CMV after hematopoietic stem cell transplantation: Difference between revisions
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− | == |
+ | == Background == |
+ | |||
⚫ | |||
+ | * Reactivation of latent recipient [[CMV]] infection is common after [[hematopoietic stem cell transplantation]] |
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− | * Treatment is typically with [[Is treated by::valganciclovir]] 900 mg po daily, but may need [[Is treated by::ganciclovir]] 5 mg/kg IV if no oral access, or [[Is treated by::foscarnet]] 90 mg/kg IV q12h followed by q24h if resistance is suspected |
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+ | |||
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+ | === Microbiology === |
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+ | |||
+ | * Refer to [[Cytomegalovirus#Microbiology|Cytomegalovirus]] |
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+ | |||
+ | === Epidemiology === |
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+ | |||
+ | * Reactivates in 60 to 70% of CMV-seropositive patients and primary infection affects 20 to 30% of seronegative recipients who have seropositive donors |
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+ | |||
+ | {| class="wikitable" |
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+ | !Donor |
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+ | !Recipient |
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+ | !Risk |
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+ | |- |
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+ | |± |
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+ | | + |
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+ | |60-70% |
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+ | |- |
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+ | | + |
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+ | |– |
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+ | |20-30% |
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+ | |- |
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+ | |– |
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+ | |– |
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+ | |5% |
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+ | |} |
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+ | |||
+ | * Risk is proportional to the amount of T cell dysfunction, so risk is higher earlier in disease and after [[fludarabine]], [[alemtuzumab]], or [[2-chlorodeoxyadenose]] |
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+ | * GVHD is another important risk factor |
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+ | |||
+ | ==Clinical Manifestations== |
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+ | |||
+ | *With monitoring and preemptive therapy, CMV pneumonitis has decreased to 5% of seropositive allogeneic recipients |
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+ | *[[Pneumonitis]] (63%) |
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+ | *[[Enteritis]] (26%) |
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+ | *[[Retinitis]] (5%) |
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+ | *Increased risk of rejection |
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+ | |||
+ | ==Management== |
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+ | |||
+ | === Prophylaxis === |
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+ | |||
+ | * Now commonly done with [[letermovir]], started within 28 days of transplantation |
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+ | |||
+ | ===Preemptive Therapy=== |
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+ | |||
⚫ | |||
+ | *Antiviral treatment follows a model of induction therapy for 14 days; if it has declined by at least 1 log, then step down to lower-dose maintenance therapy until viremia resolves fully; otherwise, continue induction dosing |
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+ | **Induction therapy |
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+ | ***[[Is treated by::Ganciclovir]] 5 mg/kg q12h |
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+ | ***If concerns about resistance or bone marrow suppression, [[Is treated by::foscarnet]] 90 mg/kg IV q12h |
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+ | **Maintenance therapy |
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+ | ***[[Is treated by::Valganciclovir]] 900 mg po daily |
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+ | ***If concerns about oral absorption, continue [[Is treated by::ganciclovir]] 5 mg/kg IV q24h |
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+ | ***If concerns about resistance or bone marrow suppression, [[Is treated by::foscarnet]] 90 mg/kg IV q24h |
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⚫ | |||
{| class="wikitable sortable" |
{| class="wikitable sortable" |
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− | ! |
+ | !Serostatus |
− | ! |
+ | !Blood products |
− | ! |
+ | !Duration of PET |
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|- |
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− | | |
+ | |D-/R- |
− | | |
+ | |CMV safe |
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+ | |weeks 2 to 12 |
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|- |
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− | | |
+ | |D+/R- |
− | | |
+ | |CMV safe |
− | | |
+ | |weeks 2 to 12 |
|- |
|- |
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− | | |
+ | |autologous R- |
− | | |
+ | |CMV safe |
− | | |
+ | |weeks 2 to 5 |
|- |
|- |
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− | | |
+ | |D±/R+ |
− | | |
+ | |CMV untested |
− | | |
+ | |weeks 2 to 12, then q2-4wk until week 26 |
|- |
|- |
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− | | |
+ | |autologous R+ |
− | | |
+ | |CMV untested |
− | | |
+ | |weeks 2 to 5 |
|} |
|} |
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+ | |||
+ | ===CMV Disease=== |
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+ | |||
+ | *Treatment is with [[Is treated by::ganciclovir]] induction for 14 to 21 days with IVIG 500 mg/kg every other day, followed by maintenance [[ganciclovir]] for at least 3 to 4 weeks |
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+ | *May need to continue maintenance for longer if patient has [[GVHD]], enteritis with deep ulcerations, or retinitis |
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[[Category:Immunocompromised hosts]] |
[[Category:Immunocompromised hosts]] |
Latest revision as of 17:21, 19 September 2020
Background
- Reactivation of latent recipient CMV infection is common after hematopoietic stem cell transplantation
Microbiology
- Refer to Cytomegalovirus
Epidemiology
- Reactivates in 60 to 70% of CMV-seropositive patients and primary infection affects 20 to 30% of seronegative recipients who have seropositive donors
Donor | Recipient | Risk |
---|---|---|
± | + | 60-70% |
+ | – | 20-30% |
– | – | 5% |
- Risk is proportional to the amount of T cell dysfunction, so risk is higher earlier in disease and after fludarabine, alemtuzumab, or 2-chlorodeoxyadenose
- GVHD is another important risk factor
Clinical Manifestations
- With monitoring and preemptive therapy, CMV pneumonitis has decreased to 5% of seropositive allogeneic recipients
- Pneumonitis (63%)
- Enteritis (26%)
- Retinitis (5%)
- Increased risk of rejection
Management
Prophylaxis
- Now commonly done with letermovir, started within 28 days of transplantation
Preemptive Therapy
- Most frequently managed with weekly viral loads and preemptive treatment (PET) at a lab-specific threshold
- Antiviral treatment follows a model of induction therapy for 14 days; if it has declined by at least 1 log, then step down to lower-dose maintenance therapy until viremia resolves fully; otherwise, continue induction dosing
- Induction therapy
- Ganciclovir 5 mg/kg q12h
- If concerns about resistance or bone marrow suppression, foscarnet 90 mg/kg IV q12h
- Maintenance therapy
- Valganciclovir 900 mg po daily
- If concerns about oral absorption, continue ganciclovir 5 mg/kg IV q24h
- If concerns about resistance or bone marrow suppression, foscarnet 90 mg/kg IV q24h
- Induction therapy
- Use CMV safe (leukoreduced or filtered) blood products if the recipient is CMV seronegative
Serostatus | Blood products | Duration of PET |
---|---|---|
D-/R- | CMV safe | weeks 2 to 12 |
D+/R- | CMV safe | weeks 2 to 12 |
autologous R- | CMV safe | weeks 2 to 5 |
D±/R+ | CMV untested | weeks 2 to 12, then q2-4wk until week 26 |
autologous R+ | CMV untested | weeks 2 to 5 |
CMV Disease
- Treatment is with ganciclovir induction for 14 to 21 days with IVIG 500 mg/kg every other day, followed by maintenance ganciclovir for at least 3 to 4 weeks
- May need to continue maintenance for longer if patient has GVHD, enteritis with deep ulcerations, or retinitis