LAUSR

A preterm (31 weeks) female neonate born at home was admitted to our tertiary neonatal unit. She was a growth restricted fetus with birth weight 1085 g (<10th centile), length 35 cm (<10th centile), and head circumference 27 cm (<10th centile). She required continuous positive airway pressure for 20 hours and was graded to full feeds by 7 days. Head ultrasounds on days 1 and 7 of life were suggestive of bilateral subependymal hemorrhages and calcifying vasculopathy of the basal ganglia from subclinical hypoxia-ischemia. The postnatal course in the first 7 weeks was uneventful except for poor weight gain and persistent mild thrombocytopenia (platelet count of 100-150 × 10/L). By the end of week 7, she developed conjugated hyperbilirubinemia and deranged liver functions (alkaline phosphatase 1040 U/L, conjugated bilirubin 67 μmol/L, alanine transferase 77 U/L). Onset of hepatitis with a background of fetal symmetrical growth restriction and mild thrombocytopenia, led to cytomegaloviral (CMV) culture being performed on urine. All 3 consecutive daily urine samples were culture positive for CMV. The serum CMV IgM levels were equivocal. The dried blood spot that had been collected at 72 hours of life for newborn screening was retrospectively tested and confirmed to be positive for CMV DNA and hence, a diagnosis of symptomatic congenital CMV was made. After discussing the pros and cons of intravenous versus oral antiviral therapy, oral valganciclovir (VGCV) treatment was commenced in week 8 at a dose of 15 mg/ kg/dose twice daily with a plan to continue for 6 months. Weekly CMV viral loads, liver function tests, and complete blood count were monitored in the initial phase of therapy. At the end of 3 weeks of VGCV therapy, there was no reduction in viral load (Table 1). At this point, blood levels of ganciclovir were undetectable and there was progressive worsening of liver functions. Hence, oral VGCV was ceased and intravenous ganciclovir therapy commenced at the dose of 5 mg/kg twice daily. This resulted in immediate improvement, associated with a substantial reduction in the viral load within a week of commencement (Table 1). Liver functions improved over a period of 4 weeks and improvement in weight gain was noted. There were no adverse effects with ganciclovir therapy. Intravenous ganciclovir was administered for 6 weeks and was followed by oral VGCV. She was discharged at a postterm age of 6 weeks with a plan to continue oral VGCV for 6 months. At discharge, the weight was 3000 g (<3rd centile), length was 50 cm (<3rd centile), and head circumference was 37 cm (41st centile). Neurological examination at the time of discharge was normal.