HIV Topics 
Viral Infections
Cytomegalovirus Infection
CMV infection in humans is common and usually asymptomatic. CMV is usually acquired during infancy or early childhood. Transmission can occur congenitally or through contact with saliva or urine or through transfusion, sexual contact or transplantation with infected organs. CMV can also be transmitted through breast milk. CMV causes 8-10% of pediatric AIDS defining illness.
Clinical features
Symptomatic congenital CMV syndrome is not very common at birth but 10-15% develops late developmental abnormalities, sensorineural hearing loss, chorioretinitis or neurological disease.
CMV retinitis
CMV retinitis is the most common CMV disease among HIV-infected children. It is usually asymptomatic and discovered on routine examination. Older children with CMV retinitis usually present with floaters, loss of peripheral or central vision. Funduscopy reveals white and yellow retinal infiltrates and retinal hemorrhages. CMV disease can also occurs in lungs, liver, GI tract, pancreas, sinuses and CNS (55 - 58). Pulmonary CMV is often difficult to assess due to presence of other organisms such as PCP. CMV pneumonia is usually an interstitial pneumonia with dry cough and hypoxemia. CMV encephalopathy is rare in children and is difficult to distinguish from HIV induced encephalopathy. Disseminated disease can present with hepatosplenomegaly generalized lymphadenopathy, fever and respiratory symptoms. CMV may also manifest as part of IRIS.
Diagnosis
Diagnosis of CMV is difficult as presence of antibodies to CMV does not necessary imply infection. Histological diagnosis is the most useful test demonstrating characteristic "owl's eye" intranuclear and smaller intracytoplasmic inclusion bodies. Staining with CMV monoclonal antibodies can also be done.
Hence, children with HIV infection should have a funduscopy done by an ophthalmologist every 6 monthly to identify CMV retinitis.
Treatment
All children with CMV infection should be treated as in patients. Ganciclovir in dose of 5 mg/kg/dose IV twice daily administered over 1-2 hours for 14-21 days followed by life-long maintenance therapy is required for treatment of disseminated CMV and CMV retinitis. Alternatively, in ganciclovir resistant CMV infections, foscarnet may be used as 60 mg/kg/dose every 8 hours for 14-21 days followed by life-long maintenance therapy. Valganciclovir is used in induction dose of 250mg/m2/day PO BD for 21 days followed by 250mg/m2 OD daily as maintenance but appropriate dose of this drug in children is still not known (59). Oral ganciclovir in dose of 30 mg/kg administered every 8 hours is effective for maintenance treatment of CMV retinitis (60, 61).
Prophylaxis
Secondary prophylaxis : Life-long maintenance therapy following treatment for CMV disease is recommended. Maintenance therapy may be discontinued in patients on HAART who have an increase in CD4 count to > 100-150 cells/cumm after 6 months of therapy. All patients who have had maintenance therapy discontinued should undergo 6 monthly ophthalmologic evaluation (62-64) as data for children is inadequate.
Primary prophylaxis : All HIV infected children with severe immunosuppression (CD4 count < 50 cells/cumm) may be considered for primary prophylaxis against CMV.
Drug of choice : Oral ganciclovir: 30 mg/kg PO TID.
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