Cytomegalovirus (CMV)
Treatment
Diagnosis of retinitis: clinical appearance of typical retinal lesions AND response to therapy. PCR of aqueous and vitreous humor optional
Diagnosis of esophagitis / colitis: endoscopic presence of ulcerations AND typical histopathological picture (cellular / nuclear inclusion bodies)
Diagnosis of encephalitis / myelitis: clinical appearance AND positive PCR in CSF AND other pathology excluded. Antibody testing and PCR in blood not useful for diagnosis of end-organ disease
During treatment: monitor renal function, adjust drug dose in renal impairment
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 foscarnet 90 mg/kg bid iv |
||
Oesophagitis/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 5 mg/kg bid iv foscarnet 90 mg/kg bid iv |
Treat until symptoms resolved and CMV replication in CSF has cleared (negative PCR DNA-CMV in CSF) Treatment is individualised according to clinical symptoms and response to treatment. |
Secondary Prophylaxis/ Maintenance Therapy
Cytomegalovirus (CMV) Retinitis
Stop: Inactive lesions treated for at least 3 months and CD4 count > 100 cells/μL and HIV-VL undetectable over 3 months
Regimens listed are alternatives
Drug / Dose |
---|
valganciclovir (preferred regimen) 900 mg qd po (with food) |
OR ganciclovir 6 mg/kg qd (x 5 days/week) iv |
OR foscarnet 90-120 mg/kg qd (x 5 days/week) iv |