CMV-related thrombocytopenia treated with foscarnet: A case series and review of the literature

Abstract

Severe thrombocytopenia as a complication of CMV infection in immune competent adults is uncommon with only a few cases reported in the literature. The mechanism of CMV-related thrombocytopenia is unclear, resulting in a wide range of treatments used. The use of the antiviral agent ganciclovir was reported in five cases, with variable results. The use of foscarnet, which does not share the myelosuppressive effects of ganciclovir, in adult immune competent patients has not been reported. We review the literature and report two cases of CMV-related thrombocytopenia that were treated with foscarnet. In both cases a recent acute infection with CMV was well established and viral eradication following treatment with foscarnet was demonstrated. In one patient thrombocytopenia resolved following treatment with foscarnet and viral eradication. In the other patient, thrombocytopenia resolved following splenectomy, which was performed after viral eradication. Due to the therapeutic consequences of this diagnosis, it may be worthwhile to perform CMV screening in selected patients with thrombocytopenia. In case CMV viremia is demonstrated, viral eradication seems to have a positive influence on the resolution of thrombocytopenia. Foscarnet is a reasonable first line anti CMV agent in this setting.

A rare case of autoimmune pancytopenia (AIP) preceded by refractory anemia: possible involvement of cytomegalovirus (CMV) infection in pathogenesis

“…The use of foscarnet, which does not share the myelosuppressive effects of ganciclovir and valganciclovir, seems to be a reasonable first line anti-CMV agent in cases of cytopenia [23]. Splenectomy [21,23,24] and intravenous immunoglobulin [19,22,24,], useful in patients affected by idiopathic thrombocytopenic purpura, are relatively ineffective or refractory for CMV-induced thrombocytopenia. However, it is known that splenectomy regain their efficacy once the primary CMV infection is controlled with anti-CMV agents [23,24].…”

“…Some physicians believe that treatment with steroids should be avoided in patients with CMV-induced thrombocytopenia because immunosuppressive treatment may cause the exacerbation of primary CMV infection and trigger further decrease in platelet count [24]. If CMV-viremia is demonstrated, viral eradication seems to have a positive influence on the resolution of thrombocytopenia [23]. Treatments with ganciclovir or valgancicloviris is currently recommended as first line treatment for immunocompromised adults with severe CMV disease, and few studies have evaluated the use of these anti-CMV drugs for the treatment in immunocompetent adults [38].…”

“…Treatments with ganciclovir or valgancicloviris is currently recommended as first line treatment for immunocompromised adults with severe CMV disease, and few studies have evaluated the use of these anti-CMV drugs for the treatment in immunocompetent adults [38]. The use of foscarnet, which does not share the myelosuppressive effects of ganciclovir and valganciclovir, seems to be a reasonable first line anti-CMV agent in cases of cytopenia [23]. Splenectomy [21,23,24] and intravenous immunoglobulin [19,22,24,], useful in patients affected by idiopathic thrombocytopenic purpura, are relatively ineffective or refractory for CMV-induced thrombocytopenia.…”

“…Splenectomy [21,23,24] and intravenous immunoglobulin [19,22,24,], useful in patients affected by idiopathic thrombocytopenic purpura, are relatively ineffective or refractory for CMV-induced thrombocytopenia. However, it is known that splenectomy regain their efficacy once the primary CMV infection is controlled with anti-CMV agents [23,24]. In the present case, anti-viral agents were not used because of remarkable effects of steroid therapy, and because CMV infection/reactivation was not presupposed and retrospectively confirmed after the initiation of steroid therapy.…”

“…Human CMV is a β human herpesvirus and can cause lifethreatening infections in immunocompromised patients. It is known that CMV infection can cause thrombocytopenia in immunocompetent adults as well as children [17][18][19][20][21][22][23][24][25]. In addition, CMV infection is known to trigger an autoimmune process against platelets even though the infection itself is transient and seemingly neither atypical nor severe in nature [19].…”