Jurnal Infeksi CCMV Dw
Transcript of Jurnal Infeksi CCMV Dw
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EVIDENCE BASED MANAGEMENT GUIDELINES
FOR THE DETECTION AND TREATMENT OF
CONGENITAL CMV
a Paediatric Infectiou Dieae Unit! St Geor"e# Uni$erit% of London! Cran&er Terrace! London S'() *RE! United
+in"do&
, Ro%a- Victoria In.r&ar% Ho/ita-! 0ueen Victoria Road! Ne1cat-e u/on T%ne NE( 2LP! United +in"do&
c Uni$erit% Co--e"e London! Di$iion of Infection and I&&unit%! Ro%a- Free Ho/ita-! Ro1-and Hi-- Street! London N'3
4PF! United +in"do&
S5 +ada&,ari a!6! E575 'i--ia& ,!(! S5 Luc8 c! P5D5 Gri9t: c! M5 S:ar-and a
I-a&&i%a: De1i ;unianti
Pe&,i&,in"
Dr5 MMDEAH Ha/ari! S/A+
Dr5 Na:1a Ar8:aei! Mi Med! S/A
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Currently no universal screeningprogramme for CMV.
The annual costs of CMV dieae to t:e US :ea-t: care
%te& 1ere eti&ated in t:e (
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ABSTRACT
CMV i t:e most common con"enita- infection innewborns 1or-d1ide5
Con"enita- CMV caue sensori-neural hearing loss in a
i"ni.cant /ro/ortion of infected ne1,orn! 1:i-e t:e&a?orit% of ne1,orn are asymptomatic.
In t:e -at t:ree %ear t:ere :a$e ,een i"ni.cantad$ance in t:e dia"noi and treat&ent of con"enita-
CMV5
'e :a$e de$e-o/ed /ractica- e$idence ,aed "uide-ine fort:e &ana"e&ent of con"enita- CMV5
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Content of S-ide
(5 Introduction
45 Ma8in" t:e dia"noi 45(5 C-inica- feature
45(5(5 S%&/to&atic con"enita- CMV infection
45(545 A%&/to&atic con"enita- CMV infection
4545 La,orator% con.r&ation of infection 4545(5 Urine $ a-i$a CMV PCR
454545 Pro,-e& 1it: tetin" Dried B-ood S/ot @DBS
4535 Furt:er in$eti"ation reuired in a ,a,% 1it: con.r&edcCMV 4535(5 B-ood tet
453545 C:oice of neuroi&a"in"
453535 O/:t:a-&ic ae&ent
453525 Audio-o"ica- ae&ent
45355 Decidin" 1:et:er t:e ,a,% i S%&/to&atic or A%&/to&atic
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35 Treatin" and &onitorin" cCMV 35(5 Treatin" %&/to&atic or"an dieae
35(5(5 ':o to treat
3545 Gancic-o$ir GCV 3535 Va-"ancic-o$ir VGCV
3535(5 Treatin" o-der c:i-dren
3525 Monitorin" 3525(5 Safet% /ara&eter
352545 Vira- -oad
352535 Dru" -e$e-
352525 Reitance aa%
25 P-annin" -on" ter& fo--o1 u/ 25(5 Audio-o"%
2545 Neurode$e-o/&enta-
2535 O/:t:a-&o-o"%
2525 Fa&i-% u//ort
5 Mana"e&ent a-"orit:& for t:e treat&ent of con"enita- CMV
>5 Conc-uion
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INTRO!CTION -"#$TR"CT
':at! ':%! ':o! ':en! ':ere! Ho1
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Introduction
Con"enita- CMV @cCMV i t:e lea%ing ofnon-genetic cause of enorineura-
:earin" -o
'or-d1ide! t:e ,irt: /re$a-ence of cCMV i
eti&ated at)(***
(45) of infected ne1,orn are symptomaticat ,irt:
(35 of infant 1:o are a%&/to&atic t:en %evelopse&uelae inc-udin" enorineura- :earin" -o @SNHL inc:i-d:ood
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An accurate %iagnosis :a to ,e &ade1it:in the 'rst three wee(s of -ife $iro-o"ica- and ero-o"ica- tet ta8en after t:i
ti&e no -on"er c-ear-% ditin"ui: ,et1eencon"enita- and acuired infection5
Vertica- tran&iion of CMV infection canoccur t:rou": three main routes Intrauterine
Intrauterine tran&iion i the most importantroute a it &a% reu-t in &a?or neuro-o"ica- eue-ae
Intra/artu&
Potnata-
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Co&&on ource
T:e &ot common source of $irufor /re"nant 1o&en i fro& youngchil%ren
Pot/artu& acuiition &ain-%t:rou": ,reat &i-8 One tud% found infant 1:o breast
fee% from seropositive mothers:a$e an eti&ated rate of infection of u/
to 3=5
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M")IN* I"*NO$I$
An accurate %iagnosis :a to ,e &ade 1it:in the 'rstthree wee(s of -ife
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45(5 C-inica- feature
45(5(5 S%&/to&atic con"enita- CMVinfectionT:e t%/ica- /:%ica- i"n inc-ude
B-ue,err% &u9n ra:
Petec:iae
IUGR
Microce/:a-%
He/ato/-eno&e"a-%
7aundice
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La,orator% reu-t
are conitent 1it:hepatic an%reticuloen%othelial involvement + Con?u"ated
:%/er,i-iru,inae&iaT:ro&,oc%to/aenia
E-e$ated :e/atictrana&inae
S%&/to&aticne1,orn
SNHL! -earnin"di9cu-tie!&icroce/:a-% and
$iua- -o @rare-%
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45(545 A%&/to&atic con"enita- CMV infection Con"enita- CMV i most commonly
asymptomatic
A//roJi&ate-% (* 1i-- %evelop $N, over the'rst /0 years of -ife
1:i-t t:e incidence of hearing loss in the general
population is only 1.2/1.34 Hearin" -o can ,e ,i-atera-
On-% * of cae of SNHL caued ,% CMV are eJ/ected to ,edetected ,% neonata- :earin" creenin" /ro"ra&&e
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4545 La,orator% con.r&ation ofinfection
4545(5 Urine $ a-i$a CMV PCR Detection of CMV in t:e urine or a-i$a i relatively
easy ,ecaue ne1,orn she% high levels of the virus fro&t:ee
Kuid and ,ot: are a&ena,-e to ra/id tetin" uin" PCR
The gol% stan%ar% for t:e dia"noi of cCMVinfection in ne1,orn :a ,een io-ation of t:e $iru int:e urine 1it:in t:e .rt t:ree 1ee8 of -ife
Rea- ti&e PCR aa% of ,ot: li&ui% an% %rie% salivaa&/-e :ad sensitivities of 5604 an% 66.64
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454545 Pro,-e& 1it: tetin" Dried B-oodS/ot @DBS
T:e detection of CMV DNA on DBS uin" PCR :aenable% the retrospective %iagnosis of cCMVin o-der chil%ren who /reent 1it: co&/ati,-ec-inica- feature uc: a $N,.
#$ 7CR has low sensitivity for accurate%iagnosis of cCMV ,ecaue a//roJi&ate-% t1ot:ird of infection 1ere &ied uin" t:i &et:od
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4535 Furt:er in$eti"ationreuired
in a ,a,% 1it: con.r&ed cCMV 4535(5 B-ood tet
B-ood Count 89#C: and Li$er Function Tet 89Ts: areeentia-
Becaue CMV can caue /anc%to/enia and :e/atiti
Renal function :ou-d a-o ,e &eaured a a ,ae-ine /riorto co&&encin" treat&ent
453545 C:oice of neuroi&a"in" Manifet 1it:
Intracrania- ca-ci.cation
Mi"rationa- a,nor&a-itie @uua--% &icro"%ria and c%tic c:an"e
Ventricu-o&e"a-%
1:ite &atter -o
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Crania- u-traound:a ,een :o1n to
,e a "ood /redictor of outco&e in%&/to&atic ne1,orn 1it: cere,ra-a,nor&a-itie useful 'rst imaging investigation in
ne1,orn 1it: u/ected cCMV
Crania- u-traound can are eai-%
o,taina,-e and and o no1 :ou-d ,e ued a a primary screening
too- to ae for intracere,ra- a,nor&a-itieinc-udin" ca-ci.cation for a-- ,a,ie 1it:con.r&ed cCMV
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453535 O/:t:a-&ic ae&ent :ou-d ,e /erfor&ed for a-- ne1,orn 1it: cCMV at t:e ti&e of dia"noi5
Retina- carrin"
Stra,i&u
Cortica- $iua- -o
453525 Audio-o"ica- ae&ent Hearin" -o can be progressive or late onset and o audio-o"ica- fo--o1 u/
i eentia-
45355 Decidin" 1:et:er t:e ,a,% i S%&/to&atic orA%&/to&atic
Fo--o1in" a fu-- c-inica-! radio-o"ica-! audio-o"% and o/:t:a-&o-o"% ae&ent1it: ,-ood in$eti"ation
A c-ear deciion :a to ,e &ade and docu&ented in t:e note! a to 1:et:ert:e ,a,% 1it: cCMV i A%&/to&atic! or i S%&/to&atic
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TR;"TIN* "NMONITORIN*
Cure and care
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35(5 Treatin" %&/to&atic or"andieae
35(5(5 ':o to treat
*anciclovir 8*CV:and valganciclovir 8V*CV:
i on-% reco&&ended for %&/to&atic ne1,orn 8inthe 'rst 1ee8 of IV GCV =mg>(g>%ose e$er% (4 :
Re%uce %evelopmental %elaysat > and (4 &ont: co&/ared to
untreated infant
T:ere are :o1e$er still onlylimite% %ata re"ardin"
T:e /:ar&aco8inetic!afet% /ro.-e and
ad$ere eect of GCV
3535 Va-"ancic-o$ir VGCV
2 mg>(g twice %aily re"i&en foriJ 1ee8
Neonate recei$in" > 1ee8 of GCV @>&"8" were similar to t:oerecei$in" VGCV
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352545 Vira- -oad ':o-e ,-ood CMV $ira- -oad @VL :ou-d ,e ta8en 1ee8-% durin"
t:e coure of treat&ent to ae treat&ent e9cac% and &onitor dieae /ro"reion
B-ood CMV $ira- -oad uua--% dro/ ,et1een ( and 4 -o" durin"treat&ent
352535 Dru" -e$e- Gancic-o$ir /ea8 -e$e- :ou-d ,e ta8en one hour after
ad&initration :ou-d ,e ,et1een ) < &"L
352525 Reitance aa% Uua--% due to mutations in gene !60 1:ic: encode t:e
$ira- /rotein 8inae or in t:e $ira- /o-%&erae "ene UL2
Treat&ent fai-ure and t:e e&er"ence of o&e reitance&utation :a$e ,een aociated 1it: t:e ue of $a-"ancic-oc$ir
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7"NNIN* ON* T;RM9OO? !7
Pri&u& non nocere
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3.2. "u%iology
T:e Nationa- Deaf C:i-dren# Societ% "uide-ine@:tt/1115ndc5or"5u8 reco&&end
,earing assessment for ,a,ie 1it: cCMV :ou-d ,e/erfor&ed e$er% 3> &ont: in t:e .rt %ear unti- a"e 3 andt:en %ear-% unti- > %ear o-d5
3.@. Neuro%evelopmental
C-inica- and neurode$e-o/&enta- fo--o1 u/ :ou-d ,eperforme% at = months and at -eat one %ear in
"enera- /aediatric c-inic5
A-- CNS %&/to&atic infant :ou-d :a$e aneurode$e-o/&enta- assessment at one year
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3.
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CONC!$ION
Get 1e-- oon c:i-d
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Conc-uion
In t:e a,ence of an% i&&inent $accine,eco&in" a$ai-a,-e and ne1 anti$ira- a"enton t:e &ar8et! treatment with *CV an%
V*CV will remain the only therapy foro&e ti&e
'e 8no1 $er% -itt-e ti-- a,out t:e -on" ter&
outco&e of t:ee dru"! so posttreatment surveillanceof ne1,orntreated 1it: GCVVGCV re&ain $er%i&/ortant