What are the symptoms of Cytomegalovirus (CMV) infection?

Symptoms of Cytomegalovirus (CMV) Infection

CMV infection presents with a wide spectrum of clinical manifestations ranging from asymptomatic infection to severe end-organ disease, with retinitis being the most common serious manifestation in immunocompromised individuals. 1

General Symptoms

• CMV infection in healthy adults is usually asymptomatic or causes a mild mononucleosis-like syndrome with fever, malaise, and lymphocytosis 2
• In immunocompromised patients, particularly those with CD4+ counts <50 cells/μL, CMV can cause severe disseminated or localized end-organ disease 1
• Risk factors for severe disease include advanced immunosuppression, previous opportunistic infections, and high HIV viral loads (>100,000 copies/mL) 1

Ocular Manifestations

• Retinitis is the most common clinical manifestation of CMV end-organ disease 1
• Symptoms may include:
  • Floaters in the visual field 1
  • Scotomata (blind spots) 1
  • Peripheral visual field defects 1
  • Decreased visual acuity (when central retina or macula is affected) 1
  • Central field defects 1
• Characteristic ophthalmologic appearance:
  • Fluffy yellow-white retinal infiltrates 1
  • Focal necrotizing retinitis 1
  • Intraretinal hemorrhage may be present 1
  • Blood vessels near lesions may appear sheathed 1
  • "Pizza pie" appearance with central retinal necrosis in advanced cases 3
• Without treatment, retinitis progresses in a "brushfire pattern" with a granular, white leading edge advancing before an atrophic scar 1

Gastrointestinal Manifestations

• CMV colitis (second most common manifestation, occurring in 5-10% of persons with AIDS and CMV end-organ disease) 1

• Symptoms include:

  • Fever 1
  • Weight loss 1
  • Anorexia 1
  • Abdominal pain 1
  • Debilitating diarrhea 1
  • Malaise 1

• Complications can include extensive mucosal hemorrhage and perforation, which can be life-threatening 1

• CMV esophagitis (occurs in <5-10% of persons with AIDS who develop CMV end-organ disease) 1

• Symptoms include:

  • Fever 1
  • Odynophagia (painful swallowing) 1
  • Nausea 1
  • Mid-epigastric or retrosternal discomfort 1

Pulmonary Manifestations

• CMV pneumonitis is uncommon but can occur in immunocompromised patients 1, 4
• Symptoms include:
  • Shortness of breath 1
  • Dyspnea on exertion 1
  • Nonproductive cough 1
  • Hypoxemia 1
• Radiographic findings include interstitial infiltrates on chest radiograph 1, 4

Neurologic Manifestations

• CMV can cause neurologic disease including 1:

  • Dementia
  • Ventriculoencephalitis
  • Ascending polyradiculomyelopathy

• Symptoms of CMV dementia:

  • Lethargy 1
  • Confusion 1
  • Fever 1
  • May mimic HIV-associated dementia 1
  • CSF typically shows lymphocytic pleocytosis, low-to-normal glucose levels, and normal-to-elevated protein levels 1

• Symptoms of CMV ventriculoencephalitis:

  • More acute course 1
  • Focal neurologic signs 1
  • Cranial nerve palsies 1
  • Nystagmus 1
  • Rapid progression to death 1
  • Periventricular enhancement on CT or MRI 1

• Symptoms of CMV polyradiculomyelopathy:

  • Guillain-Barré-like syndrome 1
  • Urinary retention 1
  • Progressive bilateral leg weakness 1
  • Loss of bowel and bladder control 1
  • Flaccid paraplegia 1
  • Spastic myelopathy (reported in some cases) 1
  • Sacral paresthesia 1
  • CSF shows neutrophilic pleocytosis, hypoglycorrhachia, and elevated protein levels 1

Congenital CMV Infection

• Affects 1 in 200 of all live born infants in high-income countries 5
• Symptoms in affected newborns may include:
  • Jaundice 5
  • Rash 5
  • Enlarged liver or spleen 5
  • Small brain (microcephaly) 5
  • Small for gestational age 5
  • Approximately 1 in 8 babies born with CMV infection will have clinically detectable signs at birth 5

Diagnostic Considerations

• CMV viremia can be detected by PCR, antigen assays, or blood culture 1
• Viremia is usually present in end-organ disease but may also occur without end-organ involvement 1
• Serum antibodies to CMV are not diagnostically useful for active disease, though a negative IgG antibody level makes CMV unlikely as the cause of disease 1
• Diagnosis of specific organ involvement often requires specialized testing:
  • Retinitis: diagnosed by characteristic retinal changes on ophthalmologic examination 1
  • Colitis/esophagitis: requires endoscopic examination with biopsy showing characteristic inclusions 1
  • Neurologic disease: diagnosed by compatible clinical syndrome and presence of CMV in CSF or brain tissue 1