From the Guidelines
Cytomegalovirus (CMV) pneumonitis in a patient on chronic steroids requires prompt treatment with intravenous ganciclovir at 5 mg/kg every 12 hours for 2-3 weeks, followed by oral valganciclovir 900 mg daily for maintenance therapy, as recommended by the most recent guidelines 1.
Risks and Considerations
The use of chronic steroids increases the risk of CMV reactivation, which can lead to severe pneumonitis and high mortality rates 1.
- CMV pneumonitis can occur in immunocompromised patients, particularly those with cancer or undergoing allogeneic hematopoietic cell transplantation (HCT) 1.
- The risk of CMV reactivation is highest among HCT recipients with CMV-seropositive status prior to transplant, with an incidence of CMV reactivation ranging from 50% to 60% 1.
- Chronic steroids can suppress T-cell immunity, which normally controls CMV, increasing the risk of reactivation and disease 1.
Treatment and Management
- Intravenous ganciclovir at 5 mg/kg every 12 hours for 2-3 weeks, followed by oral valganciclovir 900 mg daily for maintenance therapy, is the recommended treatment for CMV pneumonitis 1.
- For severe cases, consider adding CMV immunoglobulin (150 mg/kg every other day for 1-2 weeks) 1.
- Steroid doses should be reduced if possible, but abrupt discontinuation should be avoided due to the risk of adrenal crisis 1.
- Prophylactic antimicrobial coverage for other opportunistic infections may be necessary, and monitoring of CMV viral load, complete blood count, and renal function should be done regularly during treatment 1.
Long-term Prophylaxis
- Consider long-term prophylaxis with valganciclovir if the patient must remain on high-dose steroids, as recommended by the guidelines 1.
- The decision to administer corticosteroids should be made on an individual basis, taking into account the potential risks and benefits, and considering alternative treatments such as letermovir for CMV prophylaxis 1.
From the Research
Risks of Cytomegalovirus (CMV) Pneumonitis
- CMV pneumonitis is a rare but potentially life-threatening complication of CMV infection, particularly in immunocompromised individuals 2, 3.
- The use of chronic corticosteroids can increase the risk of CMV infection and pneumonitis due to immunosuppression 4, 5.
- CMV pneumonitis can present with non-specific symptoms such as fever, shortness of breath, and dry cough, making diagnosis challenging 2, 3.
Treatment and Management
- Antiviral medications such as ganciclovir and valganciclovir are effective in treating CMV infection, but resistance can develop 4, 6.
- Combination therapy with ganciclovir and high-dose intravenous immunoglobulin may be effective in preventing CMV pneumonia in high-risk patients 4.
- Measurement of CMV genome load in blood and urine can be useful in evaluating treatment response 3.
Risk Factors
- Immunocompromised status, including chronic corticosteroid use, is a significant risk factor for CMV infection and pneumonitis 4, 5.
- Donor and recipient CMV serostatus can influence the risk of CMV infection after transplant 5.
- Peak viral loads and intensity of immunosuppressive therapy can also contribute to the development of antiviral resistance 6.