Guidelines of care for dermatologic conditions in patients infected with HIV

Abstract

I.IntroductionThe American Academy of Dermatology's Guidelines/Outcomes Committee is developing guidelines of care for our profession. The development of guidelines will promote the continued delivery of quality care and assist those outside our profession in understanding the complexities and scope of care provided by dermatologists. For the benefit of members of the American Academy of Dermatology who practice outside the jurisdiction of the United States, the listed treatments may include agents that are not currently approved by the U.S. Food and Drug Administration.II.DefinitionHIV is a retrovirus that is the cause of AIDS. During infection with HIV, CD4+ T lymphocytes, as well as other cells of the immune system, are infected and depleted, leaving the patient progressively immunocompromised. As the CD4+ T-lymphocyte count decreases, patients are at increased risk for a wide variety of infections, inflammatory conditions, and malignancies.The Centers for Disease Control and Prevention (CDC) expanded the surveillance case definition for the diagnosis of AIDS in 1993 to include all HIV-infected patients with fewer than 200 CD4+ T lymphocytes/μl or with CD4+ T lymphocytes comprising less than 14% of the total lymphocyte population. The expanded definition includes pulmonary tuberculosis, recurrent pneumonia, invasive cervical carcinoma, as well as the original 23 conditions published in 1987. Among the original conditions are several which involve the skin and mucosa, including Kaposi's sarcoma, esophageal candidiasis, and recurrent herpes simplex infection.III.Rationale A.ScopeMore than 80,000 patients with AIDS were reported to the CDC in 1994, with an estimated 1 million people in the United States reported to be infected with HIV. By the end of the decade, the World Health Organization has estimated that between 30 million and 40 million people around the world will be infected with this virus. Patients acquire HIV infection through three routes: (1) sexual contact, (2) contact with blood or body fluids, and (3) vertical transmission from an infected mother to a fetus. A growing number of patients infected with HIV are infants and children.B.IssueDermatologic conditions are common in patients with HIV infection and may be the sentinel event that brings the patient to the physician. Diagnosis and treatment of dermatologic conditions in patients with HIV infection will decrease morbidity and relieve suffering, prevent the spread of infections, and identify early HIV disease. Early diagnosis of HIV infection is important in patient management, including patient education, initiation of antiretroviral therapy, and prophylaxis of opportunistic infections.Patients with HIV infection should be evaluated with a complete medical, sexual, and drug use history, followed by a physical examination. The definitive diagnosis and treatment of dermatologic disease often requires the use of invasive procedures. Universal precautions must be employed in the performance of any procedure in which there is a risk of exposure to blood or body fluids. (See American Academy of Dermatology, “Dermatology Practice Administration: Bloodborne Pathogens.”) (Appendix)The care of patients with HIV disease must not be compromised because of their HIV status, and these patients should be offered treatment comparable in efficacy to that offered to HIV-negative patients. In patients infected with HIV therapeutic responses may be blunted as a consequence of their underlying immune function, absorption of orally administered medications may be impaired, and the use of immunosuppressive medications may worsen the patient's immune status.The specific clinical manifestations of each of the dermatologic conditions covered in this guideline, as well as appropriate diagnostic tests and recommended treatments, are discussed in sections VI-VIII. Because some dermatologic diseases in patients with HIV also have a systemic component, consultation and management with other specialists may be appropriate.IV.Diagnostic criteria A.Clinical 1.History may include the following: a)General medical history as indicatedb)History of present illnessc)Risk factors for HIV including sexual practices, exposure to blood or blood products, intravenous (IV) drug used)Current and past medical problemse)Previous surgeryf)Medicationsg)Allergiesh)Review of systems with particular attention to 1)Weight loss2)Malaise3)Recurrent infections4)Fever or night sweats5)Purified protein derivative (PPD) status6)Immunizationsi)Social history including drug, tobacco, and alcohol use, pets, travel history2.Physical examination may include the following: a)Examination of affected areab)Examination of all cutaneous and mucosal surfaces including oral, conjunctival, vulvar, and rectalc)Complete physical examination with particular attention to 1)Vital signs including weight2)Lymph nodes3)Abdomen4)Neurologic and psychiatric evaluationB.Diagnostic testsPatients suspected of HIV infection should be counseled and consent obtained for HIV testing. The diagnosis of HIV infection is documented by reactivity to a screening test, usually for the presence of antibodies to HIV proteins, followed by confirmatory testing. Diagnostic tests, specifically CD4 counts and more recently viral assays, have also been used to determine the patient's clinical status. The viral load assays most commonly used are the branched DNA (bDNA) and polymerase chain reaction (PCR), which detect HIV RNA in plasma. These assays, in conjunction with the patient's clinical presentation, including CD4 counts, may be useful in guiding treatment decisions, including initiation or alteration of antiretroviral therapy.In the United States, the predominant cause of AIDS is HIV-1, although a few patients have been reported with HIV-2. At the current time, HIV testing focuses on identifying serologic reactivity to HIV-1, and patients with HIV-2 may not be detected using these assays. 1.Laboratory tests for HIV infection a)Antibody tests 1)Screening tests (a)Enzyme-linked immunosorbent assays (ELISA)(b)Second-generation ELISAs using recombinant and synthetic peptides2)Confirmatory testsWestern blotb)Direct detection tests 1)Antigen assays (a)p24 antigen capture ELISA(b)Acid-dissociated p24 ELISA2)Culture/coculture3)DNA/RNA detection (a)PCR(b)bDNA assay(c)In situ hybridization(d)Other hybridization (1)Dot blot filter(2)Southern blot(3)Northern blotc)Other assays 1)Neopterin2)β2-Microglobulin3)Urine IgG ELISA2.Other laboratory tests a)Complete blood count (CBC) with plateletsb)Urinalysisc)Serum electrolytes and glucose levels, renal and liver function testsd)Syphilis serologye)CD4 lymphocyte countsRepeat every 6 months while count is more than 600 cells/μl and every 3 months while count is less than 600 cells/μlf)PPD and anergy panel unless known history of tuberculosis or BCG immunization In persons infected with nontuberculous mycobacteria or those vaccinated with BCG, the specificity of the PPD test will be low. The usefulness of anergy testing is controversial. Consultation with an infectious disease specialist may be helpful.3.Chest roentgenography4.OtherV.Patient education and counselingPatients should receive appropriate posttest counseling in person, if possible. In counseling patients with HIV, the Agency for Health Care Policy and Research (AHCPR) recommends that providers discuss the natural history of HIV infection, the potential effects of HIV on physical and mental health, the role of health maintenance, and the availability of treatment. Patients should be counseled on safe sex practices and risks of needle sharing to prevent the spread of HIV infection. Dermatologists may seek the assistance of an individual with HIV counseling experience in discussing these issues with patients.VI.Infections/infestationsBacterial, mycobacterial, viral, fungal, and protozoal infections and infestations are common in patients with HIV. Many of the original patients with AIDS were recognized on the basis of cutaneous and mucosal infections that included oral candidiasis, chronic herpesvirus infection, and molluscum contagiosum. The occurrence of specific infectious diseases often correlates with the immune status of the patient.History and physical examination can be very helpful in defining the possible culprit of an infectious process in an HIV-infected individual. Some infections and infestations present with the same clinical features as seen in HIV-negative patients or are more florid. However, many cutaneous findings of infectious processes are atypical or nonspecific. Furthermore, some infections mimic other conditions (cryptococcosis and molluscum), and multiple infections may coexist in one patient. Thus it is important to obtain tissue for both histologic examination and culture when infection is suspected or when the diagnosis is in question. Gram's stain, Tzanck preparation, potassium hydroxide (KOH) preparation, and touch prep of the tissue (e.g., for Gram's stain, KOH preparation) can yield preliminary information about possible infectious causes and guide early therapy. Specific clinical manifestations and guidelines of care for each condition are listed below. A.Bacterial infections 1.Treponema pallidum (syphilis) a)DefinitionSyphilis is a sexually transmitted disease (STD) caused by infection with the spirochete T. pallidum.b)Rationale 1)ScopeSyphilis and HIV infection are both sexually acquired infections and therefore often occur concurrently. Patients with one STD have an increased incidence of other STDs. In addition, the presence of genital ulcers appears to increase the risk of transmission of HIV and therefore is a risk factor for the spread of AIDS.2)IssueWhen syphilis occurs in an HIV-infected individual, the clinical course, laboratory diagnosis, and response to therapy may be altered.c)Diagnostic criteria 1)Clinical characteristicsThe clinical manifestations of syphilis in patients with HIV infection are usually similar to syphilis in HIV-negative patients. However, florid or unusual manifestations of disease have been described in several case reports, particularly in patients with advanced HIV infection.2)Diagnostic testsThe AHCPR recommends that all HIV-infected adults and adolescents be examined for syphilis at the time of initial diagnosis of HIV by medical history, physical examination, and serologic testing. Initial serologic examination should be performed by means of a nontreponemal test (i.e., rapid plasma reagin [RPR] or Venereal Disease Research Laboratory [VDRL]). For those patients who are positive for syphilis by nontreponemal testing, treponemal specific testing is then performed (e.g., fluorescent treponemal antibody absorption [FTA-ABS] or microhemagglutination assay for T. pallidum [MHA-TP]). HIV-infected patients with syphilis may rarely test negative for infection, including patients with early primary disease, or those with high titer antibody levels (prozone effect). In patients with suspected syphilis who test negative, serum should be diluted and retested and alternate testing considered. Alternate testing in patients with early syphilis includes a dark-field examination and direct fluorescent antibody staining for T. pallidum (DFA-TP) from a scraping of suspected lesions or skin biopsy.d)Recommendations 1)TreatmentThe AHCPR recommends treating syphilis, without evidence of central nervous system (CNS) involvement, with three intramuscular doses of 2.4 million U each of benzathine penicillin weekly. Note that this treatment regimen differs from the CDC recommendation of a single dose of 2.4 million U of benzathine penicillin for HIV-infected patients with early syphilis. Patients with CNS involvement, as determined by abnormal cerebrospinal fluid (CSF) findings including increased protein, presence of cells, or a positive VDRL on CSF, should be treated with a regimen effective against neurosyphilis (2 million to 4 million U aqueous penicillin IV every 4 hours for 10 to 14 days). The AHCPR panel further recommends that patients who have not undergone a lumbar puncture (LP) receive treatment for presumed neurosyphilis. Controversy remains about the necessity of LP and/or treatment for presumed neurosyphilis in HIV-infected patients with early syphilis and no clinical signs or symptoms of CNS involvement. In patients who are penicillin sensitive and coinfected with HIV and syphilis, both the AHCPR and the CDC recommend consultation with a specialist for desensitization and penicillin treatment because there are no proven alternative therapies.2)Evolving therapiesAlternate treatment protocols, including single oral dosing with azithromycin and combination therapy for patients with CNS involvement (benzathine penicillin plus amoxicillin), are being investigated. Vaccines using recombinant treponemal proteins as immunogens are also being developed and may be useful for patients with chronic reinfection.3)Patient education and counselingThe development of syphilis in an HIV-infected patient should alert health care providers of the need for counseling regarding safe sex practices.4)MiscellaneousFollow-up with serologic testing is critical in following patients with HIV and syphilis to be sure that the patient has had an adequate response to therapy. The AHCPR currently recommends follow-up nontreponemal serologies at posttreatment intervals of 1, 2, 3, 6, 9, and 12 months, consistently using the same test. If the titer fails to decrease within 6 months or rises significantly, the patient should have an LP to evaluate for neurosyphilis. If the CSF is normal, re-treatment or continued close follow-up is indicated, depending on the stage of disease and the likelihood of patient compliance.Adults and adolescents with HIV should be monitored yearly with a nontreponemal test for syphilis. Patients should also be screened for syphilis following the diagnosis of any other STD.2.Staphylococcus aureus a)Scope/clinical characteristicsSkin infections with S. aureus are extremely common in HIV-infected individuals, especially children. Up to 50% of patients are S. aureus carriers. Infections may be superficial (impetigo and folliculitis) or deep (ecthyma, abscesses, cellulitis, botry-omycosis) and may be complicated by septicemia.b)RecommendationsTreatment of cutaneous staphylococcal infections is directed by the specific clinical manifestations. Recurrences are common. 1)Superficial infection (a)Penicillinase-resistant penicillin or first-generation cephalosporin until lesions resolve(b)Mupirocin for single lesions and for children(c)Clindamycin and ciprofloxacin (if streptococci have been excluded) are also good alternatives if necessary.(d)Antibacterial soaps and antihistamines may be used as adjunctive therapies.2)RecurrencesAdd rifampin, 600 mg/day for 5 to 7 days, or mupirocin (or both) in nares.3)Chronic conditionsConsider long-term antibiotics with adequate Staphylococcus coverage such as minocycline 100 mg daily in a single dose.4)Deep infectionProlonged and repeated courses with antibiotics effective against Staphylococcus are often necessary. Severe infections may require intravenous antibiotics initially followed by an oral agent. Surgical resection and drainage may be indicated.3.Pseudomonas aeruginosa a)Scope/clinical characteristicsInfection with P. aeruginosa usually occurs in HIV-infected patients with neutropenia.Clinical manifestations include 1)Folliculitis2)Deep infection (e.g., ecthyma gangrenosum, abscesses)b)Recommendations 1)FolliculitisOral antibiotic regimen with ciprofloxacin is usually adequate.2)Deep infections (a)MedicalCellulitis, ecthyma, or abscesses require intravenous penicillins with Pseudomonas coverage and/or an aminoglycoside, even though these may occur in a setting without bacteremia. Penicillins with Pseudomonas monas coverage include the following: (1)Carbenicillin(2)Ticarcillin(3)Piperacillin(4)Mezlocillin(5)Azlocillin(b)SurgicalSurgical excision of lesions may sometimes be necessary.(c)OtherThe source of pseudomonad septicemia is often a central venous line, which requires immediate removal.4.Mycobacterium spp. a)Mycobacterium avium complex (MAC) 1)Scope/clinical characteristicsInfection with MAC is a dominant feature of the AIDS epidemic. Cutaneous lesions related to disseminated disease include nodules, ulcerations, erythematous lesions, pustules, abscesses, folliculitis, panniculitis, and soft-tissue swelling. Cutaneous evidence of MAC has been reported overlying involved lymph nodes with no evidence of disseminated disease. Oral lesions have also been described as ulcers with necrotic centers.2)RecommendationsStudies have not identified an optimal regimen or confirmed that any regimen produces sustained clinical benefit for patients with disseminated MAC. The U.S. Public Health Service Task Force on Prophylaxis and Therapy for Mycobacterium Avium Complex recommends: (a)Treatment regimens should include at least two agents.(b)Every regimen should contain azithromycin or clarithromycin with ethambutol as a second drug. One or more of the following may be added as second, third, or fourth agents: (1)Clofazimine(2)Rifabutin(3)Rifampin(4)Ciprofloxacin(5)Amikacin (in some situations)(c)Therapy should continue for the life time of the patient.(b)Mycobacterium tuberculosis (TB) 1)Scope/clinical characteristicsAt early stages of HIV infection, the presentation of TB is similar to that seen in HIV-negative patients with more than 75% of patients showing exclusively pulmonary disease. At later stages, extrapulmonary disease predominates. The most common presentations of HIV-related extrapulmonary TB are lymphadenitis, miliary disease, and bone marrow involvement. Cutaneous manifestations of TB in this population have been reported in various forms including scrofuloderma, papules, vesicles, necrotic ulcerations, and subcutaneous nodules and pustules. Chronic recurrent tuberculous rectal abscesses have also been reported.2)RecommendationsHIV-infected patients with TB respond adequately to the antituberculosis regimens established by the CDC/American Thoracic Society. The optimal duration of therapy for HIV-positive patients with TB has not been established; the current minimally acceptable duration is 6 months, but the CDC recommends treatment for a total of 9 months and at least 6 months beyond culture conversion. All M. tuberculosis isolates that are initially obtained should be sent for drug susceptibility testing. Initial therapy for TB includes the following: (a)Isoniazid (adult daily oral dose of 5 mg/kg; maximum dose 300 mg)(b)Rifampin (adult daily oral dose of 10 mg/kg; maximum dose 600 mg)(c)Pyrazinamide (adult daily oral dose of 15 to 30 mg/kg; maximum dose 2 gm)(d)If the prevalence of isoniazid resistance in the community exceeds 4%, add ethambutol (adult daily oral dose of 5 to 25 mg/kg; maximum dose 2.5 gm) or streptomycin (adult daily oral dose of 15 mg/kg; maximum dose 1 gm).(e)If drug-resistant TB is isolated, the disease should be managed with at least three drugs to which the organism is susceptible. This regimen should be continued at least until bacteriologic response is documented, and it should be extended for at least 12 months with two or more of the effective drugs.c)Atypical Mycobacterium 1)Scope/clinical characteristicsMycobacterium infections in HIV-infected individuals can also be due to many atypical mycobacteria other than MAC. Numerous case reports with atypical mycobacteria have been described. Cutaneous lesions in disseminated M. haemophilium infection include scattered pustules from 0.3 to 1.0 cm in diameter, painful erythematous nodules, ulcerations, and fluctuant subcutaneous abscesses. Disseminated M. bovis cutaneous lesions have been described as a painful presternal erythematous mass and nonfollicular pustules on upper extremities and trunk. Numerous subcutaneous nodules with areas of necrosis, ulceration, and abscess formation were reported in disseminated M. fortuitum infection. Disseminated disease with M. kansasii, M. gordonae, and M. xenopi have been reported in patients with AIDS, but no specific skin lesions were described. Sporotrichotic lesions consisting of dermal nodules, verrucous nodules, ulcerated nodules and serum-filled bullae were reported in M. marinum infection of an HIV-positive patient.2)RecommendationsNo consensus regimens have been established for treatment of most species. Combination therapy is required in almost all cases of atypical Mycobacterium infection. Resistance to many drugs is common and susceptibility testing should be carried out whenever possible. Relapses and incomplete clearing are common, and disseminated disease carries a poor prognosis. Prolonged treatment or suppressive therapy may be necessary to ensure that the organism is eradicated.5.Bartonella spp. (bacillary angiomatosis) a)Scope/clinical characteristicsMost cases of bacillary angiomatosis (BA) have been described in patients with a CD4+ lymphocyte count of less than 200 cells/μl. A strong association with a cat scratch or bite has been found. The organisms that cause BA are members of the genus Bartonella (B. quintana and B. henselae). Cutaneous lesions may be solitary or multiple, varying from red to purple pinpoint papules to nodules and tumors. Individual lesions may resemble pyogenic granulomas or small hemangiomas. Subcutaneous nodules and indurated hyperpigmented plaques have also been described. Lesions can occur on the mucosal surfaces. The spectrum of Bartonella infection in patients with concomitant HIV infection includes angiomatous lesions involving liver (peliosis hepatis), lung, spleen, bone, and brain; bacteremia; and endocarditis.b)Recommendations 1)Oral erythromycin 500 mg four times a day If the patient has severe disease or is unable to tolerate oral medication, intravenous erythromycin should be given.2)Alternative antibiotics giving an excellent response include the following: (a)Doxycycline 100 mg twice daily(b)Minocycline 100 mg twice daily(c)Tetracycline 500 mg four times a day3)The optimal duration of treatment is unknown, but patients with cutaneous BA should receive appropriate antibiotic therapy for 8 to 12 weeks. Patients with more severe disease (osseous, hepatic/splenic BA) should receive a minimum of 3 to 4 months of antibiotic therapy.4)Relapse is usually associated with shorter courses of initial antibiotic therapy. If it occurs, patients should be re-treated for an additional 16 weeks or, possibly, indefinitely.B.Viral infections 1.Herpes simplex virus (HSV) a)Scope/clinical characteristicsClinical HSV disease in HIV-positive persons usually represents the reactivation of latent virus. HSV infections typically present as small, grouped vesicles on an erythematous base, which sequentially become pustules, erosions, and may progress to frank ulcers. Atypical manifestations of HSV in immunocompromised patients include deep ulcers, verrucous erosions, or mixed infections with more than one organism. The usual manifestations of HSV infection are orolabial, genital, and anorectal mucocutaneous disease, esophagitis, and, less commonly, encephalitis. As the degree of immunosuppression increases, so does the overall frequency and severity of mucocutaneous HSV disease.b)Recommendations1)Primary or recurrent episodes (a)Oral acyclovir 200 mg five times daily for mild to moderate mucocutaneous diseaseDoses of acyclovir 400 mg three to five times daily have been found to be clinically necessary for treatment in some patients.(b)Intravenous acyclovir 5 mg/kg every 8 hours should be used in settings in which absorption of oral drug is questionable or severe mucocutaneous disease is present.(c)Treatment of mucocutaneous disease should be continued until all lesions have healed.(d)If there is evidence of HSV encephalitis or viscerally disseminated HSV disease, intravenous acyclovir should be used at 10 mg/kg every 8 hours.(e)Oral famciclovir, 125 mg twice daily for 5 days, is approved for the treatment of HSV in immunocompetent patients, but has not been tested in immunocompromised patients including patients with HIV.(f)Valacyclovir is indicated for initial (1 gm twice daily for 10 days) and recurrent (500 mg twice daily for 5 days) HSV. This dosage schedule is applied to immunocompetent patients. Thrombotic thrombocytopenic purpura and hemolytic uremia syndrome, in some cases resulting in death, has occurred in patients with advanced HIV disease at doses of 8 gm/day.2)Suppression (a)Continuous suppressive therapy with oral acyclovir should be considered for patients who have frequent relapses (more than six per year), when lesions are severe and heal slowly, or when HSV is associated with other conditions such as erythema multiforme.(b)The initial dose is 400 mg twice daily, but some patients may require higher or more frequent doses to prevent recurrences.3)Acyclovir resistance (a)Most acyclovir-resistant HSV isolates are thymidine kinase–deficient.(b)Continuous infusion of acyclovir (1.5 to 2.0 mg/kg per hour) has been shown to be capable of resolving disease caused by acyclovir-resistant HSV.(c)Intravenous foscarnet (40 to 60 mg/kg every 8 hours) is effective in acyclovir-resistant HSV. Its use may allow recolonization (reappearance) by thymidine kinase–positive (acyclovir-susceptible) viruses.2.Varicella-zoster virus (VZV) a)Scope/clinical characteristicsAmong HIV-infected children and adults, the manifestations of VZV infections include primary varicella (with or without complications of pneumonia, cerebellar ataxia), an increased incidence of herpes zoster (localized or disseminated), and chronic varicella. Most adults infected with HIV have also been previously infected with VZV and thus are not susceptible to primary infection. Herpes zoster is one of the earliest opportunistic infections to arise during the course of HIV infection, and adults with HIV infection are more likely to develop herpes zoster infection than are HIV-negative persons. Chronic verrucous lesions in HIV-positive patients are usually caused by VZV and the virus is often resistant to therapy with acyclovir.b)Recommendations 1)Primary varicellaIntravenous acyclovir 10 mg/kg every 8 hours for 7 to 10 days2)Herpes zoster (a)Oral acyclovir 800 mg five times per day until lesions are healed has been shown to be effective for herpes zoster in immunocompetent adults. It can be employed for immunocompromised patients, but careful monitoring for the progression of herpes zoster is essential if this approach is selected.(b)Intravenous acyclovir 10 mg/kg every 8 hours for at least 7 days or until all lesions are healed has advantages over oral acyclovir because of the poor bioavailability (approximately 15% to 30%) of the oral dosage form.(c)Intravenous acyclovir 10 mg/kg every 8 hours for 10 days is indicated in HIV-positive patients for recurrent, severe, or disseminated herpes zoster.(d)Oral famciclovir 500 mg three times a day for 7 days has been shown to be effective in immunocompetent adults. No studies have addressed the use of this agent in HIV-positive individuals.(e)Valacyclovir 1 gm three times a day for 7 days has been shown to be effective in immunocompetent adults. See HSV recommendations for warnings on the use of valacyclovir in patients infected with HIV.3)Acyclovir resistance (a)Acyclovir-resistant VZV infection usually occurs in persons who are severely immunocompromised and receiving prolonged oral acyclovir therapy. Patients often have dermatomal or disseminated hyperkeratotic verrucous papules and plaques.(b)Cross-resistance between acyclovir and famciclovir and valacyclovir can be anticipated because of similar mechanisms of action.(c)Foscarnet 40 mg/kg every 8 hours for 10 days led to resolution of infection in four of five patients with thymidine kinase-deficient strains of VZV, but studies are needed to evaluate optimal dosage and duration of foscarnet therapy.3.Cytomegalovirus (CMV) a)Scope/clinical characteristicsCutaneous CMV infection in patients with HIV infections, especially AIDS, often portends a poor prognosis. Usually there is a nonhealing perianal ulceration that does not improve after acyclovir treatment. Papulovesicular eruptions, purpura, nodules, ulcerations, and verrucous lesions have also been reported. Often CMV infection of the skin occurs concurrently with another agent including HSV or mycobacteria. The spectrum of CMV disease includes disseminated disease, retinitis, inflammation of the gastrointestinal tract, central and peripheral nervous system disease, and interstitial pneumonia.b)Recommendations 1)InductionIntravenous ganciclovir 7.5 to 10 mg/kg per day in two or three equally divided doses for 14 days, or longer if there is a slow clinical response2)MaintenanceGanciclovir 5 to 6 mg/kg once daily, 5 to 7 days per week, for an indefinite period (reinduction doses may be need ed if relapse occurs)3)Oral ganciclovir has been found to be effective for maintenance therapy for CMV retinitis.4)Foscarnet is indicated for treatment of CMV retinitis in patients with AIDS, but experience with foscarnet for the treatment of other CMV diseases has be