A 60-year-old immunocompromised patient post-renal transplant develops fever and mononucleosis-like syndrome at week 8. CMV pp65 antigenemia assay shows 20 positive cells/200,000 WBCs. Which treatment is appropriate?
- A Acyclovir IV 5 mg/kg every 8 hours for 14 days
- B Foscarnet is first-line treatment for all CMV disease
- C Ganciclovir IV 5 mg/kg every 12 hours for 14–21 days ✓
- D No treatment needed; monitor CMV viral load only
Explanation
CMV pp65 antigenemia detects the viral lower matrix protein in peripheral blood leukocytes; a positive test with end-organ disease requires pre-emptive or therapeutic antiviral treatment. Intravenous ganciclovir (5 mg/kg every 12 hours) is the first-line treatment for CMV disease in transplant recipients, given for 14–21 days. Oral valganciclovir (900 mg BD) is an alternative for non-severe CMV. Acyclovir has poor activity against CMV as it requires CMV UL97 kinase phosphorylation, which is less efficient than for HSV. Foscarnet (pyrophosphate analogue) is reserved for ganciclovir-resistant CMV (UL97 or UL54 mutations).
Reference: Ananthanarayan & Paniker's Textbook of Microbiology, 11th ed.
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