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

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

Dukhee Nho  1   2   3 , Raeseok Lee  1   2   3 , Sung-Yeon Cho  1   2   3 , Dong-Gun Lee  1   2   4
Affiliations
Review

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

Dukhee Nho et al. Infect Chemother. 2025 Mar.

Abstract

Cytomegalovirus (CMV) is a significant concern for patients with allogeneic hematopoietic cell transplantation (allo-HCT). 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.

Keywords: Antibiotic prophylaxis; Cytomegalovirus; Hematopoietic stem cell transplantation.

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Conflict of interest statement

DGL is editorial board member of the Journal Infect Chemother; however, he did not involve in the peer reviewer selection, evaluation, and decision process of this article. Otherwise, no potential conflicts of interest relevant to this article was reported.

Figures

Figure 1
Figure 1. Patient’s clinical course.
CDV, cidofovir; FK, tacrolimus; LMV, letermovir; VGCV, valganciclovir; FOS, foscarnet.
Figure 2
Figure 2. Catholic Hematology Hospital CMV management protocol.
CMV, cytomegalovirus; HCT, hematopoietic cell transplantation; GI, gastrointestinal; AEs, adverse events; PCR, polymerase chain reaction; LLoD, lower limit of detection; OPD, outpatient department.
Figure 3
Figure 3. Surveys conducted at the Clinical Grand Round of the Korean Society of Infectious Disease conference in 2023.
CMV, cytomegalovirus.
See this image and copyright information in PMC

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