What is the recommended treatment for Cytomegalovirus (CMV) pericarditis?

Treatment of Cytomegalovirus (CMV) Pericarditis

For CMV pericarditis, intravenous ganciclovir or oral valganciclovir is recommended, with oral valganciclovir being preferred for less severe cases due to its excellent bioavailability and convenience. 1

Diagnosis Considerations

• CMV-associated pericarditis is primarily found in immunocompromised patients, particularly those with HIV infection 1
• A comprehensive workup including histological, cytological, immunohistological, and molecular investigations in pericardial fluid and peri-/epicardial biopsies should be considered for definitive diagnosis (Class IIa, Level C recommendation) 1
• Routine viral serology is not recommended except for HIV and HCV testing (Class III, Level C recommendation) 1
• PCR techniques can detect CMV nucleic acids in pericardial tissue and fluid, which is crucial for accurate diagnosis 1

Treatment Algorithm

First-line Treatment

• Antiviral therapy:

  • Oral valganciclovir: 900 mg twice daily (adjust for renal function) for immunocompetent patients with less severe disease 2
  • Intravenous ganciclovir: 5 mg/kg every 12 hours for more severe cases or immunocompromised patients 1, 3
  • Treatment duration: Typically 2-3 weeks, with monitoring of clinical response 4, 2

• Supportive therapy:

  • NSAIDs (e.g., ibuprofen 600 mg every 8 hours or aspirin 750-1000 mg every 8 hours) with gastroprotection 5
  • Colchicine (0.5 mg twice daily if ≥70 kg or 0.5 mg once daily if <70 kg) to prevent recurrences 5

Important Considerations

• Involvement of infectious disease specialists is strongly recommended 1
• Corticosteroids are generally contraindicated in viral pericarditis, as they can reactivate viral infections and lead to ongoing inflammation (Class III, Level C recommendation) 1
• Monitor for treatment response with clinical assessment, inflammatory markers, and CMV viral load testing 4, 6

Special Populations

Immunocompromised Patients

• More aggressive treatment may be required with longer duration of antiviral therapy 6
• Consider sequential therapy: initial intravenous ganciclovir followed by oral valganciclovir 6
• Close monitoring for relapse is essential, particularly in transplant recipients 4, 6

Evidence Quality and Considerations

• Valganciclovir has shown excellent bioavailability (10-fold greater than oral ganciclovir) and similar efficacy to intravenous ganciclovir in multiple studies 4, 7
• Case reports have demonstrated successful treatment of CMV myopericarditis with oral valganciclovir even in immunocompetent adults 2
• The European Society of Cardiology guidelines suggest antiviral treatment similar to that for myocarditis for CMV pericarditis, though these treatments are still under evaluation 1

Potential Pitfalls and Caveats

• Failure to identify CMV as the causative agent may lead to inappropriate corticosteroid use, which can worsen the condition 1
• Inadequate treatment duration may result in relapse, particularly in immunocompromised patients 6
• Drug toxicity, particularly bone marrow suppression with ganciclovir/valganciclovir, requires monitoring 3
• Resistance can develop with extended use of antivirals, necessitating alternative agents like foscarnet or cidofovir in refractory cases 3