Cytomegalovirus: Difference between revisions
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= Definition = |
== Definition == |
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* Human herpesvirus (DNA virus) transferred by respiratory droplets and blood transfusions that lies dormant in white blood cells |
* Human herpesvirus (DNA virus) transferred by respiratory droplets and blood transfusions that lies dormant in white blood cells |
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= Epidemiology = |
== Epidemiology == |
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* 80% of people are CMV-IgG positive |
* 80% of people are CMV-IgG positive |
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= Risk Factors = |
== Risk Factors == |
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* Crowding |
* Crowding |
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= Presentation = |
== Presentation == |
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* Asymptomatic when young |
* Asymptomatic when young |
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* Mono-like or influenza-like illness when older |
* Mono-like or influenza-like illness when older |
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= Investigations = |
== Investigations == |
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* CBC showing leukopenia or pancytopenia |
* CBC showing leukopenia or pancytopenia |
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* Detectable CMV DNA in peripheral blood, though it can rise during intercurrent illness |
* Detectable CMV DNA in peripheral blood, though it can rise during intercurrent illness |
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= Management = |
== Management == |
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* First-line: valganciclovir or ganciclovir |
* First-line: valganciclovir or ganciclovir |
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* At McMaster, expect 1-log drop within 2 weeks (lab-dependent) |
* At McMaster, expect 1-log drop within 2 weeks (lab-dependent) |
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= Prophylaxis = |
== Prophylaxis == |
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* Solid-organ transplant |
* Solid-organ transplant |
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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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= Complications = |
== Complications == |
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* Even when dormant, can cause mild immunosuppression that predisposes to fungal infections |
* Even when dormant, can cause mild immunosuppression that predisposes to fungal infections |
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** Pneumonitis in stem cell transplants |
** Pneumonitis in stem cell transplants |
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= Resistance = |
== Resistance == |
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* Inherent acyclovir resistance |
* Inherent acyclovir resistance |
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Revision as of 19:30, 15 August 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
