REPLY
How Useful Are Cytomegalovirus Cultures in Patients with HIV Infection?
John J. Zurlo;
Michael A. Polis; and
Henry Masur
1 August 1993 | Volume 119 Issue 3 | Pages 247-249
IN RESPONSE:
We are grateful that the article by Salmon and colleagues [1] about the predictive value of CMV viremia in patients with HIV infection was brought to our attention. Their data are similar to ours and support rather than refute our arguments. Their patients were considered to have CMV viremia or not based on one or more cultures done during the 3 months before and after the diagnosis of AIDS. Our study tested the first blood and urine cultures taken as part of routine screening of prospective patients seen for investigational protocols [2]. Initial and subsequent evaluations for end-organ disease were symptom-directed, except that persons with CD4 counts less than 100 cells/mm3 were usually seen by the ophthalmologist for dilated examinations. Follow-up was short for some patients, and it is likely that longer follow-up for patients with viremia would have led to the identification of more patients with end-organ disease. Although the presence of CMV viruria or viremia may minimally heighten clinical concern for this pathogen, our data and the data of others indicate that all patients with a CD4 lymphocyte count less than 100 cells/mm3 merit close clinical scrutiny for treatable complications, regardless of their CMV culture status [3-5]. As Salmon and colleagues noted, the mean time interval to the development of CMV end-organ disease after the onset of AIDS did not significantly differ between patients with and without viremia [1].
Reiter and colleagues suggest that patients with viremia or viruria might be considered for systemic therapy. In our study, only 35% of persons with viremia developed clinical disease within 6 months of having a culture taken, and, in Salmon and colleagues' study, 50% of the patients developed end-organ disease in 16.6 months [1, 2]. To administer systemic therapy with the available, relatively toxic, parenteral drugs (foscarnet or ganciclovir) would subject a majority of patients who may never develop clinically significant end-organ disease to these agents. When a convenient, nontoxic agent with anti-CMV properties becomes available, it will be important to determine whether or not early prophylaxis against CMV provides immunologic or clinical benefit.
1. Salmon D, Lacassin F, Harzic M, Leport C, Perronne C, Bricaire F, et al. Predictive value of cytomegalovirus viraemia for the occurrence of CMV organ involvement in AIDS. J Med Virol. 1990; 32: 160-3.
2. Zurlo JJ, O'Neill D, Polis MA, Manischewitz J, Yarchoan R, Baselar M, et al. Lack of clinical utility of cytomegalovirus blood and urine cultures in patients with HIV infection. Ann Intern Med. 1993; 118: 12-7.
3. Gallant JE, Moore RD, Richman DD, Keruly J, Chaisson RE, and the Zidovudine Epidemiology Study Group. Incidence and natural history of cytomegalovirus disease in patients with advanced human immunodeficiency virus disease treated with zidovudine. J Infect Dis. 1992; 166:1223-7.
4. Crowe SM, Carlin JB, Stewart KI, Lucas CR, Hoy JF. Predictive value of CD4 lymphocyte numbers for the development of opportunistic infections and malignancies in HIV-infected persons. J Acquir Immune Defic Syndr. 1991; 4:770-6.
5. Pertel P, Hirschtick R, Phair J, Chmiel J, Poggensee L, Murphy R. Risk of developing cytomegalovirus retinitis in persons infected with the human immunodeficiency virus. J Acquir Immune Defic Syndr. 1992; 5:1069-74.
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