Carrier tsmvi liver inflamed what to treat. Cytomegalovirus hepatitis symptoms. What is CMV hepatitis and its forms

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One of the most common and dangerous defeats liver is cytomegalovirus hepatitis. This disease is caused by the herpes virus. The disease is asymptomatic or has mild symptoms in the form of yellowing of the skin, enlarged liver and spleen, dark urine. With the manifestation of cytomegalo viral infection you must immediately go to the hospital, undergo an examination and begin treatment, as this threatens to spread the infection throughout the body and disease of many organs.

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What is this disease?

Cytomegalovirus hepatitis is a liver disease caused by cytomegalovirus. Such liver damage is considered an expression of the symptoms of a congenital variant of cytomegalovirus infection. If the virus enters the human body, it stays in it all its life and becomes very active when it decreases. defensive forces organism. When the liver is damaged by such a virus, the cells of the organ change, disrupting its work.

Diagnosis in pathology is difficult to carry out, since the disease has a lot of similarities with other diseases.

Causes and type of course of the disease

The virus is activated against the background of a decrease in the body's defenses.

The main cause of liver damage is cytomegalovirus, which is transmitted through the placenta from an infected mother to a child or from a person through saliva, urine and blood. It comes from blood transfusions or organ transplants. There are also such causes of the appearance of cytomegalovirus hepatitis:

decreased immunity;
the presence of HIV infection;
treatment with immunosuppressive drugs;
the presence of chronic diseases.

Features of the flow

When a virus enters the body, the immune system reduces its activity. In this case, the pathology does not manifest itself in any way. In another case, the pathology can occur in the form of symptoms similar to mononucleosis: sore throat, prolonged rise in temperature, severe fatigue. The virus enters the body through the nose, mouth, lungs, intestines and genitals. The virus then moves to bloodstream and multiplies in leukocytes. When it enters the lymphoid tissue, it exists for a long time in a latent form. If immunity is reduced, the virus is activated, and vivid symptoms of the disease develop.

Types of disease and their symptoms

Acute form of the disease

The active spread of the virus disrupts the liver.

acute form manifested by the following symptoms:

Preicteric period. Patients have a decrease in appetite, intoxication of the body. The duration of the phase is from 3 days to a week.
Icteric period. There is an increase in intoxication, abdominal pain, yellowness of the skin and intestinal upset. The phase lasts from 2 to 4 weeks.
Posticteric period. In patients, normalization of well-being is noted, the liver and spleen become normal sizes, laboratory showed come back to normal.

Chronic form

If hepatitis has become chronic, it does not manifest itself special symptoms and the disease in this case proceeds sluggishly:

there are no distinguishing indicators in the analyses;
the development of liver fibrosis is detected;
reduced toxicity.

congenital form

Infection of the fetus occurs in the womb.

The congenital form of the disease appears when the virus passes through the placenta from mother to child. In this case, the newborn may develop biliary cirrhosis, which is the main cause of death. Also, CMV hepatitis in babies occurs in an icteric and anicteric form. Contributing factors for the development of hepatitis in a newborn are:

violation of the development of the nervous system;
increased or decreased muscle tone;
the appearance of seizures;
reduced innate reflexes.

Symptoms of cytomegalovirus in congenital form:

refusal of the child from the breast;
nosebleeds;
the appearance of a hemorrhagic rash;
the appearance of yellowness of the skin;
enlargement of the spleen and liver.

Cytomegalovirus manifests itself in the first days of life.

The icteric form of the disease occurs in 2 variants:

Blessed with recovery.
Progression of the disease and transition to biliary cirrhosis, which often leads to death.

Cytomegalovirus jaundice in newborns may not cause yellowing of the skin. In this case, the symptoms of the disease are mild, almost imperceptible, and at the same time, the children have a satisfactory condition. A thorough examination of the child reveals an increase in the liver and spleen, and the test results show an increase in liver enzymes.

Other types

There is also an acquired form of the disease. It can occur in 2 forms: acute and chronic. The incubation period at acute course lasts from 2 to 3 months. In this case, the disease can proceed in an anicteric, mild, moderate and severe form. The acute period is manifested by pronounced symptoms, and upon transition to chronic view the disease is characterized by a sluggish course and does not have severe symptoms.

Which doctor should be consulted?

If the patient has discomfort in the hypochondrium on the right, or a pronounced symptomatology of the disease has developed, he needs to contact a gastroenterologist and an infectious disease specialist. Doctors will listen and write down the patient's complaints, conduct an objective examination. To exclude concomitant diseases, they will be sent for examination to other specialists, and they will also give a referral for delivery. special analyzes and laboratory research to make an accurate diagnosis.

Diagnostic measures

Laboratory studies will help to accurately determine the type of pathogen.

For the ruling correct diagnosis and effective treatment, patients need to go to the hospital. In the hospital, doctors will take a history of the disease and conduct an examination. On examination, yellowness of the skin, an increase in the size of the liver and spleen are revealed. Patients also complain of an increase in body temperature, darkening of the urine and lightening of the feces. Doctors then prescribe tests and laboratory tests, such as:

general urine and blood tests;
blood biochemistry;
virus marker analysis;
analysis for antibodies to the virus;
cytological examination of urine sediment;
liver biopsy;
Abdominal ultrasound.

Treatment of pathology of hepatitis and CMV

Cytomegalovirus hepatitis is a very dangerous disease for human life. Therefore, it is impossible to carry out treatment at home without the supervision of doctors. If symptoms appear, you should consult a doctor to undergo a correct and thorough examination. . After defining accurate diagnosis the doctor will prescribe the appropriate treatment. As a treatment, drug therapy is prescribed.

Medical treatment

For the treatment of cytomegalovirus hepatitis, the drugs presented in the table are prescribed:

For effective treatment of the disease, you need to monitor the state of the immune system and adhere to the scheme drug treatment. Be sure to enrich your food with vitamins and minerals active image life. It is also necessary to avoid contact with sick people, physical and mental overwork and not succumb to stress factors. When discomfort in the area of the liver, you should consult your doctor.

Hepatitis B virus and cytomegalovirus, like HIV, cause chronic infection. These viruses are transmitted through blood and genital secretions. They are characterized by injection and transplacental mechanisms, as well as sexual transmission of the infection. Cytomegalovirus can be transmitted through saliva. The hepatitis C virus is transmitted primarily through the blood. Sexual transmission of the hepatitis C virus is also allowed, but its role is small. Most sexual partners of individuals virus-infected hepatitis C is not infected. All of these viruses cause primary infection, which in most cases is asymptomatic. It is followed by chronic infection, which may, within a few years or decades, lead to severe complications. In contrast, the hepatitis A virus usually causes acute hepatitis, very rarely chronic. The hepatitis A virus is characterized by a fecal-oral mechanism of infection transmission. It is not transmitted through the blood.

HepatitisA

In the United States, 125,000-200,000 cases of hepatitis A are registered annually. Antibodies to the hepatitis A virus are detected in 15-25% of Americans. This disease is characterized by a fecal-oral transmission mechanism, especially among children. The sexual route of infection with the hepatitis A virus is typical for homosexual and bisexual men. This group accounts for the majority of hepatitis A cases among adults.

Clinical picture

The incubation period is usually 3-5 weeks. In adults, the disease in most cases proceeds with a clinical picture. In children, 90% of cases of hepatitis A are asymptomatic. The main manifestations include jaundice and hepatomegaly. Resolution of symptoms and normalization of biochemical indicators of liver function usually occur within 6 weeks from the onset of the disease (sometimes up to 3 months). Sometimes there is fulminant hepatitis with liver failure.

Diagnostics

Diagnosis is based on the clinical picture and biochemical indicators of liver function (AsAT, ALT) plus serological studies for antibodies to the hepatitis A virus. There are no methods for detecting hepatitis A virus antigens yet. IgM to the hepatitis A virus indicates a fresh infection; it is detected in the period from 3 weeks to 4 months from the moment of infection. IgC to the hepatitis A virus is detected 6 weeks after infection; it persists indefinitely.

Prevention

Active hepatitis A immunization is indicated (for hepatitis A serologically negative): (1) homosexual and bisexual men; (2) at high risk exposure (for example, before traveling to countries with a high incidence of hepatitis A); (3) after contact with a patient with hepatitis A. Active immunization for adults is carried out twice with an interval of 6-12 months. In addition, after contact with a patient with hepatitis A (no later than 2 weeks), immunoglobulin against hepatitis A is prescribed, 0.02 ml / kg body weight / m. The use of condoms and the avoidance of sexual contact, in which the fecal-oral mechanism of infection is possible, helps prevent infection through sexual contact.

Hepatitis B

Epidemiology and routes of infection

Incidence and prevalence can be very different. In the United States, 140,000 - 320,000 new cases of hepatitis B are registered annually. In total, there are about 750,000 patients with chronic hepatitis B in the United States. Injection and transplacental mechanisms, as well as sexual transmission of the infection, are characteristic. During sexual intercourse, the risk of infection is maximum when anal sex. The highest incidence is observed among homosexual and bisexual men, as well as among injection drug addicts. In the US, 45% of hepatitis B infections are due to heterosexual intercourse; 15% of cases are homosexual.

Clinical picture

The incubation period is usually 6-12 weeks. In most cases (36-70%), the primary infection is symptomatic, but symptoms are usually nonspecific. These include nausea, anorexia, jaundice, and hepatomegaly. In 15-20% of cases, prodromal events of the type of serum sickness are observed, including rash, polyarthritis, symptoms of cryoglobulinemia. Chronic hepatitis B is usually asymptomatic until cirrhosis or hepatocellular carcinoma develops. At the same time, biochemical and histological (with a biopsy) signs of active hepatitis may not be.

Diagnostics

Diagnosis is usually based on serological tests. Detect hepatitis B surface antigen (HbsAg); antibodies to the surface antigen of the hepatitis B virus (anti-HbsAg antibodies); hepatitis B core antigen (HbcAg). HbsAg indicates acute or chronic active hepatitis B; a patient with HbsAg is contagious. Anti-HbsAg antibodies usually indicate past hepatitis B. The hepatitis B E antigen (HbeAg) is detected in serum during the period of active virus replication; while the patient is highly contagious.

Prevention

The basis of prevention is immunization against hepatitis B. For adults, the hepatitis B vaccine is administered at a dose of 20 mg IM; repeat after 1 and 6 months. While childhood immunization is not available, it is given to all adolescents, adults with STDs, and medical workers. Injection drug users, homosexuals and bisexual men are actively immunized against hepatitis B with negative serological reactions. In this case, it is advisable to administer the first dose of the vaccine on the day of blood sampling for serological studies. The introduction of subsequent doses depends on the results of serological reactions. The use of condoms helps prevent infection through sexual contact.

Hepatitis C

Epidemiology and routes of infection

In the US, hepatitis C accounts for 15% of all acute hepatitis. In the United States, 30,000-40,000 new cases of hepatitis C are registered annually. The disease is detected in 40% of patients with cirrhosis of the liver. In the United States, between 8,000 and 10,000 people die each year from hepatitis C and its complications. Liver failure caused by hepatitis C is the most common indication for liver transplantation. The injection mechanism of transmission of infection and infection during blood transfusion are characteristic. Infection through sexual contact is possible, but rare.

Clinical picture

Acute hepatitis C is asymptomatic. Two-thirds of hepatitis C cases develop chronic hepatitis, which is usually asymptomatic until cirrhosis or liver failure develops.

Diagnostics

To detect antibodies to the hepatitis C virus is usually used linked immunosorbent assay. For confirmation positive result using immunoblotting. Reverse polymerase chain reaction allows you to evaluate the "viral load". In addition, assess the function and degree of inflammation of the liver (AlAT, biopsy).

Prevention

The basis of prevention is the examination of donors for antibodies to the hepatitis C virus, as well as the reduction of contact with other people's blood (the fight against drug addiction; measures to reduce the use of shared syringes by injecting drug users). The use of condoms is ineffective in the prevention of hepatitis C. Mass screening for hepatitis C is indicated for drug addicts and representatives of other risk groups. Examination of sexual partners of patients with hepatitis C is impractical.

Cytomegalovirus

Epidemiology and routes of infection

Cytomegalovirus infection is ubiquitous. Infection is possible through the secretions of the genital organs, saliva or blood. Perhaps intrauterine infection and infection during childbirth. Antibodies to cytomegalovirus are detected in 10-15% of adolescents. By the age of 35, they are already detected in half of the people. These figures vary greatly for different regions and different population groups. Superinfection with other strains of cytomegalovirus is possible.

Clinical picture

In most cases, cytomegalovirus infection is asymptomatic. Sometimes there is granulomatous hepatitis or a syndrome resembling mononucleosis. Intrauterine infection of a child, usually occurring during primary infection in a pregnant woman, can cause severe systemic disease and congenital pathology CNS (eg, sensorineural hearing loss). The role of cytomegalovirus infection in the development of atherosclerosis has not been fully elucidated. In patients with AIDS and in persons with severe immunodeficiency of a different nature, a severe, sometimes life-threatening, course of cytomegalovirus infection (retinitis, pneumonia, esophagitis, colitis, encephalitis) is possible.

Diagnostics

Examination of blood, urine, and genital secretions by culture, antigen determination, or DNA amplification methods is of limited practical value. Serological studies are used. Histological and cytological studies are detected with a cytomegalovirus infection that occurs with a clinical picture. Interpretation of histological and cytological studies often complex.

Prevention

Condoms prevent infection through sexual contact. Prevention of primary cytomegalovirus infection in pregnant women (use of condoms, avoidance of casual sex) helps to prevent intrauterine infection of the child. Mass examinations and examination of sexual partners are not indicated.

Other viruses

Human herpesvirus type 8

Human herpesvirus type 8 is a new virus from the herpesvirus family that causes Kaposi's sarcoma in HIV-infected people. Epidemiological data and the detection of this virus in semen indicate the possibility of its transmission through sexual contact, especially in homosexual and bisexual men. However, other mechanisms of transmission of human herpesvirus type 8 are not excluded.

AT hepatitis virusD

The hepatitis D virus is an "incomplete" virus that causes disease only in the presence of the hepatitis B virus. Infection with the hepatitis D virus in a patient with hepatitis B is clinically manifested by an exacerbation of chronic hepatitis. Hepatitis D is transmitted through the blood. Infection through sexual contact is rare.

Epstein-Barr virus

Epstein-Barr virus - the causative agent of infectious mononucleosis can be transmitted sexually. However, in most cases, infection with this virus is not associated with sexual contact and occurs through saliva. In an HIV-infected person, reactivation Epstein-Barr virus causes hairy leukoplakia of the mouth.

Human T-lymphotropic virus 1

Human T-lymphotropic virus type 1 causes adult T-cell leukemia-lymphoma and spastic paraparesis. The clinical picture of infection caused by human T-lymphotropic virus type 2 has not yet been elucidated. The epidemiology of human T-lymphotropic virus types 1 and 2 is similar to the epidemiology of hepatitis B and C. Injection and transplacental mechanisms are characteristic, as well as sexual transmission of the infection.

Enteroviruses

Enteroviruses are usually transmitted through sexual contact, in which the fecal-oral mechanism of infection is possible.

adenovirus type 19

Adenovirus type 19 causes acute conjunctivitis in combination with urethritis. Can be sexually transmitted.

Hunter Handsfield

Sexually transmitted diseases. Color atlas-reference book. - M .: "Publishing house BINOM", 2006.-296 p.: ill.

The nature of the disease

The causative agent of the disease - cytomegalovirus (Cytomegalovirus hominis) - human herpes virus type V, HHV5, has several strains. This DNA virus is well preserved in room temperature, sensitive to heat and freezing. Currently widely distributed. According to latest research, about 80% of the world's population have specific antibodies in their blood. After being defeated, the virus long time live in the body of the carrier, not manifesting itself in any way, and remains in the human DNA throughout life.

Etiology

Cytomegalovirus affects only humans, especially newborns and people with reduced immunity. It can be found, as a rule, in the secrets of salivary and lacrimal glands, nasopharynx, genital organs and feces. The main ways of transmission of the virus:

domestic;
airborne;
sexual;
organ transplantation and blood transfusion;
from mother to child - in utero and through milk during feeding.

Pathogenesis

The HHV5 virus, when it enters the body, bypasses the lymphatic system and immediately enters the bloodstream. At the same time, it acts on T-lymphocytes, suppressing immunity, and causes the growth of affected cells due to the growth of the nucleus and an increase in the volume of the cytoplasm. In hepatitis, the cytomegalovirus integrates into the cells of the biliary tract and liver (hepatocytes), turning them into cytomegaloviruses. Around such cells, foci of inflammation are formed, called mononuclear infiltrates. Due to this, intrahepatic cholestasis- reduction or cessation of bile secretion with its stagnation in the liver tissues. Often CMV infection progresses to the development of necrosis.

Concomitant diseases and possible complications

CMV virus provokes not only hepatitis. Spreading through the bloodstream throughout the body, it damages the spleen, kidneys, lungs, spinal cord and causes serious complications, often leading to lethal outcome. Against the background of cytomegalovirus hepatitis, the development of pneumonia is possible. It is characterized by localization inflammatory process in both lungs, dry cough with a possible admixture of blood. Another common complication is cytomegalovirus retinitis, an inflammation of the retina. It manifests itself in the form of a decrease in visual acuity and pain, first in one, and then in both eyes. Improper treatment can lead to loss of vision. Hitting the head and spinal cord The virus causes meningoencephalitis. It's heavy acute illness causes migraines, convulsions, paralysis, mental disorders often ends in death.

Symptoms of CMVI

Given that the latent form of cytomegalovirus infection is more common, a person may not be aware of the presence of the virus in the body. Hepatitis CMV type can occur in acute or chronic form. The acute form of the disease, in turn, has an icteric or anicteric character. With an anicteric course, the patient suffers, first of all, from a mononucleosis syndrome, similar to the signs of SARS, which manifests itself:

loss of strength, reduced performance;
headache;
elevated body temperature;
growth of lymph nodes;
increased sweating.

The yellow shade of the skin indicates an acute cytomegalovirus infection of the icteric type.

The icteric form of the disease is evidenced, first of all, by a change in the color of the skin and the white of the eyes, the so-called jaundice. Staining or discoloration of urine occurs and stool, increased levels of bilirubin in the blood, heaviness or pain in the right hypochondrium. On palpation, the liver is enlarged. The acute form of cytomegalovirus hepatitis manifests itself during the first 2-3 months after infection, then the patient feels better, a decrease in the size of the liver is observed. However, in the absence of proper treatment in incubation period, the disease becomes chronic. This trend is observed in 65% of patients. During the period of remission, the disease manifests itself only in a slight increase in the size of the liver and spleen.

Congenital CMV-type hepatitis

Cytomegalovirus hepatitis can also be congenital. It occurs in newborn babies due to infection of the mother in the first trimester of pregnancy, is diagnosed in the first months of life. It is of a primary chronic nature, as a rule, does not have pronounced symptoms. There is a compaction of the structure of the liver and the walls of the gallbladder, obstruction of the biliary tract. In infants suffering from this disease, the risk of developing fibrosis and cirrhosis of the liver increases significantly.

Diagnosis of cytomegalovirus infection and hepatitis

Only highly qualified infectious disease specialists and hepatologists can make a diagnosis of cytomegalovirus hepatitis after a thorough study of the anamnesis and several laboratory tests. To detect IgG and IgM antibodies in the blood, use serological method diagnostics. In addition, a biochemical blood test is shown to study CMVI markers and enzymes. At patients with CMV hepatitis there is a significant hyperfermentation. An effective laboratory diagnostic method is considered and PCR method- polymerase chain reaction. It allows you to isolate the DNA of the virus in the carrier genome. Through cytological studies in the urine, cytomegalic cells can be detected. The final confirmation of the diagnosis is often possible after a liver biopsy. Pathological hepatocytes take the form of an "owl's eye", they show specific inclusions.

Basic principles of treatment

To stop the development CMV virus at an early stage, special antiviral drugs are prescribed: Cidofovir, Foscarnet, Ganciclovir, Valganciclovir. Only a specialist can correctly determine the dosage and course of treatment. In the congenital form of the disease, as well as in the presence of other pathologies in the body, such as HIV infection, maintenance therapy by taking immunoglobulins is mandatory. In such cases, lifelong therapy aimed at suppressing viral replication is necessary. Patients with cytomegalovirus hepatitis are recommended diet No. 5, which excludes fatty, fried, spicy and alcohol.

In addition, symptomatic treatment is prescribed for patients with CMV infection. In the presence of mononucleosis syndrome or pneumonia, antipyretics, such as Paracetamol or Ibuprofen, and cold medicines are used. In cytomegalovirus retinitis, eye drops against inflammation of the retina.

Preventive measures

A special vaccine against cytomegalovirus infection has not yet been invented, so it makes sense to regularly undergo a doctor's examination, take an x-ray of the liver and biliary tract, because changes in their structure may indicate a virus infection. Transplant patients are at particular risk of infection. internal organs. Some time before the procedure, they should take a course of admission antiviral drugs. Any surgical interventions and cosmetic procedures must be carried out in conditions of complete sterility, and all instruments must be thoroughly disinfected.

Materials:

Cytomegalovirus is a widespread causative agent of infection, which is usually asymptomatic.

Rarely, a disease develops that resembles Infectious mononucleosis or hepatitis. In immunocompromised patients, cytomegalovirus can cause severe generalized infection with multiple organ damage and high mortality. The virus is transmitted through contaminated saliva, urine and sometimes blood.

Once infected, the virus remains in the human body for life. The DNA of the virus integrates into the genome of the host cells and most time is inactive. Periodically, cytomegalovirus reactivates and at this time is found in saliva and urine. At healthy people this process is completely controlled immune system however, opportunistic infections may develop in immunosuppressed patients or after organ transplantation. In such patients, viremia can cause hepatitis as well as damage to other organs. Another strain of the virus can also cause a recurrence of infection, that is, a person can be a carrier of several strains of cytomegalovirus that can reactivate at different times.

Isolation of the virus. The virus is isolated from the urine, saliva, blood and tissues of patients. In order to properly collect and deliver samples for analysis, you must contact the appropriate laboratory in advance.

immune response. Seroconversion indicates primary infection. IgG antibodies to cytomegalovirus are absent in the acute phase of infection and appear later. If it was not possible to conduct a study in the acute phase, a high titer of only IgG antibodies cannot be a sign acute infection- this is evidenced only by the presence of specific IgM antibodies. With relapses of cytomegalovirus infection, an increase in the titer of lgM antibodies is observed only in a third of patients who underwent transplantation, and is practically not observed in people with normal immunity. Therefore, in case of recurrence, isolation of the pathogen may be required to confirm the diagnosis.

Primary cytomegalovirus infection. Liver damage during primary infection may be asymptomatic with a slight increase liver enzyme activity. In some cases, against the background of a mild or moderate increase in the activity of liver enzymes, lung symptoms hepatitis that resolves on its own. Sometimes the disease is accompanied by hemolysis.

Infection with cytomegalovirus during blood transfusion. The virus is believed to be transmitted by leukocytes, ‘including neutrophils. Hepatitis in most cases is accompanied by a mononucleosis-like syndrome.

Transplantation. Cytomegalovirus infection - common cause hepatitis in transplant patients. The infection can enter the body with a transplanted organ, with a blood transfusion, or as a result of virus reactivation against the background of immunosuppression. In such patients, chronic asymptomatic liver damage is also possible.

To isolate the pathogen, a liver biopsy is performed. Typically, characteristic intranuclear inclusions ("owl's eye") are visible in hepatocytes, and granulomas without caseous necrosis and other signs of granulomatous inflammation.

Whether cytomegalovirus can cause extensive hepatic necrosis is still controversial. There is no evidence that the virus causes chronic hepatitis in immunocompetent people. However, with impaired immunity (for example, with AIDS), severe chronic lesion liver and bile ducts. Cases are described mixed infection hepatitis B virus and cytomegalovirus.

In confirmed cases, ganciclovir is prescribed. AIDS may require lifelong treatment.

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Cytomegalovirus hepatitis is the leading clinical manifestation of congenital cytomegalovirus infection. Liver damage in cytomegalovirus infection is always a sign of a generalized process.

What provokes / Causes of Cytomegalovirus hepatitis

The causative agent of cytomegalovirus infection- DNA-genomic virus of the genus Cytomegalovirus (Cytomegalovirus hominis) subfamily Betaherpesvirinae of the family Herpesviridae. Three strains of the virus are known: Davis, AD-169 and Kerr. Slow reproduction of the virus in the cell is possible without damaging it. The virus is inactivated by heating and freezing, and is well preserved at room temperature. At -90 °C, it remains for a long time, is relatively stable at pH 5.0-9.0, and quickly collapses at pH 3.0.

Reservoir and source of infection- a person with an acute or latent form of the disease. The virus can be found in various biological secretions: saliva, nasopharyngeal secretions, tears, urine, feces, seminal fluid, and cervical secretions.

Transmission mechanisms diverse, transmission routes- airborne, contact (direct and indirect - through household items) and transplacental. Infection is possible through sexual contact, during transplantation of internal organs (kidney or heart) and blood transfusion of an infected donor. Intranatal infection of the child is observed much more often than transplacental. The most dangerous for the fetus is infection of the mother in the first trimester of pregnancy. AT similar situations the greatest frequency of violations of intrauterine development.

Natural susceptibility of people high, but widespread latent infection. Clinical manifestations infections attributed to opportunistic diseases are possible in conditions of primary or secondary immunodeficiency.

The main epidemiological signs of cytomegalovirus infection. The disease is recorded everywhere, its widespread is evidenced by antiviral antibodies detected in 50-80% of adults. Diversity of CMV infection routes and polymorphism clinical picture determine the epidemiological and social significance CMV infections. This disease plays important role in transplantology, hemotransfusiology, perinatal pathology, can be the cause of prematurity, stillbirth, congenital developmental defects. In adults, CMV infection is seen as comorbidity in various immunodeficiency states. Ongoing pollution environment, the use of cytostatics and immunosuppressants contribute to an increase in the frequency of CMV infection. AT last years its exacerbation in HIV-infected people has become especially relevant. In pregnant women with latent CMV infection, fetal damage does not always occur. Probability intrauterine infection significantly higher in the primary infection of a woman during pregnancy. Seasonal or professional features morbidity has not been identified.

Pathogenesis (what happens?) during Cytomegalovirus hepatitis

At different ways Transmission gateways of infection may be the mucous membranes of the upper respiratory tract, gastrointestinal tract or genital organs. The virus enters the blood; short-term viremia quickly ends with the localization of the pathogen when it invades leukocytes and mononuclear phagocytes, where it replicates. Infected cells increase in size (cytomegaly), acquire a typical morphology with nuclear inclusions, which are accumulations of the virus. The formation of cytomegalic cells is accompanied by interstitial lymphohistiocytic infiltration, the development of nodular infiltrates, calcifications and fibrosis in various organs, glandular structures in the brain.

The virus is able to persist for a long time and latently in organs rich in lymphoid tissue, being protected from the effects of antibodies and interferon. At the same time, it can suppress cellular immunity by direct action on T-lymphocytes. In various immunodeficiency states (in early childhood, during pregnancy, the use of cytostatics and immunosuppressants, HIV infection) and, above all, in violations cellular immunity, additionally aggravated by the direct effect of the virus, reactivation of the pathogen and its hematogenous generalization with damage to almost all organs and systems are possible. Wherein great importance has the epitheliotropy of the virus. It is especially pronounced in relation to the epithelium salivary glands, under the influence of the virus turning into cytomegalic cells.

Liver pathology occupies a special place in CMVI. Cytomegalovirus hepatitis, which develops in response to the introduction of CMV, is characterized by the degeneration of the epithelium of the biliary tract and hepatocytes, stellate endothelial cells and vascular endothelium. They form cytomegalic cells, surrounded by inflammatory mononuclear infiltrates. The combination of these changes leads to intrahepatic cholestasis. Cytomegalic cells desquamate, fill gaps bile ducts, causing the mechanical component of jaundice. At the same time, CMV-derived hepatocytes are destructively altered up to necrosis, causing the development of cytolysis syndrome. It should be noted that in CMV hepatitis, which has a prolonged, subacute or chronic course, the leading role belongs to the cholestasis syndrome.

Symptoms of Cytomegalovirus Hepatitis

Cytomegalovirus hepatitis can proceed in anicteric and icteric form.

anicteric form CMV hepatitis proceeds with very poor clinical symptoms the condition of the children remains satisfactory. Identification of the anicteric form of hepatitis is possible due to the detection of hepatomegaly and advanced level aminotransferases. The activity of aminotransferases increases slightly (1.5-2.0 times) with the predominance of AsAT over AlAT.

In the icteric form of hepatitis, two groups of patients were distinguished: one with favorable course and gradual recovery and another group with progressive liver disease and the formation of biliary cirrhosis due to the development of cholangitis obliterans.

The condition of children with icteric form of CMV hepatitis is not significantly disturbed. They have hepatosplenomegaly. Jaundice in most children was found in the first days after birth.

icteric form CMV hepatitis with a favorable course is characterized by mild jaundice of the skin, dark urine and colored feces, hepatosplenomegaly, moderate hyperenzymemia with a predominance of AST over ALT, an increase in the level of bilirubin with a predominance of the direct fraction, and the presence of markers of active CMV replication.

One of the variants of cytomegalovirus liver damage in congenital CMVI is formation of biliary cirrhosis of the liver leading to death, usually in the second half of the first year of life.

Children born with cytomegalovirus hepatitis have low Apgar scores (a scale that reflects the state of the child's nervous system at the time of birth), insufficient muscle development, increased or decreased muscle tone. There may be short-term muscle twitches or convulsions, the child does not take the breast, all congenital reflexes are reduced. In general, the condition of such a child will be severe, hemorrhagic syndrome will be pronounced (bleeding from the nose, gastrointestinal bleeding, hemorrhagic rash on the skin and mucous membranes), the number of red blood cells and platelets in the blood will decrease, the central nervous system. Yellowness of the skin, mucous membranes and sclera appears in the first day or two, gradually increasing, it lasts for 1-2 months. On examination, the liver is enlarged, the spleen is also enlarged. Often the respiratory system is involved, children cough, there is shortness of breath. Soon, signs of hydrocephalus or microcephaly, oligophrenia, lesions optic nerves, kidneys, stomach and intestines. In the blood, hepatocellular enzymes will be sharply increased, protein and albumin protein fraction will be lowered. This course of the process often ends fatally. With a benign course, jaundice remains for 2-3 months, after which it begins to subside.

Diagnosis of Cytomegalovirus Hepatitis

Diagnosis of cytomegalovirus hepatitis was established on the basis of anamnestic, clinical and biochemical data with mandatory confirmation of the diagnosis by the detection of CMVI markers. All patients were examined for markers of parenteral viral hepatitis.

In the diagnosis of cytomegalovirus hepatitis, the results are of great importance needle biopsy liver (detection in the punctate of giant, 25-40 microns in diameter, cytomegalic cells in the form of an owl's eye with a huge nucleus and a narrow border of the cytoplasm), as well as a cytological method (detection of cytomegalic cells in the urine sediment) and a serological method (detection of antibodies - Ig M to CMVI). Differential diagnosis of CMV hepatitis is carried out with other viral hepatitis: B, Epstein-Barr, herpetic hepatitis.

AT biochemical analysis blood revealed a distinct hyperfermentemia with a predominance of AST (160.0±25.6 µmol/min.l) over ALT (120.0±25.6 µmol/min.l) and hyperbilirubinemia (112.0±8.5 µmol/l ) with a predominance of the direct fraction (62.0±6.7 µmol/l).

This is an inflammatory lesion of the hepatic parenchyma and intrahepatic biliary tract caused by cytomegaloviruses. Usually manifested by pain in the right hypochondrium, jaundice, dark urine, dyspepsia, intoxication. May occur in an anicteric form. It is diagnosed using ELISA, RIF, RSK, ultrasound of the liver, fibroelastometry, cytomorphological analysis of liver biopsy and biochemical research blood. For treatment, recombinant interferons, nucleotides and nucleosides, immunoglobulins, choleretics, hepatoprotectors, immunomodulators are used.

General information

Hepatitis is one of the localized forms of cytomegalovirus infection, in which virion replication occurs predominantly in the liver tissue. The resistance of cytomegalovirus (CMV) at room temperature, combined with susceptibility to the pathogen, led to a high prevalence of infection in the population. According to studies in the field of clinical gastroenterology and infectious diseases, 40-95% of adults and 20-60% of children are carriers of the virus, in which liver damage may occur with a decrease in immunity. The development of cytomegalovirus hepatitis is especially dangerous for newborns infected in utero - mortality in such cases reaches 10%.

The reasons

The causative agent of the disease is a DNA-containing virus of cytomegalovirus infection. The pathogen belongs to the family of herpes viruses, is distinguished by the large size of the genome nucleocapsids, can replicate without damaging the affected cell, is present in all biological fluids carrier or patient (blood, saliva, vaginal secretions and etc.). The persistence of virions in the body is accompanied by a sharp inhibition of cellular immunity. The activation of the pathogen and the manifestation of cytomegalovirus hepatitis are provoked by immunodeficiency states:

HIV infection. Liver damage is usually observed in phase IIIB (AIDS) against the background of a persistent decrease in the number of T-helpers. Hepatitis is often associated with cytomegalovirus retinitis, erosive-ulcerative colitis, gastritis, damage to the central nervous system and other organs.
Taking immunosuppressive drugs. A prerequisite for the development of hepatitis is long-term use corticosteroids, cytostatics, other drugs that depress the immune system. The risk group includes patients with oncopathology and those who have undergone organ transplantation.
Pregnancy. Reactivation of the latent virus is facilitated by a natural decrease in immunity in pregnant women, which prevents the rejection of a genetically alien fetus. Sometimes observed reinfection women with other strains of the pathogen.
Neonatal period. In 30-50% of cases, infection of a child occurs in utero, during childbirth or postpartum period. With insufficient immunity, a manifestation of the cytomegalovirus process in the form of acute or chronic hepatitis is possible.

Pathogenesis

Given the presence of the virus in all liquid media and secretions, infection occurs in different ways - fecal-oral, aerogenic, contact, vertical (transplacental, when passing through birth canal, breastfeeding), parenteral (with blood transfusion and organ transplantation). Usually, after entering the body, the causative agent of cytomegalovirus infection quickly appears in the blood, penetrates into leukocytes and mononuclear cells, where it replicates and persists for a long time. Infected cells change but do not die, remaining a reservoir of the virus.

A frequent complication of the cytomegalovirus type of hepatitis is the development of obliterating cholangitis due to blockage of the bile ducts by necrotic masses. In the future, cholangitis can lead to biliary cirrhosis of the liver - dangerous disease with a bad prognosis. A decrease in the detoxification function of hepatocytes and the accumulation of nitrogenous compounds in the blood potentiates the formation of hepatic encephalopathy, manifested by impaired consciousness, focal neurological symptoms and typical changes on the EEG.

Diagnostics

Verification of the diagnosis of cytomegalovirus hepatitis is difficult, since it is often difficult to prove the relationship between serological signs of viral infection and liver damage. Diagnostic search provides for a comprehensive laboratory and instrumental examination of the patient in order to exclude other etiological factors. Most informative:

Serological reactions. To confirm cytomegalovirus infection, different kinds reactions (RSK, ELISA, RIF), which are designed to search for specific antibodies. AT acute period diseases are determined by high titers of IgM and a small amount of low-avid IgG. Studies are performed in dynamics to monitor the growth of IgG.
Ultrasound procedure. Ultrasound of the liver is the main non-invasive method used to assess the condition of the liver tissue and intrahepatic ducts. For hepatitis, an increase in the size of the organ, a structure that is heterogeneous in echogenicity, and distal attenuation of ultrasound are typical. Sonography allows you to visualize signs of fibrotic changes.
Fibroelastometry. Modern technique aimed at determining the presence and degree of fibrosis does not require invasive research. With cytomegalovirus genesis of the disease, diffuse replacement of the parenchyma is usually detected. connective tissue. The obtained data are classified according to the international Metavir scale.
Analysis of liver tissue. Histological examination of biopsy specimens is the gold standard in establishing the etiological factor of the disease. The pathognomonic sign of CMV infection is cells with a very large nucleus and a narrow rim of the cytoplasm (in the form of an "owl's eye"). noted lymphocytic infiltration around the ducts.

In the general blood test in the acute phase of hepatitis, leukocytosis is determined, a large number of mononuclear cells, with a long course of the disease, a decrease in the level of platelets is observed. In the biochemical blood test, markers of cytolysis are detected: an increase in transaminases, the predominance of AST over ALT, signs of cholestasis (an increase in the levels of alkaline phosphatase and cholesterol).

First of all differential diagnosis carried out between cytomegalovirus liver damage and typical viral hepatitis type B, C. The results of serological reactions (detection of antibodies to CMV) and the presence of pathognomonic signs in the diagnosis are decisive in the diagnosis. microscopic examination hepatic parenchyma samples. It is also necessary to differentiate the disease from toxic hepatitis. The patient is examined and treated by a gastroenterologist or a hepatologist, an infectious disease specialist.

Treatment of cytomegalovirus hepatitis

The choice of therapeutic tactics is determined by the age of the patient, clinical form and the severity of the course of the disease, the presence of signs of generalization of infection. Newborns and patients with signs of acute hepatic inflammation are indicated for urgent hospitalization to prevent life-threatening complications. At easy course recommended rest, diet with low content fats, extractives and spices, with the exception of alcohol. Therapy to improve rheological properties bile and protection of hepatocytes.

Patients with cholestasis are prescribed preparations of ursodeoxycholic and deoxycholic acids, which reduce the lithogenicity and viscosity of bile, and have an immunomodulatory effect. Treatment of cytomegalovirus liver damage is supplemented with plant hepatoprotectors that stabilize hepatocyte membranes, prevent the destruction of cellular structures and accelerate regeneration processes. The basic antiviral agents for the treatment of moderate, severe and chronic forms of hepatitis caused by cytomegaloviruses are:

Recombinant interferons. The therapeutic effect of drugs is based on the inhibition of viral DNA replication, increased phagocytosis, and increased specific cytotoxicity of T-killers. Interferon alfa-2b derivatives make it possible to achieve stable remission in more than 80% of patients with chronic hepatitis.
Nucleosides and nucleotides. They are the drugs of choice for severe hepatitis and its combination with immunodeficiency states. Means of this group do not ensure the elimination of viral particles, but slow down their replication. Orthophosphoric acid derivatives can be used as an alternative.
Immunotherapy. Anticytomegalovirus hyperimmune human immunoglobulin contains virus-neutralizing antibodies (IgG). In addition to a direct effect on virions, immunoglobulins have an immunostimulating effect and increase nonspecific resistance organism.

Etiopathogenetic therapy is combined with symptomatic treatment. According to indications, infusions of various solutions are carried out to restore the acid-base and water-electrolyte balance. With hyperthermia, severe myalgia, non-steroidal anti-inflammatory drugs are used with caution. Perhaps the appointment of immunostimulants (thymic polypeptides, imidazothiazole derivatives). After recovery, follow-up with follow-up examinations by a gastroenterologist after 3, 6, 12 months is necessary.

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