Patient handout

CMV disease + reactivation in immunocompromised hosts (HSCT / SOT / advanced HIV / biologic) — AST IDCOP 2019; ASBMT/IDSA HSCT; DHHS 2024 OI; Marty NEJM 2017 PMID 29211658

PRODUCTION

1. Your condition

This handout is for cmv disease + reactivation in immunocompromised hosts (hsct / sot / advanced hiv / biologic) — ast idcop 2019; asbmt/idsa hsct; dhhs 2024 oi; marty nejm 2017 pmid 29211658. Your care team identified this based on: cmv pcr rising on weekly post-hsct / post-sot surveillance — pre-emptive therapy threshold (ast idcop 2019; marty nejm 2017 pmid 29211658).

Other reasons your team may use this plan: detectable cmv viremia in advanced hiv (cd4 < 100) with new symptoms — pre-emptive valganciclovir (dhhs 2024 oi); new visual disturbance / floaters / scotomata / blurred vision in cd4 < 50 or transplant recipient — emergent ophtho for cmv retinitis (dhhs 2024 oi); severe diarrhea ± gi bleeding in hsct / sot / advanced hiv — endoscopy + biopsy for cmv colitis ("owl-eye" inclusions + ihc) (ast idcop 2019).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
valganciclovir	900 mg PO BID (induction) → 900 mg PO daily (maintenance / pre-emptive single-dose regimen per center protocol)	PO	BID induction → daily maintenance	AST IDCOP 2019 first-line for pre-emptive therapy; high oral bioavailability (~60%); renal dose adjustment required (CrCl 40-59 → 450 mg BID; CrCl 25-39 → 450 mg daily; CrCl 10-24 → 450 mg q48h)

Plan: CMV pre-emptive + tissue-invasive treatment ladder — valganciclovir / IV ganciclovir → foscarnet → maribavir (AST IDCOP 2019; ASBMT/IDSA HSCT; DHHS 2024 OI; Avery CID 2022 PMID 34864943)

3. When to call your provider

Contact your care team if any of the following happen:

Persistent viremia (> 1,000 IU/mL) ≥ 2 wk despite appropriate ganciclovir/valganciclovir + adherence → ED or admit for IV ganciclovir + UL97 / UL54 genotyping (AST IDCOP 2019)
New tissue-invasive disease (retinitis / colitis / pneumonitis / esophagitis / hepatitis / encephalitis) → ED or admit for IV ganciclovir induction (AST IDCOP 2019; DHHS 2024 OI)
New visual disturbance + CD4 < 50 → emergent ophtho + ED (DHHS 2024 OI)
Severe diarrhea / GI bleed in transplant → ED + endoscopy (AST IDCOP 2019)
Hypoxia + diffuse infiltrate in HSCT → ICU + ID + heme (ASBMT/IDSA HSCT)
AKI from ganciclovir / foscarnet → dose adjust or switch + neph.aki.core.v1 cross-route (AST IDCOP 2019; KDIGO 2026)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Visual disturbance + characteristic "pizza-pie" retinal hemorrhages + exudate along vascular arcades + CD4 < 50 OR transplant recipient — zone 1 (foveal-threatening) lesion is an ophthalmology emergency(life-threatening)
Diffuse interstitial / ground-glass infiltrate + hypoxia + CMV PCR positive in HSCT recipient — alveolar hemorrhage + respiratory failure; very high mortality without aggressive therapy(life-threatening)
Severe diarrhea ± hematochezia + abdominal pain in HSCT / SOT / advanced HIV with positive CMV PCR — endoscopy + biopsy for "owl-eye" intranuclear inclusions + IHC
Altered mental status + focal neurologic deficit + CSF PCR positive for CMV + MRI showing periventricular enhancement or compatible findings — high mortality without aggressive therapy(life-threatening)
Persistent CMV viremia (> 1,000 IU/mL) for ≥ 2 wk despite appropriate ganciclovir/valganciclovir dosing with confirmed adherence + adequate exposure — UL97 (most common) or UL54 mutation on resistance genotyping
HIV-ART-naive patient with active CMV retinitis on ART start — paradoxical worsening 2-6 wk post-ART with new inflammatory features (uveitis, vitreitis, retinal vasculitis, macular edema)
Symptomatic congenital CMV neonate with CNS involvement (microcephaly, chorioretinitis, intracranial calcifications, sensorineural hearing loss); confirmed by CMV PCR + clinical findings(life-threatening)
Quantitative CMV PCR above center-specific threshold (typically 1,000-10,000 IU/mL WHO IS) on weekly surveillance post-SOT — pre-emptive valganciclovir
D+/R- SOT recipient (lung > heart > liver-pancreas > kidney) — highest risk for primary CMV infection post-transplant; universal prophylaxis OR pre-emptive PCR monitoring per AST IDCOP 2019

5. Follow-up

Secondary prophylaxis until immune recovery — HIV: valganciclovir 900 mg PO daily until CD4 > 100 × 3-6 mo + VL suppressed; HSCT: prophylaxis through immunosuppression duration; SOT: variable per organ + IS; congenital: ophtho + audiology + neurodevelopmental f/u lifelong (Kimberlin NEJM 2015 PMID 25738669); ART optimisation in HIV; transition to outpatient with ID f/u (AST IDCOP 2019; DHHS 2024 OI; Kimberlin NEJM 2015)

6. Sources

Guideline: AST IDCOP 2019 CMV in Solid Organ Transplantation (Razonable Clin Transplant 2019; multi-paper consensus) + ASBMT/IDSA HSCT CMV guidelines (Tomblyn 2009; ECIL series) + NIH/CDC/IDSA HIV-OI (DHHS 2024 OI; clinicalinfo.hiv.gov web-anchored) + Marty NEJM 2017 letermovir prophylaxis PMID 29211658 + Avery CID 2022 SOLSTICE maribavir PMID 34864943 + Kimberlin NEJM 2015 congenital CMV PMID 25738669