Schmidt G M, Horak D A, Niland J C, Duncan S R, Forman S J, Zaia J A
Department of Hematology and Bone Marrow Transplantation, City of Hope National Medical Center, Duarte, Calif. 91010.
N Engl J Med. 1991 Apr 11;324(15):1005-11. doi: 10.1056/NEJM199104113241501.
Cytomegalovirus (CMV)-associated interstitial pneumonia is a major cause of death after allogeneic bone marrow transplantation. We conducted a controlled trial of ganciclovir in recipients of bone marrow transplants who had asymptomatic pulmonary CMV infection. We also sought to identify risk factors for the development of CMV interstitial pneumonia.
After bone marrow transplantation, 104 patients who had no evidence of respiratory disease underwent routine bronchoalveolar lavage on day 35. The 40 patients who had positive cultures for CMV were randomly assigned to either prophylactic ganciclovir or observation alone. Ganciclovir (5 mg per kilogram of body weight intravenously) was given twice daily for two weeks and then five times per week until day 120.
Of the 20 culture-positive patients who received prophylactic ganciclovir, 5 (25 percent) died or had CMV pneumonia before day 120, as compared with 14 of the 20 culture-positive control patients (70 percent) who were not treated prophylactically (relative risk, 0.36; P = 0.01). No patient who received the full course of ganciclovir prophylaxis went on to have CMV interstitial pneumonia. Four patients treated with ganciclovir had maximal serum creatinine levels greater than or equal to 221 mumol per liter (2.5 mg per deciliter), as compared with none of the controls (P = 0.029). Of the 55 CMV-negative patients who could be evaluated, 12 (22 percent) had CMV pneumonia--a significantly lower rate than in the untreated CMV-positive control patients (relative risk, 0.33; P = 0.003). The strongest predictors of CMV pneumonia were a lavage-fluid culture that was positive for CMV and a CMV-positive blood culture, both from specimens obtained on day 35.
In recipients of allogeneic bone marrow, asymptomatic CMV infection of the lung is a major risk factor for subsequent CMV interstitial pneumonia. Prophylactic ganciclovir is effective in preventing the development of CMV interstitial pneumonia in patients with asymptomatic infection.
巨细胞病毒（CMV）相关性间质性肺炎是异基因骨髓移植后死亡的主要原因。我们对无症状肺部CMV感染的骨髓移植受者进行了一项更昔洛韦对照试验。我们还试图确定CMV间质性肺炎发生的危险因素。
骨髓移植后，104例无呼吸系统疾病证据的患者在第35天接受常规支气管肺泡灌洗。40例CMV培养阳性的患者被随机分配接受预防性更昔洛韦治疗或仅观察。更昔洛韦（5毫克/千克体重静脉注射）每日给药两次，持续两周，然后每周给药五次，直至第120天。
在接受预防性更昔洛韦治疗的20例培养阳性患者中，5例（25%）在第120天前死亡或发生CMV肺炎，而20例未接受预防性治疗的培养阳性对照患者中有14例（70%）（相对危险度，0.36；P = 0.01）。接受全程更昔洛韦预防治疗的患者均未发生CMV间质性肺炎。4例接受更昔洛韦治疗的患者血清肌酐最高水平大于或等于221微摩尔/升（2.5毫克/分升），而对照组无一例出现此情况（P = 0.029）。在可评估的55例CMV阴性患者中，12例（22%）发生了CMV肺炎——这一发生率显著低于未治疗的CMV阳性对照患者（相对危险度，0.33；P = 0.003）。CMV肺炎最强的预测因素是第35天获得的标本中CMV灌洗液培养阳性和CMV血培养阳性。
在异基因骨髓移植受者中，肺部无症状CMV感染是随后发生CMV间质性肺炎的主要危险因素。预防性更昔洛韦可有效预防无症状感染患者发生CMV间质性肺炎。
