Cytomegalovirus (CMV)

OVERVIEW

• disease of the immunocompromised
• the importance of reactivation of CMV  in “non-immunosuppressed patients” such as severe trauma, sepsis, shock, burns, cirrhosis and other critically ill patients is controversial
• Phases:

1. Acute disease
2. Reactivation of latent disease

RISK FACTORS

• transplant: allogenic stem cell > lung > pancreatic > liver, heart, renal
• advanced AIDS
• steroid use
• mechanical ventilation
• bacterial pneumonia and sepsis
• red cell transfusion (via immunomodulation not transmission)
• burns

CLINICAL FEATURES

Can cause:

• pneumonia, pneumonitis
• liver and renal impairment
• CMV colitis, toxic megacolon
• meningitis/encephalitis
• Guiilain-Barre syndrome
• adrenal insufficiency
• retinitis
• TTP

INVESTIGATIONS

• viral cultures: low sensitivity and time consuming (now obsolete)
• antigenemia: direct detection of CMV protein pp65 using monoclonal antibodies (sensitive but requires sufficient WBCs in peripheral blood)
• PCR assays: high sensitivity and rapid turnover time

MANAGEMENT

First line

• IV ganciclovir (14 days)

Other options

• IV foscarnet
• PO valgancyclovir
• cidofovir

OUTCOME

CMV infection results in:

• increased organ dysfunction: liver and renal
• prolonged ICU stay
• increased duration of mechanical ventilation
• increased incidence of nosocomial infection
• increased mortality

References and Links

• Bersten AD, Soni N. Oh’s Intensive Care Manual (6th edition), Butterworth-Heinemann 2009. [Google Books Preview]
• Bonalumi S, Trapanese A, Santamaria A, D’Emidio L, Mobili L. Cytomegalovirus infection in pregnancy: review of the literature. J Prenat Med. 2011 Jan;5(1):1-8. PubMed PMID: 22439067; PubMed Central PMCID: PMC3279147.
• Jain M, Duggal S, Chugh TD. Cytomegalovirus infection in non-immunosuppressed critically ill patients. J Infect Dev Ctries. 2011 Aug 12;5(8):571-9. Review. PubMed PMID: 21841300. [Free Full Text]
• Kalil AC, Florescu DF. Is cytomegalovirus reactivation increasing the mortality of patients with severe sepsis? Crit Care. 2011;15(2):138. doi: 10.1186/cc10093. Epub 2011 Mar 24. PubMed PMID: 21457496; PubMed Central PMCID: PMC3219353.
• Limaye AP, Boeckh M. CMV in critically ill patients: pathogen or bystander? Rev Med Virol. 2010 Nov;20(6):372-9. doi: 10.1002/rmv.664. Review. PubMed PMID: 20931610; PubMed Central PMCID: PMC2987685.
• Limaye AP, Kirby KA, Rubenfeld GD, Leisenring WM, Bulger EM, Neff MJ, Gibran NS, Huang ML, Santo Hayes TK, Corey L, Boeckh M. Cytomegalovirus reactivation in  critically ill immunocompetent patients. JAMA. 2008 Jul 23;300(4):413-22. doi: 10.1001/jama.300.4.413. PubMed PMID: 18647984; PubMed Central PMCID: PMC2774501.
• Osawa R, Singh N. Cytomegalovirus infection in critically ill patients: a systematic review. Crit Care. 2009;13(3):R68. doi: 10.1186/cc7875. Epub 2009 May  14. Review. PubMed PMID: 19442306; PubMed Central PMCID: PMC2717427.