Disseminated Ganciclovir-Resistant Cytomegalovirus in a Nontransplant Pediatric ALL Patient: A Case Report.

BACKGROUND: Cytomegalovirus (CMV) infection is an underrecognized complication in children with acute lymphoblastic leukemia (ALL). While CMV disease is well documented in transplant recipients, its clinical course in nontransplant settings remains poorly defined. Disseminated ganciclovir-resistant CMV infection is a rare complication in nontransplant children with ALL, and its optimal management remains uncertain. OBSERVATIONS: We describe an 8-year-old patient with T-ALL receiving maintenance chemotherapy who developed high levels of CMV viremia without initial end-organ disease and subsequent emergence of ganciclovir-resistant CMV infection. Despite prolonged valganciclovir therapy and the subsequent use of foscarnet and maribavir, the patient developed CMV-related complications, including CMV retinitis. CONCLUSION: This case underscores the potential severity of CMV in nontransplant pediatric ALL with prolonged lymphopenia, challenges of antiviral resistance, and limited treatment options for central nervous system involvement. The progression from asymptomatic viremia to clinically significant CMV disease remains poorly understood. Enhanced CMV surveillance protocols and resistance-guided treatment strategies may be warranted in selected high-risk populations.