Patient handout

CMV end-organ disease (pneumonia / colitis / retinitis / hepatitis / encephalitis) — Kotton Transplantation 2018 PMID 29596116 + Ljungman CID 2024 PMID 39041385 + Avery SOLSTICE CID 2022 PMID 34864943

PRODUCTION

1. Your condition

This handout is for cmv end-organ disease (pneumonia / colitis / retinitis / hepatitis / encephalitis) — kotton transplantation 2018 pmid 29596116 + ljungman cid 2024 pmid 39041385 + avery solstice cid 2022 pmid 34864943. Your care team identified this based on: dyspnea + fever + hypoxia + diffuse interstitial / ground-glass infiltrate in hsct recipient — cmv pneumonia is the life-threatening end-organ phenotype (asbmt/idsa hsct; ljungman cid 2024 pmid 39041385).

Other reasons your team may use this plan: severe diarrhea ± hematochezia + abdominal pain in sot / hsct / advanced hiv — cmv colitis (endoscopy + biopsy "owl-eye" inclusions + ihc) (kotton transplantation 2018 pmid 29596116); new floaters / scotomata / blurred vision in hiv cd4 < 50 or transplant recipient — emergent ophthalmology for cmv retinitis (dilated fundoscopy: "pizza-pie" hemorrhages along vascular arcades) (dhhs 2024 oi); transaminitis + positive cmv pcr in sot (esp liver transplant) — cmv hepatitis; biopsy to distinguish from rejection (kotton transplantation 2018 pmid 29596116).

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 × 14-21 d induction → 900 mg PO daily maintenance	PO	BID induction → daily maintenance	Kotton Transplantation 2018 PMID 29596116 — bioequivalent to IV ganciclovir at 900 mg PO BID per AUC; 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)
ganciclovir	5 mg/kg IV q12h × 14-21 d (induction) → step down to valganciclovir 900 mg PO BID when stable + tolerating PO	IV	q12h induction	Kotton Transplantation 2018 PMID 29596116 — IV induction for severe / GI malabsorption / NPO; renal dose adjustment; CBC monitoring q week (myelosuppression — neutropenia + thrombocytopenia); G-CSF rescue if severe ANC drop

Plan: CMV end-organ induction — non-CNS, non-marrow-suppressive (valganciclovir / IV ganciclovir; salvage maribavir for refractory/resistant) (Kotton Transplantation 2018 PMID 29596116; Avery SOLSTICE CID 2022 PMID 34864943; Ljungman CID 2024 PMID 39041385)

3. When to call your provider

Contact your care team if any of the following happen:

Rising CMV PCR → reassess for new end-organ syndrome → re-route to inpatient induction (Axis 1 Step 1 or Step 2 salvage) (Kotton Transplantation 2018 PMID 29596116)
New visual disturbance / floaters / scotomata → emergent ophtho for retinitis reactivation (DHHS 2024 OI)
New respiratory / GI / neurologic symptoms → ED for re-induction
IRIS post-ART → continue OI therapy + ART + steroid short course if severe (DHHS 2024 OI)

4. When to seek emergency care

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

CMV pneumonia in HSCT recipient (allogeneic > autologous) — diffuse interstitial / ground-glass infiltrate + hypoxia + CMV PCR positive ± BAL cytopathology / PCR — very high historic mortality without aggressive therapy(life-threatening)
CMV retinitis zone 1 (foveal-threatening) — "pizza-pie" hemorrhages + exudate along vascular arcades + foveal involvement at CD4 < 50 or transplant recipient — irreversible vision loss if delayed(life-threatening)
CMV encephalitis / ventriculitis — AMS + focal deficit + CSF PCR positive for CMV + MRI showing periventricular / subependymal enhancement — high mortality without aggressive therapy; minimum 6 wk induction(life-threatening)
CMV colitis — severe diarrhea ± hematochezia + abdominal pain in HSCT / SOT / advanced HIV + positive CMV PCR — endoscopy + biopsy "owl-eye" intranuclear inclusions + IHC
CMV hepatitis in SOT (especially liver transplant) — transaminitis + positive CMV PCR — biopsy required to distinguish from acute cellular rejection (which may co-exist)
Refractory / resistant CMV end-organ disease per Ljungman CID 2024 PMID 39041385 — persistent viremia > 1,000 IU/mL ≥ 2 wk on appropriate ganciclovir/valganciclovir with adherence + adequate exposure; UL97 most common, UL54 less common with cross-class resistance
Severe pancytopenia on ganciclovir / valganciclovir induction despite G-CSF rescue — ANC < 500 OR platelet < 25 OR transfusion-dependent — requires switch to non-marrow-suppressive salvage
AKI from foscarnet (creatinine doubling or > 2 mg/dL absolute rise) OR severe symptomatic hypocalcemia (Trousseau, Chvostek, tetany, QTc prolongation) / hypomagnesemia / hypokalemia / hyperphosphatemia
IRIS in CMV retinitis on ART start — paradoxical worsening 2-6 wk post-ART with new inflammatory features (uveitis, vitreitis, retinal vasculitis, macular edema)
CMV end-organ disease (typically pneumonia or disseminated) + septic shock features (hypotension on adequate fluids + lactate > 2 + vasopressor requirement; Sepsis-3 Singer JAMA 2016; SSC 2026)(life-threatening)

5. Follow-up

Step-down to maintenance valganciclovir post-induction; secondary prophylaxis until immune recovery (HIV: CD4 > 100 × 3-6 mo + VL suppressed; HSCT through immune-reconstitution; SOT per organ + IS); ART optimization in HIV (defer ART by ~ 2 wk after retinitis induction to reduce IRIS — DHHS 2024 OI); route BACK to umbrella `id.cmv-immunocompromised.core.v1` for longitudinal D/R-driven prophylaxis decisions (especially HSCT letermovir-completion or SOT universal-vs-pre-emptive surveillance); ophtho lifelong f/u after vision-threatening retinitis (Kotton Transplantation 2018 PMID 29596116; DHHS 2024 OI; Marty NEJM 2017 PMID 29211658 — prophylaxis-only role)

6. Sources

Guideline: Kotton CN et al, Transplantation 2018 PMID 29596116 (The Third International Consensus Guidelines on the Management of CMV in Solid-Organ Transplantation; AST-IDCOP consensus) + Ljungman P et al, Clin Infect Dis 2024 PMID 39041385 (Consensus Definitions of CMV Infection and Disease in Transplant Patients Including Resistant and Refractory CMV) + Ljungman P et al, Clin Infect Dis 2017 PMID 27682069 (Definitions of CMV Infection and Disease) + Avery RK et al, Clin Infect Dis 2022 PMID 34864943 (SOLSTICE Phase 3 maribavir for refractory/resistant CMV) + Marty FM et al, NEJM 2017 PMID 29211658 (letermovir prophylaxis post-HSCT — prophylaxis-only, NOT treatment) + DHHS 2024 OI Guidelines (clinicalinfo.hiv.gov web-anchored)