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8/22/2022  |   11:20 AM - 11:45 AM   |  Confederation II/III

Case of Congenital CMV with Ganciclovir and Foscarnet Resistance

Introduction: Valganciclovir or ganciclovir (GCV) is recommended for neonates with moderate to severe congenital CMV (cCMV). We present a case of cCMV with GCV and foscarnet (FOS) resistance. Case: A 21-year-old mother was initiated on valacyclovir following detection of CMV by PCR in amniotic fluid in the presence of microcephaly. At birth, the infant had hepatitis, cytopenias, pneumonitis, and abnormal neuroimaging. Despite early response to GCV, CMV viral load (VL) rose sharply (>10^7 copies/mL). A UL97 mutation (H520Q) conferring resistance to GCV was detected. FOS was subsequently initiated leading to downtrend in CMV VL. Despite this early response, VL increased again and a UL54 mutation (V715M) conferring FOS resistance was found. Approval was obtained for off label letermovir (LTV) use. In the absence of pharmacokinetic data, serial therapeutic drug monitoring (TDM) was performed to optimize LTV dosing. Despite decreasing VL, patient passed away from respiratory complications. Discussion: There is a paucity of data surrounding treatment strategies for patients with cCMV and GCV resistance. LTV was well tolerated with good clinical response. TDM was necessary to establish therapeutic LTV levels.

  • Describe a challenging case of congenital CMV (cCMV) with ganciclovir and foscarnet resistance
  • Describe the importance of CMV viral load monitoring and CMV resistance testing in infants with severe cCMV
  • Discuss letermovir use and monitoring in drug resistant cCMV

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Session Evaluation

Craig Frankel (POC-Point of Contact,Primary Presenter), craig.frankel@sickkids.ca;
My name is Craig Frankel and I am currently the chief Pediatric Infectious Disease fellow at the Hospital for Sick Children. I completed my Pediatrics residency training at the University of Western Ontario. Research areas of interest of mine include: congenital infections, neonatal encephalitis and immunocompromised infectious disease.


Financial - No relevant financial relationship exists.

Nonfinancial - No relevant nonfinancial relationship exists.


Financial - No relevant financial relationship exists.