Sandbox jyostna

• 1. Retinitis

• Preferred regimen (1) for immediate sight-threatening lesions: Ganciclovir intraocular implant AND Valganciclovir 900 mg PO q24h.
• Preferred regimen (2) for peripheral lesions: Valganciclovir 900 mg PO q12h for 14–21 days, then 900 mg PO q24h for maintenance therapy
• Alternative regimen: Ganciclovir 5 mg/kg IV q12h for 14–21 days, then Valganciclovir 900 mg PO q24h OR Foscarnet 60 mg/kg IV q8h or 90 mg/kg IV q12h for 14–21d, then 90–120 mg/kg IV q24h OR Cidofovir 5 mg/kg IV for 2wks, then 5 mg/kg every other wk; each dose should be administered with IV saline hydration AND oral probenecid OR repeated intravitreal injections with Fomivirsen (for relapses only, not as initial therapy)

Note (1): Most common cause of blindness in AIDS patients with <50/mm3 CD4 counts is Cytomegalovirus.

Note (2): 19/30 pts (63%) with inactive CMV retinitis who responded to HAART (increase of ≥60 CD4 cells/mL) developed immune recovery vitreitis (vision decreases and floaters with posterior segment inflammation vitreitis, papillitis & macular changes) an average of 43 wks after teatment started.

Note (3): Corticosteroid treatment decreases inflammatory reaction of immune recovery vitreitis without reactivation of CMV retinitis, either periocular Corticosteroids or short course of systemic Steroid.

Note (4): Differential diagnosis is HIV retinopathy, herpes simplex retinitis, varicella-zoster retinitis (rare, hard to diagnose).

Note (5): Valganciclovir PO equal to Ganciclovir IV in induction of remission: Cannot use Ganciclovir ocular implant alone as approx. 50% risk of CMV retinitis other eye at 6 months and 31% risk visceral disease. Risk decreases with systemic treatment but when contralateral retinitis does occur, Ganciclovir-resistant mutation often present. Concurrent systemic treatment recommended.

Note (6): Because of unique mode of action, Fomivirsen may have a role if isolates become resistant to other therapies.

Note (7): Retinal detachments 50–60% within 1 year of diagnosis of retinitis.

Note (8): Equal efficacy of IV Ganciclovir and Foscarnet. Ganciclovir avoids nephrotoxicity of Foscarnet; Foscarnet avoids bone marrow suppression of Ganciclovir. Although bone marrow toxicity may be similar to Ganciclovir. Oral Valganciclovir should replace both.

• Post treatment suppression (prophylactic) if CD4 count <100/mm3

• Preferred regimen: Valganciclovir 900 mg PO q24h.

Note (1): Discontinue if CD4 >100/mm3 for 6 months on ART.

Note (2): Patients who discontinue suppression therapy should undergo regular eye examination for early detection of relapses.

CM in Transplant patients:

Use of

valganciclovir to prevent infections in CMV seronegative recipients who receive organs from a seropositive donor & in seropositive receivers has been highly effective.

Others suggest preemptive treatment when pt develops CMV antigenemia or positive PCR post-transplant.

Herpesvirus Infections Cytomegalovirus (CMV)

Marked decrease in HIV associated CMV infections & death with Highly Active Antiretroviral Therapy. Initial treatment should optimize HAART.

Primary prophylaxis not generally recommended. Preemptive therapy in patients with increased in  CMV DNA titers in plasma & CD4 <100/mm3. Recommended by some: valganciclovir 900 mg po q24h. Authors rec. primary prophylaxis be dc if response to HAART with incerase in CD4 >100 for 6 months. 

Risk for developing CMV disease correlates with quantity of CMV DNA in plasma: each log10Ĺ associated with 3.1-fold increase in disease.