Cytomegalovirus (CMV)

Cytomegalovirus (CMV) infections

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
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 with clearance of CMV-DNA in CSF, then secondary prophylaxis Some experts recommend ganciclovir combined with foscarnet especially in progressive or relapsing cases

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

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 with clearance of CMV-DNA in CSF, then secondary prophylaxis

Some experts recommend ganciclovir combined with foscarnet especially in progressive or relapsing cases

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)

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)

Cidofovir (+ probenecid) may be considered as a therapeutic option for patients unable to tolerate the other treatments listed