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EBAC - Infectious Disease > Cytomegalovirus > Flashcards

Cytomegalovirus Flashcards

1
Q

What is Cytomegalovirus (CMV)?

A

A double-stranded DNA virus in the herpesvirus family that can cause disseminated or localized end-organ disease.

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2
Q

In which population does CMV end-organ disease primarily occur?

A

In people with HIV and advanced immunosuppression, typically with CD4+ T lymphocyte counts <50 cells/mm3.

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3
Q

What is the most common CMV end-organ disease in patients with AIDS?

A

CMV retinitis.

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4
Q

What percentage of patients with AIDS experienced CMV retinitis before potent ART?

A

An estimated 30%.

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5
Q

How much has the incidence of new cases of CMV end-organ disease declined with ART?

A

By ≥95%.

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6
Q

What is the recurrence rate of CMV retinitis lesions after immune recovery?

A

0.03/person-year.

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7
Q

What is the characteristic appearance of CMV retinitis lesions?

A

Fluffy, yellow-white retinal lesions with tiny dry-appearing, granular, dot-like ‘satellites’.

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8
Q

What are common clinical manifestations of CMV colitis?

A
  • Weight loss
  • Fever
  • Anorexia
  • Abdominal pain
  • Diarrhea
  • Malaise
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9
Q

What symptoms are associated with CMV esophagitis?

A
  • Odynophagia
  • Nausea
  • Midepigastric discomfort
  • Retrosternal discomfort
  • Fever
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10
Q

Is CMV pneumonitis common in people with HIV?

A

No, it is uncommon.

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11
Q

What are the key features of CMV neurologic disease?

A
  • Dementia
  • Ventriculoencephalitis
  • Polyradiculomyelopathy
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12
Q

How is CMV retinitis diagnosed?

A

By recognizing characteristic retinal changes during an ophthalmoscopic examination.

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13
Q

What is the diagnostic value of PCR for CMV in aqueous or vitreous humor?

A

It is useful for establishing the diagnosis in unclear cases.

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14
Q

What histopathological feature is indicative of CMV colitis?

A

Mucosal ulcerations with characteristic intranuclear and intracytoplasmic inclusions.

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15
Q

What is the primary preventive measure for CMV end-organ disease?

A

Maintaining CD4 count >100 cells/mm3 with ART.

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16
Q

What is the recommendation for patients with low CD4 counts regarding ocular health?

A

Regular assessment of visual acuity and referral to ophthalmology for changes.

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17
Q

What is the first-line therapy for treating CMV retinitis?

A
  • Oral valganciclovir
  • Intravenous ganciclovir
  • IV ganciclovir induction followed by oral valganciclovir maintenance
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18
Q

What are the potential toxicities of IV foscarnet and IV cidofovir?

A
  • Nephrotoxicity
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19
Q

What is the recommended approach for lesions immediately threatening sight?

A

Supplement systemic therapy with intravitreous injections of ganciclovir or foscarnet.

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20
Q

What is the significance of serum antibodies to CMV?

A

A negative IgG antibody level indicates that CMV is unlikely to be the cause of the disease process.

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21
Q

Fill in the blank: CMV is shed in ______, cervical secretions, and saliva.

A

semen

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22
Q

True or False: A positive PCR assay for CMV in blood is sufficient to diagnose CMV end-organ disease.

A

False.

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23
Q

What is the primary treatment for immediate sight-threatening lesions in CMV retinitis?

A

Intravitreal injections of ganciclovir or foscarnet

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24
Q

How often are intravitreal injections continued until lesion inactivity is achieved?

A

Weekly

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25
Q

What is the rationale for supplementing systemic therapy with intravitreal injections?

A

Based on pharmacokinetic considerations

26
Q

What complications can arise from intravitreal injections?

A
  • Bacterial or fungal infections
  • Hemorrhage
  • Retinal detachment
27
Q

What is the recommended treatment for patients without sight-threatening lesions?

A

Oral valganciclovir alone

28
Q

What is the duration of systemic anti-CMV therapy recommended for patients until ART induces immune recovery?

A

3 to 6 months

29
Q

What ocular complications are related to lesion size in CMV retinitis?

A
  • Immune recovery uveitis (IRU)
  • Retinal detachment
30
Q

What is the therapy of choice for patients with colitis or esophagitis?

A

IV ganciclovir

31
Q

What alternative can be used if ganciclovir-related toxicity is treatment-limiting?

32
Q

What is the concern regarding IRIS after ART initiation?

A

Substantial increase in immune reconstitution uveitis (IRU)

33
Q

When should ART be initiated after starting anti-CMV therapy?

A

No later than 1 to 2 weeks

34
Q

What is the purpose of indirect ophthalmoscopy in managing CMV retinitis?

A
  • Evaluate efficacy of treatment
  • Identify second eye involvement
  • Detect complications like IRU
35
Q

What are the adverse effects of ganciclovir/valganciclovir?

A
  • Anemia
  • Neutropenia
  • Thrombocytopenia
  • Nausea
  • Diarrhea
  • Renal dysfunction
36
Q

What should be monitored in patients receiving foscarnet?

A
  • Serum electrolytes
  • Renal function
  • Complete blood counts
37
Q

What adverse effects are associated with cidofovir?

A
  • Nephrotoxicity
  • Neutropenia
  • Uveitis
  • Hypotony
38
Q

What is immune recovery uveitis (IRU)?

A

An ocular form of IRIS characterized by inflammation in the anterior chamber or vitreous body

39
Q

What is the estimated incidence of IRU after immune recovery?

A

0.02/person-year

40
Q

What is the recommended treatment for IRU?

A

Corticosteroid therapy

41
Q

When can maintenance therapy for CMV retinitis be safely discontinued?

A

After lesions have been inactive for 3 to 6 months with sustained increases in CD4 cell counts

42
Q

What monitoring is required after discontinuing anti-CMV maintenance therapy?

A

Ophthalmologic monitoring every 3 months

43
Q

What is the risk of reactivation of CMV retinitis after stopping maintenance therapy?

44
Q

What is a potential cause of therapy failure in CMV retinitis?

A

Inadequate anti-CMV drug levels in the eye

45
Q

What is the resistance rate for ganciclovir in the pre-ART era?

A

Approximately 25% per person-year

46
Q

How can ganciclovir resistance be detected?

A

CMV DNA PCR of blood specimens followed by detection of UL97 mutations

47
Q

What is the role of oral valganciclovir in maintenance therapy?

A

Easiest and least toxic to administer to an outpatient population

48
Q

What is the recommended frequency for ophthalmologic monitoring after discontinuing anti-CMV maintenance therapy?

A

At least every 3 months and periodically after immune reconstitution.

Monitoring is crucial for early detection of CMV relapse and IRU.

49
Q

At what CD4 cell count should maintenance therapy be reinstituted?

A

When the CD4 cell count has decreased to <100 cells/mm3.

Reactivation of CMV retinitis occurs frequently in patients with CD4 <50 cells/mm3.

50
Q

What are the indications for treatment of CMV infection during pregnancy?

A

The same as for nonpregnant individuals with HIV.

Treatment considerations should include the timing of therapy to limit fetal exposure.

51
Q

What is the preferred therapy for immediate sight-threatening CMV lesions?

A

Ganciclovir 5 mg/kg IV q12h for 14–21 days, then 5 mg/kg IV daily or valganciclovir 900 mg PO daily.

Intravitreous injections may also be used to control infection.

52
Q

What is the teratogenic risk associated with ganciclovir use during pregnancy?

A

Embryotoxic among rabbits and mice, causing various malformations.

Safe use in human pregnancy has been reported in certain populations.

53
Q

What monitoring is recommended if foscarnet is used during pregnancy?

A

Weekly monitoring of amniotic fluid volumes by ultrasound after 20 weeks of gestation.

This is to detect oligohydramnios due to foscarnet’s renal toxicity.

54
Q

What should be monitored in the fetus during the third trimester of pregnancy?

A

Fetal movement counting and periodic ultrasound monitoring.

This is to check for hydrops fetalis indicating substantial anemia.

55
Q

What are the risk factors for congenital CMV?

A
  • Mothers with CD4+ <200 cells/mm3
  • Mothers with urinary CMV shedding
  • HIV transmission to infants.

Maternal CMV and infant congenital CMV are linked to increased risk of HIV perinatal transmission.

56
Q

What is the recommendation for treating asymptomatic maternal CMV infection during pregnancy?

A

Treatment is not indicated solely to prevent infant infection.

Routine screening for CMV infection in pregnancy is not recommended.

57
Q

What is the classification of the therapy for CMV retinitis based on patient tolerance?

A

Therapy should be individualized based on tolerance of systemic medications, prior exposure to anti-CMV drugs, and lesion location.

Individualized treatment improves outcomes.

58
Q

What is the duration of anti-CMV therapy for CMV esophagitis or colitis?

A

21–42 days or until signs and symptoms have resolved.

Maintenance therapy is usually not necessary but should be considered after relapses.

59
Q

What is the recommended therapy for managing well-documented CMV pneumonitis?

A

Use of IV ganciclovir or IV foscarnet is reasonable.

Treatment experience for CMV pneumonitis in HIV patients is limited.

60
Q

What combination therapy may be used for managing CMV neurological disease?

A

Ganciclovir IV plus foscarnet IV to stabilize disease.

Prompt initiation of treatment is crucial.

61
Q

What is the role of oral valganciclovir in the treatment of CMV neurological disease?

A

The role has not been established.

Further research is needed to determine its effectiveness.

62
Q

What is the optimal duration of therapy for CMV retinitis?

A

Not established.

Treatment should be initiated promptly to prevent complications.

EBAC - Infectious Disease (36 decks)

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