Cytomegalovirus Follow-up

Updated: Jan 05, 2017
  • Author: Kauser Akhter, MD; Chief Editor: Michael Stuart Bronze, MD  more...
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Follow-up

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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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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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 valganciclovir (drug of choice) [4] or 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. [83] A CMV glycoprotein-B vaccine containing an MF59 adjuvant is currently in a phase 2 randomized placebo-controlled trial in transplant recipients. [84]

Congenital CMV infection is an important cause of hearing, cognitive, and motor impairments in newborns. A phase 2, 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. [85]

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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. [86] 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 eMedicineHealth's Infections Center. Also, see eMedicineHealth's patient education article Mononucleosis.

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