Med Journal December 2021 - Page 7

Figure 2 . Chest x-ray ( A ) done at delivery revealing lower-than-expected lung volumes and Chest x-ray ( B ) done at six weeks of life with progressive pulmonary disease .
parents elected not to start ganciclovir or valganciclovir at that time .
Although the infant initially weaned off all respiratory support by nine days of life , she remained off support for only two days . Lung size was subtly smaller than expected on chest radiographs done shortly after birth ( Figure 2 ). There was a slow escalation in nasal cannula flow and oxygen requirements , and she was placed again on CPAP at a few weeks of life . She had increased work of breathing , oxygen requirements , and carbon dioxide retention , which slowly progressed and required further escalation to nasal intermittent positive pressure ventilation then non-invasive , neurally adjusted ventilatory assist ( NAVA ). She required intubation for mechanical ventilation at six weeks of life . The infant ’ s respiratory status continued to worsen on conventional ventilation over the next week . The infant developed severe pulmonary hypertension with hypoxemia on 100 % fraction of inspired oxygen . She was placed on inhaled nitric oxide . Chest radiographs done at this time showed poorly-expanded lung fields occupying less of the thorax than expected despite high ventilator pressures ( Figure 2 ).
CMV viral load was 410 337 IU / mL ( increased from 286 IU / mL on day of life one ), and ganciclovir was started at this time . Broad spectrum antibiotics were administered due to clinical decompensation with negative blood cultures and a tracheal aspirate that was positive for Serratia marcescens and Acinetobacter species .
High-frequency ventilation was attempted on multiple occasions ; however , the neonate did not tolerate this , requiring chest compressions for bradycardia twice during these trials . The infant was sustained on pressure-control ventilation with mean-airway pressures of 22 , 100 % fraction of inspired oxygen , and 20 parts per million of inhaled nitric oxide . The infant required dopamine and norepinephrine infusions to maintain an adequate blood pressure . After maintaining marginal oxygenation for one week on this support , the infant became progressively edematous and acidotic . Eventually , the infant was unable to achieve oxygen saturations above 60-70 % despite increasing ventilator support . After discussion with the parents , the infant was removed from the ventilator and died within a few minutes . Autopsy was declined .
Conclusion
This case illustrates the findings of pulmonary hypoplasia with progressive development of respiratory failure and pulmonary hypertension , which was ultimately fatal in an infant with congenital CMV infection . Evidence pertaining to prenatal and postnatal treatment options for this condition are limited and more data is needed to guide the management of infants with overwhelming congenital CMV infection .
References
1 . Malm G , Engman ML . Congenital cytomegalovirus infections . Semin Fetal Neonatal Med . 2007 June 01 ; 12 ( 3 ): 154-9 .
2 . Nigro G , Adler SP . Cytomegalovirus infections during pregnancy . Curr Opin Obstet Gynecol . 2011 April 01 ; 23 ( 2 ): 123-8 .
3 . Ross SA , Boppana SB . Congenital cytomegalovirus infection : outcome and diagnosis . Semin Pediatr Infect Dis . 2005 January 01 ; 16 ( 1 ): 44-9 .
4 . Coclite E , Di Natale C , Nigro G . Congenital and perinatal cytomegalovirus lung infection . J Matern Fetal Neonatal Med . 2013 November 01 ; 26 ( 17 ): 1671-5 .
5 . Fujioka K , Morioka I , Nishida K , Morizane M , Tanimura K , Deguchi M , et al . Pulmonary Hypoplasia Caused by Fetal Ascites in Congenital Cytomegalovirus Infection Despite Fetal Therapy . Front Pediatr . 2017 November 06 ; 5:241 .
6 . Chan ES . Massive ascites and severe pulmonary hypoplasia in a premature infant with meconium peritonitis and congenital cytomegalovirus infection . Fetal Pediatr Pathol . 2020 February 01 ; 39 ( 1 ): 71-7 .
7 . Sun CC , Keene CL , Nagey DA . Hepatic fibrosis in congenital cytomegalovirus infection : with fetal ascites and pulmonary hypoplasia . Pediatr Pathol . 1990 ; 10 ( 4 ): 641-6 .
8 . Stocker JT . Congenital cytomegalovirus infection presenting as massive ascites with secondary pulmonary hypoplasia . Hum Pathol . 1985 November 01 ; 16 ( 11 ): 1173-5 .
9 . Laudy JA , Wladimiroff JW . The fetal lung . 2 : Pulmonary hypoplasia . Ultrasound Obstet Gynecol . 2000 October 01 ; 16 ( 5 ): 482-94 . Faure-Bardon V , Magny JF , Parodi M , Couderc S , Garcia P , Maillotte AM , et al . Sequelae of Congenital Cytomegalovirus Following Maternal Primary Infections Are Limited to Those Acquired in the First Trimester of Pregnancy . Clin Infect Dis . 2019 October 15 ; 69 ( 9 ): 1526-32 .
For additional references , email ams @ arkmed . org .
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