Infect Chemother.  2025 Mar;57(1):38-44. 10.3947/ic.2024.0140.

How Should Cytomegalovirus Infection Be Managed in Allogeneic Hematopoietic Stem Cell Transplant Recipients? A Clinical Grand Round

• Nho D
• Lee R
• Cho SY
• Lee DG

• KMID: 2566779
• DOI: http://doi.org/10.3947/ic.2024.0140

Abstract

Cytomegalovirus (CMV) is a significant concern for patients with allogeneic hematopoietic cell transplantation (alloHCT). CMV management differs between institutions due to the lack of local guidelines. Here, we describe a case of refractory/resistant CMV infection treated using our institution's CMV management protocol. A 59-year-old woman who underwent allo-HCT was treated for CMV reactivation. Despite 3 months of valganciclovir administration, serum CMV level surged. CMV gene mutation test revealed a ganciclovir-resistant A594V mutation in the UL97 gene. Treatment was switched to foscarnet until the drug became unavailable nationwide. During the foscarnet shortage, cidofovir was used, leading to a decline in CMV levels when foscarnet was reintroduced and used for 2 months. Following allo-HCT, CMV prophylaxis with letermovir is crucial to prevent reactivation in seropositive recipients. CMV titers should be monitored frequently after allo-HCT. The cutoff value for preemptive therapy varies across institutions, with ganciclovir/valganciclovir usually administered as first-line therapy. Maribavir is an option in cases of ganciclovir/valganciclovir resistance or intolerance. CMV gene mutations should be examined in patients with suspected resistance after 2 weeks of appropriate treatment. This case was discussed at the Clinical Grand Round of the Annual Conference of the Korean Society of Infectious Diseases on November 2, 2023.

Keyword

Cytomegalovirus; Hematopoietic stem cell transplantation; Antibiotic prophylaxis