Review ArticlesDifficult Balance Between Multidrug-Resistant Cytomegalovirus Infection and Graft-Versus-Host Disease in an Allogeneic Hematopoietic Stem Cell Transplant Recipient Review of Antiviral Therapy and Use of Cytomegalovirus-Specific T-CellsRhee, Yoona MD∗; Santos, Carlos A.Q. MD∗; Lurain, Nell PhD†; Marinovic, Debra A. PA-C‡; Prockop, Susan E. MD§; Varma, Ankur MD‡; Papanicolaou, Genovefa MD∥; Ustun, Celalettin MD‡; Nathan, Sunita MD‡Author Information From the ∗Division of Infectious Diseases, Department of Internal Medicine †Department of Microbial Pathogens and Immunity ‡Section of Bone Marrow Transplant and Cell Therapy, Division of Hematology and Oncology, Department of Internal Medicine, Rush University Medical Center, Chicago, IL §Pediatric Bone Marrow Transplant Service, Department of Pediatrics ∥Infectious Diseases Service, Memorial Sloan Kettering Cancer Center, New York, NY. Correspondence to: Yoona Rhee, MD, Division of Infectious Diseases, Department of Internal Medicine, Rush University Medical Center, 600 S Paulina St, Suite 143, Chicago, IL 60612. E-mail: Yoona_rhee@rush.edu. Conflict of interest: G.P. is an investigator for Astellas, Chimerix, Merck, and Shire, and has received research support, consulting, and other fees from Astellas, Chimerix, and Merck. S.E.P. receives support for the conduct of sponsored trials from Atara Biotherapeutics and Mesoblast through Memorial Sloan Kettering Cancer Center (MSKCC). In addition, Atara Biotherapeutics holds the license for the third-party cytomegalovirus-specific cytotoxic T-cell lymphocyte product developed at MSKCC. S.E.P. is a co-inventor on intellectual property licensed to Atara Biotherapeutics. S.E.P. has waived her rights to this intellectual property to MSKCC and has no personal financial interests in Atara Biotherapeutics and intellectual property interests relevant to the work that is related to this manuscript. Y.R., C.A.Q.S., N.L., D.A.M., A.V., C.U., and S.N. have no relevant conflicts of interest. Infectious Diseases in Clinical Practice: September 2020 - Volume 28 - Issue 5 - p 257-260 doi: 10.1097/IPC.0000000000000858 Buy Metrics Abstract We present a case of multidrug-resistant cytomegalovirus (CMV) infection in an allogeneic hematopoietic stem cell transplant recipient with graft-versus-host disease. We demonstrate evolving viral mutations with documented resistance to first-line CMV DNA polymerase inhibitors and letermovir. Leflunomide and compassionate use investigational third-party CMV-specific cytotoxic T-cell lymphocyte infusions led to reductions in CMV viremia; however, the patient succumbed to respiratory failure. This article highlights the difficult balance between immunosuppression for graft-versus-host disease therapy and refractory CMV treatment, with a review of CMV antiviral therapy. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.