CMV Encephalitis
Cytomegalovirus (CMV) encephalitis is a serious complication often seen in AIDS patients or those with severe immune suppression, potentially leading to paralysis or fatal encephalitis. It can occur even before a significant drop in CD4 cell count. Symptoms include altered mental status, confusion, and neurological issues. Diagnosis is confirmed by detecting CMV DNA or antigen in the cerebrospinal fluid. Treatment involves dual therapy with ganciclovir and foscarnet, or alternative options if needed. Antiretroviral therapy begins after about two weeks of anti-CMV treatment, and maintenance therapy with valganciclovir continues until the CD4 count reaches ≥100 cells/microL for at least six months.
2023-12-31 20:54:04 - Editor
Epidemiology and Clinical Features
Cytomegalovirus (CMV) encephalitis is a critical complication in AIDS or severely immunocompromised patients, potentially leading to paralysis or rapidly fatal encephalitis. It occurs in up to 2% of AIDS patients, with incidence declining since the availability of antiretroviral therapy (ART). CMV disease mostly affects patients with a CD4 cell count <50 cells/microL. Presenting symptoms include altered mental status, delirium, confusion, and focal neurological abnormalities, with CMV DNA or antigen in CSF confirming the diagnosis.
Induction Treatment for CMV Encephalitis
For induction treatment of patients with CMV encephalitis, dual therapy with intravenous (IV) ganciclovir (5 mg/kg every per day) and foscarnet (90 mg/kg per day) is advisable. For individuals who cannot tolerate dual induction therapy, monotherapy with either IV ganciclovir (5 mg/kg every 12 hours) or foscarnet (90 mg/kg every 12 hours) is suggested. Cidofovir (5 mg/kg per week intravenous infusion for two weeks, then 5 mg/kg every other week) is an alternative agent in patients who cannot tolerate any of the other options. Patients should initiate ART approximately 14 days after anti- CMV therapy has started since immune recovery is an important adjunct to antiviral therapy in the treatment of CMV neurological disease. After the induction treatment of CMV has been completed, patients should be transitioned to a maintenance regimen of valganciclovir (900 mg/day) until the CD4 count has increased to ≥100 cells/microL for at least six months. (4, 5, 6)
References
1- Baril, L, Jouan, M, Caumes, E, et al. The impact of highly active antiretroviral therapy on the incidence of CMV disease in AIDS patients (abstract #I-31). 37th Interscience Conference on Antimicrobial Agents and Chemotherapy, 1997; Toronto, Canada.
2-Silva CA, Oliveira AC, Vilas-Boas L, et al. Neurologic cytomegalovirus complications in patients with AIDS: retrospective review of 13 cases and review of the literature. Rev Inst Med Trop Sao Paulo 2010; 52:305.
3- Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: Recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. http://aidsinfo.nih.gov/contentfiles /lvguidelines/adult_oi.pdf
4-Whitley RJ, Jacobson MA, Friedberg DN, et al. Guidelines for the treatment of cytomegalovirus diseases in patients with AIDS in the era of potent antiretroviral therapy: recommendations of an international panel. International AIDS Society-USA. Arch Intern Med 1998; 158:957.
5-Macdonald JC, Karavellas MP, Torriani FJ, et al. Highly active antiretroviral therapy-related immune recovery in AIDS patients with cytomegalovirus retinitis. Ophthalmology 2000; 107:877.
6- Cidofovir injection solution US prescribing information (revised July, 2015)