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  • Snapshot
    • A 45-year-old woman presents to the emergency room with painless vision loss. She has a past medical history of HIV infection and has not been on any anti-retroviral medications due to loss of health insurance last year. Her course has been complicated by CMV esophagitis in the past, which was resistant to ganciclovir. Her last CD4+ count was < 50/uL 1 week ago. On physical exam, she is found to be dehydrated with decreased skin turgor and dry mucous membranes. Funduscopic exam shows yellow-white patches of retinal opacification. After fluid resuscitation, she is started on foscarnet. (CMV retinitis)
  • Introduction
    • Drugs
      • foscarnet
    • Mechanism of action
      • inhibits viral DNA/RNA polymerase and HIV reverse transcriptase by preventing pyrophosphate from binding
        • the drug is a pyrophosphate (pyroFOSphate, FOScarnet) analog
        • does not need to be activated by a kinase
          • can be used in viral strains resistant to acyclovir and ganciclovir
    • Mechanism of resistance
      • mutation of viral DNA/RNA polymerase
    • Clinical use
      • cytomegalovirus (CMV) infections in immunocompromised patients (e.g., HIV)
        • especially if resistant to ganciclovir
        • can also be given in combination with ganciclovir
      • herpes simplex virus infections
        • especially if resistant to acyclovir
      • varicella zoster virus infections
    • Adverse effects
      • nephrotoxic
        • must correct dehydration prior to therapy
        • acute tubular necrosis
      • cardiac effects
        • QT prolongation
        • torsades de pointes
      • electrolyte abnormalities
        • hypocalcemia
        • hypomagnesemia
        • seizures
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