B20.2
DESCRIPTION
CMV disease outside the reticulo-endothelial system is an AIDS-defining illness (WHO clinical stage 4).
CMV disease is seen in patients with CD4 counts <100 cells/mm3.
The commonest manifestations are:
- retinitis,
- gitulceration,
- pneumonitis, and
- polyradiculitis.
GIT and other organ involvement must be diagnosed on biopsy.
CNS disease must be diagnosed by PCR of CSF.
The diagnosis of CMV retinitis should be confirmed by an ophthalmologist
Note: CMV serology (IgM and IgG), antigenaemia (pp65), or PCR on blood are not helpful in the diagnosis of CMV disease in HIV-infected adults.
MEDICINE TREATMENT
Valganciclovir is the treatment of choice, but this agent is toxic and expensive; and should only be used by a specialist familiar with its use.
To prevent recurrent disease commence patients on ART as soon as possible after initiating valganciclovir (see : Antiretroviral therapy).
Maintenance therapy is only applicable to CNS disease and retinitis.
Monitor FBC regularly during therapy. Avoid other medicines associated with bone marrow suppression, particularly zidovudine.
Biopsy-proven GIT disease and pneumonitis
- Valganciclovir, oral, 900 mg 12 hourly for the first 3 weeks, if available. Specialist initiated.
OR
If unable to tolerate oral medication:
- Ganciclovir, IV, 5 mg/kg 12 hourly for 14 days, if available. Specialist initiated.
Maintenance treatment is not indicated unless there has been a relapse.
CNS disease
Initial treatment:
- Valganciclovir, oral, 900 mg 12 hourly for the first 3 weeks, if available. Specialist initiated.
OR
If unable to tolerate oral medication:
- Ganciclovir, IV, 5 mg/kg 12 hourly for 14 days. Specialist initiated.
Maintenance treatment:
Only patients with a good clinical response should be considered for maintenance.
- Valganciclovir, oral, 900 mg daily until CD4 count rises to >100 cells/mm3 on ART, if available.Specialist initiated.
OR
If unable to tolerate oral medication:
Ganciclovir, IV, 5 mg/kg daily until CD4 count rises to >100 cells/mm3 on ART. Specialist initiated.
REFERRAL/CONSULTATION
Specialist or tertiary
All patients.