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ORIGINAL ARTICLE Table of Contents   
Year : 2009  |  Volume : 52  |  Issue : 1  |  Page : 46-48
Congenital rubella and cytomegalovirus infections in and around Chandigarh


Department of Virology, Post Graduate Institute of Medical Education and Research, Chandigarh 160 012, India

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   Abstract 

Aims: This study has analyzed the role of rubella and cytomegalovirus (CMV) in infections of children and pregnant women. Settings and Design: The study was carried out in a tertiary care hospital. Data from blood samples from pregnant women (asymptomatic and also women with obstetric problems) and children (suspected of intrauterine infections) that were received in the laboratory over a period of 8 years were analysed. Materials and Methods: The samples were tested for rubella- and CMV-specific IgM antibodies by capture enzyme linked immunosorbent assay. Results: In children, the overall positivity for rubella- and CMV-specific IgM antibodies was 2.8% and 12.5%, respectively. In asymptomatic pregnant females, rubella positivity was 0.7% while in women with obstetric complications it was 3.4%. IgM antibody positivity in cases of CMV was 7.8% in both asymptomatic pregnant women and also in women with obstetric complications. Conclusions: The study indicated that infection with CMV is more common than the rubella virus. The incidence of rubella has reduced over the past few years. Hence, screening for rubella infection may be reserved for women with obstetric complications only. The routine screening for CMV among all antenatal cases is a debatable issue

Keywords: Cytomegalovirus, congenital infection, IgM antibodies, rubella

How to cite this article:
Singh MP, Arora S, Das A, Mishra B, Ratho RK. Congenital rubella and cytomegalovirus infections in and around Chandigarh. Indian J Pathol Microbiol 2009;52:46-8

How to cite this URL:
Singh MP, Arora S, Das A, Mishra B, Ratho RK. Congenital rubella and cytomegalovirus infections in and around Chandigarh. Indian J Pathol Microbiol [serial online] 2009 [cited 2020 Nov 28];52:46-8. Available from: https://www.ijpmonline.org/text.asp?2009/52/1/46/44962



   Introduction Top


Human cytomegalovirus (CMV) and rubella virus are increasingly being recognized as important causes of congenital infection. Intrauterine transmission of CMV to the baby can occur irrespective of prior maternal exposure; whereas, in rubella, a previous exposure actually prevents the virus from crossing the placenta by generating protective antibodies. The incidence of congenital CMV ranges from 0.5-3.0% in all live births. [1] CMV is also linked to late abortions and still births. The endemicity of the rubella virus has also been established in India. [2] If contracted during the first trimester of pregnancy, it can infect the fetus leading to congenital rubella syndrome. Following the rubella vaccination practices, the incidence of rubella has been reduced drastically but the World Health Organization (WHO) still estimates over 100,000 children worldwide are born with congenital rubella syndrome and more so in developing countries. [3]

This study was carried out to assess the prevalence of CMV and rubella viral infections in children with suspected congenital infection and pregnant females by detection of virus specific IgM antibodies.


   Materials and Methods Top


This study included samples that were received in the Virology laboratory as a part of routine diagnostic services from January 1999 to December 2006. The samples belonged to patients from the following clinical groups:

1. Children suspected of suffering from intrauterine infections

These children presented with one or more of the following clinical manifestations - fever, pneumonia, jaundice, encephalitis, cardiac anomalies, hearing defects, nephrotic syndrome, growth retardation, or ascites. A total of 947 children were screened for suspected rubella infection and 1067 children were screened for CMV infection.

2. Pregnant women

These samples belonged to the following groups:

  1. Asymptomatic pregnant women in the age group of 17-38 years who were screened for CMV (n=166) and rubella (n=615) as part of a routine antenatal check-up.
  2. Pregnant women with obstetric complications like bad obstetric history (BOH> 2 consecutive abortions or still births) or intrauterine growth retardation (IUGR) and/ or congenital fetal malformations (CFM) detected antenatally by ultrasonogram who were screened for CMV (n=129) or rubella (n=1367) depending on clinical suspicion.


Venous blood samples were collected from all the patients, serum was separated and stored at -20 o C until tested. The samples were tested for CMV- and rubella-specific IgM antibodies by commercially available IgM capture ELISA kits (Adaltis, Italy). The manufacturer's instructions were strictly adhered to in the performance and interpretation of the tests.


   Results Top


Of the children with suspected congenital infection, rubella- and CMV-specific IgM antibodies were detected in 2.8% (26/947) and 12.5 % (133/1067), respectively. These children were divided into 3 age groups: 0-29 days, 1 month-1 year and >1 year. The rubella and CMV seropositivity in these groups is shown in [Table 1]. Dysmorphism was the common clinical presentation in rubella IgM positive cases whereas sepsis, pneumonia and neonatal jaundice were the presenting feature in CMV positive cases [Table 2].

Among the asymptomatic pregnant females screened, IgM antibodies to rubella and CMV could be detected in 0.7 % (4/615) and 7.8% (13/166) of the females.

Overall, positivity of rubella and CMV IgM antibodies in pregnant females with obstetric complications were 3.4% (47/1367) and 7.8% (10/129), respectively [Table 3].


   Discussion Top


In this study, we have analysed data over the past 8 years for rubella and CMV in a tertiary care hospital of North India. The study was carried out in three clinically distinct groups. The evidence of congenital rubella was seen in 2.8% of children with suspected congenital infection, which is at par with the declining trend in the incidence of congenital rubella syndrome from 34.5% in 1988 to 0% in 2002 as observed by Gandhoke, et al. [4] and is much less than the earlier reports of 10-20%. [5],[6] Out of 615 asymptomatic pregnant females screened for rubella in the present study, 4 (0.7%) were found to be positive. The observation was similar in recent studies [2],[7] wherein IgM positivity was observed only in 1% of pregnant women. However, 3-9% rubella IgM positivity has been shown in asymptomatic pregnant women by other investigators. [8],[9],[10] Recent studies have shown that the majority of pregnant women in the Indian population are immune to rubella [2],[4] thereby leaving only a few susceptible to contract acute rubella infection. In this study, the overall IgM positivity in women with obstetric complications was 3.4%. Singla, et al. [9] have reported higher positivity (10.4%) in women with adverse pregnancy outcomes as compared with those with normal obstetric performance (3.6%). The positivity in BOH cases in this study was 2.9%, which is much less than earlier studies that have observed a positivity of 10-28%. [8],[9],[10],[11] In our study, the rubella virus could be attributed in 5% of IUGR cases and 6.1% of congenital fetal malformation cases. Rubella virus is known for its teratogenicity and can also cause intrauterine growth retardation. If primary rubella infection occurs during the first trimester of pregnancy, the incidence of congenital rubella is 90% and the risk decreases to 25% during the third trimester. In India, the serological status of most women is not known before pregnancy. The authors believe a baseline pre-pregnancy screening of rubella is necessary because a demonstration of high immunity puts a women at relatively no risk of infection during pregnancy. Also, it will enable prescription of vaccination 1 to 3 months before conception in seronegative women thereby further reducing the incidence of congenital rubella syndrome.

In this study, laboratory evidence of CMV infection in the form of IgM antibodies were found in 12.5% of suspected infants with congenital infection. Broor, et al. [12] and Ganghoke, et al. [13] have reported IgM positivity of 20% and 18.75% in infants and children, respectively with congenital infection. Presently, the overall incidence of CMV in women of child bearing age was 7.8%. No difference was observed in IgM positivity among asymptomatic pregnant women and those with obstetric complications. Considering the fact that transmission to fetus occurs in about 40% of the cases with primary infection and results in the delivery of about 10-15% symptomatic and 85-90% asymptomatic congenitally-infected newborns, [14] the authors do not feel the need for routine screening for CMV in all antenatal cases. The 7.8% IgM positivity in asymptomatic pregnant women seen in our study is similar to earlier Delhi-based studies. [15],[16] However, some studies from India [10],[17] have observed a higher positivity of 13-20% in asymptomatic pregnant women. This study shows a seropositivity of 7.8% in women with obstetric problems. A positivity of 8-27% in women with BOH and other obstetric problems has been reported previously. [11],[18]

In our study, we observed significantly higher CMV positivity in infants presenting with hepatosplenomegaly with or without jaundice, sepsis, or pneumonia, whereas significantly higher rubella positivity was seen in infants presenting with dysmorphism. No significant difference was noted in the relative prevalence of CMV and rubella infection in infants presenting with other clinical manifestations. It is well known that congenital CMV infection usually presents as hepatosplenomegaly with or without jaundice, low birth weight, chorioretintis, or anemia.[1] On the other hand, congenital rubella syndrome usually manifests in the form of developmental defects like cataract, hearing, or cardiac defects. [19] Thus, the findings of the present study are in agreement with earlier observations. As of now, there is no strict treatment regimen for patients infected with rubella and CMV in India. However, limited clinical trials [20] have shown an improvement in hearing loss in children infected with CMV following ganciclovir treatment. Since only symptomatic infants were included in our study, this may not represent the true incidence of congenital CMV or rubella infection since it is well known that all children infected with these viruses may not develop clinical manifestations of the disease during the first year of life.

 
   References Top

1.Onorato IM, Morens DM, Martone WJ, Stansfield SK. Epidemiology of CMV infections: Recommendations for prevention and control. Rev Infect Dis 1985;7:479-97.  Back to cited text no. 1  [PUBMED]  
2.Gupta E, Dar L, Broor S. Seroprevalence of rubella in pregnant women in Delhi, India. Indian J Med Res 2006;123:833-5.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Vijayalakshmi P, Anuradha R, Prakash K, Narendran K, Ravindran M, Prajna L, et al . Rubella serosurveys at three Aravind eye hospitals in Tamil Nadu, India. Bull World Health Organ 2004;82:259-64.  Back to cited text no. 3    
4.Gandhoke I, Aggarwal A, Lal S, Khare S. Seroprevalence and incidence of Rubella in and around Delhi (1988-2002). Indian J Med Microbiol 2005;23:164-7.  Back to cited text no. 4  [PUBMED]  Medknow Journal
5.Abraham M, Abraham P, Jana AK, Kuruvilla KA, Cherian T, Moses PD, et al . Serology in congenital infections: Experience in selected symptomatic infants. Indian Pediatr 1999;36:697-700.  Back to cited text no. 5    
6.Chakravarti A, Jain M. Rubella prevalence and its transmission in children. Indian J Pathol Microbiol 2006;49:54-6.  Back to cited text no. 6  [PUBMED]  Medknow Journal
7.Deka D, Rustgi R, Singh S, Roy KK, Malhotra N. Diagnosis of acute rubella infection during pregnancy. J Obstet Gynecol India 2006;56:44-6.  Back to cited text no. 7    
8.Fomda BA, Thokar MA, Farooq U, Sheikh A. Seroprevalence of rubella in pregnant women in Kashmir. Indian J Pathol Microbiol 2004;47:435-7.  Back to cited text no. 8    
9.Singla N, Jindal N, Aggarwal A. Primary rubella virus infection: Prevalence and relationship to pregnancy wastage. Indian J Pathol Microbiol 2003;46:688-9.  Back to cited text no. 9    
10.Kaur R, Gupta N, Nair D, Kakkar M, Mathur MD. Screening for TORCH infections in pregnant women: A report from Delhi. Southeast Asian J Trop Med Public Health 1999;30:284-6.   Back to cited text no. 10  [PUBMED]  
11.Thapliyal N, Shukla PK, Kumar B, Upadhyay S, Jain G. TORCH infection in women with bad obstetric history: A pilot study in Kumaon region. Indian J Pathol Microbiol 2005;48:551-3.  Back to cited text no. 11    
12.Broor S, Kapil A, Kishore J, Seth P. Prevalence of rubella virus and cytomegalovirus infections in suspected cases of congenital infections. Indian J Pediatr 1991;58:75-8.  Back to cited text no. 12  [PUBMED]  
13.Gandhoke I, Aggarwal R, Lal S, Khare S. Congenital CMV infection in symptomatic infants in Delhi and surrounding areas. Indian J Paediatr 2006;73:1095-7.  Back to cited text no. 13    
14.Revello MG, Gerna G. Diagnosis and management of human cytomegalovirus infection in the mother, fetus and new born infant. Clin Microbiol Rev 2002;15:680-715.  Back to cited text no. 14  [PUBMED]  [FULLTEXT]
15.Chakravarty A, Kashyap B, Rathi K. The seroepidemiological study on cytomegalovirus in women of child-bearing age with special reference to pregnancy and maternal-fetal transmission. Indian J Pathol Microbiol 2005;48:518-21.  Back to cited text no. 15    
16.Ray K, Mahajan M. Seroprevalence of cytomegalovirus antibodies in patients attending STD and antenatal clinics. J Commun Dis 1997;29:85-90.  Back to cited text no. 16  [PUBMED]  
17.Lone R, Fomda BA, Thokar M, Wani T, Kakru D, Shaheen R, et al . Seroprevalence of Cytomegalovirus (CMV) in Kashmir Valley: A preliminary study. JK Pract 2004;11:261-2.  Back to cited text no. 17    
18.Turbadkar D, Mathur D, Rele M. Seroprevalence of TORCH infection in bad obstetric history. Indian J Med Microbiol 2003;21:108-10.  Back to cited text no. 18  [PUBMED]  Medknow Journal
19.Peckham C. Congenital rubella in the United Kingdom before 1970: The prevaccine era. Rev Infect Dis 1985;7:S11-6.  Back to cited text no. 19  [PUBMED]  
20.Kimberlin DW, Lin CY, Sandez P, et al . Ganciclovir (GCV) treatment of symptomatic congenital cytomegalovirus (CMV) infections: Result of a phase III randomised trial. In Program and abstracts of the fortieth interscience conference on antimicrobial agents and chemotherapy, Toronto, Canada, 2000. Abstarct 1942.p 274. American Society for Microbiology, Washington DC, USA.  Back to cited text no. 20    

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Correspondence Address:
Radha Kanta Ratho
Department of Virology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.44962

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    Tables

  [Table 1], [Table 2], [Table 3]

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