Cytomegalovirus

Cytomegalovirus is a viral disease characterized by the emergence in the tissues and organs of a kind of giant cells with intracellular inclusions. Place of initial fixation of the virus are the salivary glands. Get cytomegalovirus children, mostly babies.
Cytomegalie changes in newborns prove the possibility transplacental infection; installed and nutritional transmission of the virus through mother's milk. The virus cytomegaly effect on the fetus in all periods of fetal development , and might be a cause of embryopathy, fetopathy, prematurity and the dead birth.
There are localized and generalized forms cytomegaly. In a localized form affects the salivary glands and regional lymph nodes. In generalized form often affects the kidneys, lungs, liver, pancreas and thyroid gland, adrenal gland, pituitary gland, gastrointestinal tract, brain, and other Process ends with the development of fibrosis of the authority. Cytomegalovirus can cause sepsis or hemolytic disease of the newborn. There are phenomena toxicity, severe jaundice, hepatosplenomegaly, subcutaneous hemorrhage. May be convulsions, paresis, and paralysis, hydrocephalus, symptoms of interstitial pneumonia (shortness of breath, cyanosis). In blood, anaemia, erythroblasts, thrombocytopenia. Methods specific treatment and prevention is not developed. Used in the treatment of steroids (prednisone) for 10 to 30 days (0.8-1 mg/kg of body weight per day), the reintroduction of gamma globulin (3 ml in two days intramuscularly). To suppress the secondary infection in the acute period used antibiotics.

Cytomegalovirus (from the Greek. kytos - cell and megalos - large; synonym: cytomegalia infantum, inclusiony cytomegalovirus disease generalized inclusions) is a viral disease characterized by the formation in the tissues and organs of giant cells with large intranuclear inclusion.
The etiology and pathogenesis. The virus cytomegaly affects not only humans but also animals. However, the infection of animals for diagnostic purposes, as the virus has strict species specificity. When planting in tissue culture of human embryonic fibroblasts virus has cytopathogenic effect. In the serum of the patient detect specific antibodies.
Place of initial fixation of the virus are the salivary glands. The parotid glands are affected more often than submandibular and sublingual. Are mostly infants (often 4-b mon.). Diseases of older children and adults are casuistry. Cytomegalie changes in stillborn prove the possibility transplacental infection. Transmission of the virus after birth is not clear. The virus cytomegaly effect on the fetus in all periods of fetal development, and might be a cause of embryopathy, fetopathy, prematurity and the dead birth. The spread of the virus in the organism occurs hematogenous route, as evidenced by the presence of vasculitis in affected organs. The localized form cytomegaly characterized by lesions of the salivary glands and regional lymph nodes. The possibility of viremia in this form of the disease does not exclude the development of common toxicity even without generalized defeats of other organs.
The generalization of infection occurs more frequently due prior to weaken the pathologic process, rarely occurs alone.
Pathological anatomy. Type of tissue and organ cells with cytomegalie transformation reminds owl's eyes. The inclusion of that virus network in the nucleus of cells, reaches 8-10 microns in diameter. Around the turn area enlightenment, bordered by a nuclear membrane, the contours of which are underlined by the accumulation of chromatin and nucleoli. The kernel is located in the cytoplasm of an eccentric. In the cytoplasm, too, are found on and grain nucleoproteins. Nuclear inclusion in the experiment is formed at 12-15 day after infection, cytoplasmic, after 6 - 8 days after the appearance of nuclear. In a localized form macroscopically the salivary glands can be increased slightly full. The regional lymph nodes succulent, full-blooded; in rare cases noticeably increased, accompanied by clinical symptoms of lymphadenitis. Microscopically in the epithelium ducts and secretory departments of the salivary glands are identified typical giant cells with inclusions (Fig. 1); getting into the lumen of the ducts, they are found in smears of saliva. In interstitium cancer develop lymphohistiocytosis infiltrates and granulomas. The process ends with the development of fibrosis of the authority. In regional lymphatic nodes - reticular hyperplasia. occasionally giant cytomegalic cells.
In generalized form often affects the kidneys and lungs, followed (in decreasing frequency) liver, pancreas, thyroid gland, adrenal gland, pituitary gland, gastrointestinal tract, the brain, of the eye (retina), the myocardium. In all the mentioned bodies virus cytomegaly provides education characteristic of giant cells, development lymphohistiocytic interstitial infiltrates and the formation of granulomas of light reticular and lymphoid cells. The process ends fibrosis. Kidney cytomegalie changes are localized mainly in the cells of proximal nephron (Fig. 2); in interstitial tissue - picture interstitial nephritis. Peeling cytomegalic cells in a lumen tubules can detect them in the urine. In the lungs - interstitial and catarrhal-desquamation pneumonia, peribronchial and perivascular infiltrates. Cytomegalic cells are seen in the bronchial and alveolar epithelium (Fig. 3) and can be found in the sputum. In the liver cytomegalie changes are predominantly in the epithelium of the bile ducts with the development of subacute productive hepatitis. In the brain changes are localized mainly in subependymal area of the cerebral ventricles. Here are the foci of necrosis with calcification. Cytomegalie changes are noted in the glia, ependyma and vascular plexus, in the ganglion cells. In the gastrointestinal tract cytomegalie changes of the epithelial mucous membranes are accompanied catarrhal and ulcerous processes. Viruses, cytomegaly pancreas some researchers believe the reason for cystic fibrosis (see cystic Fibrosis).
Generalized form cytomegaly often accompanied hemorrhagic diathesis in the form of petechiae of the skin and hemorrhages in the internal organs and the presence of reactive erythroblastosis (see Erythroblastosis jet) with the formation of lesions extramedullary hematopoiesis in the liver, spleen, lymph nodes.
In utero generalization process in the embryonic period occur defects forming organs (kidneys, lungs, brain, liver, skin and others); in fetal - violations of tissue differentiation and heavy cirrhotic changes (for example, in the liver, pancreas, and so on).
Microscopic diagnosis of generalized cytomegaly difficult and may be suspected in the presence of hemorrhagic diathesis in combination with pneumonia, hepatosplenomegaly, total jaundice and symptoms of encephalitis. Especially it is necessary to think about the possibility of generalized cytomegaly in cases of a combination of above mentioned changes have developmental agencies. The final diagnosis is established only after histological examination. It is recommended that all deaths of children under one year to 1.5 years of life to explore the salivary glands, especially stillborn and from the fruit. This massive study reveals infection with a virus cytomegaly from 8 to 32% (according to Asbahu).

Fig. 1. Cytomegalie metamorphoses of epithelial cells excretory duct of the salivary gland.
Fig. 2. Cytomegalie metamorphosis of one of the cells of proximal convoluted tubules of the kidney with the proliferation reticular elements in the interstitium.
Fig. 3. Cytomegalie metamorphoses of the alveolar epithelium of light; in the alveolar septa lympho-monocytic proliferation.


The clinical picture and symptoms. For cytomegaly can be acute, subacute, or prolonged. Subacute period may end disastrously .
In some cases, cytomegalovirus can cause sepsis. Clinical manifestations localized forms cytomegaly mild and usually not diagnosed. Clinical manifestations generalized forms cytomegaly diverse and depend on the destruction of one or the other body and the age of the patient.
In congenital cytomegaly often the children are born prematurely, with various malformations (cardiovascular, urinary reproductive, bone system, gastrointestinal tract, eyes and so on). In newborns, the disease occurs with jaundice, anemia, and gepato-Lanolinum, hemorrhagic syndrome, has similarities with hemolytic disease of the newborn (on the ground of incompatibility between the blood of the mother and child) or hepatitis of different etiology.
Jaundice is usually found from the first days of life; it is associated with damage to the epithelium of the biliary tract, liver cells, red blood clots, increased hemolysis of erythrocytes. The intensity and duration of jaundice if cytomegaly different; it lasts 4-5 weeks to 2-3 months, reminding sometimes protracted physiological jaundice.
In the course of the disease is possible period of improvement and deterioration. Feces are usually yellow or slightly discolored. Urine yellow, less saturated; bile pigments and urobilin determined not always. In blood serum bilirubin increased, usually straight. In severe cases cytomegalic hepatitis transaminase levels and aldolase significantly increased. Hepatitis when cytomegaly may develop in utero, then at the birth of the child reported symptoms of congenital biliary atresia. Some newborn jaundice is poorly expressed, but there is a marked anemia with enlargement of the spleen, often with hemorrhagic syndrome. Blood erythroblasts, reticulocytosis and trombopenia.
In infants and children, mostly first year of life may be cytomegalie productive meningoencephalitis, accompanied by repeated seizures. Some children at birth is celebrated microcephaly or rapidly developing hydrocephalus, on the x-ray of the skull sometimes reveal the calcifications. From the cerebrospinal fluid is excreted virus cytomegaly. In the future, for these children, there is a significant retardation or mental retardation. Brain damage in newborn infants during the first days of life gives similar clinical picture with intracranial hemorrhage; the latter sometimes is really the place along with cytomegalie encephalitis, acute or subacute form of toxoplasmosis. In rare cases, when cytomegaly there is damage to the eyes (horioretinit, cataract, optic neuritis, malformations of the eye).
In children older than one month cytomegalovirus more often manifested in the form of interstitial pneumonia, bronchitis and peribronchial. The patients cough, shortness of breath and cyanosis different degrees. Cough in some cases begins with the first weeks of life, beginning dry, weak, further increases, becomes obsessive, sometimes coloradony. In the lungs dry and moist rales not always heard. Pneumonia when cytomegaly can be acute, subacute and with recurrences. In connection with the accession of bacterial infection are observed focal or abstemious pneumonia, acute pleurisy, pyopneumothorax, sepsis. According to some authors, cytomegalie pneumonia often combined with Pneumocystis and with cystic fibrosis. Cytomegalovirus it is combined with other infections (whooping cough, chicken pox, measles and other).
When cytomegaly often observed renal disease (focal or diffuse interstitial nephritis), clinical manifestations which often are absent or are very few. In the urine, there are traces of protein, isolated hyaline cylinders and leukocytes. In rare cases there is hematuria. In patients with cytomegalovirus, having a malformation of the urinary tract, often associated bacterial infection, marked leukocyturia, cylindruria, erythrocyturia and symptoms of renal failure.
In children older than 5 months, sometimes early (premature), there are acute lesions of the gastrointestinal tract - catarrhal or ulcerative colitis, duodenitis. In infants sometimes appears frequent loose bowel movements with the rapid development of toxemia ending lethal. Contain the combination cytomegaly with Escherichia coli infection.
When cytomegaly often suffers from the pancreas. In the clinic it is the development of malnutrition and low maintenance of enzymes in duodenal juice (lipase, diastase, trypsin). From the endocrine glands affects the pituitary gland, adrenal gland, thyroid, parathyroid, the thymus gland, ovary and testicles.
When cytomegaly in children may be congenital heart diseases and large vessels, skin angioma, rarely, acute myocarditis, fibroblasts the endocardium.
In infants in very rare cases, the skin in the form of coarse lamellar peeling, long-existing diaper rash or unhealed ulcer.
The diagnosis. Cytomegalic inclusion disease in children may be suspected when prematurity, birth defects, prolonged jaundice in newborns, skin hemorrhages with trombopenia, anemia, hepato-lenalina syndrome, recurrent convulsions, persistent cough, long-current pneumonia, bad increasing weight and other Clinical diagnosis should be confirmed virologically (sowing on tissue culture) or cytologically. Specific cytomegalic cells are found in punctate bodies or in the sediments of saliva, urine, CSF, gastric contents. In the serum of patients older than 5 months can be found complementative and neutralizing antibodies.
Forecast earlier considered absolutely unfavorable. Currently diagnosed mild forms, virologically proven, with a favorable outcome. Follow-up inspection of recovered children showed that most of them physically and mentally develops normally; in some children, who had a nervous symptoms after birth, there is a physical and mental retardation.
In a localized form cytomegaly hard proceed affiliate of the disease. When layering infection (viral or bacterial), if surgery can quickly be a generalization cytomegaly with the development of toxemia. When viremia affects the blood vessels, blood circulation is disturbed in various organs; diseases sometimes quickly ends lethally.
Generalized forms cytomegaly can be a major cause of death. The death of children often occurs from pneumonia with symptoms of toxicosis, entsefalicheskogo (convulsions), hyperthermic syndrome, sometimes syndrome Waterhouse - Friderichsen, due to the destruction of the adrenal glands (necrosis, hemorrhage), cardiac or renal insufficiency or severe bleeding in the authorities.
Treatment. Specific treatment is not. Used steroids (prednisone) within 10-30 days (0.8 - 1 mg/kg of body weight per day), the reintroduction of gamma globulin (3 ml in two days intramuscularly), intravenous - plasma, blood. To suppress the secondary infection in the acute period used antibiotics and symptomatic therapy.