Cytomegalovirus Follow-up

  • Author: Kauser Akhter, MD; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Aug 17, 2011
 

Further Inpatient Care

Patients with cytomegalovirus (CMV) disease must be well hydrated.

Nutrition is an important factor because many patients are debilitated by transplant or HIV disease.

As with any patient, attention must be focused on avoiding iatrogenic infections and problems.

Patients who develop CMV disease are immunocompromised, meaning that they at greater risk for bacterial and fungal infections. If possible, the patient's level of immunosuppression should be lowered.

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Further Outpatient Care

When ganciclovir is administered on an outpatient basis for the treatment of CMV retinitis, follow-up with a CBC count once per week (monitoring for hematological toxicity) is necessary. Monitoring electrolytes at the same time is prudent. Ganciclovir therapy should be stopped when neutrophil counts are less than 500 cells/µL. Starting growth factors, such as GM-CSF or G-CSF, may be necessary. A switch to foscarnet may be required at this time.

Patients with CMV retinitis should undergo regular ophthalmological examinations.

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Inpatient & Outpatient Medications

See Medication section.

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Deterrence/Prevention

See Treatment for a discussion about early treatment versus prophylaxis with ganciclovir.

  • Other drugs have been used for CMV prophylaxis, but none is as effective as ganciclovir. Acyclovir and valacyclovir have been used for prophylaxis and early treatment in allogeneic marrow transplant recipients. Acyclovir has also been used in recipients of other types of transplants.
  • CMV remains the most common viral cause of severe disease in the transplant population, with significant associated morbidity and mortality. This, together with the issue of drug treatment toxicities and drug interactions, makes the development of a successful vaccine a high priority.[61] A bivalent DNA CMV vaccine, VCL-CB01 (which contains plasmids that encode CMV tegument pp65 and the major CMV surface glycoprotein B), was found to be well-tolerated in a phase 1 open-label study of 44 healthy adults[62] and is now in phase II trials. These trials, which involve CMV-seropositive hematopoietic cell transplant recipients, have demonstrated that VCL-CB01 increases T-cell responses compared with placebo.[63] The final results from this trial will be useful in developing strategies to prevent CMV disease in seropositive transplant recipients.
  • Congenital CMV infection is an important cause of hearing, cognitive, and motor impairments in newborns. A phase II, placebo-controlled, randomized, double blind trial by Pass et al (2009) evaluated a recombinant CMV vaccine (envelope glycoprotein B with MF59 adjuvant). Three doses of the CMV vaccine or placebo were administered at 0, 1, and 6 months to 464 CMV-seronegative women within 1 year after they had given birth. After a minimum follow-up period of 1 year, 49 confirmed CMV infections were reported—18 in the vaccine group and 31 in the placebo group. One infant in the vaccine group was found to have congenital CMV infection, while 3 infants from the placebo group were infected. Ongoing research continues to evaluate the potential for a CMV vaccine to decrease maternal and congenital CMV infection.[64]
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Complications

See Medication.

Despite long treatment courses with valganciclovir and documented clearance of CMV viremia, CMV relapse remains common among solid organ transplant recipients.[65] A better understanding of the epidemiology of CMV infection among solid organ transplant recipients and risk factors for disease relapse is warranted.

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Prognosis

The prognosis of CMV hepatitis is generally good. Most patients recover completely. Symptoms can persist, usually in the form of fatigue, for several months after primary infection.

  • CMV pneumonia in marrow transplant recipients once carried a mortality rate higher than 85%. The use of ganciclovir plus high-dose immune globulin for the treatment of CMV pneumonia in allogeneic marrow transplant recipients has lowered the mortality rate to 30%-60%.
  • Because patients who develop CMV disease are immunocompromised, their prognosis may be determined by their underlying disease. The need for mechanical ventilation is a poor prognostic sign.
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Patient Education

For excellent patient education resources, visit eMedicine's Bacterial and Viral Infections Center. Also, see eMedicine's patient education article Mononucleosis.

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Contributor Information and Disclosures
Author

Kauser Akhter, MD  Clinical Assistant Professor, Department of Internal Medicine, Florida State University College of Medicine; Infectious Diseases Faculty Practice, Orlando Health

Disclosure: Nothing to disclose.

Coauthor(s)

Todd S Wills  MD, Associate Professor, Department of Medicine, Division of Infectious Disease and International Medicine, Program Director, Infectious Disease Fellowship Program, University of South Florida College of Medicine

Todd S Wills is a member of the following medical societies: Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Specialty Editor Board

Douglas A Drevets, MD  Assistant Professor, Department of Medicine, Section of Infectious Disease, Oklahoma University Health Sciences Center

Douglas A Drevets, MD is a member of the following medical societies: American Association of Immunologists, American Society for Microbiology, Central Society for Clinical Research, and Christian Medical & Dental Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

John W King, MD  Professor of Medicine, Chief, Section of Infectious Diseases, Director, Viral Therapeutics Clinics for Hepatitis, Louisiana State University Health Sciences Center; Consultant in Infectious Diseases, Overton Brooks Veterans Affairs Medical Center

John W King, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Federation for Medical Research, American Society for Microbiology, Association of Subspecialty Professors, Infectious Diseases Society of America, and Sigma Xi

Disclosure: emedicine $50.00 Author of chapter; MERCK None Other

Eleftherios Mylonakis, MD  Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital

Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD  Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthor Todd S Wills, MD to the development and writing of this article.

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Here, using immunofluorescent technique, a specimen of human embryonic lung (25X) reveals the presence of cytomegalovirus. Courtesy of the CDC/Dr. Craig Lyerla.
Hematoxylin-eosin–stained lung section showing typical owl-eye inclusions (480X). Courtesy of Danny L Wiedbrauk, PhD, Scientific Director, Virology & Molecular Biology, Warde Medical Laboratory, Ann Arbor, Michigan.
 
 
 
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