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Comparison of laboratory tests for the detection of cytomegalovirus in neonates with suspected congenital infection

Comparison of laboratory tests for the detection of cytomegalovirus in neonates with suspected congenital infection
Laboratory method Sample used for testing Reported sensitivity
(percent)*		 Reported specificity
(percent)*		 Comments
Viral culture Urine or saliva obtained within first 3 weeks of life 100 100 Traditional reference standard.
Detects CMV based on cytopathic changes in cell culture with fibroblast cell lines.
Usually positive within 1 to 3 days of incubation but may take up to 28 days before a negative result is declared.
Disadvantages include: relatively long time required to detect the virus, labor- and resource-intensive, and requires tissue culture facilities.
Rapid culture
(also called shell vial assay or shell vial culture)		 Urine or saliva obtained within first 3 weeks of life 92.3 to 100 100 Enhanced culture method using centrifugation and staining for early antigen production.
Allows for identification of the virus within 24 hours.
Advantage over standard viral culture is that it is rapid, simple to perform, and less expensive.
False-positive results may occur due to retained CMV antigen on the shell vial monolayer, producing a low-positive result.
A confirmatory test (either viral culture or PCR) should be performed to establish the diagnosis of congenital CMV.
PCR Urine or saliva obtained within first three 3 of life 97.4 to 100 99.9 Detects CMV DNA in the urine or saliva.
Advantages over standard and shell vial culture techniques include: rapid turnaround, does not require live virus for detection of CMV and thus is not affected by storage and transport conditions, and lower cost.
Available in many hospital-based and reference laboratories.
Occasional false-positive results occur; we suggest confirming positive tests with repeat PCR on urine or saliva or both.
Newborns with congenital CMV infection shed large quantities of CMV from both urine and saliva for prolonged periods; therefore, these tests should be positive repeatedly.
PCR Dried blood spot 34 to 77 99.9 Detects CMV DNA in the dried blood spot obtained for newborn screening.
Allows retrospective diagnosis of congenital CMV infection.
Not all infected infants are viremic at birth, accounting for low sensitivity of this test compared with PCR in urine or saliva samples.
Available in research or public health laboratories (CDC).
Quantitative PCR
(CMV DNAemia)		 Whole blood or plasma N/A  N/A Measures amount of CMV DNA in the blood.
Used for monitoring infants during therapy; not used for establishing the diagnosis of congenital CMV.
Preferred over CMV antigenemia for quantitative measurement of viremia.
CMV antigenemia Blood  N/A  N/A Detects CMV proteins (pp65) in peripheral blood leukocytes.
Not recommended in the diagnostic evaluation of infants with congenital CMV.
Serology Blood  N/A  N/A Not recommended for routine diagnosis of congenital CMV.
Presence of CMV IgG antibody in the newborn may only reflect passive transfer of maternal antibody; however, its absence makes CMV infection very unlikely.
CMV IgM antibody in the newborn is insensitive and may be falsely negative in over one-half of infected newborns.
CMV: cytomegalovirus; PCR: polymerase chain reaction; DBS: dried blood spot; CDC: Centers for Disease Control and Prevention; N/A: not available; IgG: immunoglobulin G; IgM: immunoglobulin M.
* Compared with viral culture in most studies.
¶ Shell vial assay or PCR tests have largely replaced viral culture as the methods of choice for diagnosis of congenital CMV infection because of more rapidly available results and lower cost. The choice of test used may depend on the availability.
References:
  1. Harrison GJ. Cytomegalovirus. In: Feigin and Cherry's Textbook of Pediatric Infectious Diseases, 7th ed, Cherry JD, Harrison GJ, Kaplan SL, et al (Eds), Elsevier Saunders, Philadelphia 2014. p.1969.
  2. Britt W. Cytomegalovirus. In: Infectious Diseases of the Fetus and Newborn Infant, 7th ed, Remington JS, Klein JO, Wilson CB, et al (Eds), Elsevier Saunders, Philadelphia 2011. p.706.
  3. Boppana SB, Smith RJ, Stagno S, Britt WJ. Evaluation of a microtiter plate fluorescent-antibody assay for rapid detection of human cytomegalovirus infection. J Clin Microbiol 1992; 30:721.
  4. Balcarek KB, Warren W, Smith RJ, et al. Neonatal screening for congenital cytomegalovirus infection by detection of virus in saliva. J Infect Dis 1993; 167:1433.
  5. Demmler GJ, Buffone GJ, Schimbor CM, May RA. Detection of cytomegalovirus in urine from newborns by using polymerase chain reaction DNA amplification. J Infect Dis 1988; 158:1177.
  6. Ross SA, Ahmed A, Palmer AL, et al. Detection of congenital cytomegalovirus infection by real-time polymerase chain reaction analysis of saliva or urine specimens. J Infect Dis 2014; 210:1415.
  7. Boppana SB, Ross SA, Shimamura M, et al. Saliva polymerase-chain-reaction assay for cytomegalovirus screening in newborns. N Engl J Med 2011; 364:2111.
  8. Pinninti SG, Ross SA, Shimamura M, et al. Comparison of saliva PCR assay versus rapid culture for detection of congenital cytomegalovirus infection. Pediatr Infect Dis J 2015; 34:536.
  9. Boppana SB, Ross SA, Novak Z, et al. Dried blood spot real-time polymerase chain reaction assays to screen newborns for congenital cytomegalovirus infection. JAMA 2010; 303:1375.
  10. Dollard SC, Dreon M, Hernandez-Alvarado N, et al. Sensitivity of Dried Blood Spot Testing for Detection of Congenital Cytomegalovirus Infection. JAMA Pediatr 2021; 175:e205441.
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