Management of human cytomegalovirus infection and disease after allogeneicbone marrow transplantation

Background and Objective. Human cytomegalovirus (HCMV) infection and diseas e remain a major cause of morbidity and mortality after bone marrow transpl antation. HCMV disease, especially pneumonitis, may be treated with gancicl ovir and immunoglobulin but even so the outcome is poor with mortality rate s of 30-70%. It is therefore imperative to treat HCMV infection before it d evelops into disease. The aim of this article is to describe the main strat egies used to prevent HCMV infection and to improve the survival after CMV disease in bone marrow transplant recipients. Information sources. In the present review, we examined personal papers in this field and articles published in journals covered by the Science Citati on Index and Medline. State of the Art. Major advances have been made in preventing HCMV infectio n and disease through two different approaches, both of which reduce HCMV i nduced morbidity and mortality: in preemptive therapy, patients are given g anciclovir when HCMV infection is first identified and this is continued 3- 4 months after transplantation; in prophylactic therapy ganciclovir is give n to all patients at risk of HCMV disease from engraftment up to 3-4 months post transplantation. Each strategy has advantages and disadvantages and t here is no evidence for the superiority of one over the other since the ove rall survival is the same and the incidence of death from HCMV disease is s imilar. Perspectives. The use of more sensitive tests such as HCMV PCR or antigenem ia may improve the outcome but probably will not eradicate all HCMV disease . Future possible strategies could include adoptive transfer of CD8(+) HCMV -specific cytotoxic T lymphocytes clones derived from the donor marrow or b oosting donor or patient immunity using subunit anti-HCMV vaccines such as gB or pp65. (C)1998, Ferrata Storti Foundation.