Cytomegalovirus: Difference between revisions
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== Prophylaxis == |
== Prophylaxis == |
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* Solid-organ transplant |
* '''Solid-organ transplant''' |
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** Donor+/Recipient– high risk for reactivation, the the donor organ infecting the recipient |
** Donor+/Recipient– high risk for reactivation, the the donor organ infecting the recipient |
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** Donor–/Recipient+ intermediate risk |
** Donor–/Recipient+ intermediate risk |
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** Donor+/Recipient+ intermediate risk |
** Donor+/Recipient+ intermediate risk |
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** Donor–/Recipient– lowest risk |
** Donor–/Recipient– lowest risk |
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** High and intermediate risk patients get prophylaxis with valganciclovir for some amount of duration... |
** High and intermediate risk patients get '''prophylaxis''' with valganciclovir for some amount of duration... |
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* Hematologic stem cell transplant |
* '''Hematologic stem cell transplant''' |
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** Donor+/Recipient+ high risk for reactivation |
** Donor+/Recipient+ high risk for reactivation |
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** Donor–/Recipient+ high risk |
** Donor–/Recipient+ high risk |
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** Donor+/Recipient– intermediate risk |
** Donor+/Recipient– intermediate risk |
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** Donor–/Recipient– lowest risk |
** Donor–/Recipient– lowest risk |
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** Preemptive monitoring with weekly CMV DNA PCR starting week 2 |
** '''Preemptive monitoring''' with weekly CMV DNA PCR starting week 2 |
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* Treat if greater than threshold (1425 at McMaster) or if rising titre with symptoms |
* Treat if greater than threshold (1425 at McMaster) or if rising titre with symptoms |
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Revision as of 20:58, 10 September 2019
Definition
- Human herpesvirus (DNA virus) transferred by respiratory droplets and blood transfusions that lies dormant in white blood cells
Epidemiology
- 80% of people are CMV-IgG positive
Risk Factors
- Crowding
Presentation
- Asymptomatic when young
- Mono-like or influenza-like illness when older
Investigations
- CBC showing leukopenia or pancytopenia
- Mild elevation in liver enzymes
- CMV-IgG positive
- Detectable CMV DNA in peripheral blood, though it can rise during intercurrent illness
Management
- First-line: valganciclovir or ganciclovir
- Measure baseline CBC first
- Second-line, if cytopenias: foscarnet
- Third-line: cidofovir, marabavir
- At McMaster, expect 1-log drop within 2 weeks (lab-dependent)
Prophylaxis
- Solid-organ transplant
- Donor+/Recipient– high risk for reactivation, the the donor organ infecting the recipient
- Donor–/Recipient+ intermediate risk
- Donor+/Recipient+ intermediate risk
- Donor–/Recipient– lowest risk
- High and intermediate risk patients get prophylaxis with valganciclovir for some amount of duration...
- Hematologic stem cell transplant
- Donor+/Recipient+ high risk for reactivation
- Donor–/Recipient+ high risk
- Donor+/Recipient– intermediate risk
- Donor–/Recipient– lowest risk
- Preemptive monitoring with weekly CMV DNA PCR starting week 2
- Treat if greater than threshold (1425 at McMaster) or if rising titre with symptoms
Complications
- Even when dormant, can cause mild immunosuppression that predisposes to fungal infections
- Asymptomatic shedding in lungs during intercurrent illness
- Viremia with influenza-like illness
- End-orgam damage
- CMV colitis
- Retinitis in AIDS patient (CD4 < 50-100)
- Organ inflammation of solid-organ transplants
- Pneumonitis in stem cell transplants
Resistance
- Inherent acyclovir resistance
- Tyrosine kinase mutation UL97? confers resistance to (val)ganciclovir
- Polymerase mutation U54? confers resistance to (val)ganciclovir and foscarnet
- Consider resistance if CMV DNA titres not decreasing despite appropriate treatment
- Resistance genotyping available
References
- ^ Michael J. Cannon, D. Scott Schmid, Terri B. Hyde. Review of cytomegalovirus seroprevalence and demographic characteristics associated with infection. Reviews in Medical Virology. 2010;20(4):202-213. doi:10.1002/rmv.655.
- ^ Jutta K. Preiksaitis, R. P. Bryce Larke, Glory J. Froese. Comparative seroepidemiology of cytomegalovirus infection in the Canadian Arctic and an Urban center. Journal of Medical Virology. 1988;24(3):299-307. doi:10.1002/jmv.1890240307.
