br Conclusion This patient was hypercoaguable as evidenced
Conclusion This patient was hypercoaguable as evidenced by a lower extremity DVT, pulmonary emboli, and a splenic infarct. Excluding acute CMV infectious mononucleosis, she had no disorders predisposing to splenic infarcts.4, 5 In this case, CMV infectious mononucleosis was accompanied by CMV lung involvement (by gallium scan) and liver involvement (by gallium scan), and a hypercoagable state, (DVT, pulmonary emboli, splenic infarct).18, 27, 28 The most important clinical clue to the diagnosis of CMV infectious mononucleosis was her marked atypical lymphocytosis.8, 9, 29, 30 Several diseases are associated with atypical lymphocytosis, but only EBV and CMV infectious mononucleosis may have >25% atypical lymphocytes.5, 30 To the best of our knowledge this is the first reported case of CMV infectious mononucleosis occurring in a patient with sarcoidosis complicated by splenic infarct.
Background Cytomegalovirus (CMV) infection is the most common congenital viral infection and leading cause of sensorineural hearing loss and neurodevelopmental impairment in full-term infants . It is also the most common intrauterine and perinatal viral infection among immunocompromised very low birth weight (VLBW) infants causing morbidity and mortality [, ]. CMV infection acquired postnatally may result in severe and possibly life-threatening disease in premature infants [, , ]. CMV can be transmitted through breast milk, saliva, genital secretions, urine and blood [, ]. A recent prospective, multicenter, birth cohort study showed breast milk to be the most common source of CMV infection in very low birth weight infants, rather than blood transfusion . Viral reactivation in the mother and subsequent shedding in breast milk can be seen as early as 2–3 weeks after delivery, peaks at 3–6 weeks and usually ends between 8 and 10 weeks . Freezing of the breast milk for a short time (<7 days) also does not guarantee non-infectivity . Breast milk that has been banked or stored for an extended cysteine protease may need to be tested for CMV DNA to determine the source of the CMV infection. Many studies have looked at short term stability of CMV DNA but not the long-term stability [, ]. In this study, we evaluated the stability of CMV DNA in stored refrigerated (28 days) and frozen breast milk (90 days), which is important if testing samples that have been stored outside the normal parameters or when testing retrospectively.
Results For all samples the internal control was detected in the CMV DNA PCR assay; there was no inhibition of amplification. Table 1 demonstrates the mean log10 IU/ml viral loads at the different time points and different temperatures. The mean viral load of specimens stored at 4 °C on day was 3.73 log10 IU/mL and on day 28 the viral load was 3.70 log10 IU/mL, which was not significantly different. The mean viral load of specimens stored at −20 °C on day was 3.73 log10 IU/ml and 3.79 log10 IU/mL on day 90, which was also not significantly different. The Student’s t-test showed no difference in the CMV viral load values between days 0, 4, 7, 14 and 28 for breast milk stored at 4 °C or between days 0, 4, 7, 14, 28 and 90 for breast milk frozen at −20 °C. Agreement values between time points are listed in Table 2. The Pearson’s correlation coefficient and the CCC between day and day 28 for both frozen and refrigerated samples, as well as between day and day 90 for frozen samples showed high correlation, with values above 0.90.
Discussion The prospective, multicenter, birth cohort study that evaluated blood transfusion and breast milk sources of CMV infection in very low birth weight infants was critical in understanding that the source of CMV infecting very low birthweight infants in the post-natal period could be attributed to breast milk . As a result, testing for CMV DNA in breast milk is likely to have increasing importance in managing these infants. The finding that the CMV DNA is stable in stored human breast milk for such a long duration will encourage other clinical laboratories to test their own relevant samples for presence of human CMV DNA. This in turn would prevent undesired viral transmission through the stored breast milk. This is useful in cases requiring the testing of breast milk that has been banked or stored and when breast feeding has ended or when testing breast milk retrospectively to determine time of CMV exposure.