van der Meer J T, Drew W L, Bowden R A, Galasso G J, Griffiths P D, Jabs D A, Katlama C, Spector S A, Whitley R J
Department of Infectious Diseases, Tropical Medicine and AIDS, University of Amsterdam, The Netherlands.
Antiviral Res. 1996 Nov;32(3):119-40. doi: 10.1016/s0166-3542(96)01006-6.
CMV infection and CMV disease can be difficult to differentiate and the diagnosis is usually based on a compatible clinical picture and the results of a diagnostic test for CMV. The only exception to this rule is in HIV-infected patients where fundoscopy is sufficient to diagnose CMV retinitis. Of the current diagnostic tests, qualitative and quantitative PCR, branched DNA and Hybrid Capture, are the most promising. The pp65 antigenemia assay has the disadvantage of being more labor-intensive than the DNA based tests. Preliminary data show that a positive qualitative PCR in a HIV-infected patient has a predictive value for the development of CMV retinitis. However, of the patients positive by qualitative PCR, those with high viral loads in quantitative PCR were at the greatest risk of CMV disease. This might make it possible to identify with great certainty the patients who will go on to develop CMV retinitis, thereby decreasing the number of patients eligible for preemptive or prophylactic therapy and increasing the cost-benefit of this therapeutic measure. Quantitative test might also be useful in monitoring response to therapy, but randomized trials comparing the test are needed. Prophylactic antiviral agents should not be used in seronegative transplant recipients receiving organs from seronegative donors. In high-risk transplant recipients, ganciclovir should be used. CMV vaccines are useful for the protection of babies from CMV seronegative mothers against congenital CMV disease. It also may be useful in seronegative transplant recipients receiving a seropositive donor organ, although the benefit of chemo prophylaxis may surpass that of vaccine. HIV-infected patients with CMV retinitis who relapse under either ganciclovir or foscarnet benefit from subsequent combination therapy, rather than switching to the other drug. However, the cost is high in terms of quality of life. Intravitreal therapy for CMV retinitis is very efficacious, suggesting that drug delivery is a problem in systemic therapy. However, intravitreal therapy does not protect against the development of CMV retinitis in the contralateral eye or from CMV disease elsewhere. Therefore, systemic therapy should be added. CMV disease of the CNS should be diagnosed early and treated agressively, possible with combination therapy. A diagnosis of CMV disease should be based on a compatible clinical picture and the demonstration of CMV in CSF by DNA or antigen assays which are more sensitive than culture.
巨细胞病毒（CMV）感染和CMV疾病可能难以区分，诊断通常基于相符的临床表现以及CMV诊断检测结果。该规则的唯一例外是在HIV感染患者中，眼底镜检查足以诊断CMV视网膜炎。在目前的诊断检测中，定性和定量聚合酶链反应（PCR）、分支DNA检测和杂交捕获检测最具前景。pp65抗原血症检测的缺点是比基于DNA的检测更耗费人力。初步数据表明，HIV感染患者中定性PCR呈阳性对CMV视网膜炎的发生具有预测价值。然而，在定性PCR呈阳性的患者中，定量PCR病毒载量高的患者发生CMV疾病的风险最大。这可能使我们能够非常确定地识别出将会发生CMV视网膜炎的患者，从而减少符合先发或预防性治疗条件的患者数量，并提高这种治疗措施的成本效益。定量检测在监测治疗反应方面可能也有用，但需要进行比较这些检测的随机试验。血清学阴性的移植受者接受来自血清学阴性供者的器官时，不应使用预防性抗病毒药物。在高危移植受者中，应使用更昔洛韦。CMV疫苗可有效保护血清学阴性母亲所生婴儿免受先天性CMV疾病感染。对于接受血清学阳性供者器官的血清学阴性移植受者可能也有用，尽管化学预防的益处可能超过疫苗。接受更昔洛韦或膦甲酸治疗后复发的CMV视网膜炎HIV感染患者，后续接受联合治疗比换用另一种药物更有益。然而，就生活质量而言，成本很高。CMV视网膜炎的玻璃体内治疗非常有效，这表明全身治疗存在药物递送问题。然而，玻璃体内治疗不能预防对侧眼发生CMV视网膜炎或其他部位发生CMV疾病。因此，应加用全身治疗。中枢神经系统CMV疾病应尽早诊断并积极治疗，可能需要联合治疗。CMV疾病的诊断应基于相符的临床表现以及通过比培养更敏感的DNA或抗原检测在脑脊液中证实CMV的存在。
