Re: Valtrex for CMV? 26 pound, 3 yo.

February 10, 2005

Valtrex is not effective against CMV. Valtrex is relatively safe.

Ganciclovir is not as safe (especially if used in high doses for

infections blossoming forth in extreme immune suppression, eg,

transplants, HIV) but is effective against most strains of CMV. Many

articles document safe use in pediatric populations - at lower doses,

with proper monitoring (which isn't cheap). IMO, the autism subgroup

wherein CMV is etiologically significant is receiving virtually no

research.

1: J Child Neurol. 2004 Jan;19(1):50-3.

Infantile spasms in an infant with cytomegalovirus infection treated with

ganciclovir.

Voudris K, Vagiakou EA, Mastroyianni S, Dimitriou Y, Skardoutsou A.

Department of Neurology, " P & A Kyriakou " Children's Hospital, Athens, Greece.

kvoudris@...

A 3-month-old male infant with cytomegalovirus infection and intractable partial

seizures was treated with ganciclovir for 6 weeks. The drug was well tolerated,

and virus shedding in the cerebrospinal fluid and urine was eliminated, although

infantile spasms at the age of 6 months appeared. At the age of 12 months,

intractable seizures persisted, and the psychomotor development of the infant

was markedly delayed. To our knowledge, no previous similar case has been

reported. These findings suggest that treatment with ganciclovir of infants with

cytomegalovirus infection results only in cessation of virus shedding in the

cerebrospinal fluid and urine without having a preventive effect on the future

appearance of infantile spasms. This may be due to the irreversibility of

previous brain damage from the cytomegalovirus infection and the virostatic

nature of the drug.

Publication Types:

Case Reports

PMID: 15032385 [PubMed - indexed for MEDLINE]

2: Eur J Clin Microbiol Infect Dis. 2004 Mar;23(3):218-20. Epub 2004 Feb 07.

Ganciclovir for severe cytomegalovirus primary infection in an immunocompetent

child.

Hadaya K, Kaiser L, Rubbia-Brandt L, Gervaix A, A.

Central Laboratory of Virology, Division of Infectious Diseases, Department of

Internal Medicine, University Hospitals of Geneva, Geneva, Switzerland.

Described here is the unusual case of a previously healthy 17-month-old girl who

developed severe cytomegalovirus (CMV) disease with prolonged fever and

hepatitis. The severity of her illness required hospitalization and prompted

antiviral treatment. Short-term intravenous ganciclovir treatment was associated

with immediate and sustained resolution of the symptoms as well as a sharp

decrease of CMV viremia. This observation suggests that antiviral therapy might

be considered in select cases of severe primary CMV infection in immunocompetent

children.

Publication Types:

Case Reports

PMID: 14767679 [PubMed - indexed for MEDLINE]

3: Int J Infect Dis. 2003 Dec;7(4):278-81.

Ganciclovir therapy in cytomegalovirus (CMV) infection in immunocompetent

pediatric patients.

Avila-Aguero ML, Paris MM, Alfaro W, Avila-Aguero CR, Faingezicht I.

Hospital Nacional de Ninos, San , Costa Rica. maluvi@...

OBJECTIVES: To evaluate the outcome of immunocompetent pediatric patients who

had positive cytomegalovirus (CMV) antigenemia and received ganciclovir.

METHODS: A retrospective review was done of patients who had a CMV infection

based on positive antigenemia. Medical charts were reviewed for the following

information: age, sex, underlying disease, symptoms and signs, laboratory

results, complementary diagnostic procedures, duration and dose of ganciclovir

therapy, concomitant medications, complications, and outcome. RESULTS:

Sixty-four patients with positive CMV antigenemia were identified; 15 patients

were excluded from the study because of their underlying diseases. Of the

remaining 49 patients, 26 (53%) were female; the median age was 11.5 months

(range 0.3-132 months). Sixty-one percent (30/49) of these patients received

ganciclovir (5-10 mg/kg/day) for a median of 14 days (range 7-42 days). Clinical

findings included: fever, anemia, hepatomegaly, failure to thrive, elevated

liver enzymes, splenomegaly, seizures, and thrombocytopenia. Sixty-three percent

(19/30) of the treated patients had negative antigenemia at the end of therapy.

CMV antigenemia remained positive in six (20%) patients. Nine patients received

a second course of ganciclovir. CONCLUSIONS: Ganciclovir was effective in 80% of

patients, as determined by negative antigenemia at the end of therapy.

PMID: 14656419 [PubMed - indexed for MEDLINE]

4: Pediatr Infect Dis J. 2003 Jun;22(6):504-9.

Comment in:

Pediatr Infect Dis J. 2004 Jan;23(1):88-9.

Treatment of children with congenital cytomegalovirus infection with

ganciclovir.

s MG, Greenberg DP, Sabo DL, Wald ER.

Division of Allergy, Immunology, Infectious Diseases, Department of Pediatrics,

University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh,

Pittsburgh, PA, USA.

BACKGROUND: Congenital cytomegalovirus (CMV) infection affects approximately 1%

of live births in the US. Ten percent of these infants have symptoms at birth

and another 10 to 15% acquire hearing loss or developmental problems. Congenital

CMV is the most common cause of nonhereditary sensorineural hearing loss in

children, and progressive hearing loss is common. To arrest the natural

progression of congenital CMV, children referred to our center were treated with

a prolonged course of ganciclovir. METHODS: Medical records of children with

congenital CMV who were treated with ganciclovir were reviewed to tabulate their

presenting symptoms, duration of treatment, audiologic and developmental

assessments and complications. RESULTS: We treated nine children with

symptomatic CMV with iv ganciclovir at a median age of 10 days (range, 3 days to

11 months). Findings at diagnosis included microcephaly (five of nine);

petechiae (five of nine); thrombocytopenia (seven of nine); and intracranial

calcifications (six of eight). Hearing loss was noted before therapy in five of

nine. The median duration of iv and subsequent oral ganciclovir was 1 year and

0.83 year, respectively. Median follow-up was 2 years (range, 1 to 7 years). No

child had progression of hearing loss; improvement occurred in two. Seven

children had at least one complication of ganciclovir therapy: central venous

catheter/site infection (six); catheter malfunction (three); and neutropenia

(one). CONCLUSION: Of nine children none treated with ganciclovir for congenital

CMV had detectable progressive hearing loss. Complications associated with iv

therapy occurred frequently. Currently available oral analogues of ganciclovir

may facilitate earlier and more prolonged therapy for children with symptomatic

congenital CMV and should be subjected to randomized controlled trials.

PMID: 12799506 [PubMed - indexed for MEDLINE]

5: Pediatr Crit Care Med. 2001 Jul;2(3):271-273.

Cytomegalovirus myocarditis in a healthy infant: Complete recovery after

ganciclovir treatment.

Dehtiar N, Eherlichman M, Picard E, Kleid D, Glaser J, Raveh D, Schlesinger Y.

Department of Pediatrics (Drs. Dehtiar and Eherlichman), the Pediatric Intensive

Care Unit (Drs. Picard and Kleid), the Department of Pediatric Cardiology (Dr.

Glaser), and the Infectious Diseases Unit (Drs. Raveh and Schlesinger), Shaare

Zedek Medical Center, Jerusalem, Israel.

OBJECTIVES: To report a case of acute myocarditis caused by cytomegalovirus

infection in a 15-month-old immunocompetent infant completely recovered with

ganciclovir treatment. DESIGN: Descriptive case report. SETTING: Pediatric

intensive care unit in a general hospital. Patient: A 15-month-old healthy girl

with acute, severe myocarditis. INTERVENTION: General supportive intensive care

and mechanical ventilatory support, iv immunoglobulin, and iv ganciclovir.

MEASUREMENTS AND MAIN RESULTS: Intensive supportive care including iv fluids,

mechanical ventilatory support, diuretics (furosemide, spironolactone), digoxin,

dobutamine, captopril, methylprednisolone, and iv immunoglobulin. Despite

clinical stabilization, shortening fraction remained very poor at 17%. Addition

of iv ganciclovir resulted in prompt and complete recovery of the cardiac muscle

contractility with a shortening fraction of 35% that remained normal during a

long follow-up period. CONCLUSIONS: Cytomegalovirus should be considered as a

causative agent in acute myocarditis even in the normal, immunocompetent host.

In such cases, addition of ganciclovir treatment should be strongly considered.

PMID: 12793954 [PubMed - as supplied by publisher]

6: J Pediatr Gastroenterol Nutr. 2002 Feb;34(2):154-7.

Ganciclovir treatment in infants with cytomegalovirus infection and cholestasis.

Fischler B, Casswall TH, Malmborg P, Nemeth A.

Department of Pediatrics, Huddinge University Hospital, Karolinska Institutet,

Stockholm, Sweden. bjorn.fischler@...

BACKGROUND: The authors have previously described an association between

cytomegalovirus (CMV) infection and intrahepatic and extrahepatic forms of

neonatal cholestasis. Pediatric use of the antiviral drug ganciclovir to treat

patients with CMV infection has increased. In this study, infants with CMV

infection and cholestasis were treated with ganciclovir. METHODS: Six infants

with cholestasis (age, 3-16 weeks) and with signs of ongoing CMV infection were

treated with intravenous ganciclovir for 3 to 7 weeks and observed for 4 to 31

months after treatment. Two patients had biliary atresia, one had suspected

septo-optic dysplasia and three had no obvious cause for intrahepatic

cholestasis other than ongoing CMV infection. RESULTS: Four patients, including

one with biliary atresia, responded to the treatment, whereas two patients,

including the one with septo-optic dysplasia did not. The latter patient had

episodes of symptomatic hypoglycemia during the treatment, which was

subsequently stopped. Liver function at the end of follow-up was good in four

patients, intermediate in one, and poor in one. CONCLUSION: Ganciclovir

treatment may be beneficial in infants with CMV-associated intrahepatic

cholestasis, but controlled studies are needed. Because of the possible side

effect of hypoglycemia, infants with cholestasis who have increased risk for

such episodes should not be treated.

PMID: 11840032 [PubMed - indexed for MEDLINE]

7: Arch Virol. 1997;142(3):573-80.

Ganciclovir therapy for cytomegalovirus-associated liver disease in

immunocompetent or immunocompromised children.

Nigro G, Krzysztofiak A, Bartmann U, Clerico A, Properzi E, Valia S, Castello M.

Pediatric Institute, Rome, Italy.

Ganciclovir therapy was given intravenously to 20 children with cytomegalovirus

(CMV)-associated liver disease, of whom 6 were immunocompetent and 14 were

immunocompromised (9 had AIDS and 5 had solid tumors). Immunocompetent children

had isolated liver disease diagnosed at birth (4 children), or systemic

congenital CMV infection including liver disease (2 children). Ganciclovir was

used following two regimens: A) 5 mg/kg twice daily for 8 to 86 days (mean 21);

7.5 mg/kg twice daily for 14 days followed by 10 mg/kg three times weekly for

three months. CMV infection was diagnosed by viral isolation, detection of viral

antigens, and/or CMV DNA from blood and urine. All immunocompetent children had

negative CMV culture and CMV DNA detection from blood and/or urine after 14

weeks of treatment. However, the three children who were treated with regimen B

showed normal ALT levels at the end of the maintenance course, whereas the

children who received ganciclovir with regimen A had normal ALT levels only

after about 1 year. All children with tumors initiated regimen B, but only

three, who had negative CMV detection and markedly decreased ALT levels,

received full treatment; of the remaining two children, one recovered after only

an initial course, and the other had therapy interrupted because of hepatic

failure and died 9 days later. In contrast, the children with AIDS received

several ganciclovir courses for different periods at the lower dosage: they

generally improved during treatment but did not recover completely, and five

children died with active CMV infections. Based on our study, CMV-associated

liver disease can be efficiently treated with ganciclovir both in

immunocompetent and immunodeficient children. However, a single ganciclovir

course including a higher dosage and prolonged therapy appeared to be more

effective than several courses with lower dosages.

PMID: 9349303 [PubMed - indexed for MEDLINE]

8: Clin Infect Dis. 1998 Jan;26(1):199-200.

Cytomegalovirus gastropathy in a child: resolution after ganciclovir therapy.

Wald A, Frenkel LM, DL, Christie DL.

Department of Medicine, University of Washington, Seattle, USA.

Publication Types:

Case Reports

PMID: 9455543 [PubMed - indexed for MEDLINE]

9: Neurology. 1996 Oct;47(4):925-8.

Treatment of Rasmussen's syndrome with ganciclovir.

McLachlan RS, Levin S, Blume WT.

Department of Clinical Neurological Sciences, University of Western Ontario,

London, Canada.

Since cytomegalovirus (CMV) has been implicated in the pathogenesis of

Rasmussen's syndrome, we treated four patients with ganciclovir, a potent

anti-CMV drug. A 7-year-old girl with seizures escalating to 60/day over 3

months despite triple antiepileptic drug therapy became seizure-free 5 days

after initiation of treatment with no recurrence at 1.5 years follow-up. Focal

neurologic signs, cognitive function, and the EEG returned to normal. Two

patients treated 34 and 72 months after disease onset in association with

epilepsy surgery had a reduction in seizures and one had no response. CMV genome

was detected in the brains of two of the three patients in whom it was assessed.

The response to antiviral therapy supports a viral etiology for chronic

encephalitis of Rasmussen. If the disease is suspected, treatment with

ganciclovir should be considered as early as possible.

Publication Types:

Case Reports

PMID: 8857720 [PubMed - indexed for MEDLINE]

10: Acta Paediatr Jpn. 1995 Apr;37(2):206-10.

A female infant successfully treated by ganciclovir for congenital

cytomegalovirus infection.

Fukuda S, Miyachi M, Sugimoto S, Goshima A, Futamura M, Morishima T.

Department of Neonatology, Aichi Prefectural Colony, Central Hospital, Japan.

An 11 month old female infant, diagnosed as having congenital cytomegalovirus

(CMV) infection and suffering from pneumonia and intractable diarrhea, was

treated with 9-(1,3-dihydroxy-2-propoxymethyl) guanine (DHPG), intravenously for

8 weeks. Watery diarrhea ceased and pneumonia associated with massive

endotracheal aspirates was reduced. No leukopenia, thrombocytopenia or other

side effects were observed during the therapy. The clinical findings suggest

that DHPG might be an effective and safe agent for the treatment of both

intestinal and lower respiratory CMV infection in young infants.

Publication Types:

Case Reports

PMID: 7793258 [PubMed - indexed for MEDLINE]

11: Acta Paediatr. 1995 Mar;84(3):340-1.

Ganciclovir therapy of congenital human cytomegalovirus hepatitis.

Stronati M, Revello MG, Cerbo RM, Furione M, Rondini G, Gerna G.

Division of Neonatal Intensive Care Unit, IRCCS Policlinico S Matteo, Pavia,

Italy.

Publication Types:

Case Reports

PMID: 7780261 [PubMed - indexed for MEDLINE]

12: Pediatr Infect Dis J. 1994 Mar;13(3):239-41.

Ganciclovir treatment of steroid-associated cytomegalovirus disease in a

congenitally infected neonate.

Vallejo JG, Englund JA, -Prats JA, Demmler GJ.

Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030.

Publication Types:

Case Reports

PMID: 8177639 [PubMed - indexed for MEDLINE]

13: J Pediatr. 1994 Feb;124(2):318-22.

Comment in:

J Pediatr. 1994 Oct;125(4):670-1.

Ganciclovir therapy for symptomatic congenital cytomegalovirus infection in

infants: a two-regimen experience.

Nigro G, Scholz H, Bartmann U.

Pediatric Institute of La Sapienza, University of Rome, Italy.

The efficacy of two regimens of ganciclovir therapy was evaluated in 12 infants

with symptomatic congenital cytomegalovirus (CMV) infection. Virologic

investigations included culture from urine, saliva, and cerebrospinal fluid,

detection of CMV DNA by polymerase chain reaction, and detection of CMV

class-specific antibodies (IgG, IgA, IgM) by enzyme immunoassays. Six infants

were given ganciclovir, 5 mg/kg twice daily for 2 weeks (group 1); the other six

infants were given 7.5 mg/kg twice daily for 2 weeks and 10 mg/kg three times

weekly for 3 months (group 2). In group 1 the CMV cultures of specimens from

three infants became sterile; two of these infants also had negative results on

CMV DNA studies; results of culture and CMV DNA study were still positive after

ganciclovir therapy in the remaining three infants. Subsequently, normal outcome

was observed in only two patients. In group 2, all infants had negative

CMV-culture and CMV DNA results; clinical improvement was evident in five

infants, one of whom had later development of mild psychomotor retardation. In

another infant, severe psychomotor retardation and hearing loss developed after

transient improvement developed. These preliminary data indicate that a

ganciclovir regimen including a higher dose and more prolonged therapy might be

more effective in infants with symptomatic congenital CMV infection.

PMID: 8301446 [PubMed - indexed for MEDLINE]

noahparthasmom wrote:

>Hi. I read in CSB that Valtrex is not recommended for kids under 5

>and under a certain weight. Is there any other type of anti-viral

>that can be used to suppress CMV? In addition to having reduced IgA,

>and not enough MT, my son has high levels of CMV on the

>Immunosciences Panel. (IGG 749, should be under 100). His neurologist

>is now reordering a brain scan to see if the stroke he thought Noah

>had inutero might actually be a calification, and that CMV might have

>caused his CP. Noah also fits all the other criteria for CMV.

>

>His doctor said that his cognitive delays are probably from CMV, but

>Noah was talking and imitating (though he was delayed) and regressed

>immediately after his 15 and 18 month shots.

>

>I just want to suppress the virus any way we can - if possible. All

>the other viruses came back in normal range on the panel. Whew.

>Metals and CMV - that's my mission.

>

>Thanks!

>

>Mom to Noah and Eli

>

February 10, 2005

, what a great piece of information! Thank you for digging and sending.

This group really is blessed to have you!

Re: Valtrex for CMV? 26 pound, 3 yo.

Valtrex is not effective against CMV. Valtrex is relatively safe.

Ganciclovir is not as safe (especially if used in high doses for

infections blossoming forth in extreme immune suppression, eg,

transplants, HIV) but is effective against most strains of CMV. Many

articles document safe use in pediatric populations - at lower doses,

with proper monitoring (which isn't cheap). IMO, the autism subgroup

wherein CMV is etiologically significant is receiving virtually no

research.

1: J Child Neurol. 2004 Jan;19(1):50-3.

Infantile spasms in an infant with cytomegalovirus infection treated with

ganciclovir.

Voudris K, Vagiakou EA, Mastroyianni S, Dimitriou Y, Skardoutsou A.

Department of Neurology, " P & A Kyriakou " Children's Hospital, Athens, Greece.

kvoudris@...

A 3-month-old male infant with cytomegalovirus infection and intractable

partial

seizures was treated with ganciclovir for 6 weeks. The drug was well

tolerated,

and virus shedding in the cerebrospinal fluid and urine was eliminated,

although

infantile spasms at the age of 6 months appeared. At the age of 12 months,

intractable seizures persisted, and the psychomotor development of the infant

was markedly delayed. To our knowledge, no previous similar case has been

reported. These findings suggest that treatment with ganciclovir of infants

with

cytomegalovirus infection results only in cessation of virus shedding in the

cerebrospinal fluid and urine without having a preventive effect on the future

appearance of infantile spasms. This may be due to the irreversibility of

previous brain damage from the cytomegalovirus infection and the virostatic

nature of the drug.

Publication Types:

Case Reports

PMID: 15032385 [PubMed - indexed for MEDLINE]

2: Eur J Clin Microbiol Infect Dis. 2004 Mar;23(3):218-20. Epub 2004 Feb 07.

Ganciclovir for severe cytomegalovirus primary infection in an immunocompetent

child.

Hadaya K, Kaiser L, Rubbia-Brandt L, Gervaix A, A.

Central Laboratory of Virology, Division of Infectious Diseases, Department of

Internal Medicine, University Hospitals of Geneva, Geneva, Switzerland.

Described here is the unusual case of a previously healthy 17-month-old girl

who

developed severe cytomegalovirus (CMV) disease with prolonged fever and

hepatitis. The severity of her illness required hospitalization and prompted

antiviral treatment. Short-term intravenous ganciclovir treatment was

associated

with immediate and sustained resolution of the symptoms as well as a sharp

decrease of CMV viremia. This observation suggests that antiviral therapy

might

be considered in select cases of severe primary CMV infection in

immunocompetent

children.

Publication Types:

Case Reports

PMID: 14767679 [PubMed - indexed for MEDLINE]

3: Int J Infect Dis. 2003 Dec;7(4):278-81.

Ganciclovir therapy in cytomegalovirus (CMV) infection in immunocompetent

pediatric patients.

Avila-Aguero ML, Paris MM, Alfaro W, Avila-Aguero CR, Faingezicht I.

Hospital Nacional de Ninos, San , Costa Rica.

maluvi@...