REFERAT CMV

Oleh :
ANDYN ROBIOLENY SAPARIN
132011101040

Pembimbing:
dr.Yuli Hermansyah Sp.PD

SMF ILMU PENYAKIT DALAM

RSD dr. Soebandi Jember
2018
1
CMV
 EPIDEMIOLOGI

• 60-70% dewasa dengan hasil pemeriksaan

laboratorium positif infeksi CMV.
• In utero infection occurs most commonly
among infants born to mothers with primary
infection during pregnancy
• 30-40% rate of CMV transmission to fetus
following primary infection during pregnancy
• 0.2-1% rate of CMV transmission to fetus
following recurrent infection during pregnancy
(reactivation of infection or reinfection with a
different strain of CMV)
 CMV
• CMV may be transmitted intrapartum or
postpartum
• 57% of infants whose mothers shed CMV become
infected
• 53% of infants who are breast-fed with milk that
contains CMV become infected

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 CMV
• Infection with CMV common and often inapparent
• 50-80% of women of childbearing age in United States are
CMV antibody positive
• 90% of HIV-infected women are CMV antibody positive
• Infection occurs:
– During infancy, early childhood, adolescence
– Via contact with virus-containing salvia, urine, sexual fluid,
blood, transplanted organ
– Perinatally – most common

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 INFEKSI CMV
Infeksi CMV Primer
• Terdeteksinya CMV untuk pertama kali tanpa ada riwayat infeksi
virus tersebut sebelumya.
Infeksi Rekuren
• Terjadinya lagi infeksi CMV setelah sebelumnya pernah terinfeksi
dimana pasien telah dinyatakan bebas CMV minimal 4 minggu.
• eksogen
Reinfeksi

• endogen
Reaktivasi
 TRANSMISI

• organ donor
• transfusi darah
• kontak seksual, dan
• kontak darah ataupun urin
• Transmisi intrauterin
• ASI
FAKTOR RISIKO
IMUNOKOMPETEN IMUNOKOMPROMAIS IBU HAMIL
 IMUNOKOMPETEN

• Asimptomatis
• Sembuh sendiri
 IMUNOKOMPROMAIS
• Simptomatik  lebih berat
Transplantasi organ
HIV AIDS
Ibu hamil
 IBU HAMIL

• Bayi medapat infeksi CMV  kontaminasi darah

dan sekret genitalia saat persalinan dan saat minum
ASI dari ibu.
• Ketika wanita hamil terinfeksi CMV secara primer
pada trimester pertama kehamilannya, risiko
terjadinya infeksi transpplasenta sekitar 40%.
• Pada bayi tersebut sekitar 5-15% bayi akan muncul
gejala akut saat lahir.
• 85-95% bayi yang terinfeksi CMV asimptomatis saat
laahir.
• 10-15% bayi yang asimptomatis saat llahir akan
mengalami gangguan perkembangan neurologi,
auditori, visual, dan atau dental defek.
• Sebanyak 30% bayi yang menderita infeksi CMV
berat akan mengalami kematian dan 80% akan
bertahan dengan sekuele
 GEJALA PADA IBU HAMIL

• Wanita hamil yang terinnfeksi CMV dapat

asimptomatis,
• Diagnosis dapat dicurigai ketika ditemukan hasil
USG yang abnormal:
– IUGR,
– Mikrosefali
– Ventriikulomegali
– kalsifikasi periventrikular
– echogenic bowel
 GEJALA PADA IBU HAMIL

• Manifestasi klinis yang terjadi yaitu :

– Flu like syndrome
– Malaise
– Demam
– Limfadenopati general
– Hepatosplenomegali
MANIFESTASI KLINIS INFEKSI CMV KONGENITAL
DIAGNOSIS
TERAPI INFEKSI KONGENITAL
 TERAPI
Symptomatic congenital CMV
• Ganciclovir: 6 mg/kg IV Q12H for 6 weeks (B I)
• Alternative treatment for ganciclovir-resistant CMV is
FOSCARNET

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TERAPI CMV IMUNOKOMPROMAIS
 Cytomegalovirus: Treatment (2)
Initial and maintenance treatment of disseminated
CMV and CMV retinitis
– Ganciclovir: 5 mg/kg/dose IV over period of 1-2 hours BID for 14-21
days, followed by lifelong maintenance therapy (A I)
– Combination treatment with ganciclovir and foscarnet delays
progression of retinitis inpatients failing monotherapy (B III)
– Maintenance treatment with oral valganciclovir with a ganciclovir
sustained-release ocular implant can be considered for chronic
suppression of CMV retinitis in older children and adults

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 Cytomegalovirus: Treatment (3)
Alternative treatment for ganciclovir resistance
• Foscarnet (A I) at 60 mg/kg/dose IV (infused at
1 mg/kg/minute) over period of 1-2 hours Q8H for 14-21
days, followed by lifelong therapy
• Foscarnet plus ganciclovir delays progression of retinitis in
certain patients failing monotherapy
• Toxicity:
• decreased renal function, metabolic abnormalities,
electrolyte imbalances with secondary seizures, cardiac
dysrhythmia, abnormal liver enzymes, and CNS symptoms

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 Cytomegalovirus: Adverse Events
Ganciclovir and valganciclovir
• Neutropenia may occur and may require dosage
modification
• Resistance and myelosuppression can occur
• Other toxic effects include renal impairment, CNS effects, GI
dysfunction, increased liver enzymes
• Metabolic disturbances can be minimized by slow infusion
rates
• Immune recovery uveitis, and immunologic reaction to
CMV, is related to the occurrence of IRIS and other
coinfections following initiation of ART

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 Cytomegalovirus: Treatment (4)

Treatments for adults (inadequate pediatric data)

– Valganciclovir: prodrug of ganciclovir, given orally, effective in
retinitis in adults
– Oral ganciclovir (or valganciclovir) plus ganciclovir sustained-release
intraocular implant used for retinitis
– Cidofovir for retinitis
– Fomivirsen: antisense nucleotide used as intravitreous injection

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 DIAGNOSIS
• Antibody assays indicative of maternal transfer of
IgG in children <12 months; indicative of previous
infection in children >12 months
• Positive cell culture from urine, tissues, blood
leukocytes
• DNA PCR assays more sensitive than buffy coat or
urine culture
• Quantitative DNA PCR can be used to monitor
disease and treatment
• Other methods include monoclonal antibody
staining and immunostaining for antigen

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 PENCEGAHAN

• Administer CMV antibody-negative blood and blood products if

transfusion is required
• Begin CMV antibody testing at 1 year of age in seronegative HIV-
infected infants and children who are severely immunosuppressed
• Inform parents and care providers that HIV-infected children are at
risk of CMV in daycare settings
• Minimize risk of acquiring CMV infection with optimal hygienic
practices
 Cytomegalovirus: Discontinuing Secondary
Prophylaxis

• Multiple studies indicate that maintenance therapy can be

discontinued in adults with CMV retinitis whose CD4 counts
have increased and who are on ART
• Safety of discontinuing maintenance therapy in children has
not been well studied
• Discontinuing prophylaxis and children 1-6 years of age
receiving ART and with CD4 percentage of >15% or CD4 count
>500 cells/L can be considered (C III)
• Patients who have had CMV maintenance therapy
discontinued should undergo ophthalmologic monitoring at 3-
6 month intervals

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