Cytomegalovirus (CMV): Primary or Recurrent Infection?

Wednesday, September 27, 2006

Kenneth F. Trofatter, Jr., MD, PhD

Perhaps the hardest part of making the diagnosis of CMV infection during pregnancy in mother and baby is simply suspecting that it might be a problem. Certainly, if the woman develops a prolonged (weeks) febrile illness, resembling infectious mononcleosis, and that diagnosis cannot be confirmed by routine testing, then CMV should be high on the differential diagnosis. The ante goes up considerably if the mother is a young teen having her first baby (especially if she conceived shortly after becoming sexually active or changing partners), or if she works, or has another young child, in a high risk setting such as a daycare center.

CMV grows very slowly and the incubation period from the time of exposure to onset of symptoms, or asymptomatic excretion of the virus, is on the order of 4-12 weeks. Serologic testing, which we will discuss in a minute, can often help to confirm a primary infection when it is obtained coincident with maternal symptoms. Virus detection by culture, immunofluorescent techniques, or polymerase chain reaction (PCR), best done by sampling maternal urine, may be positive (and almost always will be for months after a primary infection), but this alone does not tell us if this is a primary symptomatic CMV infection or a recurrent infection accompanying another illness.

Unfortunately, since such a high percentage of primary maternal infections are asymptomatic, or simply confused with another illness, or even written off as normal symptoms of pregnancy, usually the diagnosis is not suspected until the baby is found to be growth restricted or has subtle physical abnormalities, or a thickened placenta, to suggest it has either a chromosomal abnormality or a congenital infection, sometimes months after the maternal exposure. Under these circumstances, maternal serologic testing might not be helpful in establishing either the fetal diagnosis or the diagnosis of a primary maternal infection during pregnancy.

Establishing the presence of fetal infection requires an 'invasive' procedure. Performing a simple amniocentesis, and using any of the techniques noted above for virus detection, can confirm fetal infection with CMV in nearly 100% of cases. (Remember, the amniotic fluid from midtrimester on is mostly fetal urine, and CMV is excreted in large amounts from the kidneys following congenital infection, and often for years afterwards, even in 'asymptomatic' cases). However, unless we have confirmatory maternal serologic information, or symptomatic infection confirmed to be the result of CMV during the pregnancy, we still may not know if the congenital infection is the result of primary or recurrent maternal disease. If the diagnosis of CMV is not suspected until late in pregnancy, or not until after the birth of the baby, detection of CMV in a urine sample taken from the baby within the first two weeks' of life also suffices to confirm congenital infection. CMV is a VERY slow growing virus, so any detection of virus in this time frame most certainly represents intrauterine infection.

Now let's discuss serologic testing because this is where things become even more confusing with CMV. Usually, when we contract a virus infection like the flu, our immune systems react by first producing specific antibodies to the virus of the IgM class. These usually hang around only for no more than 2-4 weeks after the infection has been cleared. Shortly after IgM antibodies begin to be made, our bodies switch to the production of a second class of specific antibodies called IgG. IgG antibodies generally hang around for a long time after the infection is cleared and provide us with a source of 'permanent immunity' to the organism, helping to prevent reinfection, or decrease the severity of a secondary infection, with the same or similar organisms with which the antibodies might 'cross-react.'It is these IgG antibodies that also afford protective immunity to the baby because they can cross the placenta whereas IgM antibodies cannot.

We can use this information to help us to characterize the status of an infection. If neither IgM nor IgG is present, the individual has probably never been exposed to the organism of concern (or is too early in the course of the infection to have mounted any antibody response). If IgM is present and there is no IgG, then the infection is probably a 'primary' infection, indicating first time exposure to the organism, usually very early in its course. If both IgM and IgG are present, this also usually reflects a primary infection, but later in the course of the disease. And, if only IgG is present, then this indicates a state of permanent immunity established from an infection that occurred at some time in the past. In any of the first three circumstances, if an infection with a specific organism is suspected and could be of concern for a pregnancy, it is probably worth repeating the antibody titers in 4-6 weeks. In the case of CMV, IgG antibodies usually can be detected by 1-2 weeks after the onset of symptomatic infections, but because of the long incubation period of CMV, this might be a month or more after actual exposure to the virus. Rising and falling antibody titers can also help to characterize the status of an infection.

With CMV infections, things are a little trickier. The presence of IgM in the absence of IgG and in the presence of symptomatic disease (or a history of recent exposure to a known carrier) is highly presumptive of a true 'primary infection.' Similarly, the findings of both IgM and IgG with a significant rise (four-fold or more) in IgG titers (with or without a fall in IgM titers) on a follow-up screen 4-6 weeks later, usually (but not always in the case of CMV) indicates a recent primary infection. Also useful, the presence of IgG in the absence of IgM, is highly suggestive of a remote exposure to the virus, often greater than 6 months previously.

The rub with serology in classifying CMV infections comes in most often when IgM is present but IgG titers are relatively stable or mildly fluctuating. Unlike most common viral infections, CMV-specific IgM can sometimes persist 6-9 months following its appearance. And to make things even more confusing, IgM has been found to reappear on occasion with reactivation of latent CMV infections. In otherwords, except in the circumstances detailed above, we may not be able to use the presence of IgM in our counseling to tell patients that they have had a primary or recurrent infection during the pregnancy or if the infection might have occurred even prior to the current pregnancy.

Ascertaining the status of a maternal infection as primary or recurrent, when we can do it, helps in counseling the patient. Babies contracting CMV as the result of recurrent infections are much less likely to suffer the severe sequelae associated with congenital CMV. Congenital CMV infections associated with primary maternal infections early in pregnancy and accompanied by growth restriction and detectable abnormalities by fetal ultrasound, generally, have a very poor prognosis, but even then, the outcome is not entirely predictable....

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68 Comments:

At Tue Jul 10, 12:43:00 PM 2007, angel said…

my son was born with congenital cmv and was given 2 months to live however a year on he is doin well and is only partially deaf and sighted,nothing we cant get through together
At Fri Jul 13, 07:29:00 AM 2007, Kenneth F. Trofatter, Jr., MD, PhD said…

Angel: Thanks for sharing your personal story and comments. I try to make folks understand that the outcome with congenital CMV infection, even with primary infections as I am sure yours was, is highly variable. You are a special person. Thanks for reading!
At Sat Jul 21, 07:26:00 AM 2007, channy_1985 said…

Angel: My son was born by emergency c-section 17 days ago because he had stopped moving and was found to have congenital cmv.
I am desperatly looking for people in the same position to talk to as i am terrified for my sons future.
Please email me at:
channy_1985@yahoo.com.au
Thanks, Chantelle.
At Mon Jul 23, 09:13:00 PM 2007, Kenneth F. Trofatter, Jr., MD, PhD said…

Chantelle,

Below are links to the National Congenital CMV Disease Registry in the U.S. and another support group in the U.K. I hope this helps.

http://www.bcm.edu/pediatrics/index.cfm?Realm=99991126&This_Template=q_cmvsupportgroup

http://www.patient.co.uk/showdoc.asp?doc=26738769

Best of luck to you and your family.

Dr T
At Tue Oct 23, 07:00:00 PM 2007, Tracy said…

I am 33 weeks along and found out at 29 weeks that my baby has congenital CMV. At my 18 week ultrasound we discovered that my baby had IUGR and echogenic bowel. I had blood work done at that time that showed IgG present so I was told that I had previously been infected but no IgM was shown at that time. My baby continued to fall into the smaller percentages being total less than 10th percentile with his head less than 3rd percentile. At 29 weeks I had an amnio done which confirmed high levels of CMV. I was told that this was a recurrent infection with very small chance of the baby having any symptoms. Since then the baby has an enlarged ventricle in his brain and fluid around his brain. The doctors are now saying they believe this is a primary infection because of all the symptoms that are present. My question is how can this be a primary infection if at 18 weeks IgG was present but no IgM? They are planning on inducing at 37 weeks and I am desparately trying to prepare myself for wait lays ahead.
At Fri Oct 26, 04:42:00 PM 2007, Kenneth F. Trofatter, Jr., MD, PhD said…

To Tracy Oct 23: This is almost CERTAINLY a primary CMV infection. The infection could have occurred early in the pregnancy or even just before conception and that's why the IgM was no longer present. The other possibility is that you became infected with another strain of CMV than what you might have had before. Any future pregnancies should be at very low risk for severe complications if you are otherwise healthy. Best wishes and we will be thinking about and praying for you. Dr T
At Wed Dec 12, 01:11:00 AM 2007, johanna said…

Two weeks before conception CMV was found, IgG was 176 and IgM negative.
When I was 5 weeks pregnant I was tested again and my IgG level had raised to 190 and IgM was postive. According to my doctor it meant that I got a primary infection during the first weeks of pregnancy, but after reading your article I am not so sure . It seems quite complicated.
At Fri Dec 14, 03:54:00 PM 2007, Kenneth F. Trofatter, Jr., MD, PhD said…

To Johanna Dec 12: No,you had CMV BEFORE you ever conceived and that should put the current pregnancy at very low risk for the most severe complications related to congenital CMV infection. Remember, IgM is the first antibody type to respond to a new infection and that is followed by IgG. Since you had high IgG titers BEFORE conception, you must have contracted the virus before you got pregnant. That small increase in the IgM titer is not unusual with CMV and most providers do not know that. So, don't panic under these circumstances and if your doctor has any questions, have him/her give me a call. Good luck with your pregnancy and thanks for your question! Dr T
At Tue Jan 15, 09:54:00 PM 2008, Edward said…

My son is in day care and was diagnosed with CMV when my wife was 24 weeks (SON - IGG 1.77, IGM 2.93) (POS >1.11, NEG <0.9). Therefore he was positive for IGG and IGM. One week after the detection my wife was tested for CMV ( WIFE – IGG 3.01, IGM 0.31) (POS >1.11, NEG <0.9) Therefore, she was positive for IGG and negative for IGM , as I understand it. We have previously seen a perineonatologist , and the ultrasounds looked fine. We are going to schedule another visit after news of the CMV. From what I read, CMV IGM stays in the body for 6-9 months. What determinations can we make regarding a primary or recurrent infection? What can be said for my son’s high level of IGM, and my wife’s low level of IGM? Is that a good indication that my wife did not contract it from my daycare son?
At Wed Jan 16, 07:35:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Edward Jan 15: Yes, your wife is immune to CMV and her immunity preceded your son's recent infection. Unfortunately, we don't know when she contracted CMV to begin with, eiether before or early in the current pregnancy. The odds are she got it before and if this baby is growing well, it is unlikely to be severly affected even if it does get a congenital CMV infection. I would suggest screening the baby for CMV within the week after delivery, and if the baby is CMV-positive, but otherwise 'normal' simply keep up with regular hearing and eye examinations. Thanks for your question. I am sure other readers will benefit from your experience. If you think of it, let me know how things turn out. Best wishes. Dr T
At Wed Feb 13, 07:14:00 PM 2008, jrich78 said…

I am completely confused. I work in the hospital and was exposed to CMV but am unsure of when (Prior to or after conception). I'm currently 12 weeks pregnant. I called my MD for results but I do not know what to make of them. My Igg is 156 and my Igm is 1.5. I can't find numbers anywhere to help me figure this out. The ranges they gave me for Igg are 1-10 and Igm 0-.8. Mine are way outside. I think if I was exposed before my Igg would be high, but I don't know what a high number is. Does this seem like a primary or secondary exposure. Please help!
At Fri Feb 22, 06:29:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To jrich78: Unfortunately, with that high level of IgG, it is hard to say whether that is the result of a recent exposure (before or after you conceived) or simply the consequence of 'reexposure' and a secondary or 'anamnestic' antibody response (similar to what you would get with repeated doses of a vaccine). If the latter is true, then the baby is at low risk for a severe CMV infection. The IgM does not help us sort this out because it is such a low titere and as mentioned in my discussion, this could represent the tail-end of a primary infection or simply the periodic slight bump in IgM that can occur with CMV infetions, perhaps as a consequence of reactivation recurrences. You could find out (best done during the pregnancy by amniocentesis and PCR specific for CMV or after the pregnancy by sampling the baby's urine) if the baby has a congenital CMV infection, but as we also have discussed, unless the baby has some signs of severe disease (growth restriction and physical abnormalities, both detectable by ultrasound), we cannot predict the degree of compromise (IF ANY) might occur as a result of the infection. If the baby has this as the consequence of a simple reactivation recurrence on your part (while you had protective IgG), then usually the only follow-up needed is periodic vision and hearing checks and developmental milestones. Good luck. Let us know what you decide to do and the outcome. Thanks for writing and sorry I cannot be of more help at this time. Dr T
At Tue Mar 11, 12:42:00 PM 2008, Anonymous said…

I have a question. My cousin’s daughter got CMV about a year ago from a Liver transplant. I saw her about 6 months latter at my wedding. 2 months after my wedding I got pregnant. My doctor never tested me for CMV, so I don't know if I had prior immunity or not. I was just concerned as to the risks to the baby sense I was exposed to CMV 2 months before my pregnancy. I amcurrently 18 weeks pregnant.
At Wed Mar 12, 06:00:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Mar 11: there is a reasonable chance you were/are already immune. And, if you had contracted the virus as a result of contact with that child, there is also a reasonable chance you developed protective immunity before you got far enough along in the pregnancy for it to be a major problem. If your pregnancy is going well and the baby is growing normally and has no abnormalities, channces are everything is fine. I do not even know if I would recommend testing you for CMV antibodies at this point, however, you may want to do that after the delivery because if you are NOT immune at that time, you are at increased risk for being exposed over time by your own child! If you spend anymore time with you cousin's daughter during the pregnancy you might also be a little more careful. CMV isn't contagious by air-borne transmission like the flu or chickenpox, but it is readily transmitted by body fluids. Good luck with your pregnancy and let us know how things turn out! Dr T
At Sat Mar 15, 01:24:00 PM 2008, Anonymous said…

I have a 3 and 1/2 year old who is severely affected by cCMV. She got the full meal deal from this nasty virus. I am now 6 weeks pregnant. I have already had 2 boughts with fever and body aches and sore throat. Strep was diagnosed through testing the first time (2 weeks pregnant), and I don't have a diagnosis of why I experienced this second bout. I went to the doctor and had the flu and strep tests, and both were negative. Of course, I am freaking out about a possible reactivation or another strain of CMV. It is so early in my pregnancy. Please send me some helpful information. Should I have a CMV test? Thank you so much, Ashley
At Mon Mar 17, 07:27:00 AM 2008, Anonymous said…

I lost my son to a primary cmv infection back in November 2007. I really want to try for another baby but my Consultant here in the UK says that I can not try until all evidence of IgM has gone from my bloods. Is that the case? If I wanted my Consultant to contact you as he has little or no information on cmv how best would he do that?
At Wed Mar 19, 07:00:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Anonymous March 17: You should have plenty of IgG (permanent immunity to CMV) at this point and should therefore be at VERY low risk for having a baby who is severely affected by CMV. IgM can hang around for a long time following CMV infections and can even reappear for reasons that are unclear. If you wait until you never have IgM, it may be a long time before you can try to get pregnant again. Your doctor can reach me through this website if he/she is concerned about my recommendation. Dr T
At Fri Mar 21, 06:45:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Ashley Mar 15: You don't need to have another CMV test done at this time. You had a baby with CMV, so you have CMV (and probably always will), but now you also have the immunity that should protect your current pregnancy from the more severe form of the infection that your first child had. Can this baby also get CMV? Yes and there is a 1-2% chance of that, but even if it does, he/she will probably do just need periodic follow-up of hearing and eye exams after birth. Best of luck and try to relax. The odds are in your favor that everything will be just fine! Dr T
At Tue Apr 22, 11:01:00 AM 2008, Anonymous said…

I was recently told that i contracted CMV in my first or second month of pregancy. What are the chances that the baby will have CMV? If the fetus is infected with CMV, what are the chances of disabilities resulting from the virus?
At Tue Apr 22, 03:57:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Apr 22: Why do your doctors believe you contrcated CMV during your first or second month. Were you ill or did you simply have "exposure to CMV" and then had the antibody testing done? And, what were the actual test results. If you truly had a primary (very first time) infection with CMV during pregnancy, transmission rates range between 25-50% at some time during the pregnancy, but the actual affects on the baby are highly variable and somewhat unpredictable, ranging from death to no untoward effects whatsoever. To some degree, that is probably determined by the amount of protective immunity you had developed at the time the baby was actually exposed to the virus. You commented under one of my posts in September 2006 and I had one or two others that accompanied that one and several other follow-ups in repsonse t readers' questions since then. Check those out and then see if you have any other questions. The NIH also has a site devoted to CMV so you can look for that online as well. in fact, I think I have a link to that site in one of my posts. Good luck to you and let us know how things turn out. Dr T
At Wed Apr 30, 03:22:00 PM 2008, Melissa said…

I am 35 weeks pregnant and was tested for the first time about 13 weeks ago for CMV. I have been tested 3 times now, and each result shows positive for IgM, but negative for IgG. Is it possible that the IgG would take so long to develop? Also, I was diagnosed a year ago with rheumatoid arthritis (no rheumatoid factor has ever been present). Could this illness have any affect on the CMV results?
Thank you.
At Thu May 01, 06:26:00 AM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Melissa Apr 30: Why were you first tested for CMV 13 weeks ago and what have those antibody titers done over time (increased, decerased, stayed the same?)? Also, why did your doctors think you had rheumatoid arthritis (i.e., what were the signs and symptoms at the time) and what kind of testing did you have done? Have you ever been screened for HIV, Epstein-Barr, or Parvovirus B19 virus infections?

It is not unusual to have a prolonged IgM response with primary CMV infections, but usually, by this time, most individuals will have at least some detecatble IgG as well. It is possible that you might have some 'defect' in your immune response that delays your reaction to CMV and perhaps other foreign antigens, especially if you have an underlying autoimmune disorder of some sort. It is also possible that you don't have CMV at all but have, instead, some other infection, or autoimmune condition, that produces antibodies that cross-react with CMV. This is all very fascinating to me, so any feedback you can give me would be MUCH APPRECIATED. I would recommend that you baby be tested shortly after birt to see if he/she has a congenital CMV infection. This is BEST DONE, not by serology, but by screening the baby's urine for the virus by culture or PCR techniques. The reason I am concerned is that if you really have CMV, and do not make IgG, then your baby will be born without any 'acquired protection' against the virus that it would have ordinarily gotten from you. IgG, but not IgM, crosses the placenta. Please stay in touch and let me know as you find things out. This is a very special area of interest to me. Thank you for writing and best wishes! Dr T
At Wed May 14, 08:06:00 AM 2008, Melissa said…

Dear Dr. T -
Sorry about the delay in responding. I actually delivered the day after my post. My baby was early, but healthy. All of his functiioning is great and there are no signs of CMV (although I know that effects can happen much later). They did take urine and swab for PCR cultures for CMV, but the results are still pending.

As answers to some of your questions, the IgM levels stayed basically the same over the three tests. I was originally tested due to a slightly echogenic bowel for my baby in his sonogram (which the specialist then felt was flagged unnecessarily).

I was diagnosed with rhuematoid arthritis after experiencing continued joint swelling, pain, and stiffness. I was tested for HIV, Epstein-Barr, or Parvovirus B19 virus infections, with negative results. Since the symptoms were symmetrical and responded to the Plaquenil that I take, my rheumatologist continued with the RA diagnosis. I have since shared with him my CMV results, and he said he wasn't aware of any connection. I asked him to have me tested again in a little while, so that I can see if there are any IgG antibodies present.

I will get back to you when I find out the CMV results for my baby. If you have any suggestions of other testing or connection to autoimmune, I would appreciate it. Thanks for your time and interest!
--Melissa
At Thu May 15, 05:56:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Melissa: CMV infections can sometimes be associated with the transient production of autoantibodies. Let me know what the final test results are on your baby. Thanks again for writing and sharing your experiences. Dr T
At Sun Jun 01, 11:13:00 AM 2008, Melissa said…

Dr. T -
My baby's results for CMV came back negative from both the urine and nasal swab. Just wanted to share that good news.
Thanks,
Melissa
At Tue Jun 03, 06:54:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Melissa: That IS good news. Thanks for letting me know. Have fun with your baby! Dr T
At Sat Jun 07, 02:23:00 PM 2008, joanna said…

Hi there

I have just been diagnosed with CMV by my midwife and tested + for both IGG and IGM antibodies. At the time of the blood draw I was 6 weeks pregnant (6 weeks LMP). I have an appointment this Monday with a Perinatologist and will not find out the levels of each antibody until then. However, having done some reading on the topic (actually alot of reading because I am pretty worried!) I was wondering about the notion of testing for IGG Avidity in order to determine if I have a primary or recurrent infection. Here are my questions:

1) Could IGG adivity testing tell me anymore about my CMV infection (ie. primary VS recurrent)?

2) If so, what labs do the testing? I live in northern New Mexico and when I went on-line to look at the lab tests performed by the lab in my area it did not seem to do IGG avidity testing.

3) Is there any thing you can tell me about my the possibility of a congenital CVM infection in my baby given the info I have passed along? When I get the results of antibody testing on Monday I will forward the new info too.

4) Last one. I also have the disease Ulcerative Colitis and I had a really bad time with it this past winter. It was finally in remission by about the beginning of March and I got pregnant April 9-10 (I was charting so know when I ovulated). I read about some associations between colitis and CMV and you have discussed autoimmune diseases (big debate as to whether UC is autoimmune) in relation to worsened or recurrent CMV and a greater liklihood of a more severe congential infection if it occurs. Do you have any info on CMV and UC? Does the fact that I have UC shed any more light on my pregnancy and CMV?

Thank you for your time. Actually, your writing on this topic is the most comprehensive and helpful that I have found so far.

Joanna
At Tue Jun 17, 04:20:00 PM 2008, River said…

Dear Doc, I was diagnosed with CMV in February whilst pregnant. I miscarriaged at about 7weeks and have been advised not to get pregnant again for at least 4-6 months from infection. However, they have no idea when I may have been infected; I have had symptoms since last august which have continued on and off to date including lumps in neck and/or armpits and headaches, fatigue and lost of appetite. The last blood test results showed both IgG and IgM to be present and a low virus load of < 10 copies.
The question is: why am I still having symptoms and when will it actually be safe to conceive again in light of my persistent symptoms. Awaiting latest blood result due next week. What should I be looking for? Thanks River
At Sat Jun 21, 05:55:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To River: I am NOT worried about the CMV at this point, but I AM worried about your other complaints. Have you been screened for HIV and Epstein-Barr virus? Have you had any blood work done to look at your white blood count and morphology, liver function tests, thyroid function, blood sugar, etc. Have you seen a hematologist to check out those lymph nodes. They may need to be biopsied. My point is this, get in to see someone who will look past the CMV infection that probably had NOTHING to do with your miscarriage! Please let us know what you find out. Dr T
At Mon Jun 23, 10:14:00 PM 2008, Anonymous said…

Dear Doctor Trofatter,
I am going in my 20th week of pregnancy and I had the Igg and Igm antibody screens done last week as a preventative measure because we are going to have a child at my jobsite with active CMV in the coming weeks. I was told I am "immune" based on my Igm results being negative (no value given) and my Igg being positive (1.91 was the value). My OB could only tell me that I have not recently gotten the CMV virus but that I could have gotten it within the past 4-6 months. Can you tell me how she came to this conclusion? I am a little worried because I have been pregnant for 5 months which means there is a possibility I contracted it during early pregnancy. Is there really any way of knowing when I contracted CMV based on the Igg level? For instance, does it go up with time? Thank you very much for your time. I look forward to your response.
At Thu Jun 26, 06:01:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous June 23: Yes, you could have gotten it in the last 6 months, but more likely you had it BEFORE you ever got pregnant - most people do, especially if they work around young children. The IgG titers usually do not fluctuate much with time. If I were you, I would be comforted rather than scared by the results! Good luck for the rest of the pregnancy! Dr T
At Fri Jul 25, 12:09:00 PM 2008, Anonymous said…

Dear Dr. T, I was just recently diagnosed with active CMV IgM and IgG positive, they did not perform titers. I was having mono like symptoms for 3 weeks. I was trying to get pregnant. When is safe to resume my efforts to conceive?
At Fri Jul 25, 03:43:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonympus July 25: It is probably prudent to hold off conceiving until you have well-established permanent immunity - if you are young and healthy, waiting 4-6 months is probably a good idea since this is most likely a true primary infection.
Dr T
At Thu Aug 14, 12:44:00 PM 2008, Anonymous said…

I had mononucleosis kind of symphtoms in May. I was diagnosed with CMV: Igm positive and IgG positive. I was tested again two days ago and both IgM and IgG are still positive. The levels have stayed the same. My doctor told me that it would be safe to conceive as the IgG test was positive. What is your opinion?
At Sat Aug 16, 08:42:00 AM 2008, Anonymous said…

Last week I miscarried at 24 weeks. At 8 weeks I was tested for CMV and the test came back negative. I was tested again at 23 weeks and the test came back positive with my IgM at 172. Now a week later, I feel extremely tired and listless. In your opinion was this a primary case?
At Sat Aug 16, 07:30:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Aug 14: I agree with your doctor. The IgG will help provide protection and decrease the risk of a severe CMV infection in your baby. Best wishes. Dr T
At Tue Aug 26, 07:04:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Aug 16: It certainly could be and most likely is a case of primary CMV. I am sorry you lost the baby. Was the baby tested as well? Dr T
At Thu Aug 28, 06:29:00 AM 2008, Anonymous said…

Dear Doctor,
I am a 33 year old who is eager to have a 2nd child as it took 5 months to conceive the first one. I was having monolike symptoms in the beginning of July, was tested for CMV. Titers were not performed but IgM and IgG were positive. IgM and IgG negative in the past (January). When is it safe to conceive again, and should I have titers performed prior to trying.
At Tue Sep 02, 10:19:00 AM 2008, Anonymous said…

Hello, I am currently 10 weeks pregnant and at 6 weeks I was hospitalized twice for fever, headache, vasculitis (LCV), joint-muscle pain, fatigue and decreased appetite. I had elevated LFTs, +ANA, +anti-smith antibodies, elevated RNP, +cryoglobulins, elevated sed rate, decreased WBC and decreased H/H. I have a hx of MCTD with Sjogrens and Raynauds but in the past 11 years have had no significant problems (I am currently 29). I have had mono (EBV) in the past (age 21) and while hospitalized the mono spot test was positive. As the physicians were not sure what the origin of the fever was or the elevation of LFTs in relation to the autoimmune disease vs. infection, I was also tested for CMV which revealed both IgG and IgM. I am a nurse and believe that I have been exposed in the past (I work & have worked with a lot of oncology and HIV patients). I myself was negative for parvovirus, HIV, hepatitis C, etc. I am writing because while I am starting to feel better my husband has had a fever now for 12 days, in addition to anterior and posterior cervical lymphadenopathy and spleen enlargement. His CBC was WNL and his mono spot test was negative. He is experiencing fever, fatigue and 10 lb weight loss in the past 2 weeks. I asked his doctor today to do EBV and CMV titers. Do you have any thoughts about the risk of infection to the fetus? Is there anything I should ask specifically of the OB-GYN during the next visit? We do have a 2 year old daughter in day care who had some sniffles-cough-sneezing, etc. week 5 of the pregnancy.
Thanks!
At Tue Sep 02, 04:14:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Sept 2: Odds are that he has either CMV or EBV. That may or may not explain your fever and illness since you have an autoimmune condition. However, if her does seroconvert, there is a high likelihood he got either one of those viruses from you or your young child. Let me know what you find out and then I will tell you my thoughts on risk to your baby. Wishing you the best of luck. Dr T
At Wed Sep 03, 05:28:00 AM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Aug 28: You have contracted CMV between pregnancies which is definitely the way to go. You should have sufficient IgG titers (and they do not need to be repeated unless you want them to be) in 4-6 months to be protective for another baby. Remember, that baby (and any others you may have) could still get a 'congenital CMV' infection, but the chance of a severe infection will be relatively small because of the protective antibodies. Good luck and thanks for reading! Dr T
At Thu Sep 04, 12:03:00 AM 2008, Jen said…

Hi Dr T. My question is repetitive from previous posts but I would appreciate your response to my particular situation. I was tested for CMV 4 weeks ago as part of investigation into 2 miscarriages over the past 5 months (20wks and 12wks). My results were positive for both IgM and IgG (no levels given). I have no idea how long ago I had the virus.

My question is this: I would dearly love to conceive again as soon as possible. How long do I have to wait? My doctor said it was OK to try again straight away but I have seen your response about waiting 4-6 months so am now confused!

Thanks, Jen
At Sat Sep 06, 10:19:00 PM 2008, Anonymous said…

My sister just found out this week she has a case of primary CMV, she is 18weeks 5 days pregnant. The doctor advised her that it is a recent case. I do not know her levels. What are the chances the baby will have any effects from this virus. She had her 18wk scan and the baby appeared to be developing at a normal rate and did not apear to suffer physically at present. Can you offer me some information or sites for her to visit. She has been advised to have a amniocentisis but is unsure. Thanks Kim
At Sun Sep 14, 10:18:00 PM 2008, Jacquelyn said…

Hello, I was hoping you could give me some insight. I have been diagnosed with CMV and I am 9 weeks pregnant. I was exposed to a child with congenital CMV (at 4 1/2 weeks pregnant) and had my blood drawn 1 week after exposure (IgG 3.2, IgM 52.9) and again two weeks later (IgG 3.8 and IgM 75). What is your interpretation of these results? I have a 2 year old in daycare and I have worked with special needs children the last 4 1/2 years. Can CVS be used to determine if CMV has infected the fetus. I was told amniocentesis can give false negatives, I would need to have the amnio before 22 weeks. I am very early in my pregnancy and it seems like there will never be a way to determine if the fetus is infected. It seems like I am a rare case and my MD (and perinatal specialist) has not seen a lot of this since most women never know. If this is a recurrent infection research is showing that the prior immunity does does protect the fetus as much as previously thought. If something happened with this pregnancy (miscarriage or termination) how long is advised to wait before conceiving again (if this a recurrent infection)?
At Mon Sep 22, 06:19:00 AM 2008, Vicky N said…

I am currently 22 weeks pregnant. At my 20 week scan it was shown that the baby had dilated kidneys (left kidney 16.7mm, right kidney about 6.2mm). We had a more detailed scan a week later, results showing kidneys were slightly worse but left brain ventrical was slightly swollen at 10.7mm). We were referred to a more specialised hospital whose results were a blockage on the left kidney, both kidneys appear very bright with cysts - but nothing wrong with brain. We were then asked to come back for a repeat scan in 4 weeks.

The day after, my mid-wife rang to say I came back as positive for CMV. We are currently waiting for results on an amnio (first part of amnio came back as fine - it is the 10 day results we are now waiting for to see if baby has the virus).

However, I also have a genital wart at the moment. I first had them in 2000, was treated for them at the time, and they caused no problem until I found out I was pregnant, when they seemed to have re-surfaced.

My question is, could this be the cause of my CMV, and would this be a recurring infection which would deem the baby at a lower percentage of risk. Also, is it probable that the kidney problem is caused by the infection.

I appreciate that as I don't know yet if the baby is CMV positive, it is difficult to comment, but I am at my whit's end and if termination is necessary then I need to make that decision asap.

Thanks, Vicky
At Tue Sep 23, 07:28:00 AM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Sept 6: Can you tell me why your sister was tested for CMV to begin with and what were the test results? regardless, if this is a true "promary" CMV infection, there is a 25-50% chance that the baby will develop a congenital infection, but the severity of that infection, should it even occur, is highly variable. Two sites to go to for more information are the CDC (http://www.cdc.gov/cmv/) and the National CMV Registry (http://www.bcm.edu/pedi/infect/cmv/cmvbroch.htm). Please let us know what you find out about your sister's pregnancy and wish her my best! Dr T
At Tue Sep 23, 07:37:00 AM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Jacquelyn: If you had blood drawn only one week after exposure, you would not have been expected to have IgG present. CMV is a very slow growing virus and it usually takes weeks before getting IgG. So, you were either exposed for the first time even earlier (perhaps even before the pregnancy) or this is a 'recurrent' infection in which you happened to bounce your IgM titers up as will sometimes happen with CMV. The other possibility (though less likely) is that you were exposed to a different strain of CMV that may or may not have cross-reactive immunity to the first strain you already had immunity to. Amniocentesis is actually VERY reliable in picking up congenital CMV infections (although more than one may be necessary) by using CMV PCR assays, but again, that will not necessarily tell you if the baby has developed its infection as the result of a primary or recurrent infection on your part. Ultrasound assessment of fetal growth and certain abnormalities can give you some insight into the degree to which the baby has been damaged by CMV, but this too is not entrirely predictive of outcome. Despite some of the recent literature, most babies are usually very well protected against severe infections if you have prior immunity. Please let us know how things turn out. Best wishes. Dr T
At Wed Sep 24, 09:15:00 AM 2008, Jacquelyn said…

Thank you for responding Dr. Trofatter. You mention more than one amnio. may be needed. First of all why would you want more than one and when would be the best time to have the amnios? I am having an avidity test run, could this tell me if I was exposed to a different strain. When I was exposed it was by a child born with congenital CMV (although I was not told of his diagnosis. Also are recuurent infections the body being re-exposed to the same strain or the body naturally spiking.
Thank you.
At Fri Sep 26, 09:38:00 AM 2008, Anonymous said…

So is it less risky to be infected prior to pregnancy (one week)or later in pregnancy? I was exposed in the NICU one week after conception. My result of my titer have not come back yet.
At Fri Sep 26, 05:10:00 PM 2008, Michelle said…

My baby was diagnosed at 18 weeks with echogenic bowel. Risk of down syndrome is very small, and we are not carriers for cystic fibrosis. Taxoplasmosis negative also. I just got lab results for CMV. I am IgM negative at 0.33, but IgG positive at 3.86. My perinatologist does not feel that he can rule out a primary infection during pregnancy, although I've read that a negative IgM with positive IgG suggests a primary infection over 6 months previously. He was more conservative with his opinion due to the high IgG number.

What are the risks that this could be a primary infection, and therefore one that could cause neurological damage to my baby? Can you make a determination regarding the infection from these results?

Thank you
At Mon Sep 29, 07:56:00 PM 2008, Anonymous said…

Anonymous Sep 6th 2008

Thankyou for your response... my sister has decided against the amnio as she is definately continuing the pregnancy no matter the outcome. The midwives here sent her for complete blood tests as she is a child care worker working in the under 2's age group. She was advised that this was a very recent case of CMV and thet yes it was a case of primary infection. She is being monitored closely and has 3 weekly check-ups to ensure his growth is maintained. We are all staying positive that the little boy stays healthy right through til the end... Thankyou for the sites and i will send further her results once i get them off her and update you on the end result. Kim
At Tue Sep 30, 03:30:00 AM 2008, Diana said…

Hello, on the 8th of September I was tested for CMV. The results are:IgM POSITIVE (0.690) - reference levels - <0.399: negative 0.400-0.499: echivoc >0.500: pozitive
IGG POSITIVE (141.5)-reference levels- <15 AU/ml: negative >15 AU/ml: pozitive
I am not pregnant, but we really want to conceive as soon as possible. Can you please advise me if it is safe to have a baby taking into consideration the results or should we wait for IgM to become negative?
Best regards.
At Fri Oct 03, 12:13:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Jen Sept 4: Forgive the delay in my response, but I just received your comment from Healthline this week. It would be very helpful to know the titers of the IgG and IgM to help diferentiate whether this is a true primary infection or simply a recuurent infection (with a spike in IgM antibodies). If it is the latter, you can go ahead and get pregnant anytime. If it is the former, I like to wait a few months until your body develops stronger (higher avidity) IgG antibodies (permanent immunity) to minimze the risk that a baby will develop a significant congenital CMV infection. Thanks for reading! Dr T
At Fri Oct 03, 12:19:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Vicky: Your genital warts are caused by a different group of viruses - human papillomaviruses (HPV). Once you are infected with HPV, you might carry the virus for a long time with your immune system keeping things in check. During pregnancy, your cell-mediated immune response may be blunted enough to allow the virus to sart growing again. A wart is visible evidence of HPV replication. The HPV types that cause genital warts rarely cause problems with babies and they do not cause ANY of the complications that are being found with your baby now. CMV on the otherhand is a common cause of these same findings. Please let me know what you find out about the amnio and I may have some other thoughts to share. Best wishes. Dr T
At Fri Oct 03, 12:23:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To jacquelyn: You may need more than one amnio if the first does not confirm a CMV infection - although in most cases, one will do so if the baby has congenital CMV. The avidity test may help clarify the source or timing of the infection. Most recurrent infections are the result of reactivation of the virus that is already present in your body and not reexposure. Let us know what you find out. Dr T
At Fri Oct 03, 12:25:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Sept 26: The longer it is prior to pregnancy that you ocntract CMV, the less is the likelihood that the baby will have a severe congenital CMV infection. Primary infections during the first few weeks of a pregnancy can be very bad if the baby contracts the virus. Dr T
At Fri Oct 03, 12:28:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Michelle: The odds are that you contracted CMV before the pregnancy, but as you have been told, there is not 100% certainty of that. However, even if you confirmed the baby has a congenital CMV infection under these circumstances, we cannot predict whether or not the baby will suffer severe neurologic compromise - especially if your infection preceded the pregnancy. Best wishes and let us know how things turn out. Dr T
At Fri Oct 03, 12:29:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Kim: Thank you for the follow-up and I look forward to hearing back from yoou again. Dr T
At Fri Oct 03, 12:32:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Diana: At that level of IgG, you are probably safe to get pregnant anytime. It might be worth waiting just a couple of months just in case this has been a very recent primary infection. The IgG antibody becomes more protective (has a higher avidity) for the virus as time goes by. Thanks for reading!
Dr T
At Sat Oct 04, 12:50:00 PM 2008, Anonymous said…

hello, i'm 12 weeks pregnant. just recently recieved blood work back.. cmv levels are igg 9.8 and igm 1.1. I did have a u/s done a week ago and everything was fine. please help.
At Tue Oct 07, 06:25:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Oct 4: Why did you have CMV levels done? Unfortunately those results do not tell us when you actually contracted CMV or what risk this prgenancy be at for congenital CMV. Dr T
At Wed Oct 08, 11:58:00 AM 2008, Jacquelyn said…

Dr. Trofatter,
I received my results from my avidity test and it was .62. One week after exposure my IgG and IgM were 3.2 and 52.9 2 weeks after that 3.8 and 75, and 2 weeks after that 3.3 and 45. What are the chances of this passing to my baby? The avidity test was completed at 10 weeks. Thank you.
At Fri Oct 10, 03:34:00 AM 2008, Anonymous said…

i had these levels done cause it was part of my prenatal blood work that my ob did.. i'm not feeling sick in any way.. but i do remember getting sick well over 6 months ago with a really bad sore throat i couldn't even swollow, chills and very tired. maybe that is when i incountered the virus. i do have a 3 year old in daycare. he has been in daycare since he was 6 months old...could it be that my igm level at 1.1 is just my normal or does this level take a long time for it to go back to normal.. nikki
At Sat Oct 11, 10:41:00 AM 2008, Anonymous said…

i wrote you back but i don't see it posted yet... did you not get it?? please let me know..nikki
At Fri Oct 31, 06:24:00 PM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To nikki: I just NOW got your posts. I am sorry for the delay. That illness you had 6 months ago may well have been a primary CMV infection. It can sometimes take a long time for the IgM titers to fall and then again, sometimes they will rise again sporadically with CMV. If that was indeed you primary exposure, you should have had plenty of time to develop protective IgG antibodies for pregnancy. Best wishes and again, I am sorry it took so long to get back in touch. Dr T
At Sat Nov 01, 09:48:00 AM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To Jacquelyn: Hello again. I am still hoping you actually contracted CMV before the pregnancy and had some protective immunity on board. In that case the baby has probably a 1-2% chance of having a congenital CMV infection, but a much lower risk of a sever problem related to the same. I am curious as to how things turn out in your case, so please stay in touch and let us know as the pregnancy progresses. Best wishes. Dr T
At Tue Nov 25, 06:10:00 AM 2008, Anonymous said…

Hi I need some advice I am 15 weeks pregnant and I live in Italy. I have been tested twice for CMV the first results came back as IGG 35 IGM 0.64, i have since been tested again and the results have now come back as IGG 145 and IGM 0.64. In Italy they do not explain the results to you when you collect them and so I am worried that with the jump in IGG I have a primary infection. I do not see my doctor until next monday, please help me make sense of the results! Tnanks
At Fri Nov 28, 11:06:00 AM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…

To anonymous Nov 25: Tell me why you had the testing done to begin with. This could be the late recovery phase of a primary infection or simply evidence of previous infection at some time in the remote past. Best wishes. Dr T

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Cytomegalovirus (CMV): Primary or Recurrent Infection?

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