Six neonates were eligible for study. All had hyper-bilirubinemia, hepatosplenomegaly and hematological manifestations. Developmental delay, sensorineural hearing loss, chorioretinitis, and obstructive jaundice was present in four, two, one and one children, respectively. Three children had persistent viremia, anemia and end-organ damage. Ganciclovir was started at this stage in one child and sometime later in another. Both these patients had significant decline in viremia after 8 weeks. Ganciclovir was stopped in the first following complete clearance of choreo-retinitis, and in the other following normalization of hematological parameters. Both showed catch- up in development.

At follow-up of 8-26 months (mean 13 mo) post- diagnosis, two cases, who spontaneously cleared the virus are asymptomatic and thriving well. One child, who spontaneously cleared the virus but had significant comorbidities, has mental retardation, spasticity and profound SNHL. The first child who received ganciclovir had severe SNHL for which a cochlear implant was given followed by speech therapy, with encouraging response. The other case which received ganciclovir is asymptomatic and thriving, with no evidence of end-organ damage.

Controversy exists when to treat CMV infection, as symptoms, especially in cases presenting acutely, are often transient and reversible. Those showing end-organ damage with significant viremia should be treated with ganciclovir, which causes reduction of viral load and reversal of manifestations(3). Schedules vary in literature and fewer still have monitored therapy against viral loads(3-5). Our schedule was dictated by clinical response and viral monitoring but reflected reported regimes. Outcomes ranged from spontaneous clearance of the virus and clinical resolution to severe SNHL.

Treatment was well tolerated. Complications were mild and no episodes of treatment related neutropenia occurred. A mild increase in viral loads was seen on cessation of therapy, which has also been reported earlier(3). We practiced selective screening followed by confirmatory qualitative estimation of CMV-DNA, where the RLU reading indirectly also gave a guide to viral load. Unnecessary treatment in patients with decreasing levels and clinical resolution could be avoided.

We conclude that treatment of neonatal CMV should be reserved for those with persistent viremia, progressive disease and end-organ damage.

Contributors: SSY, GN and SN: record keeping, collection of data and analysis. GN and SN: study design and protocols. GN, SB and GG: manuscript preparation and critical review. GN will act as guarantor.

Funding: None

Competing interests: None stated.