Z Geburtshilfe Neonatol 2020; 224(02): 71-78
DOI: 10.1055/a-0966-9915
Übersicht
© Georg Thieme Verlag KG Stuttgart · New York

Therapeutische Optionen bei konnataler Zytomegalievirus (CMV)-Infektion – Implikationen für die Einführung eines Screeningprogramms

Therapy Options for Infants with Congenital Cytomegalovirus Infection – Implications for Setting Up Neonatal Screening Programs
Christoph Bührer
1   Klinik für Neonatologie, Charité – Universitätsmedizin Berlin, Berlin
,
Oliver Blankenstein*
2   Neugeborenen-Screeninglabor Berlin-Brandenburg, Charité – Universitätsmedizin, Berlin
,
Rainer Rossi*
3   Kinder- und Jugendmedizin – Perinatalzentrum, Vivantes Klinikum Neukölln, Berlin
,
für die Screeningkommission der Deutschen Gesellschaft für Kinder- und Jugendmedizin (Mitglieder am Ende des Artikels) › Institutsangaben
Weitere Informationen

Publikationsverlauf

eingereicht 23. April 2019

angenommen nach Überarbeitung 24. Juni 2019

Publikationsdatum:
19. August 2019 (online)

Zusammenfassung

Einleitung Seit der bundesweiten Einführung des Neugeborenen-Screenings auf Phenylketonurie (1968) ist die Liste der Zielkrankheiten in Deutschland stetig auf mittlerweile 17 (mit Hörminderung und Hüftgelenksdysplasie) angewachsen (2018). Das Beispiel des fehlgeschlagenen Neuroblastom-Screenings hat gezeigt, wie durch Therapie von Erkrankungen, die nur durch ein Screening entdeckt werden, Kinder zu Schaden kommen können. Für das versuchsweise in verschiedenen Regionen eingeführte Screening auf konnatale Zytomegalievirus (CMV)-Infektionen ist derzeit ungeklärt, ob und wie ein auf diese Weise identifiziertes Kind behandelt werden soll.

Methodik Selektive Suche nach Therapiestudien in PubMed und der Internationalen Plattform Klinischer Studienregister (ICTRP) der Weltgesundheitsorganisation (WHO).

Ergebnisse Bisher liegen lediglich Ergebnisse einer einzigen randomisierten Studie mit einer nicht behandelten Kontrollgruppe vor (Intervention: Ganciclovir über 6 Wochen intravenös). In diese waren nur Kinder mit symptomatischer CMV-Infektion eingeschlossen. Die Intervention war mit einer signifikanten Reduktion neu auftretender Hörminderungen assoziiert. Leichte Vorteile einer 6-monatigen gegenüber einer 6-wöchigen Therapie mit der oral applizierbaren Ganciclovir-Vorstufe Valganciclovir zeigten sich bezüglich der neurologischen Entwicklung in einer zweiten, ebenfalls auf Kinder mit symptomatischer CMV-Infektion beschränkten randomisierten Studie. In einer Beobachtungsstudie von Kindern mit konnataler CMV-Infektion und isolierter Hörstörung, die über 12 Monate mit Valganciclovir behandelt wurden, wiesen 2/3 eine Verbesserung des Hörens auf (mediane Nachbeobachtungszeit 4½ Jahre).

Schlussfolgerung Aufgrund des fehlenden Wirksamkeitsnachweis wird die Behandlung von Neugeborenen mit oligosymptomatischer konnataler CMV-Infektion einschließlich einer isolierten Hörstörung kontrovers diskutiert. Eine generell akzeptierte Therapieempfehlung ist jedoch eine notwendige Voraussetzung für ein Screening auf konnatale CMV-Infektionen.

Abstract

Introduction The number of diseases covered by universal neonatal screening in Germany has risen steadily from 1 (phenylketonuria) in 1968 to 17 (with hearing impairment and congenital hip dysplasia) in 2018. Treatment, however, of disorders diagnosed by screening may harm children, as failed neuroblastoma screening has shown. There are several pilot studies to detect congenital cytomegalovirus (CMV) infection but no consensus as to the treatment of the infants identified.

Methodology Systematic search for studies investigating therapy of congenital CMV infection, using PubMed and the WHO International Clinical Trials Registry Platform (ICTRP).

Results We found only one controlled trial that randomized infants with symptomatic congenital CMV infection (involving the central nervous system) to treatment (intravenous ganciclovir for 6 weeks) or no treatment. Treatment was associated with significantly less hearing deterioration. A second trial comparing 6 weeks vs. 6 months of treatment with valganciclovir, an oral prodrug of ganciclovir, found no benefit for hearing but modestly improved developmental outcomes associated with 6 months of treatment. In contrast, an open-label registry reported benefits for infants with congenital CMV infection and isolated hearing who received valganciclovir for 12 months, with hearing improvement in 2/3 of cases after a median follow-up of 4½ years.

Conclusions Antiviral treatment of neonates with congenital CMV infection and few symptoms including isolated hearing loss remains controversial. A generally accepted therapy, however, is pivotal before introducing universal or targeted screening for congenital CMV infection.

* für die Screening-Kommission der Deutschen Gesellschaft für Kinder- und Jugendmedizin. Weitere Mitglieder der Screening- Kommission der Deutschen Gesellschaft für Kinder- und Jugendmedizin: Jutta Gärtner (Göttingen), Orsolya Genzel Boroviczeny (München), Uta Nennstiel (Oberschleißheim), Georg F. Hoffmann (Heidelberg), Burkhard Lawrenz (Arnsberg), Olaf Sommerburg (Heidelberg), Carsten Speckmann (Freiburg).


 
  • Literatur

  • 1 Lachmann R, Loenenbach A, Waterboer T. et al. Cytomegalovirus (CMV) seroprevalence in the adult population of Germany. PLoS One 2018; 13: e0200267 doi:10.1371/journal.pone.0200267
  • 2 Paradiž KR, Seme K, Puklavec E. et al. Prevalence of congenital cytomegalovirus infection in Slovenia: a study on 2,841 newborns. J Med Virol 2012; 84: 109-115 doi:10.1002/jmv.22230
  • 3 Olusanya BO, Slusher TM, Boppana SB. Prevalence of congenital cytomegalovirus infection in Nigeria: a pilot study. Pediatr Infect Dis J 2015; 34: 322-324 doi:10.1097/INF.0000000000000555
  • 4 Enders G, Daiminger A, Bader U. et al. Intrauterine transmission and clinical outcome of 248 pregnancies with primary cytomegalovirus infection in relation to gestational age. J Clin Virol 2011; 52: 244-246 doi:10.1016/j.jcv.2011.07.005
  • 5 Arora N, Novak Z, Fowler KB. et al. Cytomegalovirus viruria and DNAemia in healthy seropositive women. J Infect Dis 2010; 202: 1800-1803 doi:10.1086/657412
  • 6 Naessens A, Casteels A, Decatte L. et al. A serologic strategy for detecting neonates at risk for congenital cytomegalovirus infection. J Pediatr 2005; 146: 194-197 doi:10.1016/j.jpeds.2004.09.025
  • 7 de Vries JJ, van Zwet EW, Dekker FW. et al. The apparent paradox of maternal seropositivity as a risk factor for congenital cytomegalovirus infection: a population-based prediction model. Rev Med Virol 2013; 23: 241-249 doi:10.1002/rmv.1744
  • 8 Fink KR, Thapa MM, Ishak GE. et al. Neuroimaging of pediatric central nervous system cytomegalovirus infection. Radiographics 2010; 30: 1779-1796 doi:10.1148/rg.307105043
  • 9 Townsend CL, Peckham CS, Tookey PA. Surveillance of congenital cytomegalovirus in the UK and Ireland. Arch Dis Child Fetal Neonatal Ed 2011; 96: F398-F403 doi:10.1136/adc.2010.199901
  • 10 Goderis J, De Leenheer E, Smets K. et al. Hearing loss and congenital CMV infection: a systematic review. Pediatrics 2014; 134: 972-982 doi:10.1542/peds.2014-1173
  • 11 Yamaguchi A, Oh-Ishi T, Arai T. et al. Screening for seemingly healthy newborns with congenital cytomegalovirus infection by quantitative real-time polymerase chain reaction using newborn urine: an observational study. BMJ Open 2017; 7: e013810 doi:10.1136/bmjopen-2016-013810
  • 12 Karltorp E, Löfkvist U, Lewensohn-Fuchs I. et al. Impaired balance and neurodevelopmental disabilities among children with congenital cytomegalovirus infection. Acta Pædiatr 2014; 103: 1165-1173 doi:10.1111/apa.12745
  • 13 Lopez AS, Lanzieri TM, Claussen AH. et al. Intelligence and academic achievement with asymptomatic congenital cytomegalovirus infection. Pediatrics 2017; 140 doi:10.1542/peds.2017-1517
  • 14 Engman ML, Lewensohn-Fuchs I, Mosskin M. et al. Congenital cytomegalovirus infection: the impact of cerebral cortical malformations. Acta Pædiatr 2010; 99: 1344-1349 doi:10.1111/j.1651-2227.2010.01852.x
  • 15 Smithers-Sheedy H, Raynes-Greenow C, Badawi N. et al. Congenital cytomegalovirus among children with cerebral palsy. J Pediatr 2017; 181: 267-271 e261 doi:10.1016/j.jpeds.2016.10.024
  • 16 Avettand-Fenoël V, Marlin S, Vauloup-Fellous C. et al. Congenital cytomegalovirus is the second most frequent cause of bilateral hearing loss in young French children. J Pediatr 2013; 162: 593-599 doi:10.1016/j.jpeds.2012.08.009
  • 17 Bartlett AW, McMullan B, Rawlinson WD. et al. Hearing and neurodevelopmental outcomes for children with asymptomatic congenital cytomegalovirus infection: A systematic review. Rev Med Virol 2017; DOI: 10.1002/rmv.1938.
  • 18 Lanzieri TM, Chung W, Flores M. et al. Hearing loss in children with asymptomatic congenital cytomegalovirus infection. Pediatrics 2017; 139 doi:10.1542/peds.2016-2610
  • 19 Lanzieri TM, Chung W, Leung J. et al. Hearing trajectory in children with congenital cytomegalovirus infection. Otolaryngol Head Neck Surg 2018; 158: 736-744 doi:10.1177/0194599818758247
  • 20 Dreher AM, Arora N, Fowler KB. et al. Spectrum of disease and outcome in children with symptomatic congenital cytomegalovirus infection. J Pediatr 2014; 164: 855-859 doi:10.1016/j.jpeds.2013.12.007
  • 21 Williams EJ, Kadambari S, Berrington JE. et al. Feasibility and acceptability of targeted screening for congenital CMV-related hearing loss. Arch Dis Child Fetal Neonatal Ed 2014; 99: F230-F236 doi:10.1136/archdischild-2013-305276
  • 22 Kadambari S, Luck S, Davis A. et al. Evaluating the feasibility of integrating salivary testing for congenital CMV into the Newborn Hearing Screening Programme in the UK. Eur J Pediatr 2015; 174: 1117-1121 doi:10.1007/s00431-015-2506-8
  • 23 Kawada J, Torii Y, Kawano Y. et al. Viral load in children with congenital cytomegalovirus infection identified on newborn hearing screening. J Clin Virol 2015; 65: 41-45 doi:10.1016/j.jcv.2015.01.015
  • 24 Ari-Even Roth D, Lubin D, Kuint J. et al. Contribution of targeted saliva screening for congenital CMV-related hearing loss in newborns who fail hearing screening. Arch Dis Child Fetal Neonatal Ed 2017; 102: F519-F524 doi:10.1136/archdischild-2016-311859
  • 25 Vancor E, Shapiro ED, Loyal J. Results of a targeted screening program for congenital cytomegalovirus infection in infants who fail newborn hearing screening. J Pediatric Infect Dis Soc 2019; 8: 55-59 doi:10.1093/jpids/pix105
  • 26 Rawlinson WD, Palasanthiran P, Hall B. et al. Neonates with congenital Cytomegalovirus and hearing loss identified via the universal newborn hearing screening program. J Clin Virol 2018; 102: 110-115 doi:10.1016/j.jcv.2018.03.006
  • 27 Beswick R, David M, Higashi H. et al. Integration of congenital cytomegalovirus screening within a newborn hearing screening programme. J Paediatr Child Health 2019; DOI: 10.1111/jpc.14428.
  • 28 Boppana SB, Ross SA, Novak Z. et al. Dried blood spot real-time polymerase chain reaction assays to screen newborns for congenital cytomegalovirus infection. JAMA 2010; 303: 1375-1382 doi:10.1001/jama.2010.423
  • 29 Ross SA, Ahmed A, Palmer AL. et al. Newborn dried blood spot polymerase chain reaction to identify infants with congenital cytomegalovirus-associated sensorineural hearing loss. J Pediatr 2017; 184: 57-61 e51 doi:10.1016/j.jpeds.2017.01.047
  • 30 Vives-Oñós I, Codina-Grau MG, Noguera-Julian A. et al. Is polymerase chain reaction in neonatal dried blood spots reliable for the diagnosis of congenital cytomegalovirus infection?. Pediatr Infect Dis J 2018; DOI: 10.1097/INF.0000000000002144.
  • 31 Boppana SB, Ross SA, Shimamura M. et al. Saliva polymerase-chain-reaction assay for cytomegalovirus screening in newborns. N Engl J Med 2011; 364: 2111-2118 doi:10.1056/NEJMoa1006561
  • 32 Ross SA, Ahmed A, Palmer AL. et al. Detection of congenital cytomegalovirus infection by real-time polymerase chain reaction analysis of saliva or urine specimens. J Infect Dis 2014; 210: 1415-1418 doi:10.1093/infdis/jiu263
  • 33 Waters A, Jennings K, Fitzpatrick E. et al. Incidence of congenital cytomegalovirus infection in Ireland: implications for screening and diagnosis. J Clin Virol 2014; 59: 156-160 doi:10.1016/j.jcv.2013.12.007
  • 34 Fowler KB, Ross SA, Shimamura M. et al. Racial and ethnic differences in the prevalence of congenital cytomegalovirus infection. J Pediatr 2018; 200: 196-201 e191 doi:10.1016/j.jpeds.2018.04.043
  • 35 Barkai G, Ari-Even Roth D, Barzilai A. et al. Universal neonatal cytomegalovirus screening using saliva - report of clinical experience. J Clin Virol 2014; 60: 361-366 doi:10.1016/j.jcv.2014.04.024
  • 36 Nishida K, Morioka I, Nakamachi Y. et al. Neurological outcomes in symptomatic congenital cytomegalovirus-infected infants after introduction of newborn urine screening and antiviral treatment. Brain Dev 2016; 38: 209-216 doi:10.1016/j.braindev.2015.08.003
  • 37 Leruez-Ville M, Magny JF, Couderc S. et al. Risk factors for congenital cytomegalovirus infection following primary and nonprimary maternal infection: a prospective neonatal screening study using polymerase chain reaction in saliva. Clin Infect Dis 2017; 65: 398-404 doi:10.1093/cid/cix337
  • 38 Wilson MM. Jungner principles and practices of screening for disease. Geneva: World Health Organization. Public health papers; 1968. 34
  • 39 Kimberlin DW, Lin CY, Sanchez PJ. et al. Effect of ganciclovir therapy on hearing in symptomatic congenital cytomegalovirus disease involving the central nervous system: a randomized, controlled trial. J Pediatr 2003; 143: 16-25
  • 40 Kimberlin DW, Acosta EP, Sanchez PJ. et al. Pharmacokinetic and pharmacodynamic assessment of oral valganciclovir in the treatment of symptomatic congenital cytomegalovirus disease. J Infect Dis 2008; 197: 836-845 doi:10.1086/528376
  • 41 Oliver SE, Cloud GA, Sanchez PJ. et al. Neurodevelopmental outcomes following ganciclovir therapy in symptomatic congenital cytomegalovirus infections involving the central nervous system. J Clin Virol 2009; 46 (Suppl. 04) S22-S26 doi:10.1016/j.jcv.2009.08.012
  • 42 Kimberlin DW, Jester PM, Sanchez PJ. et al. Valganciclovir for symptomatic congenital cytomegalovirus disease. N Engl J Med 2015; 372: 933-943 doi:10.1056/NEJMoa1404599
  • 43 Schulzke S, Bührer C. Valganciclovir for treatment of congenital cytomegalovirus infection. Eur J Pediatr 2006; 165: 575-576 doi:10.1007/s00431-006-0109-0
  • 44 Acosta EP, Brundage RC, King JR. et al. Ganciclovir population pharmacokinetics in neonates following intravenous administration of ganciclovir and oral administration of a liquid valganciclovir formulation. Clin Pharmacol Ther 2007; 81: 867-872 doi:10.1038/sj.clpt.6100150
  • 45 Galli L, Novelli A, Chiappini E. et al. Valganciclovir for congenital CMV infection: a pilot study on plasma concentration in newborns and infants. Pediatr Infect Dis J 2007; 26: 451-453 doi:0.1097/01.inf.0000261111.90075.4d
  • 46 Ohyama S, Morioka I, Fukushima S. et al. Efficacy of valganciclovir treatment depends on the severity of hearing dysfunction in symptomatic infants with congenital cytomegalovirus infection. Int J Mol Sci 2019; 20 doi:10.3390/ijms20061388
  • 47 Lombardi G, Garofoli F, Villani P. et al. Oral valganciclovir treatment in newborns with symptomatic congenital cytomegalovirus infection. Eur J Clin Microbiol Infect Dis 2009; 28: 1465-1470 doi:10.1007/s10096-009-0806-5
  • 48 del Rosal T, Baquero-Artigao F, Blazquez D. et al. Treatment of symptomatic congenital cytomegalovirus infection beyond the neonatal period. J Clin Virol 2012; 55: 72-74 doi:10.1016/j.jcv.2012.06.001
  • 49 Mazzaferri F, Cordioli M, Conti M. et al. Symptomatic congenital Cytomegalovirus deafness: the impact of a six-week course of antiviral treatment on hearing improvement. Infez Med 2017; 25: 347-350
  • 50 McCrary H, Sheng X, Greene T. et al. Long-term hearing outcomes of children with symptomatic congenital CMV treated with valganciclovir. Int J Pediatr Otorhinolaryngol 2019; 118: 124-127 doi:10.1016/j.ijporl.2018.12.027
  • 51 Ziv L, Yacobovich J, Pardo J. et al. Hematologic adverse events associated with prolonged valganciclovir treatment in congenital cytomegalovirus infection. Pediatr Infect Dis J 2019; 38: 127-130 doi:10.1097/INF.0000000000002079
  • 52 Pasternak Y, Ziv L, Attias J. et al. Valganciclovir is beneficial in children with congenital cytomegalovirus and isolated hearing loss. J Pediatr 2018; 199: 166-170 doi:10.1016/j.jpeds.2018.02.028
  • 53 Amir J, Attias J, Pardo J. Treatment of late-onset hearing loss in infants with congenital cytomegalovirus infection. Clin Pediatr (Phila) 2014; 53: 444-448 doi:10.1177/0009922813510204
  • 54 Kampmann SE, Schindele B, Apelt L. et al. Pyrosequencing allows the detection of emergent ganciclovir resistance mutations after HCMV infection. Med Microbiol Immunol 2011; 200: 109-113 doi:10.1007/s00430-010-0181-y
  • 55 Campanini G, Zavattoni M, Cristina E. et al. Multiple ganciclovir-resistant strains in a newborn with symptomatic congenital human cytomegalovirus infection. J Clin Virol 2012; 54: 86-88 doi:10.1016/j.jcv.2012.01.020
  • 56 Choi KY, Sharon B, Balfour Jr. HH. et al. Emergence of antiviral resistance during oral valganciclovir treatment of an infant with congenital cytomegalovirus (CMV) infection. J Clin Virol 2013; 57: 356-360 doi:10.1016/j.jcv.2013.04.004
  • 57 Morillo-Gutierrez B, Waugh S, Pickering A. et al. Emerging (val)ganciclovir resistance during treatment of congenital CMV infection: a case report and review of the literature. BMC Pediatr 2017; 17: 181 doi:10.1186/s12887-017-0933-6
  • 58 Balasubramanian H, Thompson K, Blyth C. et al. Failure of oral valganciclovir treatment in congenital cytomegalovirus hepatitis in a neonate. Clin Pediatr (Phila) 2017; 56: 83-84 doi:10.1177/0009922816642741
  • 59 El-Sayed MF, Goldfarb DM, Fulford M. et al. Severe late-onset multisystem cytomegalovirus infection in a premature neonate previously treated for congenital infection. BMC Pediatr 2013; 13: 142 doi:10.1186/1471-2431-13-142
  • 60 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 2017; 17: e177-e188 doi:10.1016/S1473-3099(17)30143-3
  • 61 Luck SE, Wieringa JW, Blazquez-Gamero D. et al. Congenital cytomegalovirus: a European expert consensus statement on diagnosis and management. Pediatr Infect Dis J 2017; 36: 1205-1213 doi:10.1097/INF.0000000000001763
  • 62 Witzke O, Nitschke M, Bartels M. et al. Valganciclovir prophylaxis versus preemptive therapy in cytomegalovirus-positive renal allograft recipients: long-term results after 7 years of a randomized clinical trial. Transplantation 2018; 102: 876-882 doi:10.1097/TP.0000000000002024
  • 63 Woods WG, Gao RN, Shuster JJ. et al. Screening of infants and mortality due to neuroblastoma. N Engl J Med 2002; 346: 1041-1046 doi:10.1056/NEJMoa012387
  • 64 Schilling FH, Spix C, Berthold F. et al. Neuroblastoma screening at one year of age. N Engl J Med 2002; 346: 1047-1053 doi:10.1056/NEJMoa012277
  • 65 Tsubono Y, Hisamichi S. A halt to neuroblastoma screening in Japan. N Engl J Med 2004; 350: 2010-2011 doi:10.1056/NEJM200405063501922