depend on the patient’s condition and the form of the disease.

Virus prevalence

Cytomegaly is a viral infection belonging to the Herpesviridae family. Infection occurs through contact with saliva, tears, or sexual relations with a patient or carrier of CMV.

A separate route of infection is from mother to unborn child. How easy it is to become infected with the virus and how widespread it is is illustrated by estimates that approximately 40% of healthy adults in Europe may have antibodies to CMV.

The virus uses host cells to replicate (reproduce). It is characteristic that it can remain in them for many years, waiting in a hidden form for the appearance of favorable circumstances for the re-development of the infection.

These include all conditions that compromise the immune system, such as HIV infection, immunosuppressive treatment and cancer.

According to Dr. Komarovsky, cytomegaly during pregnancy poses a great danger to the fetus, especially if infection with the virus occurs in the first trimester. The consequence could even be a miscarriage. And if the pregnancy continues to develop, the virus can lead to many birth defects in the child.

The infection is common because it occurs in the human environment. There are many sources and ways in which cytomegalovirus spreads. The incidence of infection is estimated at 40–80% and even 100% among people of low social status.

10–70% of preschool children living in large groups become infected with the virus from their peers. It is observed that on average 1% of children are infected with CMV at the time of birth.

Infection during pregnancy

Cytomegalovirus is increasingly a problem for pregnant patients who have reduced immunity. Here we are talking about either the resumption of the activity of a microorganism dormant in the body during pregnancy, or the infection of a woman with a new type of pathogen. Primary CMV infection in women carrying a baby is usually asymptomatic. Rarely, during the course of cytomegalovirus infection, pregnant women experience sore throat and head, cough and fever.

Cytomegalovirus infection in the third trimester of pregnancy can lead to premature birth. Infection of newborns rarely occurs during this process. Prematurity and fetal dystrophy increase the risk of development.

If an infected mother is breastfeeding, her baby may acquire the pathogen in the first months of life. About 40–60% of newborns are infected through breast milk. The infection, however, is asymptomatic and does not leave any consequences for the child’s health.

Symptoms of congenital pathology

In newborns who have been exposed to infection in utero, symptoms of the disease may appear in the long term in the form of damage to the central nervous system, hearing and vision defects. If CMV develops in a woman in the first months of pregnancy, complications may occur in the child. Cytomegalovirus is also dangerous because of the consequences it carries. First of all this:

If infection occurs during the final stage of pregnancy, there is a risk of disease of the body organs, which can lead to liver damage, thrombocytopenia, purpura or interstitial inflammation of the lungs. However, even if the baby was infected during or after childbirth, the disease does not give obvious symptoms.

Pathology can develop in approximately 10–15% of babies immediately after birth or within two weeks after it.

Symptoms in children and adolescents:

Newborns and infants who exhibit the above symptoms should be referred as soon as possible to specialized centers with appropriate personnel and laboratory equipment that can perform tests to confirm or rule out cytomegalovirus in children.

The most common symptoms of congenital cytomegalovirus include elevated liver enzymes, jaundice, and an enlarged liver. Meanwhile, thrombocytopenia is sometimes accompanied by changes in the skin.

When inflammation spreads to the macula of the eye, there is a risk of vision loss, strabismus, or damage to the optic nerve. Hearing impairment occurs in 50% of children. Due to congenital cytomegalovirus, 10% of newborns die. Those children who survive usually have varying degrees of mental retardation, balance problems, hearing and vision defects, and learning difficulties.

Symptoms of cytomegalovirus in older children

Approximately 99% of cases of CMV in older children are asymptomatic. Cytomegaly begins with a period of uncharacteristic flu-like symptoms. The period of development of infection for individual routes of transmission of the virus is not precisely known, but it can be assumed that on average it is 1–2 months.

Signs of the disease in childhood:

• heat;
• musculoskeletal pain;
• skin rash;
• feeling of general weakness and fatigue.

This is sometimes accompanied by an enlargement of the liver and spleen, pharyngitis, as well as enlargement of the lymph nodes, especially the cervical ones.

Relatively often, cytomegalovirus infection in children leads to inflammation of the liver, including jaundice and an increase in the concentration of organ enzymes in laboratory tests.

Previous infections of the original type are not completely eliminated from the body. CMV has the ability to remain for many years in a latent form in the host's cells, where it awaits the emergence of favorable circumstances, such as HIV infection, the condition after an organ transplant, taking medications that suppress the immune system, or cancer.

The secondary form of infection, i.e. reactivation of a latent infection, causes much more severe symptoms.

Among them are:

Symptoms of infection, both acquired and congenital, are varied and at the same time similar to problems with other diseases. For each patient in whom a pathogen is suspected, specific laboratory tests should be performed to identify it. Studies are widely performed to detect specific antibodies of various classes.

The basis is serological blood tests for the presence of specific antibodies belonging to two classes - IgM and IgG.

These antibodies are present in the blood from the very beginning of the infection and can persist long after the symptoms of the disease have disappeared. Their examination is most often carried out twice with an interval of 14–28 days. An active CMV infection is indicated by the detection of a high titer of IgM antibodies and confirmation of at least a fourfold increase in the concentration of IgG antibodies.

Other laboratory methods for confirming infection include identifying the genetic material of the virus using the PCR method. The material for research is most often blood or urine, saliva, or amniotic fluid.

It is necessary to screen women for IgM and IgG antibodies before pregnancy. Positive results in both cases indicate infection with the CMV virus. If only the result is , it means the virus is in dormant mode (carriage). Positive IgM may indicate a recent infection or viral reactivation.

In the case of newborns, especially those born prematurely (immaturity of the immune response in the first months of life), and people with reduced resistance, the study of exclusively specific antibodies may not be sufficient to establish a diagnosis. It is necessary to use other methods of detecting the virus.

Of great importance in establishing a diagnosis is the assessment of the child by various specialists (neurologist, ophthalmologist, otolaryngologist and others, depending on the indications) and the performance of subsequent studies, especially assessing the function of the liver, kidneys, bone marrow, construction and activity of the central nervous system. Among them:

• ultrasound examination (ultrasound);
• CT scan;

Treatment of cytomegalovirus in children

Antiviral treatment for cytomegalovirus in children is only recommended if their immune system is not fighting off the infection properly.

In such situations, Ganciclovir is most often used, a drug that inhibits the action of DNA polymerase, i.e., an enzyme necessary for the functioning of the virus. Treatment for CMV usually lasts 2 to 4 weeks. Other antiviral drugs used include Foscarnet and Cidofovir. However, due to the potential risk of side effects of the most commonly used drugs, antiviral treatment and intravenous administration of these medications in children under one year of age are limited.

In young children (up to 5 years), therapy includes the administration of drugs aimed at combating symptoms, reducing fever, reducing the severity of pain and disinfecting the throat.

Much more important is to prevent the occurrence of pathology, avoiding being in the company of people after immunosuppression, patients with influenza or mononucleosis, as well as preschool children. The ideal solution would be to introduce compulsory vaccination for girls before puberty. Unfortunately, a vaccine for CMV has not yet been invented. There are no medications that can be effective in combating the virus in pregnant women.

Cytomegalovirus in a child, as in adolescents and adults, cannot be completely cured, since the pathogen remains in the body in the latency phase after the acute form. Unfavorable conditions (significant immunity disorders) can lead to increased infection.

RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2017

Congenital cytomegalovirus infection (P35.1), Cytomegalovirus disease (B25), Cytomegalovirus disease, unspecified (B25.9), Cytomegalovirus mononucleosis (B27.1)

Infectious diseases in children, Pediatrics

general information

Short description

Approved
Joint Commission on Healthcare Quality
Ministry of Health of the Republic of Kazakhstan
dated August 18, 2017
Protocol No. 26

Cytomegalovirus infection (CMVI)- an infection caused by a pathogen from the group of betaherpesviruses, for which the main target cells in the human body, often transformed into cytomegalic cells during its replication, are monocytes, macrophages, granulocytes, epithelial and endothelial cells, fibroblasts, smooth muscle cells. CMV infection is characterized by diverse manifestations from asymptomatic to generalized (septic) course with severe damage to the central nervous system and other organs.

INTRODUCTORY PART

ICD-10 code(s):

	ICD-10
B25	Cytomegalovirus disease
B25.0	Cytomegalovirus pneumonitis (J17.1)
B25.1	Cytomegalovirus hepatitis (K77.0)
B25.2	Cytomegalovirus pancreatitis (K87.1)
B25.8	Other cytomegalovirus diseases
B25.9	Cytomegalovirus disease, unspecified
B27.1	Cytomegalovirus mononucleosis
R35.1	Congenital cytomegalovirus infection

Date of protocol development/revision: 2017

Abbreviations used in the protocol:

GP	-	general doctor
ICE	-	disseminated intravascular coagulation
AlAT	-	alanine aminotransferase
MRI	-	Magnetic resonance imaging
PCR	-	polymerase chain reaction
ELISA	-	linked immunosorbent assay
CMV	-	cytomegalovirus infection
ESR	-	erythrocyte sedimentation rate
ChBD	-	Frequently ill children
IgG	-	immunoglobulins class G
IgM	-	immunoglobulins class M
CT	-	CT scan

Protocol users: general practitioners, pediatric infectious disease specialists, pediatricians, paramedics, emergency doctors.

Level of evidence scale:

A	A high-quality meta-analysis, systematic review of RCTs, or large RCTs with a very low probability (++) of bias, the results of which can be generalized to an appropriate population.
IN	High-quality (++) systematic review of cohort or case-control studies or high-quality (++) cohort or case-control studies with very low risk of bias, or RCTs with low (+) risk of bias, the results of which can be generalized to an appropriate population .
WITH	Cohort or case-control study or controlled trial without randomization with a low risk of bias (+), the results of which can be generalized to the relevant population or RCT with a very low or low risk of bias (++ or +), the results of which cannot be directly distributed to the relevant population.
D	Case series or uncontrolled study or expert opinion.
GPP	Best pharmaceutical practice.

Classification

Classification:

According to the nature of infection:	. Congenital (intrauterine). . Postnatal (acquired).
With the flow:	. Acute (up to 3 months) . Subacute (3-6 months) . Prolonged (6-12 months) . Chronic (more than 12 months)
According to clinical form:	. Localized (sialoadenitis, hepatitis, encephalitis, nephritis, pneumonia, gastroenteritis, pancreatitis, exanthema, thrombocytopenia). . Common: . mixed (combined); . generalized; . mononucleosis-like form caused by CMV.
By the nature of detection of CMV markers:	. With virus replication. . No virus replication.
By stages and periods of the disease:	. Active stage: . manifestation stage; . stage of relapse with a period of activation. . Inactive stage: . convalescence stage; . remission stage.
Associated variants of CMV infection:	. With congenital malformations; . with bacterial and fungal diseases; . with herpes virus infections; . in HIV-infected persons and with other immunodeficiency conditions.
CMV outcomes:	. Recovery; . transformation into a latent form; . congenital anomalies (defects) of the heart, brain, liver, kidneys, pancreas; . deafness, visual defects; . retardation in physical and mental development; . chronic inflammatory processes in organs and systems (neutropenia, anemia, cardiomyopathy, hepatitis, etc.).

Diagnostics

DIAGNOSTIC METHODS, APPROACHES AND PROCEDURES

Diagnostic criteria

Complaints:
· prolonged fever, often subfebrile;
· weakness;
· increased fatigue;
· enlargement and pain of the salivary glands;
· enlarged lymph nodes (usually cervical, submandibular);
· cough;
· jaundice;
· nausea, vomiting;
· stomach ache;
· diarrhea;
· decreased visual acuity with visual field defects;
· neurological complaints (headache, dizziness, vomiting, paresthesia, convulsions, etc.).

Anamnesis:

Physical examination:

Gradual development, prolonged undulating fever of the wrong type above 38.5C, weakness, drowsiness, fatigue, loss of appetite, arthralgia, myalgia, frequent acute respiratory viral infections, bronchitis including obstructive bronchitis, lymphadenopathy, less often splenomegaly, hepatomegaly, hepatitis. Congenital CMV infection, acute form. The nature of the lesion depends on the timing of infection. - If infected in the early stages (first 4-6 weeks), fetal death, spontaneous miscarriage, or the formation of a systemic pathology similar to genetic diseases are possible. - If infected in the first 3 months of pregnancy, a teratogenic effect on the fetus is possible. - If infected at a later date, there may be a congenital CMV infection that is not accompanied by developmental defects. - The birth of a child with clinical manifestations of congenital CMV infection indicates the prenatal nature of the infection and almost always indicates a primary CMV infection suffered by the mother during pregnancy. - maternal history: a) obstetric pathology during previous and current pregnancy: premature birth, miscarriages, threatened miscarriage, polyhydramnios, gestosis, fetoplacental insufficiency. b) extragenital pathology: low-grade fever, lymphadenopathy, acute respiratory infections or mononucleosis-like syndrome, hepatosplenomegaly.

For congenital CMV infection: thrombocytopenic purpura, sensorineural hearing loss, jaundice, hepatosplenomegaly, microcephaly, malnutrition, prematurity, hepatitis, encephalitis, chorioretinitis. In premature, weakened children with a burdened perinatal history, clinical manifestation of CMV infection is possible already by 3-5 weeks of life. Most often, interstitial pneumonia is observed, and the development of prolonged jaundice, hepatosplenomegaly, anemia and other hematological disorders is possible. Congenital CMV, chronic form: a wave-like course of the chronic form of intrauterine CMV infection is observed in some who have suffered the acute form of the disease. When infected in the first months of pregnancy, the severity of pathological changes varies widely. Often, congenital malformations are formed - clubfoot, deafness, deformation of the palate, microcephaly. Liver damage can occur in the form of chronic hepatitis. Changes in the lungs are characterized by the development of pneumosclerosis and fibrosis. Acquired form of CMVI: mononucleosis, "ARD" - similar diseases, acute respiratory syndrome, prolonged low-grade fever, interstitial pneumonia, pleurisy, hepatitis, pancreatitis, interstitial nephritis (microproteinuria, microhematuria, abacterial leukocyturia) rarely - nephrotic syndrome, retinitis, iridocyclitis, uveitis (vision loss), enterocolitis, vasculitis, damage to the central nervous system - ventriculitis, myelitis, polyneuropathy, polyradiculopathy, Guillain-Barré syndrome (paresis and paralysis of demyelinating origin, myocarditis, carditis, anemia, leukopenia, neutropenia, thrombocytopenia (pancytopenia due to bone marrow damage). The latent form does not manifest itself with clear clinical symptoms; sometimes mild flu-like illnesses and vague low-grade fever are observed. Its diagnosis is based on laboratory data.

Type of lesion	Gestation period	Nature of the lesion
Blastopathy	0-14 day	Death of the embryo, miscarriage, or the formation of a systemic pathology similar to genetic diseases.
Embryopathies	15-75 day	Developmental defects at the organ or cellular level (true defects). Miscarriage.
Early fetopathies	76-180 day	Development of a generalized inflammatory reaction with a predominance of alterative and exudative components and the outcome in fibrous-sclerotic deformations of organs (false defects). Possible termination of pregnancy.
Late fetopathies	From 181 days until birth	Development of a manifest inflammatory reaction with damage to various organs and systems (hepatitis, encephalitis, thrombocytopenia, pneumonia, etc.)

Laboratory research :
· UAC - leukopenia, neutrophilia/lymphocytosis, thrombocytopenia, atypical mononuclear cells;
· OAM - microproteinuria, microhematuria, leukocyturia;
· PCR - determination of CMV DNA in urine, blood, saliva;
· ELISA - determination of anti-CMV IgM and anti-CMV IgG with avidity index.

Additional laboratory and instrumental studies:
· biochemical blood test for bilirubin, ALT for icteric syndrome;
· coagulogram - for hemorrhagic syndrome;
· cerebrospinal fluid analysis - if meningitis and encephalitis are suspected;
· pulse oximetry - for respiratory failure (measures peripheral hemoglobin oxygen saturation in arterial blood and pulse rate in beats per minute, calculated on average in 5-20 seconds);
· chest x-ray (if symptoms of pneumonia are present).

Markers of active CMV replication:
· viremia;
· antigenemia (pp 65 (UL83), etc.);
· DNAemia;

Immunological markers of active CMV infection:
· seroconversion (detection of anti-CMV-IgM and/or low-avidity anti-CMV-IgG in previously seronegative individuals);
· 4-fold or higher increase in anti-CMV-IgG titers in “paired”
serums."

Primary CMV: regardless of the clinical variants of the disease, with primary CMV, direct (viremia, DNA-emia or AG-emia) and indirect (anti-CMV-Ab IgM and/or low-avidity anti-CMV-Ab IgG) laboratory markers of active replication of the cytomegaly virus are detected.

Reactivation of CMV infection: the period of active replication of the virus during persistent disease in previously seropositive individuals (i.e., previously infected). Laboratory criteria for CMV reactivation are the detection in the blood of the virus itself (viremia), or its genome (DNA-emia), or its antigens (AG-emia), along with the identification of serological markers (anti-CMV-Ab class IgM and/or low-avidity anti-CMV antibodies of the IgG class) in previously seropositive individuals.

The risk of fetal infection and laboratory criteria for diagnosing various variants of the course of CMV infection during pregnancy

Form of infection during pregnancy	Presence of viremia	CMV antigens	Anti-CMV-AT	Risk of infection fetal growth
Latent	No	Not detected	IgG	Extremely low
Persistent	No	Are detected	IgG	Up to 2%
Reactivated Naya	Eat	Are detected	IgG increases, IgM may appear	Up to 8%
Primary infection	Eat	Are detected	IgM, post- foam naras dancing low avid IgG in “par- ny serums"	Up to 50%

Indications for specialist consultation:
· cardiologist - in the presence of congenital heart disease;
· neurosurgeon - for developmental defects of the central nervous system;
· neurologist to assess neurological development;
· hematologist for severe hematological changes and hemorrhagic syndrome;
· ophthalmologist - to examine the fundus of the eye;
· otolaryngologist - to study central hearing.

Diagnostic algorithm:

Differential diagnosis

Differential diagnosis and rationale for additional studies:

Diagnosis	Rationale for differential diagnosis	Surveys	Diagnosis exclusion criteria
HIV infection	Fever, polyadenopathy, rash, hepatolienal syndrome	ELISA PCR	Individual lymph nodes of different groups are enlarged, painless, tonsillitis is not typical, ulcerative lesions mucous membranes of the oral cavity and genital organs, manifestations of opportunistic infections (candidiasis). Positive HIV test using ELISA and PCR methods.
Viral hepatitis	Hepatosplenomegaly, jaundice.	. Biochemical blood test for bilirubin and ALT; . ELISA - HB s Ag and anti-HCV antibodies; . PCR HBV DNA and HCV RNA	Prolonged fever is not typical. Positive blood test results: ELISA - HBsAg and anti-HCV antibodies; PCR HBV DNA and HCV RNA. Increased bilirubin due to the direct fraction and ALT.
Tuberculosis	Prolonged fever and cough.	X-ray of the lungs	Chronic cough (> 30 days); Poor development/weight loss or weight loss; Positive Mantoux reaction; History of contact with a patient with tuberculosis; Radiological signs: primary complex or miliary tuberculosis; Detection of Mycobacterium tuberculosis during sputum examination in older children.
Toxoplasmosis	Encephalitis, lymphadenopathy, hepatomegaly, jaundice, exanthema.	ELISA - determination of IgM and IgG to T.gondii; PCR - determination of T.gondii DNA	chorioretinitis, calcifications in the brain, visceral lesions. Positive results: ELISA - IgM and IgG to T.gondii; PCR - T. gondii DNA.
Listeriosis	The presence of fever, hepatomegaly, increased transaminase levels, and sometimes bilirubin levels.	ELISA, bacteriological analysis of feces, urine	Prolonged fever, moderately severe hyperbilirubinemia, in the KLA often leukocytosis, neutrophilia, significantly accelerated ESR, damage to other systems and organs. Positive ELISA results - IgM to Listeria and isolation of Listeria culture.
Adenovirus infection	Fever, polyadenopathy, enlarged spleen and liver, pharyngitis, tonsillitis.	Virus detection in strokes-imprints with nasal mucosa using immunofluorescent analysis.	Lymph nodes are moderately enlarged, single, painless; rhinorrhea, productive cough. Often conjunctivitis, tonsillitis, pharyngitis and diarrhea.
Rubella	Enlarged occipital lymph nodes, exanthema.	ELISA - determination of IgM to the rubella virus.	The symptoms are short-lived, only the occipital and posterior cervical lymph nodes are affected. Detection of specific antibodies - IgM to the rubella virus.
Infectious mononucleosis	Lymphadenopathy, tonsillitis, hepatolienal syndrome, fever.	ELISA - determination of IgM VCA to EBV.	Systemic enlargement of lymph nodes predominates. Detection of specific antibodies - IgM VCA to EBV.

Treatment

Drugs (active ingredients) used in treatment

Treatment (outpatient clinic)

OUTPATIENT TREATMENT TACTICS
At the outpatient level, children with mild CMV infection without damage to internal organs receive treatment. Treatment of mild forms of CMV infection consists of symptomatic therapy.

Non-drug treatment:
Mode:
· Semi-bed rest (during the entire period of fever).

Drug treatment:
· To relieve hyperthermic syndrome above 38.5 0 C:
- paracetamol 10-15 mg/kg with an interval of at least 4 hours, no more than three days by mouth or per rectum or ibuprofen at a dose of 5-10 mg/kg no more than 3 times a day by mouth.

List of essential medicines:

List of additional medicines:

Surgical intervention: No.

Further management[ 1-4,6 ] :
· children with CMV are subject to dispensary observation and control examination for the activity of the infectious process (anti-CMV IgM and anti-CMV IgG with determination of the avidity index) at 1, 3, 6 and 12 months.
· medical exemption from preventive vaccinations for 3 months.

Indicators of treatment effectiveness and safety of diagnostic and treatment methods[ 1-4,6 ] :
· normalization of body temperature;

· absence of anti-CMV IgM and positive anti-CMV IgG with high avidity.

Treatment (inpatient)

TREATMENT TACTICS AT THE INPATIENT LEVEL
Treatment of CMV infection consists of etiotropic and symptomatic therapy. Indications for etiotropic treatment of CMV infection include damage to internal organs and laboratory markers of active viral replication (viremia, DNAemia, antigenemia).
The use of ganciclovir in pediatric practice is limited due to its high toxicity, which contributes to the formation of leukopenia, thrombocytopenia, liver and kidney damage. But if there are vital indications, the toxicity of the drug should not become a reason for refusing its use. Treatment should be carried out under the control of blood test parameters ( N.B.!

At the same time, specific anticytomegalovirus immunoglobulins are prescribed with the use of antiviral drugs. These antibodies are complementary to the glycoproteins of the viral envelope. Their neutralization prevents infection of unaffected cells by the virus. Thus, immunoglobulin inhibits the spread of CMV in the body and reduces subsequent replication of the virus. The drug neutralizes viruses that are located extracellularly or associated with cell membranes. Immunoglobulin has no effect on viruses that are intracellular.
The administration of specific anticytomegalovirus immunoglobulin lasts until positive clinical dynamics are obtained and takes 10-12 or more injections.

Patient observation card, patient routing[ 1-4 ] :

Non-drug treatment[ 1-7 ] :
· Bed rest (during the entire period of fever);
· Diet: Table No. 13, small warm drinks (milk-vegetable diet).

Drug treatment[ 1-7,10,11 ] :
to relieve hyperthermic syndrome above 38.5 o C, the following is prescribed:
- paracetamol 10-15 mg/kg at intervals of at least 4 hours, no more than three days, orally or perrectum;
or
- ibuprofen at a dose of 5-10 mg/kg no more than 3 times a day by mouth;
· for the purpose of detoxification therapy, intravenous infusion at the rate of 30 - 50 ml / kg / day with the inclusion of solutions:
- 5% or 10% dextrose (10-15 ml/kg);
- 0.9% sodium chloride (10-15 ml/kg);

For the purpose of etiotropic therapy:
standard dosage for the treatment of CMV retinitis:
- initial therapy: intravenous infusion of ganciclovir 5 mg/kg body weight every 12 hours (10 mg/kg/day) for 14-21 days (for patients with normal renal function) in combination with human immunoglobulin against cytomegalovirus at a dose 100 units/kg intravenously every 2 days until clinical symptoms disappear;
- maintenance therapy: ganciclovir 5 mg/kg intravenously over 1 hour, daily for 7 days;
- children with severe and moderate forms of CMV infection - ganciclovir according to the regimen: 5-7.5 mg/kg body weight per day intravenously in 2 doses over 14-21 days in combination with human immunoglobulin against cytomegalovirus at a dose of 100 U/kg intravenously drip after 2 days - until clinical symptoms disappear;
- newborns with CMV infection with central nervous system damage - ganciclovir 6 mg/kg every 12 hours for 6 weeks.
(N.B.! - Ganciclovir should be used after registration in the territory of the Republic of Kazakhstan).

Antibacterial drugs are prescribed depending on the suspected and/or isolated pathogen in the development of bacterial complications.
- Ceftriaxone - intravenous infusion over 60 minutes, newborns 20-50 mg/kg once daily.
Children from 1 month to 12 years: body weight up to 50 kg 50 mg/kg once a day; up to 80 mg/kg per day for severe infections. Infections (meningitis); Doses 50 mg/kg or more intravenously - body weight 50 kg or more, children 12-18 years old
Child from 12-18 years old 1 g per day; 2-4 g per day for severe infections and meningitis;
- Cefotaxime - infections caused by susceptible gram-positive and gram-negative bacteria. By intramuscular or intravenous administration or intravenous infusion. Newborns up to 7 days 25 mg/kg every 12 hours; The dose is doubled for severe infection.
- Cefuroxime infections caused by susceptible gram-positive and gram-negative bacteria, orally (as cefuroxime axetil)
Children: 3 months-2 years 10 mg/kg (not more than 125 mg)
twice a day;
Children: 2-12 years 15 mg/kg (maximum 250 mg) twice daily;
Children: 12-18 years 250 mg twice daily;
Dosages are increased for severe lower respiratory tract infections,
Or if pneumonia is suspected.

List of essential medicines:

Pharmacological group	International nonproprietary name of the drug	Mode of application	UD
Anilides	Paracetamol	Syrup for oral administration 60 ml and 100 ml, 5 ml - 125 mg; tablets for oral administration, 0.2 g and 0.5 g; rectal suppositories; solution for injection (150 mg in 1 ml).	A
Immunoglobulins, normal human	Human immunoglobulin against cytomegalovirus*	solution for intravenous administration 50 or 100 units/ml: fl. 10 ml, 20 ml and 50 ml	IN
Antiviral drug	ganciclovir*	Lyophilized powder for the preparation of solution for intravenous administration: (in bottles of 500 mg).	IN

NB!- Ganciclovir should be used after registration on the territory of the Republic of Kazakhstan

List of additional medicines[ 1-7,10,-13 ] :

Other irrigation solutions	Dextrose	Solution for infusion 5% 200 ml, 400 ml; 10% 200 ml, 400 ml	WITH
	Ceftriaxone	Powder for the preparation of solution for intravenous and intramuscular administration 1 g Intravenous infusion over 60 minutes	A
Antibacterial drug - cephalosporin series	Cefotaxime	Powder for the preparation of a solution for intravenous and intramuscular administration 1 g.	A
Antibacterial drug - cephalosporin series	Cefuroxime	powder for solution for injection complete with solvent 250 mg, 750 mg, 1500 mg	A
Saline solutions	Sodium chloride solution	Solution for infusion 0.9% 100 ml, 250 ml, 400 ml	WITH

Surgical intervention: No.

Further management :
· Children with congenital CMV are subject to dispensary observation and control examination for the activity of the infectious process (determining the level of specific IgM and IgG) at 1, 3, 6 and 12 months after discharge from the hospital, followed by an annual examination by a neurologist, otolaryngologist and ophthalmologist up to 7 years.
· Medical exemption from preventive vaccinations for 6 months.

Indicators of treatment effectiveness [ 1-4 ] :
· relief of fever and intoxication;
· absence of clinical symptoms;
· absence of CMV in blood, urine and saliva (virus DNA);
· absence of anti-CMV IgM and anti-CMV IgG with low avidity;
· presence of anti-CMV IgG with high avidity.

Hospitalization

INDICATIONS FOR HOSPITALIZATION, INDICATING THE TYPE OF HOSPITALIZATION

Indications for planned hospitalization: No

Indications for emergency hospitalization:
· Children with severe and moderate forms of CMV infection.

Information

Sources and literature

1. Minutes of meetings of the Joint Commission on the quality of medical services of the Ministry of Health of the Republic of Kazakhstan, 2017
   1. 1) Roberg M.Kliegman, Bonita F.Stanton, Joseph W.St.Geme, Nina F.Schoor/Nelson Textbook of Pediatrics. Twentieth edition. International Edition.// Elsevier-2016, vol. 2nd. 2) Uchaikin V.F., Nisevich N.I., Shamshieva O.V. Infectious diseases in children: textbook - Moscow, GEOTAR-Media, 2011 - 688 p. 3) Recommendations and guidelines for perinatal practice. Guidelines on CMV congenital infection J. Perinat. Med. 37 (2009) 433–445 Copyright by Walter de Gruyter Berlin New York. DOI 10.1515/JPM.2009.127 4) Bravender T. Epstein-Barr virus, cytomegalovirus, and infectious mononucleosis / T. Bravender // Adolesc Med State Art Rev. – 2010. – Vol. 21, No. 2. – P. 251-264. 5) Providing inpatient care to children (WHO Guidelines for the management of the most common diseases in primary level hospitals, adapted to the conditions of the Republic of Kazakhstan) 2016. 450 pp. Europe. 6) Cytomegalovirus infection: diagnostic and therapeutic aspects: Textbook. Manual / Neverov V.A., Vasiliev V.V., Kirpichnikova G.I.; edited by Yu.V. Lobzin. - St. Petersburg, 2010. - 40 p. 7) Cytomegalovirus infection. Etiology, epidemiology, pathogenesis, clinic, laboratory diagnostics, treatment, prevention / S.G. Mardanly, G.I. Kirpichnikova, V.A. Neverov. - Elektrogorsk: JSC "EKOlab", 2011. - 32 p. 8) Kitaima, J. Differential transmission and postnatal outcomes in triplets with intrauterine cytomegalovirus infection / J. Kitaima // J. Pediatr Dev Pathol. – 2012. – V. 15 (2). – P. 151–155. 16. 9) Enders, G. Intrauterine transmission and clinical out- come of 248 pregnancies with primary cytomegalovirus infection in relation to gestational age / G. Enders // J. Clin. Virol. – 2011. – V. 52 (3). – P. 244–246. 10) ADLER SP, NIGRO G. Findings and conclusions from CMV hyperimmune globulin treatment trials. J Clin Virol 2009; 46(Suppl 4): S54-57. 11) AMIR J, WOLF DG, LEVY I. Treatment of symptomatic congenital cytomegalovirus infection with intravenous ganciclovir followed by longterm oral valganciclovir. Eur J Pediatr 2010; 169: 1061-1067. 12) Large reference book of medicines / ed. L. E. Ziganshina, V. K. Lepakhina, V. I. Petrova, R. U. Khabrieva. - M.: GEOTAR-Media, 2011. - 3344 p. 13) BNF for children 2014-2015

Information

ORGANIZATIONAL ASPECTS OF THE PROTOCOL

List of protocol developers:
1) Baesheva Dinagul Ayapbekovna - Doctor of Medical Sciences, Associate Professor, Head of the Department of Children's Infectious Diseases, Astana Medical University JSC.
2) Efendiyev Imdat Musa ogly - Candidate of Medical Sciences, Head of the Department of Children's Infectious Diseases and Phthisiology, RSE on PCV
"State Medical University of Semey".
3) Kuttykuzhanova Galiya Gabdullaevna - Doctor of Medical Sciences, Professor, Professor of the Department of Children's Infectious Diseases of the RSE at the PVC "Kazakh National Medical University named after. S.D. Asfendiyarov.
4) Devdariani Khatuna Georgievna - Candidate of Medical Sciences, Associate Professor of the Department of Children's Infectious Diseases, RSE at the Karaganda State Medical University.
5) Zhumagalieva Galina Dautovna - Candidate of Medical Sciences, Associate Professor, head of the course of childhood infections, RSE at the West Kazakhstan State University named after. Marat Ospanov."
6) Mazhitov Talgat Mansurovich - Doctor of Medical Sciences, Professor, Professor of the Department of Clinical Pharmacology, Astana Medical University JSC.
7) Umesheva Kumuskul Abdullaevna - Candidate of Medical Sciences, Associate Professor of the Department of Children's Infectious Diseases, RSE at the PVC "Kazakh National Medical University named after. S.D. Asfendiyarov."
8) Alshynbekova Gulsharbat Kanagatovna - Candidate of Medical Sciences, acting professor of the Department of Children's Infectious Diseases, RSE at the Karaganda State Medical University.

Disclosure of no conflict of interest: No .

Reviewers:
1) Kosherova Bakhyt Nurgalievna - Doctor of Medical Sciences, Professor of the RSE at Karaganda State Medical University, Vice-Rector for Clinical Work and Continuing Professional Development, Professor of the Department of Infectious Diseases.

Indication of the conditions for reviewing the protocol: review of the protocol 5 years after its publication and from the date of its entry into force or if new methods with a level of evidence are available.

Attached files

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