Cytomegalovirus (CMVI) infection most often occurs in patients with compromised immunological status, for example in HIV-infected patients or during immunosuppressive therapy in patients undergoing organ transplantation. Damage to the central nervous system is the rarest form of CMVI, but with the most poor prognosis. In case of CMV encephalitis or myelitis, specific treatment must be instituted as soon as possible. There is currently no internationally accepted therapeutic approach; international guidelines recommend ganciclovir and foscarnet as the drugs of choice. They have similar efficacy and both penetrate the central nervous system well, however, the data currently available from controlled clinical trials are insufficient to draw firm conclusions about the effectiveness of such therapy.

The risk group for developing cytomegalovirus infection includes HIV-infected patients who have undergone organ, bone marrow, or peripheral blood cell transplantation. In these immunosuppressed patients, latent CMVI may occur, but most often the clinical picture develops during the primary infection. In this case, a variety of organs can be affected, and an infection of the central nervous system takes the last place in the frequency of appearance.

The forms of manifestation of cytomegalovirus infection with damage to the central nervous system may be different. It can manifest as encephalitis, meningoencephalitis, ventriculoencephalitis and myeloradiculitis. The prognosis depends on the clinical manifestations, therefore with myelitis it is more favorable than in case of encephalitis.

The study of the efficacy and safety of antivirals for the treatment of cytomegalovirus infection has so far only been carried out in clinical trials in patients with retinitis and colitis CMV, because the number of patients diagnosed with CMV infection of the central nervous system, established at an early stage of the disease or by intravital route, is low.

The antivirals being studied for the specific treatment of cytomegalovirus infection (ganciclovir, foscarnet and cidofovir) have an antistatic effect and therefore do not cause the elimination of the virus, the replication of which can be restored after the end of treatment.

Ganciclovir is known to be effective in patients with HIV-associated CMV retinitis and colitis. In addition, the drug prevents the manifestation of infection in patients after transplantation. At the same time, some strains of CMV show resistance to ganciclovir, which can also occur in the absence of previous treatment with this drug. Foscarnet has similar efficacy in CMV retinitis and CMV antigenemia after allogenic replacement of peripheral blood. Both drugs penetrate well through the BBB and are found in cerebrospinal fluid at concentrations of 27 to 64% and 13 to 68% of their content in the blood plasma, respectively.

Research results show that these drugs can be effective as monotherapy or in combination for the treatment of myelitis and CMV encephalitis in immunosuppressive patients in 74% of cases, but the average life expectancy of patients after diagnosis of a CMV lesion of the central nervous system is only about 3 months. In general, in addition to a marked improvement in the condition of patients infected with CMV of the central nervous system, the prognosis is in most cases unfavorable, in particular for patients infected with HIV.

Cidofovir is the latest antiviral drug with activity against CMV, which has been shown to be effective in treating late and recurrent CMV retinitis based on clinical trial results. The ratio of plasma and cerebrospinal fluid concentrations of this drug is not currently known.

Specific treatment for encephalitis and myelitis should be started as soon as possible. In accordance with the recommendations of the International AIDS Society and the European group of experts, the treatment of HIV-infected patients with CMV disease of the central nervous system should start with the appointment of ganciclovir and foscarnet, as they enter the central nervous system and are generally effective.

The choice between ganciclovir and foscarnet is determined by the patient's blood test parameters and the state of kidney function. Combination therapy with these drugs should be prescribed to patients who have already received antiviral therapy, as well as in the event of disease progression in the context of monotherapy with one of the drugs. Foscarnet is prescribed iv with severe neutropenia or thrombocytopenia, and ganciclovir is indicated for patients with renal impairment, as well as for hepatotoxic drugs receiving concomitant therapy. Patients who have previously received antiviral therapy for CMV are indicated for the combination of ganciclovir with foscarnet due to the possibility of infection with resistant strains of CMV.

Cidofovir has been proposed as a second-line medication for treatment failure with a combination of ganciclovir and foscarnet. To date, this drug has not been sufficiently studied and its use has not been definitively approved.

Currently, studies are underway on new antiviral drugs for the treatment of cytomegalovirus infections, such as valganciclovir, tomeglovir, maribavir, etc.

In addition to the use of active CMV drugs, HIV-infected patients also require highly active antiretroviral therapy, which not only acts on HIV, but also improves prognosis due to the restoration of altered immunological parameters. For immunocompetent patients with transverse myelitis, a short course of corticosteroids is indicated.

Supportive therapy is prescribed to improve or stabilize the process and continues until the immunological parameters are restored (CD4 cells are greater than 100-150 / ml for 6 months) in HIV patients or until that immunosuppressive drugs be canceled in patients undergoing organ transplantation. The need for maintenance therapy in immunocompetent patients is not currently understood.