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CMV Pneumonitis — SCE Infectious Diseases MCQ

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HardImmunocompromised HostCMV PneumonitisSCE Infectious Diseases

A 45-year-old man undergoing allogeneic stem cell transplant develops fever on day +55 with bilateral ground-glass opacities on CT chest. BAL fluid is negative for bacteria, fungi, and PJP. BAL CMV PCR is positive at 5,500 copies/mL. Serum CMV PCR is 1,200 copies/mL. He is already on Letermovir prophylaxis. What is the most appropriate action?

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Correct answer: E — Switch from Letermovir prophylaxis to IV Ganciclovir at treatment dose

Letermovir is a CMV terminase inhibitor used for prophylaxis in allogeneic HSCT recipients but it does not treat established CMV disease. BAL positivity with clinical disease (pneumonitis) requires escalation to treatment-dose IV Ganciclovir (5 mg/kg BD). CMV resistance to Letermovir (UL56 mutations) should be tested. Ganciclovir-related myelosuppression must be monitored closely in post-HSCT patients. Foscarnet is used if Ganciclovir is contraindicated (e.g. severe neutropenia).

Reference: ECIL-7 2019 – CMV management in HSCT; NICE 2023 – Letermovir