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 (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.
Some guidelines recommend ganciclovir combined with foscarnet especially in relapse

Secondary Prophylaxis/ Maintenance Therapy

Cytomegalovirus (CMV) Retinitis

Stop: Treated lesions inactive and 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 qd (x 5 days/week) iv