Cytomegalovirus Polymerase Chain Reaction Test Research Articles

Results of Routine Antenatal Screening for Cytomegalovirus at a Tertiary Center.

Cytomegalovirus (CMV) is the most common viral infection. In this study, we discussed the results of pregnant women who underwent antenatal CMV screening in a tertiary center and the value of CMV antenatal screening. For this retrospective study, the data of pregnant patients with antenatal CMV screening test results between 2019 and 2022 were obtained from hospital records. CMV immunoglobulin M (IgM), CMV IgG, anti-IgG avidity test results, amniocentesis, CMV polymerase chain reaction (PCR), and the outcome of the babies were recorded. A total of 31,912 CMV IgM and 26,969 CMV IgG tests were performed. CMV IgG seropositivity was observed in 78.99% of pregnant women, and 0.09% of the pregnant women were confirmed to have a positive CMV IgM test result. Pregnant women with positive IgM accompanying low avidity were referred to perinatology clinics for detailed ultrasonography and amniocentesis. Only 3 of the 44 pregnant women who underwent amniocentesis were confirmed to have positive CMV PCR testing. CMV screening should be preserved for pregnant women with ultrasonographic findings at high risk of congenital CMV infection.

Real world effectiveness and feasibility of pharmacist‐led preemptive CMV treatment in high risk (CMV D+R−) liver transplant

AbstractBackgroundRecent data have demonstrated a lower incidence of cytomegalovirus (CMV) disease utilizing preemptive CMV treatment compared to universal prophylaxis in CMV seronegative liver transplant recipients who receive allografts from CMV seropositive donors (donor‐positive [D+]recipient‐negative [R−]). However, there are little data on the feasibility and outcomes after switching transplant center protocols from universal CMV prophylaxis to preemptive treatment.MethodsAll D+R− adult liver transplant recipients underwent pharmacist‐led weekly monitoring of World Health Organization standardized quantitative plasma CMV deoxyribonucleic acid (DNA) after transplant for 6 months. Valganciclovir was started when plasma CMV viral load (VL) reached 100 IU/mL. All patients who were at least 12 months post‐liver transplant were retrospectively reviewed for incidence of CMV DNAemia and CMV disease in this cohort study.ResultsAmong 30 CMV D+R− liver transplant recipients, 23 (77%) developed target CMV DNAemia (≥100 IU/mL) at a median of 26 (range: 10–37) days after transplant with a median peak CMV VL of 947 IU/mL. Valganciclovir was started promptly with a median lag time of 1 (range: 0–5) day. There were no differences in surgical or infectious complications and readmission rates between patients with and without CMV DNAemia. Two patients had possible CMV disease in the first 6 months. None developed CMV disease in 6–12 months posttransplant. Only two patients who developed CMV DNAemia had acute cellular rejection, and none had graft loss or death. Weekly CMV polymerase chain reaction (PCR) testing was late on only three occasions for all patients before reaching the target CMV VL (<4%). Among those who remained nonviremic, 85% of scheduled weekly CMV PCR testing was completed in the first 3 months.ConclusionPreemptive CMV treatment in high‐risk liver transplant recipients is feasible and safe. There was a low rate of CMV disease in the first 12 months post‐liver transplant with a pharmacist‐led protocol.

Clinical Value of Serial Quantitative Analysis of Cytomegalovirus DNA in Blood and Saliva Over the First 24Months of Life in Congenital Infection: The French Cymepedia Cohort.

To evaluate cytomegalovirus (CMV) viral load dynamics in blood and saliva during the first 2years of life in symptomatic and asymptomatic infected infants and to identify whether these kinetics could have practical clinical implications. The Cymepedia cohort prospectively included 256 congenitally infected neonates followed for 2years. Whole blood and saliva were collected at inclusion and months 4 and 12, and saliva at months 18 and 24. Real-time CMV polymerase chain reaction (PCR) was performed, results expressed as log10 IU/mL in blood and in copies per milliliter in saliva. Viral load in saliva progressively decreased from 7.5 log10 at birth to 3.3 log10 at month 24. CMV PCR in saliva was positive in 100% and 96% of infants at 6 and 12months, respectively. In the first month of life, neonatal saliva viral load of less than 5 log10 was related to a late CMV transplacental passage. Detection in blood was positive in 92% of neonates (147/159) in the first month of life. No viral load threshold values in blood or saliva could be associated with a high risk of sequelae. Neonatal blood viral load of less than 3 log10 IU/mL had a 100% negative predictive value for long-term sequelae. Viral loads in blood and saliva by CMV PCR testing in congenital infection fall over the first 24months. In this study of infants affected mainly after primary maternal infection during pregnancy, all salivary samples were positive in the first 6months of life and sequelae were not seen in infants with neonatal blood viral load of less than 3 log10 IU/mL.

Cost-effectiveness of a cytomegalovirus screening strategy in neonates born after 34 weeks small for gestational age

IntroductionInfection by cytomegalovirus (CMV) is one of the most common congenital infections, with a global prevalence of 0.3%–2.4%. In Spain, CMV screening is not performed during pregnancy, but rather in neonates with risk factors, and, in many hospitals, in those born small for gestational age (SGA). Screening is usually performed by measurement of the viral load in urine by polymerase chain reaction (PCR) and/or head ultrasound in search of compatible features.The aim of the study was to assess the yield of the CMV PCR test in urine and head ultrasound examination in asymptomatic neonates born SGA after 34 weeks’ gestation. The secondary objective was to assess the cost-effectiveness of this strategy. Design and methodsWe conducted an observational and retrospective study between January and December 2019 in a tertiary care hospital. It included neonates delivered after 34 weeks, SGA and without additional risk factors assessed with a CMV PCR test in urine and/or head ultrasound. ResultsThe sample included 259 patients. It was divided in 2 groups: group 1, patients with a head circumference, weight and length below the 10th percentile (53 patients; 20.5%), and group 2, patients in whom only the weight was below the 10th percentile (206 patients; 79.5%). The incidence of late preterm birth, twin pregnancy, neonatal admission and exposure to illicit drugs during gestation was higher in group 1. A total of 186 urine PCR tests and 223 head ultrasounds were performed overall, and both tests were performed more frequently in group 1 (P=.002). There was only 1 positive CMV PCR test result in the sample (0.54%), corresponding to a patient in group 2 with no abnormal sonographic findings who remained asymptomatic throughout the follow-up. Two head ultrasound examinations yielded abnormal findings, in both cases unrelated to congenital CMV infection. We performed a cost-effectiveness analysis and determined that the cumulative cost of head ultrasound examinations and urine CMV PCR tests in our sample amounted to Є17 000 for the detection of a single asymptomatic positive case. ConclusionIn our population, screening for congenital CMV infection in asymptomatic late preterm and term newborns whose only risk factor is SGA does not seem to be cost effective. It would be necessary to expand the sample to other populations.

Coste efectividad de la estrategia de cribado de citomegalovirus en recién nacidos mayores de 34 semanas de bajo peso para la edad gestacional

IntroductionInfection by cytomegalovirus (CMV) is one of the most common congenital infections, with a global prevalence of 0.3%-2.4%. In Spain, CMV screening is not performed during pregnancy, but rather in neonates with risk factors, and, in many hospitals, in those born small for gestational age (SGA). Screening is usually performed by measurement of the viral load in urine by polymerase chain reaction (PCR) and/or head ultrasound in search of compatible features.The aim of the study was to assess the yield of the CMV PCR test in urine and head ultrasound examination in asymptomatic neonates born SGA after 34 weeks’ gestation. The secondary objective was to assess the cost-effectiveness of this strategy. Design and methodsWe conducted an observational and retrospective study between January and December 2019 in a tertiary care hospital. It included neonates delivered after 34 weeks, SGA and without additional risk factors assessed with a CMV PCR test in urine and/or head ultrasound. ResultsThe sample included 259 patients. It was divided in two groups: group 1, patients with a head circumference, weight and length below the 10th percentile (53 patients; 20.5%), and group 2, patients in whom only the weight was below the 10th percentile (206 patients; 79.5%). The incidence of late preterm birth, twin pregnancy, neonatal admission and exposure to illicit drugs during gestation was higher in group 1. A total of 186 urine PCR tests and 223 head ultrasounds were performed overall, and both tests were performed more frequently in group 1 (P=.002). There was only one positive CMV PCR test result in the sample (0.54%), corresponding to a patient in group 2 with no abnormal sonographic findings who remained asymptomatic throughout the followup. Two head ultrasound examinations yielded abnormal findings, in both cases unrelated to congenital CMV infection. We performed a cost-effectiveness analysis and determined that the cumulative cost of head ultrasound examinations and urine CMV PCR tests in our sample amounted to €17000 for the detection of a single asymptomatic positive case. ConclusionIn our population, screening for congenital CMV infection in asymptomatic late preterm and term newborns whose only risk factor is SGA does not seem to be cost effective. It would be necessary to expand the sample to other populations.

Serum Cytomegalovirus Polymerase Chain Reaction Test Is a Valuable Negative Predictor of Infection in Acute Severe Ulcerative Colitis.

Diagnosis of cytomegalovirus (CMV) colitis in the setting of severe ulcerative colitis (UC) remains a clinical challenge. This study aimed to determine the utility of serum CMV polymerase chain reaction (PCR) as a non-invasive test for the diagnosis of CMV superinfection in patients hospitalized with UC. This retrospective study included consecutive admitted patients with UC who had serum testing for CMV completed as part of standard hospital procedure and CMV colitis diagnosed by expert pathologists. Two hundred and six patients with UC were included; 13 patients (6%) had histologically confirmed CMV colitis. Eleven of 13 patients with CMV colitis (84%) and 3 of 193 (1.5%) patients without CMV colitis had a positive serum PCR test (p < 0.0001). ROC analysis showed that a CMV PCR level of 259IU/mL had a sensitivity and specificity of 77% and 99%, respectively, for diagnosis of CMV colitis with an AUC of 0.9 (p < 0.0001). Serum CMV PCR level significantly correlated to the number of inclusion bodies on biopsy specimens with data available (n = 8) (r = 0.8, p = 0.02). CMV positivity did not predict the need for salvage therapy, admission or 1-year colectomy rates. Serum CMV PCR has an excellent negative predictive value and demonstrates a strong correlation with CMV positivity on histology. This work supports a rationale for serum CMV PCR testing on admission to assess the risk of CMV colitis in patients with severe UC.

S725 Utility of Serum Cytomegalovirus Polymerase Chain Reaction Test in the Setting of Acute Severe Ulcerative Colitis

S725 Utility of Serum Cytomegalovirus Polymerase Chain Reaction Test in the Setting of Acute Severe Ulcerative Colitis

Application of a New Paradigm for Cytomegalovirus Disease Prevention in Mayo Clinic’s First Face Transplant

The optimal approach to preventing cytomegalovirus (CMV) disease after face transplant is unknown. We report an individualized hybrid approach, initially using valganciclovir prophylaxis followed by surveillance and preemptive therapy guided by viral and immunologic markers. A 31-year-old man received a near-total face allotransplant for gunshot injury–related severe facial deformities. He was CMV seronegative, and the donor was CMV seropositive (D+/R− mismatch), and he received intravenous ganciclovir followed by oral valganciclovir prophylaxis. Monthly CD8+ T-cell immune competence assay revealed no CMV-specific CD8+ T-cell immunity development during valganciclovir prophylaxis. Because of severe leukopenia, valganciclovir was discontinued at 7 months after transplant when the patient had recovered and sustained normal global CD8+ T-cell function. Weekly CMV polymerase chain reaction testing detected asymptomatic CMV replication (plasma CMV, 549 IU/mL) 3 months later. Short-course preemptive valganciclovir treatment resulted in sustained virologic clearance. The patient had development of CMV-specific CD8+ T cells (12 cells/μL) together with CMV IgM and IgG. No rejection or infection relapse was detected 20 months after transplant. In conclusion, viral and immunologic monitoring allowed for an individualized approach to effective CMV disease prevention after face transplant. This case highlights the importance of understanding the interplay between the host immunity and the pathogen in determining the clinical course and outcome of CMV and other infectious disease syndromes.

Successful therapy for severe cytomegalovirus gastritis in a diabetic woman

Cytomegalovirus (CMV) gastritis is very rare in immunocompetent persons. CMV infection of the gastrointestinal tract is frequent and may be serious in immunocompromised patients.1 Symptoms of CMV gastritis are usually epigastralgia, fever, and bleeding. We report a diabetic patient with diffuse gastritis caused by CMV, which responded significantly to ganciclovir therapy. A 77-year-old woman with diabetes mellitus well under control presented with coffee-ground vomitus for two days on November 5, 2013. The patient did not receive prior blood transfusion and steroid use. Laboratory data included a white blood cell count of 16 300/μL; hemoglobin, 10.8 g/dL; platelet count, 219 000/μL; and creatinine, 1.24 mg/dL. Upper endoscopy showed reflux esophagitis and diffuse gastric ulcers (Figure 1A). Mucosal biopsy of the stomach showed chronic active gastritis with necrosis. Helicobacter pylori microorganisms and anticytokeratin antibodies (AE1/AE3) were not identified. Intravenous pantoprazole followed by oral lansoprazole therapy was given. However, severe episodes of gastric bleeding recurred. A computed tomography scan revealed severe gastric wall thickening without lymphadenopathy or tumor in the abdomen (Figure 1B). She was transferred to intensive care unit for aspiration pneumonia with septic shock. Intravenous pantoprazole was reused. Norepinephrine, antibiotic imipenem, and low-dose hydrocortisone (200 mg/day × 1 day, 100 mg/day × 6 days) were given for septic shock. On December 9, CMV–polymerase chain reaction (PCR) tests were performed for gastric juice and blood sample, results of which were positive. CMV antigenemia revealed two positive cells per 200 000 polymorphonuclear cells. Human immunodeficiency virus (HIV) antibody was found to be negative. Blood carcinoembryonic antigen was 4.0 ng/mL. Follow-up endoscopy still showed diffuse gastric ulcers with nodules (Figure 1C), but immunohistochemical staining for CMV on mucosal biopsy was positive. Ganciclovir was given intravenously, and thereby gastric bleeding improved. Ganciclovir was continued for three weeks until negative result on CMV–PCR testing for gastric juice on January 9, 2014. Subsequent oral valganciclovir was maintained for four weeks. On January 16, follow-up endoscopy showed improving gastric ulcers (Figure 1D) and negative CMV immunostaining. The patient was discharged uneventfully on February 12, 2014. CMV is a virus that infects both healthy and compromised hosts. In healthy hosts, CMV most often manifests as an infectious mononucleosis-like illness. In immunocompromised hosts, CMV often presents as pneumonitis, retinitis, hepatitis, or colitis.2 CMV gastritis is seen almost exclusively in HIV-infected and posttransplantation patients.3, 4 CMV gastritis in immunocompetent hosts is quite rare but is particularly challenging. Endoscopic features are quite variable and include macroscopically normal mucosa, diffuse erythema, nodules, pseudotumors, erosions, and ulcers. Definite diagnosis is based on endoscopic gastric biopsy, especially with specific CMV immunostaining.5 In the present case, we found positive result on CMV–PCR testing for gastric juice, which may be a useful screening tool for rapid diagnosis of CMV gastritis. We successfully adapted negative conversion CMV–PCR testing for gastric juice as an aide for therapeutic guide to shift intravenous ganciclovir to oral valganciclovir in subsequent therapy. Possibly, early detection and treatment for CMV gastritis could shorten the duration of bleeding symptoms and hospital stay. Although the diffuse gastric ulcers occurred before the hydrocortisone use, we could not exclude the possibility that hydrocortisone might aggravate the CMV disease. In conclusion, CMV gastritis manifesting as acute upper gastrointestinal bleeding may occur in immunocompetent hosts. Although not commonly seen in bleeding gastritis, CMV should be considered among patients with diffuse ulcerative gastritis and thus prolonged antiviral therapy is needed. CMV–PCR testing for gastric juice could be a diagnostic tool before biopsies are made available. The above study has been granted exemption from review by the Institutional Review Board of Chi-Mei Medical Center (application no. 10412-E02).

A Modified Intensive Strategy to Prevent Cytomegalovirus Disease in Seropositive Umbilical Cord Blood Transplantation Recipients

We previously demonstrated a lower rate of cytomegalovirus (CMV) reactivation and disease among seropositive umbilical cord blood transplantation (CBT) recipients receiving an intensive prophylaxis strategy consisting of ganciclovir on days −8 to −2 pretransplantation, high-dose valacyclovir post-transplantation, and twice-weekly serum CMV polymerase chain reaction testing. We hypothesized that a modified intensive strategy excluding pretransplantation ganciclovir would be similarly effective. We compared the risk of CMV reactivation, occurrence of CMV disease, and duration of anti-CMV therapy by day 100 post-CBT in patients receiving the modified intensive and intensive strategies. Forty patients received the modified intensive strategy, and 43 received the intensive strategy. There was no difference in the hazard for CMV reactivation (hazard ratio, 1.1; P = .77). No patients in the modified intensive cohort, but 2 patients in the intensive cohort, developed CMV disease (P = .53). There was no difference in the hazard for early (≤30 days post-CBT; P = .76) or high-level (>1000 IU/mL; P = .37) CMV reactivation. Patients in the modified intensive cohort had marginally higher CMV viral loads and percentage of days of CMV detection and treatment, although the contribution of pretransplantation ganciclovir to these differences is unclear. The overall percentage of treatment days was 32% in both cohorts after accounting for pretransplantation ganciclovir. In conclusion, exclusion of prophylactic ganciclovir before CBT did not impact the risk of CMV reactivation or disease, although CMV kinetics appeared to differ by prevention strategy. Best practices for CMV prevention will need further study as new prophylactic strategies become available.

Transfusion in CMV seronegative T-depleted allogeneic stem cell transplant recipients with CMV-unselected blood components results in zero CMV transmissions in the era of universal leukocyte reduction: a U.K. dual centre experience.

To establish rates of cytomegalovirus (CMV) transmission with use of CMV-unselected (CMV-U), leukocyte-reduced blood components transfused to CMV-seronegative patient/CMV-seronegative donor (CMV neg/neg) allogeneic stem cell transplantation (SCT) recipients including those receiving T-depleted grafts. CMV infection remains a major cause of morbidity following SCT. CMV-seronegative SCT recipients are particularly at risk of transfusion transmitted CMV (TT-CMV) and until recently they have received blood components from CMV-seronegative donors with significant resource implications. Although leukocyte reduction of blood components is reported to minimise risk of TT-CMV, its efficacy in high-risk situations, such as in T-depleted transplant recipients, is unknown. We retrospectively analysed the incidence of TT-CMV in CMV neg/neg allogeneic SCT recipients transfused with CMV-U, leukocyte-reduced blood components in two transplantation centres in the UK. Patients were monitored for CMV infection by weekly CMV polymerase chain reaction testing. Leukocyte reduction of blood components was in accordance with current UK standards. Among 76 patients, including 59 receiving in vivo T-depletion, no episodes of CMV infection were detected. Patients were transfused with 1442 CMV-unselected, leukocyte-reduced components, equating to 1862 donor exposures. Our findings confirm the safety of leukocyte reduction as a strategy in preventing TT-CMV in high-risk allogeneic SCT recipients.

Cytomegalovirus Localization in Atherosclerotic Plaques is Associated with Acute Coronary Syndromes: Report of 105 Patients

It has been shown that cytomegalovirus (CMV) is present in coronary atherosclerotic plaques, but the clinical relevance of this presence remains to be elucidated. In this study we sought to examine CMV infection in atherosclerosis patients defined by different methods and to identify the clinical significance of CMV replication in the atherosclerotic plaques. The study included 105 consecutive patients who were admitted to our department and underwent coronary artery bypass grafting (CABG) surgical interventions. Coronary atherosclerotic specimens as well as 53 specimens from the mamillary artery of these same patients were analyzed. Enzyme-linked immunosorbent assay (ELISA) and polymerase chain reaction (PCR) methods were used for evaluations. The CMV PCR test result was positive for 28 (26.7%) of patients with coronary artery atherosclerosis. After adjusting for other risk factors, coronary artery disease patients with a history of acute coronary syndrome were more likely to be positive for CMV PCR test (P=0.027; odds ratio: 4.2; 95% CI: 1.18-15.0). They were also more likely to have a positive family history for cardiovascular diseases (CVD). This study confirms previous evidence about the replication of CMV virus in the atherosclerotic plaques of coronary arteries and brings clinical significance to this observation by showing a higher prevalence of acute coronary syndromes in those patients with CMV-infected plaques. Our study also suggests a familial vulnerability to CMV replication in the coronary artery walls.

A Case of Cytomegalovirus-Induced Arthritis after Lymphocyte-Depleting Therapy for Kidney Allograft Rejection

Cytomegalovirus viremia and tissue-invasive disease are common after kidney transplantation. Chemoprophylaxis has made substantial improvement in this clinical problem. Here we report a 29-year-old woman who had kidney allograft rejection and received lymphocyte-depleting therapy. She presented with a new oligo-arthritis that led to 2 successive arthrocenteses. The etiology of the inflammation could not be determined initially. On the second arthrocentesis, a synovial fluid cytomegalovirus polymerase chain reaction test was positive. The patient responded to treatment with valganciclovir, had negative follow-up serum cytomegalovirus polymerase chain reaction tests, and experienced resolution of her joint inflammation. We review briefly the data for cytomegalovirus chemoprophylaxis, preemptive screening, and treatment recommendations.

Bronchoalveolar lavage in immunocompromised patients with haematological malignancy – value of new microbiological methods

To assess the usefulness of new culture-independent microbiological methods to analyse bronchoalveolar lavage (BAL) fluid from haematological patients with clinical pneumonia. Results of 135 BALs from 122 disease episodes in 99 patients treated between 1996 and 2002 were retrospectively analysed. Forty-three patients had undergone haematopoietic stem cell transplantation and 56 patients had been treated with conventional chemotherapy for haematological malignancy. In addition to conventional microbiological methods, polymerase chain reaction (PCR) tests for Pneumocystis carinii, cytomegalovirus (CMV), Legionella sp., mycobacterium, Mycoplasma pneumoniae, and Chlamydia pneumoniae and the Aspergillus antigen test were performed. Three (2.2%) quantitative and four (3.0%) special bacterial cultures gave an aetiological diagnosis. A respiratory virus was isolated in 10 episodes (8.2%). The diagnostic yield increased to 35.6% (48 of 135) by other methods. The P. carinii PCR test was positive in 21 of 24 patients with P. carinii pneumonia, being the only microbiological indication of P. carinii in four cases. The CMV PCR test was positive in 18 patients, but in 14 patients the clinical significance of the finding remained unproven. The Aspergillus antigen test was positive in seven of nine patients with aspergillosis, being the only microbiological indication of Aspergillus in three cases. The result of BAL indicated commencement of specific antimicrobial treatment in 27 episodes (22.1%). The contribution of new culture-independent methods to the total diagnostic yield was of note. Among these methods, the P. carinii PCR and Aspergillus antigen tests proved the most valuable, while the CMV PCR test was not clinically useful.

Incidence and risk factors for developing cytomegalovirus retinitis in HIV-infected patients receiving protease inhibitor therapy. Spanish CMV-AIDS Study Group.

To assess the incidence and risk factors for cytomegalovirus (CMV) retinitis in HIV-infected patients who initiated protease inhibitor-containing antiretroviral therapy. Prospective, multicentre study. A cohort of 172 HIV-infected patients with a CD4 cell count below 100x10(6) cells/l at the time of protease inhibitor introduction. Confirmed CMV retinitis and mortality, according to CD4 cell count, HIV load, and CMV viraemia. The cumulative incidence of CMV retinitis was 5% at 1 year and 6% at 2 years. Only a positive CMV polymerase chain reaction (PCR) test at therapy initiation was significantly associated with the development of disease (relative hazard, 4.41; 95% confidence interval, 2.12-8.93; P<0.00001). The 12-month Kaplan-Meier CMV retinitis event rate was 38% in patients who were CMV PCR-positive compared with 2% in those who were CMV PCR-negative (P<0.001). Mean CMV load was significantly higher in those individuals who went on to develop CMV retinitis (3700 versus 384 copies/ml, P = 0.002). Only 2% of patients remained CMV PCR-positive after 3 months of protease inhibitor therapy, and CMV viraemia was not associated with a worse therapy response or shorter survival. Transient CMV positivity without a higher risk of disease was observed in 7% of patients at the first month on therapy. Protease inhibitor-containing antiretroviral therapy significantly reduces the incidence of CMV viraemia and disease. Although a positive CMV PCR test identifies those patients on therapy at highest risk of CMV retinitis, it is not associated with an increased risk of death or a worse response to protease inhibitor therapy.

Cost-effectiveness of cytomegalovirus (CMV) disease prevention in patients with AIDS: oral ganciclovir and CMV polymerase chain reaction testing.

To perform a cost-effectiveness analysis of strategies to prevent cytomegalovirus (CMV) disease. Markov model and published data. Hypothetical HIV-infected patients with CD4 cell counts < or = 50 x 10(6)/l and positive CMV serologies. Oral ganciclovir daily versus plasma CMV DNA polymerase chain reaction (PCR) testing every 3 months with oral ganciclovir for patients with positive tests. The number of CMV disease cases prevented by the interventions, life expectancy, disease-free life expectancy, and the cost to extend life by 1 year. Oral ganciclovir preventive therapy reduces the lifetime number of CMV disease cases by 50 per 1000 cohort, extends life expectancy by 5 days and disease-free life expectancy by 18 days, and costs US$ 1,762,517 per year of life extended. Periodic PCR testing reduces the lifetime number of CMV disease cases by eight per 1000 cohort, extends life expectancy by 1 day and disease-free life expectancy by 3 days, and costs US$ 495,158 per year of life extended. The prevention strategies could be acceptably cost effective only under a combination of optimistic assumptions and reduced costs. Oral ganciclovir preventive therapy and periodic plasma testing for CMV PCR with oral ganciclovir for those with positive tests result in small benefits at great cost. They are not cost-effective prevention strategies for persons with advanced HIV infection and positive CMV serologies.