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Cytomegalovirus infection: the point in 2001
1Department of Internal Medicine, Cochin Hospital, Paris, France. dominique.salmon@cch.ap-hop-paris.fr
Insights
Highly active antiretroviral therapy (HAART) has significantly reduced cytomegalovirus (CMV) disease in HIV patients. New detection tools and oral valganciclovir offer improved management strategies for remaining high-risk cases.
Area of Science:
- Ophthalmology
- Infectious Diseases
- Virology
Background:
- Cytomegalovirus (CMV) disease was a major opportunistic infection in HIV patients before highly active antiretroviral therapy (HAART).
- HAART has decreased CMV disease incidence by over 80%, with remaining cases primarily in non-responsive, profoundly immunosuppressed individuals.
- Inflammatory retinitis is occasionally observed in HAART patients with prior retinitis, even with immune reconstitution.
Purpose of the Study:
- To review the current landscape of CMV disease in the HAART era.
- To highlight advancements in CMV detection and treatment options.
- To redefine risk factors and management strategies for CMV disease in HIV-infected individuals.
Main Methods:
- Review of recent literature on CMV disease in HIV patients on HAART.
- Analysis of new diagnostic tools, including plasma CMV DNA polymerase chain reaction (PCR).
- Evaluation of therapeutic advancements, such as valganciclovir (VGCV).
Main Results:
- Patients at risk for CMV disease in the HAART era are identified by low CD4 counts and markers of CMV dissemination (plasma CMV DNA or pp65 antigenaemia).
- Valganciclovir (VGCV) shows promise as an effective oral treatment for CMV retinitis, comparable to intravenous ganciclovir (GCV).
- Patients with inactive CMV retinitis on HAART may discontinue maintenance therapy under regular surveillance.
Conclusions:
- CMV disease management in HIV has evolved significantly with HAART, improved diagnostics, and new therapies like VGCV.
- Risk stratification and pre-emptive strategies are crucial for managing residual CMV disease.
- Careful monitoring allows for potential discontinuation of maintenance therapy in select patients.
Abstract:
The incidence of cytomegalovirus (CMV) disease, one of the most prevalent opportunistic infections in HIV-infected persons in the early 1990s, has decreased by more than 80% since the introduction of highly active antiretroviral therapy (HAART). The rare cases of CMV disease still observed in Western countries occur mainly in profoundly immunosuppressed patients who have failed to respond to HAART. A new finding is the occasional occurrence of inflammatory retinitis in some patients on HAART with a history of healed retinitis. New tools for CMV detection have become available recently, including use of polymerase chain reaction (PCR) to detect CMV DNA from plasma. It has been possible to redefine, in the HAART period, patients at risk for CMV disease as those who have a low CD4 cell count as well as a blood marker of CMV blood dissemination (plasma CMV DNAaemia or high pp65 antigenaemia). Besides the classical therapeutic approach using ganciclovir (GCV), foscarnet and cidofovir, development of valganciclovir (VGCV), an orally administered prodrug of GCV, appears promising. There is evidence to suggest that it is as effective as intravenous GCV for the treatment of CMV retinitis, and it is currently being studied as a pre-emptive therapy in patients at high risk for CMV disease. Finally, patients with inactive CMV retinitis receiving HAART and with stable immune reconstitution may be able to discontinue maintenance therapy provided a regular ophthalmological and virological surveillance is maintained.