CMV

Question 1

What type of virus is CMV?

Answer 1

Beta-herpes virus
Double stranded linear DNA
HHV-5

Question 2

How common is CMV seroprevalence?

Answer 2

60-100%
In infants it is 0.5-1% and may cause sensorineural hearing loss/intellectual disability if congenitally acquired

Question 3

What are the routes of transmission of CMV?

Answer 3

Person-to-person e.g. kissing, intimate contact, sex
Vertical transmission e.g. MTCT
Blood transfusion
HSCT

Question 4

What cells does CMV infect?

Answer 4

Leukocytes
Endothelial cells

Question 5

What is the most common organ-invasive disease caused by CMV in AIDS?

Answer 5

Chorioretinitis
Colitis is the second most common

Question 6

What are the risk factors for CMV?

Answer 6

• CMV D+/R- status in transplantation
• Immunosuppressive drugs - especially steroids, MMF, ATG, alemtuzumab.
• AIDS
• IBD
• Acute illness
• Maternal CMV during pregnancy

Question 7

Which immunosuppressive drugs have lower risk of CMV?

Answer 7

Sirolimus
Everolimus

Question 8

What do investigations show in CMV?

Answer 8

FBC - lymphocytosis if immunocompetent, leukopenia and thrombocytopenia if not
Cr - may be high in renal transplant
AST/ALT - raised
ALP - raised if hepatobiliary involvement
CMV-IgM - indicative of acute infection, IgG past.
NAT - positive for CMV
CD4 - low in AIDS at <50
CXR - may show pneumonitis
Biopsy - owls eye inclusions in pneumocytes

Question 9

Is CMV asymptomatic?

Answer 9

Asymptomatic in the immunocompetent
Symptomatic in the immunocompromised e.g. fever, BM suppression, end-organ diseases.

Question 10

What is the diagnostic test for acute CMV?

Answer 10

Serology for CMV-IgM which binds with low avidity but NAT is more rapid and sensitive

Question 11

How do you manage CMV in the immunocompetent?

Answer 11

Self-resolves

Question 12

How do you manage CMV in the immunocompromised?

Answer 12

Transplant recipients with CMV - PO valganciclovir/IV ganciclovir
AIDS patients e.g. with retinitis - IV ganciclovir or foscarnet +/- cidofovir

AND reduce immunosuppression

*cidofovir and foscarnet are both IV and less preferred due to toxicity

Question 13

How do you manage resistant CMV?

Answer 13

Genotypic resistance analysis - especially if prolonged antiviral treatment

Question 14

How do you manage congenital CMV?

Answer 14

6 months oral valginciclovir

Question 14

How do you manage congenital CMV?

Answer 14

6 months oral valginciclovir

Question 15

What are the manifestations of CMV in the immunocompromised?

Answer 15

• Retinitis
• Encephalitis
• Pneumointis
• Gastroenteritis

Symptoms:
* Malaise
* Fever
* Diarrhoea
* N&V
* Visual floaters and blindness, abnormal fundoscopy

Question 16

What are the prevention strategies for CMV in the immunocompromised with transplants?

Answer 16

HSCT: CMV viral load twice weekly - treat if virus reactivates, until suppressed (pre-emptive therapy)

Solid organ transplant: Valganciclovir prophylaxis for 100 days

Question 17

What are the side effects of treatments for CMV?

Answer 17

A
Ganciclovir and valganciclovir (oral) - BM suppression i.e. leukopenia and thrombocytopenia

Foscarnet (IV) - nephrotoxicity and electrolyte distubance (Ca, Mg, P)

Cidofovir (nephrotoxicity)

IVIg - flushing, chills, muscle cramps, fever, nausea