1 00:00:13,460 --> 00:00:18,360 Sara Dong: Hi everyone, welcome to Febrile- a cultured podcast about all things infectious disease. 2 00:00:18,700 --> 00:00:23,720 We use consult questions to dive into ID clinical reasoning, diagnostics and antimicrobial management. 3 00:00:24,140 --> 00:00:25,560 I'm your host, Sara Dong. 4 00:00:25,900 --> 00:00:27,680 I'm an adult and pediatric ID fellow. 5 00:00:27,909 --> 00:00:32,519 Here on Febrile, we use patient cases and consult questions to learn about high yield ID topics. 6 00:00:32,610 --> 00:00:37,400 We'll present pieces of the story of a patient's case, and then pause along the way to hear from our guest consultant. 7 00:00:37,850 --> 00:00:43,460 This is our first case in the newest Febrile series entitled "Curious Congenital Conundrums.". 8 00:00:43,520 --> 00:00:50,780 You can check out our introduction episode in last week's Febrile Digest with Justin Penner, but today I am joined by Nuria and Hermione. 9 00:00:50,880 --> 00:00:52,220 Now I'll give him a quick introduction. 10 00:00:52,480 --> 00:00:53,820 Our co-host today is Dr. 11 00:00:53,820 --> 00:00:55,640 Nuria Sanchez-Clemente. 12 00:00:55,780 --> 00:01:03,240 She is a pediatric registrar and National Institute for Health Research (NIHR) Academic Clinical Lecturer in pediatric infection and immunity at St. 13 00:01:03,240 --> 00:01:04,519 George's University in London. 14 00:01:04,900 --> 00:01:13,249 She completed a MSc in Tropical Medicine at the London School of Hygiene and Tropical Medicine and undertook the first systematic review of Peruvian bartonellosis. 15 00:01:13,340 --> 00:01:22,440 She also has previously lived in Brazil where she did her PhD on congenital Zika syndrome, studying the perinatal outcomes of Zika pregnancy cohort in a state of Sao Paulo. 16 00:01:22,540 --> 00:01:32,455 And since then she has continued to work with teams in Brazil, the London School of Hygiene and Tropical Medicine, and WHO to study the long term consequences for children born with congenital Zika. 17 00:01:32,515 --> 00:01:36,815 In addition to all of this, she has more recently been focused on migrant health and health inequalities. 18 00:01:36,945 --> 00:01:51,525 She's been studying patterns of pediatric primary and secondary healthcare usage between migrants and non migrants in the UK, and has also been working on the "Respond" refugee family project at University College London Hospitals, leading ID clinics for unaccompanied asylum seeking children. 19 00:01:51,990 --> 00:01:54,009 Our guest discussant today is Dr. 20 00:01:54,009 --> 00:01:55,050 Hermione Lyall. 21 00:01:55,190 --> 00:02:02,289 She is a consultant in pediatric ID at the Imperial College Healthcare NHS Trust and a Professor of Practice at Imperial College. 22 00:02:02,830 --> 00:02:11,290 She runs both HIV and congenital infection clinics at St Mary's hospital in London, and is ward attending consultant for pediatric infectious diseases four months per year. 23 00:02:11,870 --> 00:02:19,490 She is a member of Penta ID or Pediatric European Network for Treatment of Aids, and participates in HIV treatment trials for children. 24 00:02:19,750 --> 00:02:31,300 She has been actively involved in development of international courses for education of pediatric infections for many years, working with Penta and the European Society for Pediatric ID or ESPID. 25 00:02:31,320 --> 00:02:38,145 From 2018 to 2021, she was a member of the board of ESPID and is now a trustee on the board for the ESPID foundation. 26 00:02:38,365 --> 00:02:48,265 In 2020, with colleagues from around Europe, she set up CCMVNet, an international network built around registry of children with congenital CMV, and she's currently the chair of the network. 27 00:02:48,615 --> 00:02:49,705 Welcome to the show! 28 00:02:50,900 --> 00:02:51,490 Nuria Sanchez-Clemente: Thank you. 29 00:02:51,870 --> 00:02:55,170 Sara Dong: Before we jump into the case, we always ask one non-medical question. 30 00:02:55,910 --> 00:03:03,010 Um, if you would be willing to share a little piece of culture that you enjoyed recently, such as a book or a song or anything that you like. 31 00:03:03,360 --> 00:03:04,350 What do you think, Hermione? 32 00:03:04,880 --> 00:03:24,350 Hermione Lyall: Well, I recently read the latest book by Anthony Doerr called Cloud Cuckoo Land and if you want to read an amazing book that has everything about humanity in it, uh, in the past, the present and the future, go there. 33 00:03:24,690 --> 00:03:24,970 Sara Dong: Excellent. 34 00:03:24,980 --> 00:03:26,530 Thank you so much for sharing. 35 00:03:27,350 --> 00:03:30,010 Uh, alright, well, I'll hand it over to Neuria to get us started. 36 00:03:30,830 --> 00:03:31,120 Nuria Sanchez-Clemente: Okay. 37 00:03:31,140 --> 00:03:42,280 So Hermione, it's a Friday afternoon and you are called by your pediatric colleague from a local district general hospital with a patient conundrum that they would like your advice about. 38 00:03:43,299 --> 00:03:52,829 So the patient was referred to the local pediatric infectious diseases multidisciplinary meeting by the obstetrics team at 14 weeks gestation. 39 00:03:53,649 --> 00:04:05,149 The patient is a 29 year old G2P1 previously healthy woman, whom was initially referred to the obstetrics team two weeks earlier with a rash and low grade fever. 40 00:04:06,329 --> 00:04:09,939 The rash was described as macular, blanching and non-pruritic. 41 00:04:10,649 --> 00:04:16,029 She had a mild cough, pharyngitis, rhinorrhea, and a temperature of 38.2 Celsius. 42 00:04:16,904 --> 00:04:24,405 The patient felt otherwise well, had unremarkable antenatal course so far with routine antenatal care with her GP. 43 00:04:24,405 --> 00:04:29,405 She had a previously uneventful pregnancy carried to term three years previously. 44 00:04:29,980 --> 00:04:32,319 She has no significant past medical history. 45 00:04:33,329 --> 00:04:43,439 After completing 18 months of maternity leave that time, she went back to work as an early childhood educator almost a year ago where she continues to work now. 46 00:04:44,340 --> 00:04:46,760 She doesn't take any medication and has no allergies. 47 00:04:47,740 --> 00:05:04,280 As part of the obstetric evaluation, basic bloods were taken including an FBC, CRP, liver enzymes, electrolytes, blood culture, and serology for EBV, CMV, Toxoplasma, parvovirus, rubella and syphilis. 48 00:05:05,060 --> 00:05:10,480 She recovered well from her illness within seven days, and her bloods have now returned with the following results. 49 00:05:11,140 --> 00:05:15,650 Her EBV is IgM negative, but IgG positive. 50 00:05:16,750 --> 00:05:20,370 Her CMV is IgM positive and IgG negative. 51 00:05:21,230 --> 00:05:24,370 Toxoplasma IgM negative and IgG negative. 52 00:05:25,159 --> 00:05:31,530 Parvovirus IgM and IgG negative, and Rubella IgM negative, but IgG positive. 53 00:05:32,630 --> 00:05:36,309 Syphilis wise, TPPA was negative and RPR as well. 54 00:05:37,210 --> 00:05:46,590 Her Hb is 122, platelets 298, white cell count of 12.7, monocytes of 1.5, eosinophils 0.4. 55 00:05:47,210 --> 00:05:50,230 Her CRP is 29 and her electrolytes are normal. 56 00:05:50,890 --> 00:05:54,419 Her ALT is 47 and her blood culture is negative. 57 00:05:56,000 --> 00:05:57,340 So Dr. 58 00:05:57,340 --> 00:06:07,059 Lyall, are there any additional questions that you have in the history that you would like to clarify with your colleagues and are there any important clues in the history already provided? 59 00:06:07,890 --> 00:06:33,110 Hermione Lyall: Okay, so I think there are some interesting things going on here and this lady is currently 14 weeks, became unwell when she was 12 weeks, has got an IgM positive in her serology to CMV and all the other serologies and blood tests are not really telling anything that we would be worried about. 60 00:06:33,690 --> 00:06:39,780 But I think we would be concerned that she's IgM positive to CMV and IgG negative. 61 00:06:41,260 --> 00:06:48,930 So, I guess, what would be interesting to know is has she had any scan yet? 62 00:06:49,150 --> 00:06:55,930 So do we know for sure, uh, about her, the timing of her pregnancy, is she definitely at 14 weeks? 63 00:06:56,510 --> 00:06:58,010 So is that being confirmed? 64 00:06:58,710 --> 00:07:14,600 And I think the other thing we kind of want to know is that, has she had any booking bloods done, so has had any antenatal basic serology, um, and was that done a month ago or six weeks ago? 65 00:07:15,220 --> 00:07:22,230 I'm going to say in this country, in the UK, we don't do antenatal screening for CMV. 66 00:07:22,730 --> 00:07:28,630 In the UK, we only do antenatal screening for HIV, hepatitis B and syphilis. 67 00:07:29,460 --> 00:07:46,970 In some countries, they do do screening at baseline for CMV, but if there is a blood that has already been taken on this lady a few weeks earlier, it would be very useful to know whether she had any CMV antibodies on that earlier sample. 68 00:07:47,865 --> 00:07:52,215 Especially if it was a few weeks, uh, if it was before she became unwell. 69 00:07:53,395 --> 00:08:03,244 Many people when they get, uh, prior CMV actually have no symptoms at all, and the symptoms that she's got could be anything. 70 00:08:03,304 --> 00:08:04,405 It could be any virus. 71 00:08:04,744 --> 00:08:13,100 And sometimes you can get cross reactive IgMs in pregnancy that don't mean anything very much. 72 00:08:13,600 --> 00:08:17,060 So I think we have to try and see if we can get some morphology. 73 00:08:17,880 --> 00:08:25,820 Uh, we might also want to get some virology, see if she's actually got CMV viremia or got CMV in the urine. 74 00:08:26,360 --> 00:08:33,450 And that might help us to clarify a bit more closely, whether we think she is having a primary CMV infection. 75 00:08:34,630 --> 00:08:36,850 The other thing, which is in the history here. 76 00:08:37,120 --> 00:08:52,610 Well, there are two things, which are a concern, is that we know that women who are having their second baby, if they are seronegative, they're probably the ones who are most at risk of seroconverting. 77 00:08:52,950 --> 00:08:56,960 Uh, there's some very nice French studies that have demonstrated that. 78 00:08:57,580 --> 00:09:18,420 Uh, and we also know that women who work in childcare, so with young children and are exposed to lot, lots of snotty, grubby toddlers, are also more at risk of getting CMV from snot and saliva and urine and toys and all the rest of it. 79 00:09:18,760 --> 00:09:27,290 So this lady CMV have some risks that we would be worried, uh, about for getting primary CMV if she hasn't had it before. 80 00:09:28,110 --> 00:09:28,680 Nuria Sanchez-Clemente: Okay, brilliant. 81 00:09:29,820 --> 00:09:37,050 So I think that covers a lot of additional tests, a lot of what we, the tests that have already been done as well. 82 00:09:37,590 --> 00:09:50,325 So I think we will fast forward to 12, another 12 days, and you get another call, uh, from your colleagues with some of the results of the, the tests that you have mentioned. 83 00:09:51,385 --> 00:09:53,205 HIV serology is negative. 84 00:09:54,145 --> 00:09:59,255 Hep B surface antigen is negative, core antibody negative, and, surface antibodies positive. 85 00:10:00,395 --> 00:10:01,655 Hep C serology is negative. 86 00:10:03,005 --> 00:10:11,795 The repeat CMV serology, um, is IgM positive, and IgG is now positive as well with a low validity of 10%. 87 00:10:12,735 --> 00:10:16,665 Initial booking bloods from the current pregnancy have been requested. 88 00:10:17,275 --> 00:10:23,115 At this time at booking, mom was IgM, CMV IgM negative, and IgG negative. 89 00:10:24,145 --> 00:10:30,465 Current CMV urine is PCR positive and blood PCR is positive as well. 90 00:10:31,340 --> 00:10:39,310 Also of note, so the ultrasound showed normal single fetus, appropriate size for dates, no abnormalities noted. 91 00:10:40,250 --> 00:10:44,990 Um, and also amniocentesis was offered, but the family declined. 92 00:10:45,890 --> 00:10:50,650 So what management advice would you give to your colleagues at this stage? 93 00:10:51,520 --> 00:10:51,810 Hermione Lyall: Okay. 94 00:10:52,150 --> 00:11:09,400 So I think it's pretty clear then that this mom has had a primary seroconversion for CMV infection in the first trimester of pregnancy, because we see here that she's still IgM positive. 95 00:11:10,010 --> 00:11:23,175 She's now beginning to produce IgG and that IgG is of low avidity, which tells us that it is new IgG, and that goes along with recent seroconversion. 96 00:11:23,655 --> 00:11:30,275 And that is kind of confirmed by the fact, uh, that her very first booking blood was completely negative. 97 00:11:30,775 --> 00:11:33,795 We don't know how many weeks that was actually done. 98 00:11:34,455 --> 00:11:40,545 Uh, but she has got, she is, she is viremic and she's got, uh, CMV in the urine. 99 00:11:42,415 --> 00:11:53,915 So I think, um, this is obviously a worrying situation because if we look at seroconversion, uh, to CMV in pregnancy. 100 00:11:54,895 --> 00:12:03,865 If you have primary seroconversion, overall, there is about a 30 to 40% risk of transmission to the fetus. 101 00:12:04,745 --> 00:12:08,645 The risk actually increases as pregnancy progresses. 102 00:12:09,385 --> 00:12:13,765 So it's higher in the third trimester and lower in the first trimester. 103 00:12:14,065 --> 00:12:19,245 So it's about 20 to 30% if you're just talking about the first trimester. 104 00:12:19,905 --> 00:12:31,075 But the danger is that we know that first trimester infection, primary infection, is associated with the highest risk of damage to the fetus. 105 00:12:31,945 --> 00:12:56,355 And there is a, uh, a very good study that has been undertaken by our French colleagues, uh, Marianne Leruez-Ville and Madam Faure-Bardon which was done in the kind of 2010, 11 to 17, I think, where they followed up more than two high hundred and 50 women who had primary infection, uh, in pregnancy. 106 00:12:57,055 --> 00:13:00,115 And they followed their babies up to 24 months of age. 107 00:13:01,160 --> 00:13:10,780 And overall about 16% of those babies had significant sequelae including neurological and sensory neural healing loss. 108 00:13:11,480 --> 00:13:17,460 And those babies were more or less all born in, were all infected in the first trimester. 109 00:13:18,480 --> 00:13:22,690 So it is highest risk and the highest risk of damage. 110 00:13:23,750 --> 00:13:26,050 So is there anything that we can do about it? 111 00:13:26,870 --> 00:13:48,955 And I think there's a key that is beginning to unlock something here because, uh, in the Lancet in 2020, our colleagues from Israel published, uh, a randomized control trial of treating women who sero convert in the first trimester with high dose valcyclovir. 112 00:13:49,925 --> 00:13:59,455 This is a placebo control randomized trial where they looked for evidence of seroconversion, uh, before 16 weeks. 113 00:14:01,065 --> 00:14:07,655 And, uh, if women were had evidence of seroconversion, then they started them on high dose valacyclovir. 114 00:14:08,265 --> 00:14:16,885 And overall the risk of transmission to the fetus was reduced by about 63% in the treated women. 115 00:14:17,665 --> 00:14:29,675 And if they separated out between periconceptual infection and actually first trimester infection, it was more like 77% for the women where it was first trimester infection. 116 00:14:30,615 --> 00:14:45,595 And the crucial thing really was the time it took to get started on the valacyclovir in relation to the timing of seroconversion and the shorter that was, the better the risk, the better the chance of the fetus not being infected. 117 00:14:46,775 --> 00:14:50,670 So our mother was definitely seronegative at the beginning. 118 00:14:50,690 --> 00:14:53,420 So I think she's probably not a periconceptual. 119 00:14:53,690 --> 00:15:02,150 So I think we could definitely offer this woman the possibility of going on high dose valacyclovir to reduce the risk of transmission. 120 00:15:02,690 --> 00:15:10,730 And if she was living in Israel or in Northern Italy or in Paris, then she would definitely be offered this kind of treatment. 121 00:15:11,325 --> 00:15:19,425 If she was living in Germany, uh, she might be offered the possibility of, um, CMV hyperimmune globulin. 122 00:15:20,005 --> 00:15:32,935 Uh, there are some randomized controlled trials of using this treatment, which have not been particularly effective, but that is probably because the dosing was not adequate and it isn't given frequently enough. 123 00:15:33,395 --> 00:15:42,975 And there is some data from Germany where if you give, uh, high dose treatment frequently early on, you can probably reduce the transmission. 124 00:15:43,435 --> 00:15:51,935 But this is obviously a very expensive and very interventional treatment that isn't going to be applicable in most parts of the world. 125 00:15:52,565 --> 00:15:59,665 Whereas high dose valacyclovir is, uh, although it's quite an undertaking because it's eight grams. 126 00:16:00,045 --> 00:16:02,105 So it's two pills, four times a day. 127 00:16:02,645 --> 00:16:09,375 Uh, and as long as women know, they have to remain well hydrated, it's actually relatively well tolerated. 128 00:16:09,835 --> 00:16:13,415 And in terms of teratogenicity we know that it is safe. 129 00:16:15,305 --> 00:16:21,565 So I, I would definitely be saying to this mom, it would be a good idea to be on treatment. 130 00:16:22,105 --> 00:16:32,325 Now in the valacyclovir study, the women only took the treatment up until 21 weeks gestation, uh, and then they stopped then. 131 00:16:32,905 --> 00:16:41,075 And in that study they had an amniocentesis and, uh, although the primary endpoint was actually transmission at birth. 132 00:16:41,695 --> 00:16:54,215 So I think it's important to say that that, uh, period of trying to prevent transmission is just during the actual, uh, initial viremia in that early phase. 133 00:16:54,595 --> 00:16:59,335 So the mother doesn't necessarily have to be on treatment all the way through the pregnancy. 134 00:17:00,165 --> 00:17:00,455 Nuria Sanchez-Clemente: Okay. 135 00:17:01,295 --> 00:17:01,495 Excellent. 136 00:17:02,745 --> 00:17:09,940 You get a call, however, several months later from the same colleagues, uh, for advice regarding the same patient. 137 00:17:10,480 --> 00:17:16,020 And they say that preventative treatment was offered, but unfortunately declined. 138 00:17:16,920 --> 00:17:23,380 So the patient delivered at 37 weeks of gestation with Apgars of eight and nine at one and five minutes. 139 00:17:23,800 --> 00:17:26,170 And no resuscitation was required at the time. 140 00:17:27,030 --> 00:17:31,680 And the weight of the female infant, uh, was on the sixth centile (%ile). 141 00:17:31,730 --> 00:17:33,850 And the head circumference on the fourth centile (%ile). 142 00:17:34,770 --> 00:17:37,140 The remainder of the neonatal exam is normal. 143 00:17:38,200 --> 00:17:52,570 They spent 24 hours in hospital initially, and mom is breastfeeding and the child has now been referred back to the infectious diseases team at 12 days of life, as she failed her newborn hearing screen. 144 00:17:53,480 --> 00:18:01,010 Repeated, auditory, brain stem responses demonstrated severe sensory neural hearing loss in the left ear. 145 00:18:01,990 --> 00:18:06,730 So now at this point, what additional tests would you recommend? 146 00:18:07,360 --> 00:18:26,810 Hermione Lyall: Okay, so I think, um, we are obviously concerned that this baby could actually, uh, be infected with CMV and it's a bit disappointing that the baby didn't actually have urine or saliva tested on the first day of life. 147 00:18:27,030 --> 00:18:37,130 If somebody had actually paid attention to the mother's antenatal history, they would know that we should have been testing this baby right at the very beginning to see if it had congenital CMV. 148 00:18:37,630 --> 00:18:41,320 So, uh, it's a real shame that they didn't do on day one. 149 00:18:42,360 --> 00:18:51,900 Um, so the fact that the baby has got confirmed sensorineural hearing loss in the left ear, uh, makes us worried that this baby is infected. 150 00:18:53,120 --> 00:19:05,740 Um, I mean, the baby is a little bit small, but it's not particularly out of proportion, but that doesn't mean to say that this baby hasn't got CNS effects of CMV. 151 00:19:06,200 --> 00:19:14,730 So I think we have to go through all the systems where we can get end organ disease and look for trouble that CMV might have caused. 152 00:19:15,390 --> 00:19:23,815 So my normal thing would be to send saliva, urine, and blood to look for the virus. 153 00:19:24,840 --> 00:19:33,580 Um, and I'm going to do everything, rather than just sending the saliva and waiting, because we're already on day 12. 154 00:19:34,440 --> 00:19:51,010 And if we're going to treat this baby, we want to have done all the investigations in time to get the treatments started a soon as possible, really, but ideally before a month of age, as was the case in the original, uh, Kimberlin study. 155 00:19:52,190 --> 00:19:55,930 So we want to send saliva, urine and blood for CMV. 156 00:19:56,430 --> 00:19:59,170 We want to look and see is the bone marrow affected. 157 00:19:59,230 --> 00:20:00,690 So what is the full blood count? 158 00:20:00,790 --> 00:20:03,930 Is this baby thrombocytopenic or neutropenic? 159 00:20:04,390 --> 00:20:06,180 We want to know about the liver. 160 00:20:06,530 --> 00:20:12,750 Does the baby have hepatitis, uh, or conjugated hyperbilirubinemia as we sometimes see. 161 00:20:13,470 --> 00:20:21,700 Uh, we want to get our ophthalmology colleagues to have a look in the back of the eyes, has the baby got any retinitis or any scarring. 162 00:20:22,280 --> 00:20:26,820 And then we want to look in the most important place, which is actually the brain. 163 00:20:27,800 --> 00:20:35,820 And, uh, what I would normally do, uh, is both a brain MRI and an ultrasound scan. 164 00:20:36,935 --> 00:20:46,715 The ultrasound scan is useful, particularly because it's good for showing calcification, but the MRI, uh, can show us much more. 165 00:20:47,255 --> 00:21:13,355 So the MRI can show us the classic signs that we're looking for, whether there are periventricular cysts, whether there's any increased intensity in the white matter, uh, and perhaps most worrying of all, whether there is polymicrogyria, which is the migration disorder, which is associated with early infection, uh, and the most serious consequences. 166 00:21:14,455 --> 00:21:29,795 And often with polymicrogyria, you may see what looked like slightly dilated ventricles, but this is more really about actually loss of brain tissue, uh, so that you have, and, and that is when you may have a smaller head as well. 167 00:21:30,925 --> 00:21:36,185 So I think we want to bring the baby in, uh, and do all of these things. 168 00:21:36,885 --> 00:21:43,225 Um, people would say, well, you know, what about getting out the Guthrie card and doing the dry blood spot testing? 169 00:21:44,005 --> 00:21:57,925 Um, I mean, I dunno what it's like, where you are, but where I work that is a complete palava uh, and it takes quite a lot, a long time, and we'll be lucky if we get the result back in two weeks, uh, which is gonna put a lot of delay. 170 00:21:58,385 --> 00:22:07,205 And it's important for everybody to know that the dry blood spot, uh, at best only has between 80 and 85% sensitivity. 171 00:22:07,665 --> 00:22:15,340 So a positive, dry blood spot is useful, but a negative dry blood spot does not exclude congenital CMV. 172 00:22:15,720 --> 00:22:24,020 So if I'm within the 21 days of doing the tests, then I'm going to send the urine, saliva and blood. 173 00:22:24,530 --> 00:22:26,910 Nuria Sanchez-Clemente: So they call you back with an update on the results. 174 00:22:27,250 --> 00:22:38,650 Um, so they, they did manage to get a newborn blood spot which was negative and saliva are PCR positive with more than 80,000 counts per mL. 175 00:22:39,530 --> 00:22:42,110 The blood PCR is indeterminant. 176 00:22:42,160 --> 00:22:52,645 There was an error in processing, um, and the MRI unfortunately shows polymicrogyria with, but with normal internal auditory meatus views. 177 00:22:53,665 --> 00:22:57,045 Uh, the ophthalmology exam is thankfully normal. 178 00:22:57,945 --> 00:23:03,805 The ALT is normal and the full blood count has also got normal platelets, HB and cell counts. 179 00:23:04,425 --> 00:23:07,285 So based on this, would you recommend treatment? 180 00:23:07,585 --> 00:23:10,595 And if so, how would you monitor for drug toxicity? 181 00:23:11,805 --> 00:23:21,205 Hermione Lyall: I definitely would recommend treatment for this baby because I know that it has been infected in the first trimester. 182 00:23:21,745 --> 00:23:28,485 And I know that it has polymicrogyria, which is, uh, a significant finding on the MRI scan. 183 00:23:30,095 --> 00:23:42,235 But actually, if you went back to the David Kimberlin randomization, uh, and you looked at this baby, uh, and in those early studies there weren't MRI scans done. 184 00:23:42,655 --> 00:23:46,955 Uh, so they didn't have the kind of vision into the brain that we have now. 185 00:23:48,060 --> 00:23:50,800 You might actually say that this, oh, no, you wouldn't. 186 00:23:50,870 --> 00:23:53,000 Well it's deaf in one year. 187 00:23:53,420 --> 00:24:00,920 So it's only got hearing loss in one year and in some countries that would still be considered to be asymptomatic. 188 00:24:01,620 --> 00:24:04,920 In other countries that would be considered to be symptomatic. 189 00:24:05,620 --> 00:24:21,905 Uh, but certainly I think, uh, we have in, in, in the UK, we have taken a relatively aggressive approach and for a baby who is deaf in one ear and has polymicrogyria, I would definitely, uh, advise treatment. 190 00:24:22,485 --> 00:24:37,695 And the other important thing to say is that we know, uh, from some of the earlier USA studies that babies who are deaf in one year have up to a 50% chance of progressive hearing loss in the other, their ear. 191 00:24:38,195 --> 00:24:42,015 So that is, to me, a really important reason for treatment. 192 00:24:43,055 --> 00:24:58,075 And although the David Kimberlin trial showed a relatively modest, uh, reduction in progression of hearing loss and improvement in neurodevelopmental outcomes at 24 months, it doesn't cure things. 193 00:24:58,695 --> 00:25:06,155 Um, and we still have to monitor these children carefully in terms of hearing, uh, and, and, and development. 194 00:25:07,175 --> 00:25:18,915 Um, so whilst, uh, the child's on treatment and we're talking about six months of oral valganciclovir 16 mg/kg/dose BID. 195 00:25:18,930 --> 00:25:21,710 Uh, valganciclovir is a drug with toxicity. 196 00:25:22,850 --> 00:25:35,070 Um, so it can have short term toxicities, including bone marrow suppression and abnormal liver function, and it can have potential long term toxicity too. 197 00:25:36,145 --> 00:25:41,335 Personally, I see these babies on a monthly basis when they're on treatment. 198 00:25:41,995 --> 00:25:51,075 Uh, and I check their blood count and their liver tests, and that enables me to make sure that they're tolerating the medication okay. 199 00:25:51,415 --> 00:25:57,115 But that also enables me to increase the dose on a monthly basis as they are growing bigger. 200 00:25:58,015 --> 00:26:18,365 I always inform the parents that, uh, valganciclovir is a drug, which has the potential to cause damage to DNA, and that has been shown in some animal studies, uh, and that might at some time increase the a risk of malignancy. 201 00:26:18,825 --> 00:26:25,715 However that hasn't been shown to date in any children who've been treated with congenital CMV. 202 00:26:26,215 --> 00:26:42,745 So it's a potential, but you know, when you put this in the balance, what we're trying to do here is give this baby the best outcome that we can, bearing in mind what has already happened to it, and it, if it was my baby, I would still, uh, go ahead and treat it. 203 00:26:44,525 --> 00:26:49,705 So, uh, yeah, I think that, you know, that's an important discussion to have with the parents. 204 00:26:50,005 --> 00:27:00,685 And it's also important to remember that, uh, valganciclovir is actually, uh, not licensed for treatment of newborns either. 205 00:27:00,905 --> 00:27:05,715 So it is, if you like, important that parents recognize that. 206 00:27:06,405 --> 00:27:14,945 Nuria Sanchez-Clemente: So far, the child has received three months of valganciclovir, um, and thankfully has tolerated the treatment very well without any side effects. 207 00:27:15,725 --> 00:27:24,625 Um, and so what, what other kind of followup would you recommend for this, for this child in terms of sort of the multidisciplinary team? 208 00:27:25,525 --> 00:27:30,175 Hermione Lyall: This baby is going to be at risk of having neurodevelopmental issues. 209 00:27:31,075 --> 00:27:36,855 And you're going to be monitoring quite closely how the head circumference is progressing. 210 00:27:37,605 --> 00:27:42,260 Certainly, uh, this baby, we've got to keep a very close eye on the hearing. 211 00:27:42,920 --> 00:27:46,140 So at least six monthly hearing assessments. 212 00:27:46,880 --> 00:27:52,340 Um, and actually, you know, some parts of the world will do more frequent hearing assessments. 213 00:27:53,040 --> 00:27:54,980 Uh, so we've gotta keep a close eye on that. 214 00:27:55,680 --> 00:28:02,130 And then we're going to be monitoring, how is this baby doing in term sort of its uh, neurodevelopmental milestones. 215 00:28:03,110 --> 00:28:14,015 And, uh, even if doing all right at three months, um, you know, these babies, it may not necessarily be motor issues that they have. 216 00:28:15,180 --> 00:28:18,800 But they are more at risk also of developing seizures. 217 00:28:19,340 --> 00:28:25,240 And we've just recently been looking in our cohort at the babies who have gone on to develop seizures. 218 00:28:25,660 --> 00:28:36,220 And they were almost entirely babies who had polymicrogyria and, um, they usually developed towards the end of the first year of life. 219 00:28:36,400 --> 00:28:40,580 So they weren't usually there earlier, uh, in the first six months. 220 00:28:41,520 --> 00:28:43,380 Um, so we need to watch out for that. 221 00:28:44,040 --> 00:28:51,700 And then I think it's all the important input from physio and speech and language and occupational, uh, therapy. 222 00:28:52,560 --> 00:29:10,815 Um, and commonly children with congenital CMV have problems with communication and learning, and it's not uncommon for them to be on that autistic spectrum as well and have difficulties with communicating. 223 00:29:11,555 --> 00:29:19,760 Nuria Sanchez-Clemente: So the patient completes six months of valganciclovir, uh, now without any complications and the medication is discontinued. 224 00:29:20,660 --> 00:29:24,240 Her left-sided hearing loss is stable, but remains severe. 225 00:29:24,700 --> 00:29:35,630 And so she's referred to ENT for consideration of hearing, hearing augmentation surgery and the right ear, um, hearing has remained unchanged and normal to date. 226 00:29:36,755 --> 00:29:45,615 The mom asked if there are any additional precautions she should take in future pregnancies, and if there are any family groups she could go to for peer support? 227 00:29:46,640 --> 00:29:57,520 Hermione Lyall: I mean, it's interesting because cochlear implantation, uh, the kind of access to cochlear implantation is very different, uh, again, in different parts of the world. 228 00:29:58,300 --> 00:30:06,630 In the UK, for example, to get access to cochlear implantation, if you only have hearing loss in one ear would be extremely difficult. 229 00:30:07,105 --> 00:30:24,165 But I know that in Canada, that is, uh, that is available and it is something to think about in a baby who is at still at risk of losing the hearing in the good ear that if you've already augmented the bad ear, then you might be sort of protecting the options of this child. 230 00:30:25,505 --> 00:30:29,475 So that I think is a debate in the CMV world. 231 00:30:30,735 --> 00:30:37,470 Um, I think it's a very important question about what do I do for subsequent pregnancies? 232 00:30:38,450 --> 00:31:00,980 The first thing to say is that there's quite a bit of randomized controlled trial data, uh, that demonstrates that if women know about CMV and unfortunately so many people have never even heard of this virus, but if people know about it, then they can take action to reduce the risk of transmission. 233 00:31:02,030 --> 00:31:23,720 And there are some relatively simple things to do, uh, which is, uh, not coming into contact with saliva, so not kissing your child on the mouth, not eating the food that your child is half finished on the plate, uh, washing your hands after changing nappies, washing your hands after tidying up all the mess. 234 00:31:24,760 --> 00:31:39,540 Now that is easy enough to say but it's kind of hard to do when you're running around a wild toddler and it's probably even harder when you are actually working in a, in a nursery looking after several children. 235 00:31:41,080 --> 00:31:47,460 But I think, you know, COVID has taught us a lot about how to reduce exposure to viruses. 236 00:31:48,080 --> 00:32:01,650 And I think actually health, well, women who are working in nursery education, you know, should be thinking about how often do they wash their hands and are they wearing gloves when they're changing nappies and all that so sort of thing. 237 00:32:02,545 --> 00:32:15,765 It is interesting that women who work in healthcare, so nurses and doctors who work in pediatrics, uh, who you might think might also be more at risk of getting CMV probably aren't. 238 00:32:16,035 --> 00:32:28,595 They probably don't have any increased risk over other healthcare workers, and that's because they don't treat their babies, the babies and children that they're looking after, in the same way, as somebody in a nursery. 239 00:32:28,855 --> 00:32:35,415 You're already putting gloves on everything and, you know, you've, you're taking a much more aseptic kind of approach. 240 00:32:36,435 --> 00:33:03,220 So I think we need to give this mom the advice about how to avoid contact with CMV in future, but we can also reassure her that if you are already seropositive at the beginning of the pregnancy, so if you've had CMV before, then your risk of transmission to the fetus is much, much less than in primary seroconversion. 241 00:33:03,680 --> 00:33:08,060 And in resource rich settings is probably less than 3%. 242 00:33:08,790 --> 00:33:15,370 So being seropositive already protects your baby quite considerably, the next one coming along. 243 00:33:16,775 --> 00:33:28,105 That doesn't mean to say you can't actually be reinfected by another strain and in the world as a whole, that is probably the way that most babies in resource poor settings get infected. 244 00:33:28,845 --> 00:33:44,865 And from the baby's perspective, uh, it doesn't matter whether it's primary infection or reinfection, the baby can still be as severely infected if they get infected, but the overall risk is much, much smaller. 245 00:33:45,845 --> 00:34:07,700 And in the UK, we have a really fantastic organization called CMV Action, uh, which is a charity, which is run by families of children with congenital CMV, which has beautiful, uh, information for families, for healthcare workers, for the population in general. 246 00:34:08,440 --> 00:34:14,500 Um, and you know, where, uh, a mom can actually go to get peer support as well. 247 00:34:15,280 --> 00:34:23,290 So I direct all my families to CMV Action, and I think there are similar groups, uh, in other countries as well. 248 00:34:23,620 --> 00:34:24,170 Nuria Sanchez-Clemente: Thank you. 249 00:34:24,905 --> 00:34:35,715 Just to finish off really is whether there's any other additional concepts, um, regarding CMV or anything else that you think is worth mentioning at this point. 250 00:34:36,415 --> 00:34:42,315 Hermione Lyall: Um, I think that a couple of things that, uh, that come to mind. 251 00:34:43,415 --> 00:34:56,710 The first thing is, now that we have this randomized controlled trial evidence that we could prevent transmission in the most, at the most dangerous time, when there's more, most risk of damage. 252 00:34:57,990 --> 00:35:17,990 I think we, I think countries, healthcare systems should be reviewing, uh, how they manage CMV in pregnancy and thinking about whether all women should be getting access to screening, antenatal screening, but that really means very early antenatal screening. 253 00:35:18,070 --> 00:35:26,990 I mean, ideally it means doing your first blood test at like four to six weeks and your second blood test at like, you know, eight to 10 weeks or something like that. 254 00:35:27,525 --> 00:35:31,105 If you want to get in there and give the treatment in a timely fashion. 255 00:35:32,325 --> 00:35:39,205 I think that is something that in our center, we are going to start looking at how could we try to offer that to, to women? 256 00:35:39,905 --> 00:35:46,715 And I think if women knew about CMV and if they knew this was available, they would want to have that option. 257 00:35:47,415 --> 00:35:54,635 Uh, so I think we've got to focus on preventing those really damaging first trimester infections. 258 00:35:56,055 --> 00:36:10,415 And then the other thing, which, I mean, I, there is so much about congenital CMV that we really don't understand, but we don't understand why it is that some babies are so much more severely affected than others. 259 00:36:11,155 --> 00:36:15,965 Why it is that some babies, for example, have hearing loss and others do not. 260 00:36:16,425 --> 00:36:24,765 And indeed why it is that you can have hearing loss at birth, but then you can develop hearing loss at kind of two or three or four. 261 00:36:25,345 --> 00:36:26,645 And what is going on there? 262 00:36:26,785 --> 00:36:31,935 Is that virological or immunological or a mixture of both? 263 00:36:32,595 --> 00:36:38,355 Is that genetically determined in your immune response to the virus or something? 264 00:36:39,055 --> 00:36:43,195 So there's an awful lot that we still need to understand better. 265 00:36:44,835 --> 00:37:04,135 We focused here on the more severely affected baby in the first trimester, but actually there are far more infants who are probably infected later on and who may not be so severe, don't necessarily have polymicrogyria, but can certainly have, uh, other CNS effects and hearing loss. 266 00:37:04,945 --> 00:37:13,885 And we still don't know enough about whether treatment for those babies can really improve the outcomes for them. 267 00:37:14,435 --> 00:37:17,955 Particularly in terms of learning and communication and so on. 268 00:37:18,415 --> 00:37:27,475 And there are some clinical trials going on at the moment, looking at these less symptomatic babies and whether early treatment, uh, is, is good for them. 269 00:37:29,295 --> 00:37:32,795 We need, I mean, if you look at all the CMV studies. 270 00:37:33,605 --> 00:37:40,415 Many of them have relatively small numbers, a hundred children or 200 children or something like that. 271 00:37:40,875 --> 00:37:57,690 We need to collect much larger numbers so that we have a really big cohort of children and we can far better understand and look into these issues of, uh, you know, where we might get some clues about genetic susceptibility or whatever. 272 00:37:58,470 --> 00:38:10,500 And, uh, we have set up in Europe, uh, what we call CCMVNet, uh, which is based, uh, on, around, uh, originally the Spanish cohort. 273 00:38:11,200 --> 00:38:31,450 Uh, and Danny Blazquez-Gamero has a brilliant, uh, uh, database, and we're now trying to enroll children and babies from all over Europe, as much as we can, uh, and to try and better understand all the different early biomarkers, uh, and learn more about the outcomes. 274 00:38:31,790 --> 00:38:35,090 How important are the findings on the MRI scan? 275 00:38:35,560 --> 00:38:43,410 What does it mean if you've got cysts or white matter abnormalities, will that lead to more or less issues later on? 276 00:38:44,260 --> 00:38:47,640 We just, we have so much more to learn is the bottom line. 277 00:38:48,100 --> 00:38:52,280 Um, but if we can prevent it well, that is obviously a really good thing. 278 00:38:54,325 --> 00:38:59,225 Sara Dong: I'm so grateful for Nuria and Hermione for joining Febrile today and teaching us about CMV. 279 00:38:59,605 --> 00:39:03,065 Please stay tuned for the rest of our Curious Congenital Conundrum series. 280 00:39:03,495 --> 00:39:05,945 This is just the first of four cases on the way. 281 00:39:06,285 --> 00:39:14,895 Our usual disclaimer, all presented patients on this podcast are inspired by patient experiences, but cases are constructed or significantly altered and de-identified for learning purposes. 282 00:39:15,250 --> 00:39:29,590 If you are new to Febrile or haven't checked it out before, please look at our website febrilepodcast.com where you can find Consult Notes, which are written complements of the show with links to references, as well as a library of ID infographics, which you can use to learn and teach others about ID. 283 00:39:29,730 --> 00:39:32,550 Thanks for listening, stay safe, and I'll see you next time.