Cytomegalovirus (CMV)

Cytomegalovirus infections

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. Some 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
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 in CSF)

Treatment is individualised according to clinical symptoms and response to treatment

Some guidelines recommend ganciclovir combined with foscarnet

Secondary Prophylaxis/ Maintenance Therapy

CMV Retinitis

Stop: if CD4 count > 100 cells/μL and HIV-VL undetectable over 3 months

Regimens listed are alternatives

Drug / Dose
valganciclovir
900 mg qd po (with food)
OR ganciclovir
5 mg/kg qd (x 5 days/week) iv
OR foscarnet
90-120 mg/kg/day (x 5 days/week) iv

OR cidofovir
5 mg/kg every 2 weeks iv
+ probenecid
+ NaCL 9% hydration