Title: Reply to: Ganciclovir Treatment in Infants With Cytomegalovirus Infection and Cholestasis
Abstract: Reply to: Ganciclovir Treatment in Infants With Cytomegalovirus Infection and Cholestasis To the Editor: In our paper on the use of ganciclovir in cholestatic infants we have clearly stated the descriptive and retrospective nature of the report. Thus, we would claim that most questions raised by Dr. Jonas have been accounted for. For example, the aim is clearly stated and serial measurements of bilirubin and bile acids are described in Table 2. Furthermore, the question of whether CMV is of pathogenetic importance is carefully discussed. As indicated in the Introduction we have previously shown that CMV-DNA can be detected by PCR in liver biopsy specimens from this patient group (1). We would like to add that CMV-DNA could be detected in the liver biopsy of Patient 4 in the present paper, as well. Unfortunately, none of the other five patients had their liver biopsies tested for CMV-DNA. Looking more closely at the treatment duration we do not think the variation in time is very striking. Patient 4 was actually treated before all the other patients, during the first half of the 1990s when the experience from the literature was rather limited. It is evident that Patient 3 ran an increased risk of developing hypoglycemia. However, we did notice a very striking pattern with repeated and symptomatic episodes of hypoglycemia during ganciclovir challenge and prompt resolution after withdrawal. Our main suggestion is that ganciclovir should be avoided in such vulnerable patients. As suggested by Dr. Jonas, small studies in uncommon conditions may be of importance. One very good example is the knowledge gained from non-randomized studies on the effect of interferon treatment in hepatitis C virus infected children (2). We think that our paper has focused on another important clinical issue for pediatric hepatologists. It is possible that other clinicians have treated similarly on a few occasions, with or without reporting the results. Despite the retrospective and uncontrolled nature of our work we still think the report gives valuable clinical, biochemical, and virological information on an important topic. Björn Fischler Thomas Casswall Petter Malmborg Antal Nemeth