This document discusses cytomegalovirus (CMV), a herpesvirus. CMV can cause latent infections and reactivate in immunocompromised individuals, potentially leading to complications like retinitis, pneumonitis, or colitis. Laboratory findings can help distinguish between CMV and Epstein-Barr virus infections. Treatment for CMV infection involves antiviral medications like ganciclovir, valganciclovir, foscarnet, or cidofovir.

1. JeopardyJeopardy
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Old School Complications
Infection and
treatment Herpes!
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 CMV is this type of virus, which is this type ofCMV is this type of virus, which is this type of
virus.virus.
 Herpesviruses (HHV), double stranded DNAHerpesviruses (HHV), double stranded DNA
virusvirus

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 CMV latency site (reminder, HSV and VSV hangCMV latency site (reminder, HSV and VSV hang
out in the nerve root ganglion)out in the nerve root ganglion)
 Monocyte, lymphocyte, endothelial cell, epithelialMonocyte, lymphocyte, endothelial cell, epithelial
cells.cells.

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 Neonatal manifestations (TORCHES)Neonatal manifestations (TORCHES)
 Hearing loss, seizures, petechial rash, blueberryHearing loss, seizures, petechial rash, blueberry
muffin rashmuffin rash

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 EBV and CMV both cause mononucleosisEBV and CMV both cause mononucleosis
infections. What are lab findings that mightinfections. What are lab findings that might
distinguish EBV and CMV?distinguish EBV and CMV?
 EBV: monospot +, lymphocytosis, elevated LDHEBV: monospot +, lymphocytosis, elevated LDH
 CMV: monospot -, leukopeniaCMV: monospot -, leukopenia

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 Infected cells have these characteristicInfected cells have these characteristic
inclusionsinclusions
 Owl eyesOwl eyes

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 Symptoms of acute CMV infectionSymptoms of acute CMV infection
 Usually asymptomaticUsually asymptomatic
 virus remains latent in the monocyte,virus remains latent in the monocyte,
lymphocyte, endothelial cell, and epithelial celllymphocyte, endothelial cell, and epithelial cell

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 **DAILY DOUBLE** Immunocompromised host**DAILY DOUBLE** Immunocompromised host
complications (list 3)complications (list 3)
 CMV retinitis, myelosuppression (leukopenia,CMV retinitis, myelosuppression (leukopenia,
thrombocytopenia), pneumonitis, colitis,thrombocytopenia), pneumonitis, colitis,
esophagitis, and hepatitisesophagitis, and hepatitis

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 40F with AIDS (CD4=54) is admitted for 1 mo diffuse abd pain,40F with AIDS (CD4=54) is admitted for 1 mo diffuse abd pain,
fever, sweats, fatigue, and wt loss. No swallowing or other focal sx.fever, sweats, fatigue, and wt loss. No swallowing or other focal sx.
PE: diffuse lymphadenopathy, hepatosplenomegaly. WBC 3.6,PE: diffuse lymphadenopathy, hepatosplenomegaly. WBC 3.6,
elevated alk phos, otherwise LFTs normal. Abd CT with diffuseelevated alk phos, otherwise LFTs normal. Abd CT with diffuse
hepatic and splenic enlargement, nl small bowel, lymphadenopathy.hepatic and splenic enlargement, nl small bowel, lymphadenopathy.
What is the diagnosis?What is the diagnosis?
 A) CMV infectionA) CMV infection
 B) disseminated candidal infectionB) disseminated candidal infection
 C) disseminatedC) disseminated mycobacteriummycobacterium avium complex infectionavium complex infection
 D) Mediation toxicityD) Mediation toxicity
C) Reminder that the symptoms of disseminated CMV in patient
with AIDS is retinitis and esophagitis, cytopenias, etc. Focal
organ involvement

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 CMV retinitis has this characteristic PE findingCMV retinitis has this characteristic PE finding
 Cotton wool spotsCotton wool spots
 Edematous and ischemicEdematous and ischemic
neuronal tissueneuronal tissue

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 44M evaluted for acute rejection of a transplanted kidney. PMH44M evaluted for acute rejection of a transplanted kidney. PMH
ADPKD, renal transplant D-/R- CMV 18mo ago. Meds includeADPKD, renal transplant D-/R- CMV 18mo ago. Meds include
amlodipine, tacrolimus, prednisone, and mycophenolate mofetil. WBCamlodipine, tacrolimus, prednisone, and mycophenolate mofetil. WBC
4.5, Cr 1.8. What infection should this patient receive prophylaxis?4.5, Cr 1.8. What infection should this patient receive prophylaxis?
 A) aspergillus, B) CMV, C) PJP, D) MACA) aspergillus, B) CMV, C) PJP, D) MAC
 C—PJP higher immunosuppressive medicationC—PJP higher immunosuppressive medication
in the setting of the acute rejection (usually 6-12in the setting of the acute rejection (usually 6-12
months).months).

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 Treatment of CMV, ganciclovir has thisTreatment of CMV, ganciclovir has this
mechanism of actionmechanism of action
 Guanosine analog. Inhibits viral DNAGuanosine analog. Inhibits viral DNA
polymerase by chain terminationpolymerase by chain termination

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 Name two guanosine analogs do not have anName two guanosine analogs do not have an
affect on CMVaffect on CMV
 Acyclovir, valacylovir, famciclovirAcyclovir, valacylovir, famciclovir

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 Name 3 first or second line treatments for CMVName 3 first or second line treatments for CMV
 First line ganciclovir (IV) and valgancyclovirFirst line ganciclovir (IV) and valgancyclovir
 Second line foscarnet and cidofovirSecond line foscarnet and cidofovir

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 Distinguish active, latent, and secondary CMVDistinguish active, latent, and secondary CMV
infection in a post transplant orinfection in a post transplant or
immunocompromised patientimmunocompromised patient
 Active infection – presence of CMV in bloodActive infection – presence of CMV in blood
 Latent infection – after resolution of the acuteLatent infection – after resolution of the acute
infection, patient is CMV +infection, patient is CMV +
 Secondary infection – reactivation of latentSecondary infection – reactivation of latent
infectioninfection

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 TreatmentTreatment of drug resistant CMVof drug resistant CMV
 Add foscarnateAdd foscarnate
 Decrease immunosuppressionDecrease immunosuppression
 IV GALCYCLOVIR – INCREASED DOSEIV GALCYCLOVIR – INCREASED DOSE

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 I say findings, you say HHV type.I say findings, you say HHV type.
 HepatosplenomegalyHepatosplenomegaly
 EBV – splenomegaly seen in about 50% ofEBV – splenomegaly seen in about 50% of
patientspatients

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 I say findings, you say HHV type.I say findings, you say HHV type.
 Temporal lobe encephalitisTemporal lobe encephalitis
 HSV 1HSV 1

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 I say findings, you say HHV type.I say findings, you say HHV type.
 retinitisretinitis
 CMV (“sight”omegalovirus)CMV (“sight”omegalovirus)

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 I say findings, you say HHV type.I say findings, you say HHV type.
 Pharyngitis, lymphadenopathyPharyngitis, lymphadenopathy
 EBVEBV

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 35F with PBC s/p liver transplant 3 mo ago evaluated for35F with PBC s/p liver transplant 3 mo ago evaluated for
fever, fatigue, sweats, and dull midchest pain for 2fever, fatigue, sweats, and dull midchest pain for 2
weeks. She was seronegative for CMV and EBV, butweeks. She was seronegative for CMV and EBV, but
donor positive for both. Medications include tacrolimus,donor positive for both. Medications include tacrolimus,
prednisone, mycophenolate, mofetil, and bactrim. CTprednisone, mycophenolate, mofetil, and bactrim. CT
chest 3cm hilar LN.chest 3cm hilar LN.
Which of the following is the most likely cause of clinicalWhich of the following is the most likely cause of clinical
findings?findings?
A) CMV B) invasive candidal infection, C) post transplantA) CMV B) invasive candidal infection, C) post transplant
lymphoproliferative disease, D) reactivation of TBlymphoproliferative disease, D) reactivation of TB
 PTLD, B cell proliferation, which is induced byPTLD, B cell proliferation, which is induced by
EBV.EBV.