Clinical Manual for Management of the HIV-Infected ... - myCME.com

6–26 | Clinical Manual for Management of the HIV-Infected Adult/2006
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gastrointestinal pathogens such as Mycobacterium
avium complex, Cryptosporidium, other parasites, and
lymphoma.
For suspected CMV pneumonitis, consider
Pneumocystis jiroveci pneumonia (PCP).
For suspected CMV encephalitis, consider causes
of neurologic deterioration such as progressive
multifocal leukoencephalopathy, toxoplasmosis,
central nervous system lymphoma, and other mass
lesions.
P: Plan
Diagnostic Evaluation
CMV can be detected by serology, culture, antigen
testing, nucleic acid amplification, or examination of
tissue samples. However, serologic tests are not reliable
for diagnosing CMV disease because most adults are
seropositive and because patients with advanced AIDS
may serorevert while remaining infected. Furthermore,
for HIV-infected patients, demonstration of CMV
in the blood, urine, semen, cervical secretions, or
bronchoalveolar lavage (BAL) fluid does not necessarily
indicate active disease, although patients with endorgan
disease are usually viremic.
Diagnosis of end-organ disease generally requires
demonstration of tissue invasion. The recommended
evaluation is as follows.
CMV retinitis
Dilated retinal examination should be performed
emergently by an ophthalmologist experienced in the
diagnosis of CMV retinitis. The diagnosis is usually
based on the identification of typical lesions.
Gastrointestinal CMV disease (esophagitis or colitis)
Perform endoscopy with visualization of ulcers, and
conduct tissue biopsy showing viral inclusions to
demonstrate viral invasion.
Pulmonary CMV disease
Perform chest radiography showing interstitial
pneumonia, and conduct lung tissue biopsy showing
inclusion bodies.
Neurologic CMV disease
♦ Encephalitis: Magnetic resonance imaging (MRI)
of the brain should be done to rule out mass lesions.
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Periventricular or meningeal enhancement may
be detected with CMV disease. Lumbar puncture
should be performed; cerebrospinal fluid (CSF)
should be analyzed for CMV (by polymerase chain
reaction, which is sensitive and specific), cell count
(may show lymphocytic or mixed lymphocytic or
polymorphonuclear pleocytosis), glucose (may be
low), and protein (may be high). A brain biopsy
may be performed if the diagnosis is uncertain after
imaging and CSF evaluation.
Polyradiculopathy: Spinal MRI should be done to
rule out mass lesions. In CMV disease, nerve root
thickening may be present. Lumbar puncture with
CSF analysis should be performed, as described
above.
Myelitis: Spinal MRI should be done to rule out
mass lesions. Cord enhancement may be present.
Lumbar puncture with CSF analysis should be
performed, as described above.
Other sites
Detection of CMV at other sites requires BAL,
visualization with endoscopy, or tissue biopsy.
Viral inclusions (“owl’s eye cells”) in biopsied
tissue demonstrate invasive disease (as opposed to
colonization). Because retinitis is the most common
manifestation of CMV disease, patients with
gastrointestinal, central nervous system, or pulmonary
disease should undergo ophthalmologic evaluation to
detect subclinical retinal disease.
Treatment
Ganciclovir, valganciclovir, foscarnet, and cidofovir may
be effective for treating CMV end-organ disease. The
choice of therapy depends on the site and severity of the
infection, the level of underlying immunosuppression,
the patient’s ability to tolerate the medications and
adhere to the treatment regimen, and the potential
medication interactions.
Immune reconstitution through ART is also a key
component of CMV treatment and relapse prevention.
The optimal timing of ART initiation in relation to the
treatment of CMV is not clear. CMV flares may occur
if patients develop immune reconstitution inflammatory
syndrome (see chapter Immune Reconstitution Syndrome),
but in most cases of nonneurologic disease, ART
probably should not be delayed.