Jpn. J. Infect. Dis., 53, 2000

Laboratory and Epidemiology Communications

Cytomegalovirus Infection ofNewboms Infected with HIV‑ 1

from Mother: Case Report
HikaruYamanaka* , Junko Yamanaka, Ken‑Ichi Okazaki, Eriko Hayakawa, Hirofumi Miyazawa,
Tadatoshi Kuratsuji, Ikumi Genkal , Akira Yasuokal and Shinichi Okal

Department of Pediatrics and JAIDS Clinical Center; International Medica/ Center ofJapan,
Toyama Il21‑1, Shinjuku‑ku, Tob70 16218655
Communicated by Hiroshi Yoshikura(Accepted November 20, 2000)

In addidon to PneumoqJStLg carini, cytomegaloviruS (CMV)
is an important opportunistic pathogen in HIV‑I‑infectedofHARRT, his CD4 count recovered to 2,284/LEI, and HIV
RNA decreased to 3.2 × 103 copies/ml. On the 19仇血y, CMV

patients, particularly ln pediatric patients. We present here
CMV infection observed in two mother‑to‑child HIV‑1

antigenemia (8 CMV‑posidve cells/1.5 × 105 white blood cells)

appeared. On day 21, as a white lesion due to CMV retinitis

infection cases.

in the right eyeground was detected, gancyclovir treatment

Case 1: Aboy was bom to an HIV‑1 positive mother. His
father was also HIV‑ I positive. They were Ignorant Of theirown infection until the baby was found to be HIV‑ 1 infected.
He was delivered at the 39th gestation week by Caesarean
section. The body weight was 3 ,300 g. He received both breastand bottle feeding. He was admitted to a hospital at the ageof 2 months for pneumonia and bronchitis. He was intubatedwhich had been started with an oral dose of 30 mg/kg/day
since admission was switched to the therapeutic dose (i.V.

dose of 5 mgn(g/12 h).Asthe eyeground lesion diminishedin 25 days, the dose was reduced to the maintenance dose

(i･V･ dose of 5 mg/kg/day)･ However, after 12 days ofth9maintenance dose, relapse of the eyeground lesion was noted

and the gancyclovir dose was retumed to the therapeutic dose.
As the retinitis worsened with the decrease of gancyclovir

and his breathing was controlled by an artificial respirator.

Increase of anti‑CMV IgM suggested CMV infection. His

dose, the continued administration of gancyclovir wi血closecondition deteriorated gradually. When he was fわund to bemonitoring of both the eyeground lesion and the side effects

HIVl1‑infected at the age of6 months, he was sent to ourhospital. His CD4 count was 46/lil, and HIV‑RNA was 2.7

tion between the level ofCMV antigenemia and the severity

× 106 copies/ml. The clinical stage was CDC class C. HARRTof retinitis was noticed.

of the treatment was necessary. In this patient, no clear rela‑consisting of zidovudine (AZT), 1amivudine (3TC), andIn both cases, the CMV retinitis was detected shortly a洗er

nelfinavir (NFV) was iTmediately started･ On the fifth day

the start ofHARRT. But, as the babies had not been examined

of HARRT, bilateral retlnal vasculitis, edema, and bleeding

for the eyeground before, the relation between HARRT andwere detected.AsCMV antigenemia was present (3 CMV‑

the development of the retinitis wぉunclear. nLey had probably

administration ofgancyclovir every 12 h at a dose of5 mg/

already had the CMV retinitis before the initiation ofHARRT.
In case 1 , the control ofCMV infection was relatively easy

kg/day was started on day seven.Asthe retinal conditionthough the patient's general condition including CD4 countrecovered after 29 days of the treatment, the dose wasand HIV‑1 viremia was poor. In case 2, the control orCMV

positive cells/I.5 X 105white blood cells), intravenous (i.V.)

reduced to a maintenance dose of 5 mgn(g/day. After 1 3 days

infection was difrlCult despite the relatively strong control ofof the maintenance dose,仇e retinal lesion did not reoccur.

CD4 and HIV viremia. TTle reason for these apparently contra‑

The gancyclovir treatment was switched to an oral mainte‑

dictory results was not clear. One possibility is that it wasnance dose of 50 mg/kg/day and the patient was discharged･caused by a wide variation among individuals as to when theFor prevention of retinal detachment, retlnal laser photo‑performed under anaesthesia on days 35 and 77. On day 32,

anti‑CMV starts to be produced, i.e., the case 2 baby may
have developed anti‑CMV antibody later than the case 1 baby.
The anti‑CMV antibody positivlty rate among Pregnant

HIVRNA decreased to 4 × 104 copies/ml and CD4 count rose

women is higher in Japan than in European countries or仇eup to 136/〟1.

US ( 1 ‑2). Consequently,therisk ofCMVinfectioninnewborns

Coagulation and intraocular inoculation of gancyclovir were

Case 2: Aboy was bom to an HIV‑1 positive mother. Shewas Ignorant Ofher own infectionuntil the boy was diagnosed
as HIV‑1 positive. The boy was bom via a normal vaglnaldelivery and his body weight was 3,016 g. At the age of3

in Japan is considered higher. Both babies presented in thisreport must have been infected by HIV‑1 and CMV during
delivery or after birth.

CMV infection reportedly aggravates the clinical course

months, he developed carinl PneumOnitis and symptoms ofof HIV‑I infected babies: half of the reported cases either

CMV infection. He was found to be HIV‑1 positive and sent

died or attained the class C symptom stage within 1 8 months,

to our hospital at the age of7 months. His CD4 count was949/LLl. HIV RNA was 7.3 X 105 copies/ml. From the clinicalsymptoms, he was in the stage of CDC class a. HARRTand complications of the central nervous system have beenfound in 30% of the cases (3)･ Therefore, early diagnosi! ofCMV infection is important. Systematic ophthalmologlCal
examination of babies bom to HIV‑ 1 positive mothers will beconsistlng OfAZT, 3TC,and NFV was started. A洗er 14 days

necessary. If the babies are found CMV‑infected, treatment
for CMV as well as that for HIV‑I should be started. But the* Corresponding author: hyamanak@imcj.hosp.go.jp

215

Jpn. J. Infect. Dis., 53, 2000

Viro1., 37, 303‑306.

present reglmenS Ofthe combined therapy have to be furtherevaluated. It will be also important to take measures for2. Hoshiba, T.,Asamoto,A.andYabuki,A. (1998): I)ecreased

preventmg mother‑to‑child CMV infection, such as treatment
with hyperimmune anti‑CMV sera or vaccination (4).

incidence ofanti‑cytomegalovirus antibody posidve preg‑

nant women. Nihon‑Rinsho, 56, 193‑1 96 (in Japanese).

3. Kovacs, A., Schluchter, M., Easley, K., Demmler, G･,Shearer, W., La Russa, P., Pitt, J., Cooper, E., Goldfarb,J., Hodes, D., Kattan, M. and Mclntosh, K. (1999):REFERENCES

1. Hirota, K., Muraguchi, K., Watabe, N., Okumura, M.,Kozu, M., Takahashi, K., Machida, Y., Funayama, Y.,

Cytomegalovirus infection and HIV‑ 1 disease progres‑sion in infants born to HIV‑1‑infected women. N. Engl.

Oshima, T. and Numazaki, Y ( 1992): Prospective study

J. Mらd., 341, 77‑84.

on matemal, intrauterine, and perinatal infectionswith

4. Marodi, L. (2000): CMV in HIV‑infected newborns･Pediatr. Res., 47, 173.

cytomegalovirus in Japan during 1976‑1990. ∫. Med.

216