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Opportunistic Infections: Cytomegalovirus Disease

Basic Information

Cytomegalovirus (CMV) is latent in most persons with HIV -- in nearly 70% of heterosexuals and 95% of gay men. Like many other opportunistic infections, the pathogen lies "dormant" in the body after:

  • initial infection in infancy or childhood
  • sexual transmission
  • receiving infected blood products

The virus typically reactivates in persons whose CD4 cell counts fall below 100 -- or, more frequently, below 50. This herpesvirus causes active disease in persons with advanced HIV disease and most often manifests itself as:

  • CMV retinitis (in up to 40% of patients)
  • CMV gastrointestinal disease including CMV esophagitis (10%) and CMV colitis (in less than 10%)

It can affect virtually any organ however, and less frequently, though increasing in incidence, can cause neurologic disease including encephalitis and very rarely pulmonary disease suggesting CMV dissemination.

Its principal target remains the eye -- the retina -- and CMV can cause both sight-threatening and non-sight-threatening retinitis, an infection of the nerve layer at the back of the eye. Left untreated, CMV will lead to blindness in the eye that is infected (it has the ability to spread to the other eye) in the great majority of instances. Incidence is linked to falling CD4 count. Loss of sight due to swelling of the retina's cells is considered reversible. However loss of sight due to retinal detachment and death of cells is irreversible.

CMV esophagitis causes inflammation in the lower esophagus and produces ulcers while CMV colitis is an infection of the intestines and can produce life-threatening conditions -- perforation and hemorrhage.

Symptoms

CMV retinitis:

  • Early disease is often asymptomatic.
  • Painless
  • First symptom is often "floaters" moving across the patient's visual field.
  • Loss of visual acuity

CMV esophagitis:

  • Pain and difficulty in swallowing

CMV colitis:

  • Diarrhea (severe)
  • Fever
  • Loss of appetite
  • Abdominal pain
  • Weight loss
  • Lethargy

CMV infection in general is marked by:

  • Lowering of white blood cell count
  • Fever
  • Weight loss
  • Muscular pain

Diagnosis/Treatment

CMV retinitis remains a clinical diagnosis and should be performed by an experienced ophthalmologist who can diagnose the presence of so-called "owl's eye" or "pizza pie retinal lesions". Pinpointing location of the lesion will be an important component in individual treatment goals and therapy. Retinitis seen through an undilated pupil through direct ophthalmoscope is sight-threatening and immediate diagnosis and treatment is indicated.

CMV esophagitis can be diagnosed by endoscopy and esophageal biopsy while CMV colitis can be diagnosed by colonoscopy and tissue biopsy.

Treatment for CMV is ever-changing and a challenge for the patient's medical team, given the toxicity of current drugs, drug interactions, drug resistance, effective dosage, disagreement over advisability of prophylaxis for CMV gastrointestinal disease and so on. What is agreed upon is that quick diagnosis and early treatment are essential.

Currently intravenous ganciclovir and/or intravenous foscarnet are the mainstays of treatment and have proven beneficial in lengthening patient survival rate, but each drug has adverse side effects in a number of patients and are contraindicated for some patients, i.e.:

  • Ganciclovir affects bone marrow tissue and cannot be used with AZT.
  • Foscarnet is associated with a toxic effect on the kidneys.

Cidoffovir, also with proven efficacy against CMV disease, is another option to be considered.

For best results, a patient should be treated by a medical team knowledgeable about and experienced in treating HIV-related CMV. Treatment must be tailored to the individual patient after evaluating the patient's current health status and health history.

Lifelong suppressive therapy is indicated since the antiviral drugs used in treatment, while effective in stopping the spread of the virus, do not eliminate it from the body.

Oral ganciclovir has been proven effective in treatment of retinitis -- but as with the intravenous medications there are risks and benefits in using this medication. However it has been shown to be effective as a prophylaxis against CMV retinitis and is usually recommended to patients for maintenance therapy. Prophylaxis for CMV esophagitis and CMV colitis are controversial.

CMV retinitis requires routine surveillance ophthalmology. Promise has been shown also by the recent vitriol implant -- a surgically implanted device which sustain-releases ganciclovir into the eye.

It is hoped that antiretroviral therapy for HIV disease will contribute to a lessening reliance on CMV antivirals.

We at Always Your Choice are experienced in diagnosing and treating many cases of HIV-related CMV. If you have this disease, would like more information about it, or would like to review options for possible prophylaxis, we would be happy to see you.