What is the initial treatment for symptomatic cytomegalovirus (CMV) infection in children presenting with symptoms?

Initial Treatment for Symptomatic Cytomegalovirus (CMV) Infection in Children

Intravenous ganciclovir is the drug of choice for initial treatment of symptomatic CMV infection in children, administered at 5 mg/kg/dose twice daily for 14-21 days, followed by maintenance therapy. 1

Treatment Algorithm Based on Clinical Presentation

For Disseminated CMV Disease (including CMV retinitis):

1. First-line therapy:

   • Intravenous ganciclovir 5 mg/kg/dose twice daily administered over 1-2 hours for 14-21 days 1
   • Follow with appropriate maintenance therapy

2. Alternative therapy (for ganciclovir-resistant infections or intolerance):

   • Foscarnet 60 mg/kg/dose every 8 hours administered intravenously over 1-2 hours for 14-21 days 1
   • Must be administered slowly (no faster than 1 mg/kg/minute)
   • Saline fluid loading recommended to minimize renal toxicity

3. For sight-threatening CMV retinitis:

   • Consider combination therapy with ganciclovir and foscarnet 1

For Congenital CMV Disease in Newborns:

• Intravenous ganciclovir 4-6 mg/kg every 12 hours for 6 weeks 1
• Higher dose (12 mg/kg/day total) leads to substantial decrease in viral load 1
• Consider transition to oral valganciclovir for extended therapy 2

Monitoring During Treatment

• Complete blood counts weekly to monitor for neutropenia and thrombocytopenia
• Renal function tests regularly (serum creatinine)
• Liver function tests
• Quantitative viral load monitoring to assess response
• For children with CMV retinitis: ophthalmologic examinations

Important Considerations and Potential Complications

Side Effects to Monitor:

1. Myelosuppression:

   • Neutropenia (most common and concerning)
   • Anemia
   • Thrombocytopenia
   • Dose reduction or interruption may be necessary in up to 40% of patients 1
   • Granulocyte colony-stimulating factor can be used for severe neutropenia 1

2. Renal toxicity:

   • Monitor serum creatinine
   • May require dose modification

3. Other adverse effects:

   • CNS effects
   • Gastrointestinal dysfunction
   • Thrombophlebitis
   • Elevated liver enzymes

Special Populations:

• HIV-infected children: May require lifelong maintenance therapy after initial treatment 1
• Congenital CMV: Early treatment with ganciclovir has shown benefits in preventing hearing deterioration 1, 2

Follow-up and Long-term Management

• For congenital CMV, extended therapy beyond the initial 6 weeks may improve outcomes, particularly hearing 2
• For HIV-infected children with CMV disease, lifelong maintenance therapy is recommended 1
• Regular audiometric testing for children with congenital CMV
• Developmental assessments for children with CNS involvement

Emerging Treatment Options

For older children who can take oral medications, valganciclovir (a prodrug of ganciclovir) may be considered for maintenance therapy after initial IV treatment, though pediatric dosing data is limited 1, 3. Valganciclovir has shown promise in extended treatment protocols for congenital CMV 2.