Use of Maribavir and Letermovir for Ganciclovir-Resistant Cytomegalovirus Infection in Lung Transplant Recipients

Introduction

Cytomegalovirus (CMV) infection is a major contributor to morbidity and mortality in solid organ transplant recipients. Ganciclovir-resistant (gan-R) CMV is an emerging concern associated with potent immunosuppression and increased durations of antiviral exposure. Limited data exists regarding efficacy of maribavir and letermovir for treatment and secondary prophylaxis in resistant CMV.

Case Report

We report a series of 3 lung transplant recipients with gan-R CMV infection treated with maribavir or letermovir between June 1, 2015 and June 1, 2020. Maribavir and letermovir were initiated as monotherapy for CMV treatment in 3 and 1 patients, respectively, with maribavir dosing per institutional study protocol. Patient A was transitioned to letermovir prophylaxis following maribavir treatment. Patient C was transferred to an outside hospital for CMV T-cell therapy and was not discharged on antiviral prophylaxis. Both maribavir and letermovir were well-tolerated by patients.

Summary

Maribavir 200 mg twice daily resulted in CMV viral suppression in one patient. Patients B and C received much shorter durations of maribavir treatment, which may have been associated with delayed quantitative viral reduction as described in the literature, and subsequent transition to alternative therapy. Further research is needed to evaluate the impact of salvage therapy with maribavir or letermovir on patient outcomes.