AIDS-related cytomegalovirus gastrointestinal disease
- Mark A Jacobson, MD
Mark A Jacobson, MD
- Clinical Health Sciences Professor of Medicine
- University of California San Francisco
Cytomegalovirus (CMV) gastrointestinal disease is an uncommon but serious complication of AIDS. Prior to the availability of potent antiretroviral therapy (ART), CMV gastrointestinal disease occurred in up to 5 percent of patients with AIDS, primarily in those with advanced immunosuppression. However, the incidence of CMV gastrointestinal disease has decreased substantially since ART became available [1,2]. (See "Selecting antiretroviral regimens for the treatment-naïve HIV-infected patient".)
A discussion of the pathogenesis and clinical manifestations of other CMV-related diseases in HIV-infected patients is found elsewhere. (See "AIDS-related cytomegalovirus neurologic disease" and "Pathogenesis, clinical manifestations, and diagnosis of AIDS-related cytomegalovirus retinitis" and "Cytomegalovirus infection as a cause of pulmonary disease in HIV-infected patients".)
In persons with prior CMV infection and a CD4 cell count <50 cells/microL, reactivation of latent virus causes a systemic disease that is characterized by intermittent or constant viremia which can lead to colonization or localized infections in one or multiple target organs, including the gastrointestinal tract . CMV gastrointestinal disease was first reported as a manifestation of AIDS in 1983. In early case series, patients generally died within several months without CMV-specific treatment, and hemorrhage or perforation often complicated the course of disease. The prognosis of such patients remained poor despite the advent of antiviral drugs for the treatment of CMV. As an example, the median survival was reported to be four months after the diagnosis of CMV colitis and eight months after CMV esophagitis, even with ganciclovir therapy [4-6]. However, as with all HIV-related opportunistic infections, the prognosis has improved markedly with the utilization of antiretroviral therapy (ART). (See 'Impact of ART' below.)
Risk factors — Most cases of CMV disease occur in the setting of advanced immunosuppression, with CD4 cell counts < 50 cells/microL . The presence of CMV in blood (as measured by culture, CMV DNA amplification, or antigen detection) is also a risk factor for the development of invasive disease . However, patients with viremia may not have invasive disease. (See 'Viral detection' below.)
Impact of ART — The prognosis of patients with AIDS and CMV gastrointestinal disease has improved dramatically since effective ART became available in the late 1990s [9,10]. Most cases of end organ disease now occur in patients who are not receiving ART, either due to late diagnosis of HIV disease or poor adherence to prescribed therapy.
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- NATURAL HISTORY
- Risk factors
- Impact of ART
- CLINICAL MANIFESTATIONS
- DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS
- When to suspect CMV gastrointestinal disease
- Endoscopic evaluation
- Additional testing
- - Viral detection
- - Serology
- Ophthalmologic evaluation in all patients with CMV disease
- Differential diagnosis
- Induction therapy
- - The use of oral therapy
- - Duration
- - When to initiate ART
- Maintenance therapy
- Treatment failure
- PATIENT MONITORING
- SUMMARY AND RECOMMENDATIONS