Congenital CMV Infection

Clinical Presentation

• Often asymptomatic (90%) but accounts for most SNHL (sensorineural hearing loss)
• Symptomatic presents with: IUGR/SGA, microcephaly, petechiae/purpura ('blueberry muffin'), hepatosplenomegaly
• Jaundice, chorioretinitis, hypotonia, and seizures may also be present

Diagnostic Workup

• Saliva or Urine CMV PCR within the FIRST 21 DAYS of life (gold standard, avoids confusing acquired vs congenital)
• Comprehensive eye exam by pediatric ophthalmologist
• ABR (Auditory Brainstem Response) test to evaluate for SNHL
• Head ultrasound or MRI (classic finding: periventricular calcifications, ventriculomegaly)
• Labs: CBC (thrombocytopenia), Liver panel (elevated transaminases, direct hyperbilirubinemia)

Management Strategy

• Antiviral therapy (Oral Valganciclovir or IV Ganciclovir) recommended for 6 months ONLY for symptomatically infected neonates involving CNS or multiple organs
• Monitor absolute neutrophil count strictly while on antivirals (myelosuppression risk)
• Ongoing outpatient audiology monitoring (SNHL can be progressive/late-onset)
• Infectious disease and Neurology consultations

Infection Control & Pharmacokinetics

• Ampicillin dosing (<7 days, >2kg): 100 mg/kg/dose IV q8h for meningitis coverage; 50mg/kg/dose q12h for bacteremia.
• Gentamicin dosing: 4-5 mg/kg/dose IV q24h; MUST check trough levels prior to 3rd dose (Target trough < 1.0 mcg/mL).
• Strict contact and droplet precautions until specific viral/bacterial pathogen is ruled out.
• Assess for osteomyelitis/septic arthritis with thorough physical exam including joint mobility and symmetry.
• LP execution: Defer lumbar puncture ONLY if infant is hemodynamically unstable or profoundly thrombocytopenic.

Standardized Discharge & Follow-Up Criteria

• Adequate weight gain explicitly > 15-30g/day over a continuous 3-5 day period.
• Maintenance of temperature in an open crib with standard clothing for 48 hours.
• Successful completion of the 90-120 minute Infant Car Seat Challenge.
• Caregiver successfully completed CPR training, rooming-in, and independent medication administration.
• Referrals placed for High-Risk Infant Follow-Up Clinic, Early Intervention (PT/OT), and appropriate sub-specialists.

Diagnostic & Management Algorithm

• cCMV Evaluation: [START] Microcephaly + Periventricular calcifications -> [ACTION] Saliva/Urine CMV PCR -> [DECISION] Positive? -> [YES] Valganciclovir for 6 months -> [MONITOR] Serial Audiology

References

1. Kimberlin DW, Jester PM, Sanchez PJ, et al. Valganciclovir for symptomatic congenital cytomegalovirus disease. N Engl J Med.
2. Rawlinson WD, Boppana SB, Fowler KB, et al. Congenital cytomegalovirus infection in pregnancy and the neonate: consensus recommendations for prevention, diagnosis, and therapy. Lancet Infect Dis.