Cytomegalovirus (CMV)
Diagnosis and treatment
Diagnosis:
Retinitis: typical retinal lesions at ophthalmological examination AND response to therapy. Identification of CMV-DNA by NAT in of aqueous and vitreous humor optional
Esophagitis/colitis: endoscopic presence of ulcerations AND typical histopathological picture (cellular / nuclear inclusion bodies) with identification of CMV antigens
Encephalitis/polyradiculomyelitis: clinical appearance AND Identification of CMV-DNA by NAT in CSF
Identification of CMV-DNA in blood supportive, but not diagnostic of end-organ disease
Notes on treatment:
monitor renal function and adjust drug dose in renal impairment. See also Anti-infective/ART interaction table
Drug / Dose | Comments | |
---|---|---|
Retinitis, Immediate sight-threatening lesions | ganciclovir 5 mg/kg bid iv |
3 weeks, then secondary prophylaxis |
OR foscarnet 90 mg/kg bid iv |
Foscarnet used as alternative therapy if toxicity or resistance to ganciclovir. Most experts would add intravitreal injections of ganciclovir (2 mg) or foscarnet (2.4 mg) for 1-4 doses over 7-10 days in combination with systemic CMV treatment | |
Retinitis, small peripheral retinal lesions | valganciclovir 900 mg bid po (with food) |
2-3 weeks, then secondary prophylaxis |
OR ganciclovir 5 mg/kg bid iv |
||
OR foscarnet 90 mg/kg bid iv |
If adverse reactions or ineligibility to ganciclovir/valganciclovir | |
Esophagitis/Colitis | ganciclovir 5 mg/kg bid iv |
3-6 weeks, until symptoms resolved, then secondary prophylaxis (switch to oral valganciclovir once tolerated) |
OR foscarnet 90 mg/kg bid iv |
||
OR valganciclovir 900 mg bid po (with food) |
In milder disease if oral treatment tolerated | |
Encephalitis/Myelitis |
ganciclovir foscarnet |
Treat until symptoms resolved with clearance of CMV-DNA in CSF, then secondary prophylaxis Some experts recommend ganciclovir combined with foscarnet especially in progressive or relapsing cases |
Cidofovir (+ probenecid) may be considered as a therapeutic option for patients unable to tolerate the other treatments listed |
Secondary Prophylaxis/ Maintenance Therapy
Cytomegalovirus (CMV) Retinitis
Stop: Inactive lesions treated for at least 3 months AND CD4 count > 100 cells/µL with HIV-VL undetectable over 3 months
Regimens listed are alternatives
Drug / Dose |
---|
valganciclovir (preferred regimen) 900 mg qd po (with food) |
OR ganciclovir 5 mg/kg qd iv (x 5 days/ week) |
OR foscarnet 90-120 mg/kg qd iv (x 5 days/ week) |