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Special Article |

Guidelines for the Treatment of Cytomegalovirus Diseases in Patients With AIDS in the Era of Potent Antiretroviral Therapy Recommendations of an International Panel

Richard J. Whitley, MD; Mark A. Jacobson, MD; Dorothy N. Friedberg, MD, PhD; Gary N. Holland, MD; Douglas A. Jabs, MD; Douglas T. Dieterich, MD; W. David Hardy, MD; Michael A. Polis, MD, MPH; Thomas A. Deutsch, MD; Judith Feinberg, MD; Stephen A. Spector, MD; Sharon Walmsley, MD, FRCPC; W. Lawrence Drew, MD, PhD; William G. Powderly, MD; Paul D. Griffiths, MD; Constance A. Benson, MD; Harold A. Kessler, MD ; for the International AIDS Society–USA
Arch Intern Med. 1998;158(9):957-969. doi:10.1001/archinte.158.9.957.
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Objective  To provide recommendations for the treatment of acquired immunodeficiency syndrome–related cytomegalovirus (CMV) end-organ diseases, including retinitis, colitis, pneumonitis, and neurologic diseases.

Participants  A 17-member panel of physicians with expertise in clinical and virological research and in-patient care in the field of CMV diseases.

Evidence  Available clinical and virological study results. Recommendations are rated according to the quality and strength of available evidence. Recommendations were limited to the treatment of CMV diseases; prophylaxis recommendations are not included.

Process  The panel was convened in February 1997 and met regularly through November 1997. Subgroups of the panel summarized and presented available information on specific topics to the full panel; recommendations and ratings were determined by group consensus.

Conclusions  Although the epidemiological features of CMV diseases are changing in the setting of potent, combination antiretroviral therapy, continued attention must be paid to CMV diseases in patients infected with the human immunodeficiency virus to prevent irreversible end-organ dysfunction. The initial and maintenance treatment of CMV retinitis must be individualized based on the characteristics of the lesions, including location and extent, specific patient factors, and characteristics of available therapies among others. Management of relapse or refractory retinitis must be likewise individualized. Ophthalmologic screening for patients at high risk for retinitis or who have a prior diagnosis of extraretinal disease is recommended. Recommendations for gastrointestinal, pulmonary, and neurologic manifestations are included.

Figures in this Article


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A, The anatomical zones of the retina. Zone 1 encompasses less than 10% of the total retina and includes the area surrounding the optic disc and fovea; lesions here are considered to be immediately threatening to sight. Zone 2 is the midperipheral retina; zone 3, the far peripheral retina. Zone 3 includes the area of attachment of the vitreous base, and necrotic holes that develop here have the highest risk of leading to retinal detachments. B, The posterior portion of the fundus, with the border separating zones 1 and 2 indicated. The photograph corresponds to the approximate area that can be examined with the handheld, monocular direct ophthalmoscope. C, A photographic montage of a fundus, showing a peripheral lesion in the anterior portion of zone 2 and in zone 3. This lesion could only be visualized with an indirect ophthalmoscope. Panels A and B reprinted from Holland et al15 with permission, copyright 1989. Panel C was reprinted courtesy of the Studies of the Ocular Complications of AIDS Research Group.

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