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| | __NOTOC__ |
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| * '''Cytomegalovirus treatment'''<ref>{{cite book | last = Gilbert | first = David | title = The Sanford guide to antimicrobial therapy 2014 | publisher = Antimicrobial Therapy | location = Sperryville, Va | year = 2014 | isbn = 978-1930808782 }}</ref> | | *Endocrine cells in insulinoma are organised in nests and trabecular pattern scattered throughout a fibro-vascular stroma with well-localised fibrous septa separating it from normal tissue<ref name="PadidelaFiest2014">{{cite journal|last1=Padidela|first1=R.|last2=Fiest|first2=M.|last3=Arya|first3=V.|last4=Smith|first4=V. V.|last5=Ashworth|first5=M.|last6=Rampling|first6=D.|last7=Newbould|first7=M.|last8=Batra|first8=G.|last9=James|first9=J.|last10=Wright|first10=N. B.|last11=Dunne|first11=M. J.|last12=Clayton|first12=P. E.|last13=Banerjee|first13=I.|last14=Hussain|first14=K.|title=Insulinoma in childhood: clinical, radiological, molecular and histological aspects of nine patients|journal=European Journal of Endocrinology|volume=170|issue=5|year=2014|pages=741–747|issn=0804-4643|doi=10.1530/EJE-13-1008}}</ref> |
| :* 1. '''Immunocompetent patients'''
| | *Absence of exocrine tissue with the loss of normal pancreatic architecture |
| ::* 1.1 '''Mononucleosis syndrome'''
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| :::* Preferred regimen: supportive therapy
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| ::* 1.2 '''CMV in pregnancy'''
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| :::* Preferred regimen: Hyperimmune 200 IU/kg of maternal weight as single-dose during pregnancy
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| :* 2. '''Immunocompromised patients'''
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| ::* 2.1 '''Retinitis'''
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| :::* Preferred regimen (1): [[Ganciclovir]] intraocular implant {{plus}} [[Valganciclovir]] 900 mg PO bid for 14-21 days {{then}} [[Valganciclovir]] 900mg PO qq for maintenance therapy - for immediate sight-threatening lesions
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| :::* Preferred regimen (2): [[Valganciclovir]] 900 mg PO bid for 14-21 days {{then}} [[Valganciclovir]] 900 mg PO qq for maintenance therapy - for peripheral lesions
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| :::* Alternative regimen (1): [[Foscarnet]] 60 mg/kg IV q8h {{or}} [[Foscarnet]] 90 mg/kg IV q12h for 14-21 days {{then}} [[Foscarnet]] 90-120 mg/kg IV q24h
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| :::* Alternative regimen (2): [[Cidofovir]] 5 mg/kg IV for 2 weeks {{then}} [[Cidofovir]] 5 mg/kg IV every other week - each dose should be admnistered with IV saline hydration and probenecid
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| :::* Alternative regimen (3): [[Ganciclovir]] 5 mg/kg IV q12h for 14-21 days {{then}} [[Valganciclovir]] 900 mg PO bid
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| :::* Alternative regimen (4): [[Fomivirsen]] intravitreal injection - for relapses
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| :::* Note: keep a maintenance dose of [[Valganciclovir]] 900 mg PO qd until CD4 >100/mm³
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| ::* 2.2 '''Transplant patients'''
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| :::* Preferred regimen: [[Valganciclovir]] 900 mg PO bid {{or}} [[Ganciclovir]] 5 mg/kg IV q12h for at least 2-3 weeek
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| :::* Note: Use [[Valganciclovir]] 900 mg PO qd for 1-3 months if high dose of immunosuppression.
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| ::* 2.3 '''Colitis, esophagitis, gastritis'''
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| :::* Preferred regimen: [[Ganciclovir]] 5 mg/kg/dose IV q12h for 3-6 weeks weeks for induction. There is no agreement on the use of maintenance.
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| :::* Alternative regimen: [[Cidofovir]] 5 mg/kg IV for 2 weeks, then 5 mg/kg every other week; each dose should be administered with IV saline hydration and oral probenecid 2 g PO 3h before each dose and further 1 g doses after 2h and 8h.
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| :::* Note: Switch to oral [[Valganciclovir]] when PO tolerated & when symptoms not severe enough to interfere with absorption.
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| ::* 2.4 '''Pneumonia'''
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| :::* Preferred regimen: [[Valganciclovir]] 900 mg PO bid for 14–21 days, then 900 mg PO qd for maintenance therapy
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| :::* Alternative regimen for retinitis: [[Ganciclovir]] 5 mg/kg IV q12h for 14–21 days, then [[Valganciclovir]] 900 mg PO qd
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| :::* Note: In bone marrow transplant patients, combine therapy with CMV immune globulin.
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| ::* 2.5 '''Encephalitis, ventriculitis'''
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| :::* Note: Treatment not defined, but should be considered the same as retinitis. Disease may develop while taking [[Ganciclovir]] as suppressive therapy.
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| ::* 2.6 '''Lumbosacral polyradiculopathy'''
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| :::* Preferred regimen: [[Ganciclovir]], as with retinitis
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| :::* Alternative regimen: [[Foscarnet]] 40 mg/kg IV q12h another option
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| :::* Alternative regimen: [[Cidofovir]] 5 mg/kg IV for 2 weeks, then 5 mg/kg every other week; each dose should be administered with IV saline hydration and oral probenecid 2 g PO 3h before each dose and further 1 g doses after 2h and 8h.
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| :::* Note (1): Switch to [[Valganciclovir]] when possible.
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| :::* Note (2): Suppression continued until CD4 remains >100/mm³ for 6 months.
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| ::*2.7 '''Peri/postnatal severe CMV infection in very low birth weight infants'''
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| :::*Preferred regimen: [[Ganciclovir]] 6 mg/kg/dose IV q12h for 3 weeks<ref name="pmid25243446">{{cite journal| author=Josephson CD, Caliendo AM, Easley KA, Knezevic A, Shenvi N, Hinkes MT et al.| title=Blood transfusion and breast milk transmission of cytomegalovirus in very low-birth-weight infants: a prospective cohort study. | journal=JAMA Pediatr | year= 2014 | volume= 168 | issue= 11 | pages= 1054-62 | pmid=25243446 | doi=10.1001/jamapediatrics.2014.1360 | pmc=PMC4392178 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25243446 }} </ref>
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| | Patients with insulinomas usually develop neuroglycopenic symptoms. These include recurrent headache, lethargy, [[diplopia]], and [[blurred vision]], particularly with exercise or fasting. Severe [[hypoglycemia]] may result in [[seizure]]s, [[coma]], and permanent neurological damage. Symptoms resulting from the catecholaminergic response to hypoglycemia (i.e. tremulousness, palpitations, [[tachycardia]], sweating, hunger, anxiety, nausea) are not as common. Sudden weight gain (the patient can become massively obese) is sometimes seen. A neater list of symptoms would include: |
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| | * [[Anxiety]] |
| | * Behavior changes |
| | * [[Blurred vision]] |
| | * [[Confusion]] |
| | * [[Convulsions]] |
| | * [[Dizziness]] |
| | * [[Headache]] |
| | * [[Hunger]] |
| | * [[Loss of consciousness]] |
| | * [[Rapid heart rate]] |
| | * [[Sweating]] |
| | * [[Tremor]] |
| | * [[Weight gain]] |
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| ====Antibiotic Regimen====
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| In case of serious skin, soft tissues, and bones infection, a combination of [[antibiotic]]s need to be administered:<ref name="pmid17277290">{{cite journal| author=Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F et al.| title=An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. | journal=Am J Respir Crit Care Med | year= 2007 | volume= 175 | issue= 4 | pages= 367-416 | pmid=17277290 | doi=10.1164/rccm.200604-571ST | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17277290 }} </ref>
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| * [[Macrolide]]: [[clarithromycin]] ''OR'' [[azithromycin]]
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| ''PLUS''
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| * Parenteral antibiotics: [[amikacin]], [[cefoxitin]] ''OR'' [[imipenem]]
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| Note that, during the initial therapy, [[amikacin]] should be administered with [[cefoxitin]] up to two weeks or until the patient improves clinically.<ref name="pmid17277290">{{cite journal| author=Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F et al.| title=An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. | journal=Am J Respir Crit Care Med | year= 2007 | volume= 175 | issue= 4 | pages= 367-416 | pmid=17277290 | doi=10.1164/rccm.200604-571ST | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17277290 }} </ref>
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| ====Antibiotic Dosage====
| | <ref name="pmid1356383">{{cite journal| author=| title=Proceedings of the 1991 International Congress of Rhinology. Tokyo, Japan. | journal=Rhinol Suppl | year= 1992 | volume= 14 | issue= | pages= 1-273 | pmid=1356383 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1356383 }} </ref> |
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| | style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |Antibiotic ||style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |Dosage
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| |style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |[[Clarithromycin]]||style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |1,000 mg/day<ref name="pmid17277290">{{cite journal| author=Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F et al.| title=An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. | journal=Am J Respir Crit Care Med | year= 2007 | volume= 175 | issue= 4 | pages= 367-416 | pmid=17277290 | doi=10.1164/rccm.200604-571ST | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17277290 }} </ref>
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| |style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |[[Azithromycin]]||style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | 250 mg/day<ref name="pmid17277290">{{cite journal| author=Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F et al.| title=An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. | journal=Am J Respir Crit Care Med | year= 2007 | volume= 175 | issue= 4 | pages= 367-416 | pmid=17277290 | doi=10.1164/rccm.200604-571ST | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17277290 }} </ref>
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| |style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |[[Amikacin]]||style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |
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| ''Once a day regimen'' <br>
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| - Adults <50 years and normal renal function: 10-15 mg/kg <br>
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| - Age >50 years and/or anticipated long term therapy for more than 3 weeks: 10 mg/kg <br>
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| ''Three times per week regimen'' <br>
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| - 25 mg/kg<ref name="pmid17277290">{{cite journal| author=Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F et al.| title=An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. | journal=Am J Respir Crit Care Med | year= 2007 | volume= 175 | issue= 4 | pages= 367-416 | pmid=17277290 | doi=10.1164/rccm.200604-571ST | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17277290 }} </ref>
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| |style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |[[Cefoxitin]]||style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | High dose, up to 12 g/day, divided dose<ref name="pmid17277290">{{cite journal| author=Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F et al.| title=An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. | journal=Am J Respir Crit Care Med | year= 2007 | volume= 175 | issue= 4 | pages= 367-416 | pmid=17277290 | doi=10.1164/rccm.200604-571ST | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17277290 }} </ref>
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| |style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |[[Imipenem]]||style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | 500 mg, 2-4 times/day<ref name="pmid17277290">{{cite journal| author=Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F et al.| title=An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. | journal=Am J Respir Crit Care Med | year= 2007 | volume= 175 | issue= 4 | pages= 367-416 | pmid=17277290 | doi=10.1164/rccm.200604-571ST | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17277290 }} </ref>
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| ====Antibiotic Duration of Therapy====
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| * [[Skin or soft tissue infection]]: At least 4 months<ref name="pmid17277290">{{cite journal| author=Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F et al.| title=An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. | journal=Am J Respir Crit Care Med | year= 2007 | volume= 175 | issue= 4 | pages= 367-416 | pmid=17277290 | doi=10.1164/rccm.200604-571ST | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17277290 }} </ref>
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| * [[Bone]] infection: 6 months<ref name="pmid17277290">{{cite journal| author=Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F et al.| title=An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. | journal=Am J Respir Crit Care Med | year= 2007 | volume= 175 | issue= 4 | pages= 367-416 | pmid=17277290 | doi=10.1164/rccm.200604-571ST | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17277290 }} </ref>
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| ====Antibiotic Regimen====
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| There is no optimal multidrug regimen for the treatment of pulmonary ''M. abscessus'' infection. A successful treatment is defined by 12 months of negative sputum culture. In the majority of cases, pulmonary ''M. abscessus'' infection is chronic and incurable.
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| The suggested combination of [[antibiotic]]s to be administered is:<ref name="pmid17277290">{{cite journal| author=Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F et al.| title=An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. | journal=Am J Respir Crit Care Med | year= 2007 | volume= 175 | issue= 4 | pages= 367-416 | pmid=17277290 | doi=10.1164/rccm.200604-571ST | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17277290 }} </ref>
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| * [[Macrolide]]: [[clarithromycin]] ''OR'' [[azithromycin]]
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| ''PLUS''
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| * [[Amikacin]]
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| ''PLUS''
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| * [[Cefoxitin]] ''OR'' [[imipenem]]
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| Note that, in case of [[macrolide]] resistance, the antibiotic therapy should be chosen based on the suscepibility profile of ''M. abscessus''.
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| ====Duration of the Antibiotic Regimen====
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| 2-4 months
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