Κυτταρομεγαλοιός-CMV

ΣΥΓΓΕΝΗΣ ΛΟΙΜΩΞΗ ΑΠΟ ΚΥΤΤΑΡΟΜΕΓΑΛΟΙΟ (CMV)

Πρόκειται για μια κοινή λοίμωξη η οποία είναι μέρος της οικογένειας των ιών του έρπητα. Μόλις μολυνθεί ένα άτομο, ο ιός παραμένει αδρανής στο σώμα του για το υπόλοιπο της ζωής του.
Συγγενής λοίμωξη CMV συμβαίνει όταν μια μητέρα που έχει μολυνθεί με CMV, η λοίμωξη μεταδίδεται στο έμβρυο.

Η λοίµωξη από τον κυτταροµεγαλοϊό (cytomegalovirus, CΜV) είναι η πιο συχνή συγγενής λοίµωξη λόγω της ευρείας διασποράς του ιού και της µακροχρόνιας αποβολής του µετά από πρωτοπαθή ή υποτροπιάζουσα λοίµωξη. Οι πιθανότητες προσβολής του κυήµατος µετά πρωτοπαθή λοίµωξη της εγκύου είναι 15% – 50%, ενώ σε υποτροπή κατά την κύηση είναι 1%. Μετάδοση µπορεί να συµβεί σ όλη τη διάρκεια της κύησης, αλλά ο κίνδυνος βαριάς συγγενούς νόσου είναι µεγαλύτερος στους πρώτους 4-5 µήνες. Επίσης, ο ιός µπορεί να µεταδοθεί µε το θηλασµό.

Πώς μεταδίδεται ο CMV;

Ο CMV μεταδίδεται μέσω σωματικών υγρών: σάλιο, σπέρμα, αίμα, ούρα, τα κολπικά υγρά και το μητρικό γάλα.

Διάγνωση στην κύηση

Πρωτολοίμωξη στην κύηση συμβαίνει σε λιγότερο από 1% των γυναικών.

Συγγενής λοίμωξη CMV προκαλείται όταν μεταδίδεται ο ιός από τη μητέρα στο έμβρυο μέσω του πλακούντα. Ο πλακούντας είναι ένα όργανο που συνδέει το αναπτυσσόμενο έμβρυο στο τοίχωμα της μήτρας για να επιτρέψει πρόσληψη των θρεπτικών συστατικών, την απομάκρυνση των αποβλήτων και την ανταλλαγή αερίων μέσω της προσφοράς αίματος της μητέρας.
Οι περισσότερες περιπτώσεις συγγενούς CMV λοίμωξης προκαλούνται όταν μία έγκυος γυναίκα έχει προσβληθεί από τον ιό CMV για πρώτη φορά κατά τη διάρκεια ή λίγο πριν, εγκυμοσύνη.
Σε ορισμένες περιπτώσεις, μία προηγουμένως ανενεργή λοίμωξη CMV μπορεί να επανεμφανιστεί τη διάρκεια της εγκυμοσύνης, ως αποτέλεσμα εξασθενημένου ανοσοποιητικού συστήματος της μητέρας. Η έγκυος μπορεί επίσης να παρουσιάσει εκ νέου μόλυνση με ένα άλλο στέλεχος του ιού CMV με αποτέλεσμα να περάσει στο αγέννητο μωρό της.
Στις περισσότερες περιπτώσεις, όπου ο CMV έχει περάσει από τη μητέρα στο μωρό, ο ιός δεν προκαλεί καμία ζημιά στο έμβρυο. Ωστόσο, εάν μία μεγάλη ποσότητα του ιού έχει μεταδοθεί στο έμβρυο, μπορεί δυνητικά να προκαλέσει συμπτώματα και συναφείς ανωμαλίες.

Έλεγχος για CMV κύηση
Ανάγκη διαχωρισμού πρωτοπαθούς από δευτεροπαθή λοίμωξη.
Ανίχνευση ειδικών αντισωμάτων IgG & IgM.

  • IgG θετικα: υποδηλώνουν παλαιά λοίμωξη
  • IgM θετικά: υποδηλώνουν πρόσφατη λοίμωξη

Η δευτεροπαθής λοίμωξη διαγιγνώσκεται με την παρουσία θετικών IgG και αρνητικών IgM αντισωμάτων πριν την εγκυμοσύνη και με σημαντική αύξηση των τίτλων των αντισωμάτων IgG με ή χωρίς την παρουσία αντισωμάτων IgM.

  • CMV avidity test: πρόκειται για πιο ειδικευμένη εξέταση η οποία μπορεί να προσδιορίσει το χρόνο μόλυνσης.
  • Low avidity <30%: υποδηλώνει πρόσφατη λοίμωξη του τελευταίου τριμήνου
  • High avidity >60%: υποδηλώνει παλαιά λοίμωξη πέραν του τριμήνου ή δευτεροπαθή λοίμωξη
  • Αμνιοπαρακέντηση: συνιστάται 7 εβδομάδες μετά τη λοίμωξη (seroconversion) και μετά την 20η εβδομάδα κύησης. Η συγκεκριμένη εξέταση θεωρείται διαγνωστική και μπορεί να μας πει πραγματικά το κατά πόσον το έμβρυο έχει λοίμωξη.

Υπερηχογραφικά ευρήματα που σχετίζονται με CMV

  • Ενδομήτρια καθυστέρηση της ανάπτυξης του εμβρύου
  • Μικροκεφαλία
  • Υδροκεφαλία
  • Εγκεφαλικές αποτιτανώσεις
  • Ασκίτης, εμβρυικός ύδρωπας
  • Ολιγάμνιο
  • Υπερηχογενές έντερο
  • Ηπατικές αποτιτανώσεις

Ποια είναι τα σημάδια και τα συμπτώματα της συγγενούς λοίμωξης από CMV;

Περίπου το 90% των βρεφών που γεννιούνται με συγγενή CMV δεν εμφανίζουν κανένα σύμπτωμα κατά τη γέννηση (ασυμπτωματικά).
Ένας μικρός αριθμός των βρεφών με ασυμπτωματική συγγενή CMV λοίμωξη μπορεί να αναπτύξει κάποιο βαθμό απώλειας ακοής στα πρώτα χρόνια της ζωής του. Η απώλεια της ακοής μπορεί να κυμαίνεται από ήπια έως πλήρης.
Τα προβλήματα ακοής μπορεί να επηρεάσουν μόνο το ένα αυτί (μονόπλευρη απώλεια ακοής) ή μπορεί να προκαλέσει προβλήματα και στα δύο αυτιά (αμφοτερόπλευρη απώλεια ακοής). Τα παιδιά με αμφοτερόπλευρη απώλεια ακοής είναι πιθανό να παρουσιάσουν προβλήματα με την ομιλία και την επικοινωνία, καθώς μεγαλώνουν.

Ένα στα 10 μωρά που γεννήθηκαν με συγγενή CMV έχουν συμπτώματα κατά τη γέννηση. Αυτά περιλαμβάνουν:

  • ίκτερος – κίτρινο χρώμα του δέρματος και κιτρίνισμα του λευκού των ματιών
  • πνευμονία
  • εξάνθημα
  • ηπατο/σπληνομεγαλία
  • χαμηλό βάρος κατά τη γέννηση
  • σπασμούς
  • μικροκεφαλία (μικρό μέγεθος του κεφαλιού)
  • Ενδοµήτρια καθυστέρηση στην ανάπτυξη ή, σπανιότερα, προωρότητα.
  • Εκδηλώσεις γενικευµένης νόσου: Ηπατοσπληνοµεγαλία, ηπατίτιδα, ίκτερος, θροµβοπενία, πετεχειώδη και άλλα εξανθήµατα.
  • ΚΝΣ: Μικροκεφαλία, περικοιλιακές επασβεστώσεις και, σπανιότερα, σπασµοί, υδροκέφαλος και κυστικές βλάβες εγκεφάλου
  • Νευροαισθητηριακές: Νευρογενής βαρηκοΐα, χοριοαµφιβληστροειδίτιδα.
  • ∆ιαταραχές από τα δόντια, κυρίως τα νεογιλά (υποπλασία αδαµαντίνης).
  • Οι συγγενείς διαµαρτίες δεν είναι ιδιαίτερα συχνές και θεωρείται πιθανό ότι πρόκειται για τυχαία εµφάνισή τους σε νεογνά µε συγγενή λοίµωξη από CMV.

Ενώ μερικά από αυτά τα συμπτώματα μπορεί να αντιμετωπιστούν, μερικά μωρά θα αναπτύξουν μακροπρόθεσμα προβλήματα, ως αποτέλεσμα της μόλυνσης.

Έως και 90% των βρεφών που γεννιούνται με συγγενή CMV που έχουν συμπτώματα κατά τη γέννηση αναπτύσσουν μία ή περισσότερες σωματικές ή διανοητικές αναπηρίες.
Αυτές περιλαμβάνουν:

  • απώλεια ακοής (25-65%)
  • προβλήματα όρασης (12-22%)
  • νοητική καθυστέρηση (47-61%)
  • νευρομυικές διαταραχές (35-49%)
  • σπασμούς (11%)

Πρόγνωση και µόνιµες βλάβες.

Συµπτωµατική νόσο εµφανίζει το 10% περίπου των προσβληµένων νεογνών, από τα οποία το 20%-30% έχει κακή εξέλιξη. Η µακροχρόνια πρόγνωση των παιδιών µε συµπτωµατική συγγενή λοίµωξη που επιζούν δεν είναι καλή, επειδή των 90-95% εµφανίζουν µόνιµες βλάβες, όπως είναι η νευρογενής βαρηκοΐα (25-65%), νοητική υστέρηση (47-61%), νευροµυϊκές διαταραχές (35-49%), σπασµοί (11%) και χοριαµφιβληστροειδίτιδα (12-22%). .

Θεραπεία συγγενούς λοίμωξης από CMV

Συγγενής λοίμωξη από CMV μπορεί να αντιμετωπιστεί με αντιιικά φάρμακα (Ganciclovir). Αυτά δεν μπορούν να θεραπεύσουν τη λοίμωξη από CMV, αλλά μπορεί να επιβραδύνουν την πρόοδό της, αλλά σε ποσοστό περίπου 20% παρουσιάζουν τοξικότητα στο αίμα.

Ειδική πρόληψη δεν υπάρχει. Έχει παρασκευαστεί εµβόλιο από εξασθενηµένους ιούς, µε το οποίο επιτυγχάνεται οροµετατροπή αλλά δε φαίνεται να ελαττώνει τη συχνότητα της συγγενούς λοίµωξης και δεν συστήνεται προς το παρόν. Έτσι, το µόνο προληπτικό µέτρο που µπορεί να εφαρµοστεί είναι η αποφυγή των εστιών µόλυνσης, που είναι οι βρεφονηπιακοί σταθµοί και τα τµήµατα όπου νοσηλεύονται νεογνά ή ανοσοκατασταλµένοι ασθενείς. Σε ύποπτη ή βέβαιη λοίµωξη της εγκύου, µπορεί να γίνει διάγνωση των προσβεβληµένων εµβρύων µε υπερηχ- γράφηµα και ανίχνευση του ιού µε καλλιέργειες ή PCR στο αµνιακό υγρό ή το εµβρυϊκό αίµα και να δοθούν ανάλογες συµβουλές στους γονείς.

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