Foscarnet therapy for ganciclovir-resistant cytomegalovirus retinitis in patients with AIDS

Antiviral activities of nucleosides and nucleotides against wild-type and drug-resistant strains of murine cytomegalovirus

Resistance of human cytomegalovirus to approved antiviral drugs is becoming a problem of increasing concern. In order to further study drug resistance in a related virus, strains of murine cytomegalovirus (MCMV) have been prepared in vitro by extensive adaptation of the virus to increasingly higher concentrations of either ganciclovir, foscarnet, or (S)-9-(3-hydroxy-2-[phosphonylmethoxy]propyl)cytosine (HPMPC). Plaque reduction 50% effective concentrations (EC50) for the above inhibitors increased 9-, 7-, and 23-fold, respectively (against the corresponding virus), compared to wild-type MCMV. Each virus was then evaluated against other known anti-MCMV agents to determine cross-resistance patterns. These compounds included 3-hydroxy-phosphonylmethoxypropyl derivatives of adenine (HPMPA) and guanine (HPMPG), 2-phosphonylmethoxyethyl derivatives of adenine (PMEA) and 2,6-diaminopurine (PMEDAP), cyclobutylguanine, acyclovir, and the methylene phosphonate derivatives of acyclovir (SR3722) and ganciclovir (SR3773). The ganciclovir-resistant MCMV was cross-resistant to foscarnet, HPMPA, HPMPC, HPMPG, SR3722, and SR3773. The foscarnet-resistant virus was also resistant to acyclovir, PMEA, PMEDAP, SR3722, and SR3773. The HPMPC-resistant MCMV was cross-resistant to HPMPA, HPMPG, and SR3773. Changes in susceptibility were from 3- to 22-fold relative to the wild-type virus. Virus yield reduction data correlated with the plaque assay results. Only cyclobutylguanine was approximately equally active against wild-type and the three drug-resistant MCMVs. The patterns of cross-resistance correlated with resistance seen in human cytomegalovirus strains expressing altered DNA polymerase function. The GCV-resistant and HPMPC-resistant viruses were markedly attenuated in their ability to kill severe combined immunodeficient mice.

Inhibition of human cytomegalovirus in culture by alkenyl guanine analogs of the thiazolo[4,5-d]pyrimidine ring system

A series of alkyl and alkenyl guanine analogs containing a thiazolo[4,5-d]pyrimidine ring system were prepared by reaction of the appropriate alkyl halide with the sodium salt of the heterocycle. In preliminary antiviral efficacy evaluations against laboratory strains of both human cytomegalovirus (HCMV) and herpes simplex virus types 1 and 2, it was determined that two of the compounds (T70072 and T01132) were more active and less toxic in stationary-phase cell monolayers than were the other derivatives tested. T01132 and T70072, which have 2-pentenyl and 3-methyl-2-butenyl moieties attached to position 3 of the 5-aminothiazolo[4,5-d]pyrimidine-2,7-dione, respectively, were then more extensively evaluated for anti-HCMV activity. The concentrations of T01132 and T70072 required to inhibit HCMV by 50% in plaque reduction assays were approximately 0.5 and 6.8 microM, respectively. These two compounds inhibited the growth of KB, MRC-5, or Vero cells at concentrations of 75 to 150 microM, depending upon the cell line. In bone marrow progenitor cells T01132 was slightly less toxic than ganciclovir (DHPG). The 50% inhibitory concentrations of T01132 against clinical isolates and DHPG-resistant strains of HCMV were approximately the same as those obtained for laboratory strains of HCMV (approximately 0.5 microM). When tested in combination with DHPG, the resultant antiviral activity was determined to be additive but not synergistic. Experiments performed using variations of the viral multiplicity of infection (MOI) demonstrated that T01132 was more active than DHPG at a low MOI (0.002 or 0.02). However, when a higher MOI (0.2 or 2.0) was used, DHPG was more efficacious than T01132. In experiments in which drug was added at various times post-viral infection, T01132 was most effective when added within the first 24 h post-HCMV infection while DHPG was able to protect cells in this assay system when added up to 48 h postinfection, indicating that T01132 is exerting its antiviral effect on events leading up to and possibly including viral DNA synthesis. The data presented in this report suggest that the antiviral activity of alkenyl-substituted thiazolopyrimidine derivatives may represent a mechanism of action against herpesviruses alternative to that of classical nucleoside analogs such as acyclovir or DHPG.

Foscarnet. A reappraisal of its antiviral activity, pharmacokinetic properties and therapeutic use in immunocompromised patients with viral infections

The DNA polymerase of human herpes viruses, including cytomegalovirus (CMV), and the reverse transcriptase of human immunodeficiency virus (HIV) are selectively inhibited in vitro by the pyrophosphate analogue foscarnet. Inhibition is reversible on withdrawal of foscarnet and additive or synergistic effects have been demonstrated in vitro with other antiviral drugs, including ganciclovir and zidovudine. Foscarnet appears to have negligible effects on host enzymes and cells. Complete or partial clinical resolution of ocular symptoms is obtained in more than 89% of patients with acquired immunodeficiency syndrome (AIDS) and CMV retinitis during foscarnet induction therapy, but relapse occurs soon after ceasing treatment. Maintenance treatment given daily can extend the period of remission considerably. Foscarnet and ganciclovir monotherapy had similar efficacy in the treatment of CMV retinitis in patients with AIDS in several studies, and have been used concomitantly in immunocompromised patients with recalcitrant CMV infections. In 1 trial, patients receiving foscarnet survived for significantly longer than those receiving ganciclovir. Foscarnet has been used successfully in the treatment of limited numbers of immunocompromised patients with CMV-associated gastrointestinal (improvement in over 67% of patients) and other infections. Aciclovir-resistant herpes simplex infections in immunocompromised patients have also been treated successfully with foscarnet. Almost 90% of a foscarnet dose is excreted in the urine. Reversible nephrotoxicity is common during foscarnet therapy, but may be reduced by dosage adjustment and adequate hydration. Anaemia, nausea and vomiting, disturbances in electrolyte levels and genital ulceration have also been associated with administration of the drug. The different tolerability profiles of foscarnet and zidovudine facilitate the use of these agents in combination in patients with AIDS and CMV infection; whereas ganciclovir, like zidovudine, is associated with dose-limiting haematological toxicity. The apparent survival benefits seen in these patients when receiving foscarnet and zidovudine (possibly linked to synergy between zidovudine and foscarnet and/or the inherent anti-HIV activity of foscarnet), appear to offer potentially important advantages for foscarnet over ganciclovir in the treatment of selected patients with AIDS and CMV infections.

Current management of cytomegalovirus disease in patients with AIDS

Cytomegalovirus (CMV) infection is common in both homosexual and heterosexual HIV-infected patients, and causes disease in a substantial proportion of patients with AIDS and very low CD4+ cell counts. Both ganciclovir, an analog of the nucleoside guanosine, and foscarnet, an analog of pyrophosphate, are licensed for treatment of CMV retinitis. They may also have a role in the treatment of gastrointestinal disease caused by CMV. In the Studies of Ocular Complications of AIDS comparative trial the two agents were equally effective against CMV retinitis, but patients receiving foscarnet had significantly longer survival, even after adjusting for covariates including antiretroviral therapy. Ongoing studies are evaluating higher dosages of foscarnet for maintenance therapy and combined therapy with ganciclovir and foscarnet. Tolerance of ganciclovir therapy has been facilitated by adjunctive therapy with colony-stimulating factors. Because both ganciclovir and foscarnet must be administered by intravenous infusion and are associated with significant toxicities, other anti-CMV agents are under active development, including HPMPC and an oral formulation of ganciclovir. Management of CMV retinitis involves individualizing therapy, balancing side effects and administration requirements, and, in many clinical settings, the overall cost of treatment.

Combined daily therapy with intravenous ganciclovir and foscarnet for patients with recurrent cytomegalovirus retinitis

We treated seven patients (nine eyes) who had cytomegalovirus retinitis with daily intravenous ganciclovir plus foscarnet. All patients had demonstrated multiple progressions of retinitis on single-drug therapy, and some were intolerant to induction doses of one or both medications. Before combination therapy, the median number of progressions was five per patient. The mean interval between progressions was 11 weeks, and the mean interval before the final progression was four weeks. While taking combination therapy, two patients showed progression after 14 and 34 weeks. Two patients showed no progression after 17 and 36 weeks of follow-up. Three patients died after five, 14, and 23 weeks, respectively, without progression of retinitis. In every patient, the progression-free interval was longer during combination therapy than the previous progression-free interval during single-drug therapy. In no case was combination therapy stopped because of toxicity. Combination therapy was fairly well tolerated and appeared to prolong the interval to progression and to preserve vision in our patients.

High dose intravitreal foscarnet in the treatment of cytomegalovirus retinitis in AIDS

The efficacy and tolerance of high dose intravitreal foscarnet for cytomegalovirus retinitis in patients with AIDS was studied. Foscarnet in a dose of 2400 micrograms was injected directly into the vitreous of 11 patients (15 eyes). Five patients had active retinitis (eight eyes, 53.3%), and received a 3 week induction therapy of six injections as the first step. Six patients had initial inactive retinitis (seven eyes, 46.7%), and received only maintenance therapy which consisted of a weekly injection. The main indications for intravitreal therapy were: myelosuppression, kidney toxicity, catheter related sepsis, or refusal of intravenous therapy. The patients were followed for a mean period of 16 weeks (range 8-28 weeks) and received a total of 304 injections. Vitreous foscarnet levels were measured by high performance liquid chromatography. After a 3 week course of induction therapy, complete resolution of the active retinitis was seen in 62.5% (5/8 cases), while 37.5% (3/8 cases) had partial resolution. No cases failed to respond or progress. The rate of relapse on maintenance therapy was 33% (five of 15 eyes) by 20 weeks, and two of these eyes did not respond to reinduction and progressed in involvement of the macula or optic nerve. Neither important local complications nor intraocular drug toxicity were observed. Vitreous foscarnet levels in two different patients were 896 mumol/l and 74.9 mumol/l at 22 3/4 hours and 42 1/2 hours after the injection. Intravitreal foscarnet appears to be a safe, effective, and useful alternative in patients with intolerance to intravenous and viral therapy.

Esophageal infections: risk factors, presentation, diagnosis, and treatment

Infections of the esophagus are unusual in the general population and strongly imply immunodeficiency, although immunocompetent individuals are not exempt. HIV infection is predominant among risk factors for infectious esophagitis. For all immunocompromised patients, the most frequently identified esophageal pathogens are Candida, CMV, and HSV. Peculiar to HIV-infected patients are idiopathic esophageal ulcers as well as unusual bacteria and parasites. Patterns of presentation differ with each infecting organism, and clinical features should be used as a guide in achieving a correct diagnosis. For example, a patient with AIDS presenting with esophageal symptoms and thrush, along with abdominal pain, nausea, vomiting, and fever, is unlikely to resolve all symptoms with empiric antifungal therapy alone. Parsimony of diagnosis does not hold among immunodeficient patients in whom concurrent infections are common. Accurate and timely diagnoses are essential as effective treatments are available for particular etiologies. Finally, among immunocompromised patients, all esophageal symptoms are not necessarily due to an infection, and possible diagnoses of pill esophagitis, acid-peptic injury, or structural and functional abnormalities should not be overlooked.

"The end of innocence" revisited: resistance of herpesviruses to antiviral drugs

In the past 4 years, interest in drug-resistant herpesviruses has evolved from the realm of academic laboratory studies to that of great clinical importance. Recurrent and persistent infections due to the herpes simplex viruses, varicella-zoster virus, and human cytomegalovirus have been an unwelcome consequence of immunosuppression in graft recipients, cancer patients, and those suffering from AIDS. Treatment of these infections with the available antiviral drugs, such as acyclovir, ganciclovir, and foscarnet, has resulted in both clinical benefit and the emergence of drug-resistant variants. In addition, the role of Epstein-Barr virus is being clarified for an array of disease syndromes, and therapeutic approaches are beginning to emerge. In the present review, the emergence and clinical importance of drug resistance among the herpesviruses have been explored. Furthermore, particular attention has been focused on our understanding of the mechanisms of drug resistance and how that understanding will guide us in the development of more effective antiviral drugs and drug usage.

Antiviral activity of a phosphorothioate oligonucleotide complementary to RNA of the human cytomegalovirus major immediate-early region

Phosphorothioate oligonucleotides complementary to mRNA of the human cytomegalovirus (HCMV) DNA polymerase gene or to RNA transcripts of the major immediate-early regions 1 and 2 (IE1 and IE2) of HCMV were evaluated for antiviral activity in a 96-well immunoassay with primary human dermal fibroblasts as host cells. Oligonucleotides complementary to RNA of the IE2 region exhibited the most potent antiviral activity. One of these oligonucleotides, ISIS 2922, was at least 30-fold more potent than the nucleoside analog, ganciclovir, with a 50% effective concentration of 0.37 microM in the 96-well immunoassay. In an infectious virus yield reduction assay, ISIS 2922 and ganciclovir reduced production of infectious virus by 2 log units at concentrations of 2.2 and 36 microM, respectively. A control oligonucleotide showed no inhibition of virus production at concentrations as high as 3 microM. ISIS 2922 reduced IE protein synthesis in HCMV-infected cells in a dose-dependent manner which correlated with antiviral activity. The antiviral activity of ISIS 2922 was not due to oligonucleotide-induced cytotoxicity since effects on cell viability or proliferation were observed only at concentrations well in excess of effective antiviral concentrations. The specificity and potency of ISIS 2922 suggest that it may be useful for the treatment of cytomegalovirus disease in humans.

Herpes virus infections in immunocompromised patients: problems and therapeutic interventions

Herpes virus infections are responsible for morbidity and mortality among immunosuppressed patients. During the last decade substantial advances have been achieved through improvement of diagnostic techniques, development of effective antiviral agents and the use of different strategies for prophylaxis and treatment. Cytomegalovirus infection and disease can today be prevented and treated effectively; however, antiviral resistance is beginning to emerge as a potential major clinical problem. Similarly, infections with herpes simplex virus and varicella-zoster virus can be effectively treated, but antiviral resistance has also emerged for these viruses. Two new herpes viruses, human herpes viruses 6 and 7, have been discovered, and it is possible that these viruses can also cause significant problems in immunosuppressed individuals. New antiviral agents will be needed during the next decade to allow further advances in the treatment of herpes virus infections.

Antiviral susceptibility testing of cytomegalovirus: criteria for detecting resistance to antivirals

Testing cytomegaloviruses for antiviral susceptibility is increasing especially since the reports of 'resistance' to ganciclovir and foscarnet (Erice et al., 1989; Knox et al., 1991). There is however no standardized method for susceptibility testing nor are there criteria for designating an isolate as sensitive or resistant. In a previous paper we utilized a plaque reduction assay and suggested that a resistant strain be defined as one requiring > 12 microM ganciclovir for inhibition of 50% of viral plaques. (Drew et al., 1991) This concentration was chosen because it was at least four-fold greater than the mean concentration required to inhibit pretherapy isolates. In this paper we present the results of testing a large number of isolates prior to and during therapy with either ganciclovir or foscarnet. By analyzing the results of these assays we propose revised criteria for susceptibility of cytomegalovirus </= 5 microM for ganciclovir and <400 microM for foscarnet.

Retinal disease associated with AIDS

In recent years an enormous amount of new information in the area of retinitis and retinal disease in immunosuppressed patients has been acquired. There have been exciting new developments in our understanding of the pathogenesis of retinal disease in AIDS patients as well as important advances in the diagnosis and therapy of infectious retinitis. This article will summarise the recent advances in this area and outline the direction of future research as it applies to the clinical management of patients with retinal manifestations of AIDS. Diagnostic and therapeutic difficulties will be addressed including the appropriate selection of antiviral drugs and other therapeutic modalities in patients with sight-threatening retinitis.

Ocular complications of the acquired immunodeficiency syndrome. Focus on the treatment of cytomegalovirus retinitis with ganciclovir and foscarnet

The most common ocular complication in patients with the acquired immunodeficiency syndrome (AIDS) is cytomegalovirus retinitis. Incidence figures vary from 20 to 76%. Patients with cytomegalovirus may suffer from mild visual impairment of one or both eyes, but as the disease progresses the retinitis will almost certainly lead to blindness. Although cytomegalovirus retinitis is not a life-threatening infection, it can largely diminish the patient's quality of life. Clinical trials for the treatment of cytomegalovirus retinitis with a number of antiviral drugs have resulted in two drugs of choice, ganciclovir and foscarnet. Both drugs have an initial efficacy with induction therapy of 80-90%, but maintenance therapy is always needed to prevent a relapse. To exclude systemic side-effects of ganciclovir, intravitreal administration has been investigated with good results. Combination therapy of foscarnet and ganciclovir may be worthwhile in resistant cytomegalovirus retinitis.

Antimicrobial strategies in the care of organ transplant recipients

Since the early days of transplantation, infection has been a major consequence of antirejection immunosuppressive therapy. Increasingly effective prophylactic and preemptive strategies are being developed to prevent the infectious consequences of immunosuppressive therapy. Although the data base is incomplete and there remains a compelling need for well-designed, randomized, comparative trials, the potential for controlling life-threatening viral, bacterial, fungal, and protozoal infections exists. The cornerstone of this effort is the recognition that effective immunosuppressive strategies require an antimicrobial program to make them safe and that such an antimicrobial program needs to be individualized in order to be appropriately matched with the needs of the antirejection program. Thus, escalation and de-escalation of the antimicrobial program should be carried out to match the immunosuppressive program. Infection and rejection remain closely intertwined, linked by the immunosuppressive program that is prescribed.

Foscarnet-induced severe hypomagnesemia and other electrolyte disorders

OBJECTIVE

To report a case of possible foscarnet-induced severe hypomagnesemia and other electrolyte disorders.

CASE SUMMARY

An AIDS patient experienced an exacerbation of cytomegalovirus retinitis and was treated with foscarnet. The patient experienced muscle twitches, tremulousness, and anxiety on day 17 of foscarnet therapy. Laboratory results indicated hypomagnesemia, hypocalcemia, hypokalemia, and hypophosphatemia. After electrolyte supplementation and discontinuation of foscarnet, the symptoms resolved and laboratory indices returned to normal.

DISCUSSION

Electrolyte disorders associated with foscarnet are reviewed. Severe hypomagnesemia occurred in this patient and published literature is highlighted. In addition, known and/or possible mechanisms of the disorders are discussed.

CONCLUSIONS

It is probable that foscarnet contributed to the electrolyte disorders and symptomatology in this patient. Electrolytes must be monitored frequently during foscarnet therapy. Also, concomitant therapy with antianxiety medications that may mask the symptoms of electrolyte disorders should be undertaken with caution.

Activity of different antiviral drug combinations against human cytomegalovirus replication in vitro

The effects of different antiviral drug combinations on the replication of various human cytomegalovirus (CMV) strains in human embryonic lung (HEL) fibroblasts were evaluated. HPMPC combined with either ganciclovir, foscarnet or acyclovir showed additive to synergistic inhibition of CMV replication. Combinations of zidovudine with HPMPC, ganciclovir, foscarnet or acyclovir also resulted in additive to synergistic inhibition of CMV replication. Synergism tended to be higher for the clinical CMV isolates than for the reference strains AD-169 and Davis. Suppression of CMV replication was obtained at lower drug concentrations when the drugs were combined than when the drugs were used alone. At the highest drug concentrations used in the antiviral activity experiments, neither drug alone nor its combination suppressed host cell growth. If higher drug concentrations were used, zidovudine increased the inhibitory effects of ganciclovir, acyclovir and foscarnet but not of HPMPC, on cell proliferation. Use of combinations in the therapy of CMV infections may be considered to enhance drug efficacy, to reduce toxicity and, possibly, to diminish the risk of emergence of drug-resistant virus strains.

Point mutations in the DNA polymerase gene of human cytomegalovirus that result in resistance to antiviral agents

Three independently isolated mutants of human cytomegalovirus strain AD169 were found to be resistant to ganciclovir at a 50% effective dose of 200 microM. Phosphorylation of ganciclovir was reduced 10-fold in mutant-infected cells compared with AD169-infected cells. All three mutants were also determined to be resistant to the nucleotide analogs (S)-1-[(3-hydroxy-2- phosphonylmethoxy)propyl]adenine (HPMPA) and (S)-1-[(3-hydroxy-2-phosphonylmethoxy)propyl]cytosine (HPMPC) and hypersensitive to thymine-1-D-arabinofuranoside (AraT). Single base changes resulting in amino acid substitutions were demonstrated in the nucleotide sequence of the DNA polymerase gene of each mutant. The polymerase mutation contained in one of the mutants was transferred to the wild-type AD169 background. Ganciclovir phosphorylation in cells infected with the recombinant virus produced by this transfer was found to be equivalent to that of AD169-infected cells. The ganciclovir resistance of the recombinant was reduced fourfold compared with that of the parental mutant; however, the recombinant remained resistant to HPMPA and HPMPC and hypersensitive to AraT. The ganciclovir resistance of the mutants therefore appears to result from mutations in two genes: (i) a kinase which phosphorylates ganciclovir and (ii) the viral DNA polymerase.

Rapid determination of human cytomegalovirus susceptibility to ganciclovir directly from clinical specimen primocultures

We were able to rapidly determine the susceptibility of human cytomegalovirus to ganciclovir using a late antigen synthesis reduction assay directly on primocultures of clinical specimens. This test was compared with a conventional susceptibility assay which was performed with cell-free virus obtained after cytomegalovirus isolation and in vitro passages. Both tests produced similar results. The rapid test, unlike conventional assays, is able to provide a result within 5 days after receipt of the specimen and could thus play a direct role in the therapeutic decision.

AIDS: Part II

Great strides have been made in the therapy of human immunodeficiency virus (HIV) infection. Currently approved drugs include zidovudine and didanosine. A third drug, dideoxycytidine (zalcitibine), has recently been filed for approval with the Food and Drug Administration. All these drugs work through inhibition of the reverse transcriptase enzyme. Zidovudine is the only drug that has shown clinical efficacy against HIV. Treatment of patients with advanced HIV disease (i.e., acquired immune deficiency syndrome [AIDS] or symptomatic infection with < 200 CD4+ lymphocytes per mm3), results in a prolongation and improved quality of life. Zidovudine is the only antiretroviral agent approved for the treatment of asymptomatic patients. Early intervention with zidovudine has been shown to delay progression to AIDS when patients' CD4+ lymphocyte counts decline to less than 500/mm3, irrespective of clinical signs or symptoms of HIV infection. Didanosine is currently indicated for the treatment of patients with advanced HIV disease who are intolerant to or failing zidovudine therapy. The major toxicity of zidovudine is bone marrow suppression with anemia and granulocytopenia (which occurs in from 1% to 45% of patients, depending on the clinical stage of disease and the dose of the drug). Didanosine and zalcitibine have both been associated with a severe peripheral neuropathy, which is generally reversible on cessation of the drug. In addition, didanosine has been implicated as a cause of pancreatitis that has been fatal in a small percentage of cases. The toxicities of didanosine and zalcitibine range from 1% to 10%, depending on dose, duration of therapy, and the presence of underlying HIV-related peripheral neuropathy or a previous history of pancreatitis. The clinical hallmark of HIV infection is the development of opportunistic infections and malignancies, which are a consequence of the profound immunodeficiency. The risk of an opportunistic infection increases significantly as the T-helper lymphocyte count declines to less than 20%, or 200 to 250/mm3. The spectrum of opportunistic infections ranges from viruses to protozoa. Patients with advanced HIV disease are also at increased risk of infection with nonopportunistic, community-acquired pathogens. Primary and secondary prophylaxis against the most common AIDS-defining opportunistic infection, Pneumocystis carinii pneumonia, is now recommended. Studies are currently underway to determine the efficacy of prophylaxis against other opportunistic pathogens. Treatment of opportunistic infections associated with AIDS has improved significantly over the past 5 years as new drugs and combination regimens of antimicrobials have been developed.(ABSTRACT TRUNCATED AT 400 WORDS)

Detection of human cytomegalovirus in plasma of AIDS patients during acute visceral disease by DNA amplification

By using the polymerase chain reaction (PCR) amplification procedure, 19 (83%) of 23 plasma specimens obtained from individuals with AIDS and human cytomegalovirus (HCMV) visceral disease were found to be positive for plasma viremia as detected by PCR (PV-PCR), whereas 78% of cultures of peripheral blood leukocytes from the same samples were found to be positive. All 11 specimens prospectively obtained from individuals with acute HCMV disease were positive by PV-PCR. Plasma specimens from patients who received ganciclovir therapy rapidly became both culture and PV-PCR negative, and there was an excellent correlation between the two procedures. DNA detected by PV-PCR was unaffected by filtering plasma through a 0.2-microns-pore-size filter, although a conserved cellular gene, HLA-DQ alpha, was undetectable by PCR following filtration. HCMV DNA in plasma could be quantitated by PV-PCR by using endpoint serial dilutions, with detectable virus being present in 10(1) to 10(-2) microliters of plasma. A low titer of infectious virus could be detected in 2 of 11 plasma samples. The detection of HCMV DNA in plasma by PV-PCR promises to be a useful procedure for monitoring patients with AIDS suspected of having impending, acute, or recurrent HCMV visceral disease and suggests an additional route by which virus may disseminate in the immunocompromised host.

Systemic antiviral drugs used in ophthalmology

Over the past two decades, the recognition of viral enzymes and proteins that can serve as molecular targets of drugs has revolutionized the treatment of viral infections. Beginning with acyclovir, a number of systemically administered agents which are both relatively safe and effective for the treatment of herpetic infections and human immunodeficiency virus (HIV) infections have become widely available. Because of increased numbers of herpes virus infections, as well as the rising epidemic of HIV infections, the ophthalmologist is, more likely than ever before to be involved in the treatment of severe and frequent ocular infections caused by herpes viruses. In addition, the acute retinal necrosis (ARN) syndrome has been demonstrated to be caused by herpes viruses and a once rare retinal infection caused by cytomegalovirus is common in patients with the acquired immunodeficiency syndrome (AIDS). In this article, four systemic antiviral drugs (Vidarabine, Acyclovir, Ganciclovir, and Foscarnet) that have demonstrated usefulness in the treatment of ophthalmic disease are reviewed in detail with regard to their mechanisms, applications, effectiveness, and side effects.

Comparison of shell viral culture and serology for the diagnosis of human cytomegalovirus infection in neonates and immunocompromised subjects

The present retrospective study compares the laboratory diagnosis of cytomegalic inclusion disease (CID) by the use of "shell vial culture" [i.e., immunoperoxidase staining of human cytomegalovirus (HCMV) early antigen in human fibroblasts 24 h postinoculation] to the results of serology (i.e. immunoglobulins IgG, IgM, and IgA HCMV antibody testing) in 21 infants with congenital or postnatally acquired HCMV infection, 5 patients with lymphoproliferative disorders, 35 human immunodeficiency virus (HIV)-seropositive patients who met the Centers for Disease Control (CDC) criteria for stages IVA and IVB of HIV infection, and 115 patients suffering from the acquired immunodeficiency syndrome, AIDS (stages IVC-IVE according to CDC criteria). HCMV infection was diagnosed by means of the shell vial culture inoculated with patient samples (e.g., urine, bronchoalveolar lavage, induced sputum, etc.) and serology in 163 (92.6%) and 65 (36.9%) patients, respectively. Viral shedding was detected by shell vial culture in 100% of the neonates, 80% of the patients suffering from lymphoproliferative disorders, 100% of the AIDS related complex (ARC) and 89.6% of the AIDS patients. In contrast, serologic testing for HCMV-specific antibodies was positive in only 28.6%, 42.9%, and 34.8% of the neonates, ARC, and AIDS patients, respectively. In lymphoma patients, serologic testing gave identical results (80%) to the shell vial culture technique. With the use of the shell vial procedure, active HCMV infection in immunocompromised subjects and neonates can be recognized more reliably than by serologic testing. Nevertheless, in a low percentage of patients (7.4%), virus isolation by the shell vial culture may fail to detect HCMV infection.

Nonpulmonary manifestations of cytomegalovirus infection in immunocompromised patients

Nonpulmonary manifestations of cytomegalovirus (CMV) infection in immunocompromised patients include chorioretinitis, gastrointestinal infection, and central nervous system disease. Diagnosis of end organ disease, especially in the gastrointestinal tract, is best substantiated by histologic evidence of CMV inclusions. Positive cultures of CMV provide evidence for supporting infection but do not define actual end organ disease. Satisfactory treatment of the disease can be accomplished with ganciclovir or foscarnet, although these agents only suppress virus replication. In many instances, severe CMV-induced end organ disease in immunocompromised patients will progress despite treatment. In some instances, resistance to the antiviral agent is the basis for drug failure. Patients at high risk for CMV disease can be identified, and studies of prophylaxis are in progress.

Maintenance therapy for cytomegalovirus retinitis in patients with acquired immunodeficiency syndrome: foscarnet

The use of ganciclovir in the treatment of cytomegalovirus (CMV) retinitis in patients with acquired immunodeficiency syndrome (AIDS) is limited by marrow toxicity and by the development of resistance to this agent in CMV strains capable of causing progressive disease. Foscarnet retains activity against ganciclovir-resistant CMV and has an adverse effect profile different from that of ganciclovir. Preliminary data from studies conducted under the AIDS Clinical Trials Group (ACTG) program indicate that intravenous foscarnet maintenance therapy at 60, 90, and 120 mg/kg/day in AIDS patients with CMV retinitis successfully completing foscarnet induction therapy is associated with median times to retinitis progression of 90, 95, and greater than 123 days, respectively. An ACTG trial of foscarnet in patients failing ganciclovir therapy has been initiated, as has a trial jointly sponsored by the National Eye Institute and the National Institute of Allergy and Infectious Diseases comparing the safety and efficacy of foscarnet and ganciclovir. Also underway is a trial evaluating the effects of combination and alternating regimens of these two agents.

Antiviral agents

In recent years, the antiviral armamentarium has expanded considerably. Currently available agents are virustatic, inhibiting specific steps in the process of viral replication. No agent is active against nonreplicating or latent viruses. Acyclovir is useful in the treatment of genital herpes, herpes simplex encephalitis, mucocutaneous herpetic infection, varicella infection in the immunosuppressed host, and herpes zoster infection in the normal and the immunosuppressed host. It can also be used for prevention of herpesvirus infection in immunocompromised patients. Ganciclovir is indicated for the treatment of cytomegalovirus retinitis in patients with acquired immunodeficiency syndrome (AIDS) and is effective in the management of organ-specific cytomegalovirus infection in other immunocompromised patients. Chronic hepatitis C and condyloma acuminatum due to human papillomavirus respond to therapy with interferon alfa-2b. Patients with human immunodeficiency virus infection and CD4 lymphocyte counts of less than 500 cells/mm3 should be treated with zidovudine. Amantadine is useful in a therapeutic and prophylactic role in the management of influenza A virus infection. With the expanded use of and indications for antiviral therapy, clinically significant resistance to these agents has been encountered with increasing frequency.