Chronic Cytomegalovirus Research Articles

Geographic Disparities in Cytomegalovirus Infection During Pregnancy.

Cytomegalovirus (CMV) is the most common infectious cause of fetal malformations and childhood hearing loss. CMV is more common among socially disadvantaged groups, and it clusters geographically in poor communities. We conducted a geospatial analysis of chronic and primary CMV infection among pregnant women around Durham, NC. We performed a geospatial analysis of subjects from an ongoing study of CMV infection among pregnant women using geographic information systems and spatial statistics. Subjects were categorized on the basis of results of their CMV immunoglobulin G avidity testing as seronegative, seropositive, or primary infection. We used generalized additive models to analyze the spatial distributions of individuals who fell into each category and to control for confounders such as race and age. We used a generalized estimating equation to correlate community-level variables with CMV status. Of 3527 pregnant women aged 15 to 59 years, 93.4% were either white or black. CMV seropositivity was significantly more common among non-Hispanic white subjects than among minority subjects (odds ratio, 3.76 [95% confidence interval, 3.25-4.34]). We identified a cluster in which women had elevated odds of CMV seropositivity in the urban neighborhoods of Durham. Cases of primary CMV infection were more common in areas with higher-than-average CMV seroprevalence. Neighborhood median family income was associated inversely with the prevalence of chronic CMV. We found a high prevalence of CMV seropositivity in urban low-income neighborhoods among pregnant women, particularly among racial and ethnic minorities. Seronegative pregnant women from these communities might be at heightened risk for primary CMV infection.

Clinical and immunological analysis of patients with activated phosphoinositide 3-kinase δ syndrome resulting from PIK3CD mutation

Objective: To explore the clinical and immunological features, gene mutations, treatment and prognosis in patients with activated phosphoinositide 3-kinase δ syndrome (APDS) caused by PIK3CD gene heterozygous germline mutation. Method: The data of clinical, immunological phenotype, treatment, and prognosis of 15 patients with APDS, who visited Children's Hospital of Chongqing Medical University, Peking Union Medical College Hospital, and Shenzhen Children's Hospital from June 2014 to November 2016, were collected and analyzed. Result: Of the 15 patients, 11 were males, remaining 4 patients were females. The median age of disease onset was 1 year, and median age at diagnosis was 4 years and 4 months. All patients had the de novo heterozygous germline mutation in PIK3CD (c. 3061G>A, p. E1021K). The common initial symptoms were respiratory infections, including pneumonia (12 cases) , bronchiectasis (5 cases). Other common clinical manifestations were recurrent and chronic diarrhea (11 cases), Epstein-Barr virus (EBV) and/or cytomegalovirus (CMV) viremia (10 cases), hepatosplenomegaly (13 cases), and lymphadenopathy (10 cases). The main immunological features were increased IgM (11 cases), decreased IgG (6 cases), decreased numbers of CD4+ T cell (7 cases) especially naïve CD4+ T cell (9 cases), reduced numbers of B cells (11 cases) particularly naïve B cells (9 cases), increased numbers of transitional B cells (5 cases) and CD8+ terminally differentiated effector memory T cells (5 cases). After 1-29 months follow up, 13 of the 15 cases remain survived, of whom 5 cases received regular intravenous immunoglobulin (IVIG) therapy, with reduced frequency of infections and improved severity of infections; of whom 3 cases received oral rapamycin therapy at the dosage of 1 mg/ (m2·d) and with a decrease in nonneoplastic lymphoproliferation. Conclusion: E1021K is a hotspot for mutation in the PIK3CD gene in patients with APDS. Regular IVIG can improve their quality of life. Targetel treatment with rapamycin could mitigate hepatosplenomegaly.

Hematopoietic stem cell transplantation corrects WIP deficiency

Hematopoietic stem cell transplantation corrects WIP deficiency

ИЗМЕНЕНИЕ СОСТАВА ЛИПИДОВ У БЕРЕМЕННЫХ С ЦИТОМЕГАЛОВИРУСНОЙ ИНФЕКЦИЕЙ В ТРЕТЬЕМ ТРИМЕСТРЕ ГЕСТАЦИИ В ЗАВИСИМОСТИ ОТ ТИТРА АНТИТЕЛ ИММУНОГЛОБУЛИНА КЛАССА G

The work was carried out to study the processes of lipid peroxidation, antioxidant defense, the content of phospholipase A2, the main structural phospholipids (phosphatidylethanolamine, phosphatidylcholine and its lizoform) in the peripheral blood of women with reactivation of chronic cytomegalovirus (CMV) infection in the III trimester of gestation depending on the titer of IgG antibodies to CMV. The method of random sample was used to select 90 pregnant women. The study group consisted of 60 pregnant women with exacerbation of chronic CMV infection in the third trimester. It was divided into two subgroups: subgroup A (30 women with active CMV infection, the titer of IgG antibodies to CMV was 1:1600); subgroup B (30 women with latent CMV infection, the titer of IgG antibodies to CMV was 1:800). The control group consisted of 30 healthy pregnant women who matched the study group by the period of gestation and age. It was found out that lipid metabolism imbalance in plasma and erythrocytes of the peripheral blood was one of the reasons for progression of the pathological process of CMV infection in pregnant women. Changes in the composition of erythrocyte membrane phospholipids, i.e the reduction of phosphatidylethanolamine by 22% (p<0.001), of phosphatidylcholine by 23% (p<0.001), an increase in the content of lysophosphatidylcholine by 34% (p<0.001), are regarded as membrane destabilizing processes. Their development is caused by uncontrolled free radical reactions leading to the initiation of peroxidation of cell membrane lipid oxidation (the increase in the concentration of TBA-active products by 78% (p<0.001), and the activation of lipolytic enzymes (increased concentration of phospholipase A2 by 60% (p<0.001). These changes occur against the oppression of antioxidant protection (reducing the concentration of α-tocopherol by 26% (p<0.001). The rate of change of lipid metabolism in these structures as manifestations of membrane destructive phenomena depends on the titer of IgG antibodies to CMV and is most pronounced when there is the active form of CMV infection (titer IgG antibodies to CMV is 1:1600). The mentioned pathological processes taken together aggravate the condition of pregnant women with CMV infection and create a favorable background for further progression of the pathological process, which greatly burdens the prenatal period and childbirth. The results obtained allow us to establish the important role of lipid metabolism disorders in the pathogenesis of CMV infection, which can be the basis for the expansion of the diagnostic and therapeutic base for this pathology of pregnant women.

РОЛЬ ЭСТРАДИОЛА В ПОДДЕРЖАНИИ ФЕТОПЛАЦЕНТАРНОЙ СИСТЕМЫ

The aim of the study is to define the role of abnormalities in the formation of estriol hormones in the development of hormonal dysfunction of fetoplacental system. There were examined 39 placentas from women with exacerbation of chronic cytomegalovirus infection at the third trimester of pregnancy and IgG antibody titer 1:1600 and 30 placentas from women with latent CMV infection and titer 1:400. The activity of androstenedione dehydrogenase was found out with histochemical method on cryostat sections of freshly frozen tissues of placentas by Lloyd’s method. The assessment of intensiveness of histochemical reaction was done with cytophotometric method by Scion program. Estradiol in homogenate of placenta was measured with immune-enzyme method. The quantity of nuclei of placenta syncytiotrophoblast in the state of apoptosis was done with cytophotometric method on paraffin sections stained by ISEL method. By the results of the study the exacerbation of CMV infection at the third trimester of pregnancy leads to the decrease of intensiveness of histochemical reaction in placentas to androstenedione dehydrogenase till 32.1±2.88 pixel/mcm2 (at the latent course it is 54.2±4.31 pixel/mcm2, р<0.001), and in homogenate of placenta to the decrease of estradiol till 18443.2±117.53 pmole/l (at the latent course of the disease it is 28977.7±158.13 pmole/l, p<0.001), on paraffin sections in syncytiotrophoblast by the increase of nuclei number in the state of apoptosis till 5.0±0.03% (at latent course of the disease it is 1.2±0.001%, р<0.001) and vacuole formation, which leads to destructive damages of syncytiotrophoblast cytoplasm. The obtained results prove that the exacerbation of CMV infection at the third trimester of pregnancy causes the decrease of estriol hormones formation, which is accompanied by the damage of morphostructure and exchange processes in cell elements of placenta.

НАРУШЕНИЕ ПРЕОБРАЗОВАНИЯ АНДРОСТЕНДИОЛА В ПЛАЦЕНТЕ ПРИ БЕРЕМЕННОСТИ, ОСЛОЖНЕННОЙ РЕАКТИВАЦИЕЙ ЦИТОМЕГАЛОВИРУСНОЙ ИНФЕКЦИИ В ПЕРВОМ ТРИМЕСТРЕ

The aim is to analyze androstenediol converting in villous chorions at gestation against cytomegalovirus infection activation during the first trimester of pregnancy. 48 villous chorions samples taken during medical abortion at 8-10th weeks of gestation of women with chronic cytomegalovirus reactivation during pregnancy became the material for study, and 35 villous chorions samples were taken as the control. The results of pregnant women examination were analyzed from the point of cytomegalovirus infection activity with immune-enzyme method by the presence of IgM antibodies or by the value of 4-times and more growth of IgG antibodies titer in paired sera in dynamics in 10 days. IgG avidity index to cytomegalovirus was more than 75% in all women. Androstenediol converting was assessed with histochemical methods. Quantitative evaluation of the reaction products was carried out on sections under the microscope MT (Japan) associated with software-hardware complex «SCION Corporation» (USA). Histochemical reaction product of the androstenediol dehydrogenase was well detected in cyto- and syncytiotrophoblast of chorious villi. Reaction activity in the material from women with reactivation of cytomegalovirus infection during pregnancy was low, which indicated a reduction in the reserve for the synthesis of estrogen. The concentration of estriol and estradiol in villous chorions during reactivation of cytomegalovirus infection decreased till 24.9±2.01 nmol/l and 15765.1±107.77 pmol/l, respectively.

Primary T-cell immunodeficiency with functional revertant somatic mosaicism in CD247

Primary T-cell immunodeficiency with functional revertant somatic mosaicism in CD247

Cytomegalovirus Infection and Coronary Artery Disease: A Single-Center Serological Study in Northwestern Iran

Te role of chronic Cytomegalovirus (CMV) infection and inflammation in the pathogenesis of atherosclerosis and Coronary Artery Disease (CAD) is still not clear. Objectives: Tis study aimed to explore the seroprevalence of anti-CMV antibodies and inflammatory markers in patients with stable angina who had undergone diagnostic coronary angiography for clinical suspicion of CAD. Patients and Methods: Tis cross-sectional, descriptive study was conducted on 181 patients with stable angina selected randomly among the patients referred to Seyyedoshohada Heart Hospital of Urmia, Iran for diagnostic coronary angiography between August 2012 and December 2013. Te patients were categorized into CAD and non-CAD groups based on their angiographic fndings. Ten, anti-CMV IgG and IgM antibodies were tested using the Enzyme-Linked Immunosorbent Assay (ELISA) method (Diapron, Rome, Italy). Serum C-Reactive Protein (CRP) was also measured by a qualitative method (Aniston Kit). Results: Based on angiographic fndings, 141 patients (77.9%) had atheromatous plaques in their coronary arteries, while coronary arteries were free of any plaques in 40 cases (22.1%). Besides, 99.3% of the patients in the CAD group and all the patients in the non-CAD group were anti-CMV IgG positive. Te rate of anti-CMV IgM seropositivity was 11.7% in the CAD group and 13.2% in the non-CAD group (P = 0.78). However, no signifcant difference was observed between the groups with and without angiographicallydocumented CAD in terms of CRP seropositivity (64.7% vs. 56.4%, P = 0.34). Conclusions: Regardless of having angiographically-proven CAD, almost all the cases referred for coronary angiography in our study had a previous exposure to CMV infection as determined by the presence of anti-CMV IgG antibodies in their sera. In fact, the results indicated no signifcant associations between CMV infection and the presence of CAD.

CGAS-STING Signaling Regulates Initial Innate Control of Cytomegalovirus Infection.

Several innate sensing pathways contribute to the control of early cytomegalovirus (CMV) infection, leading to a multiphasic type I interferon (IFN-I) response that limits viral replication and promotes host defenses. Toll-like receptor (TLR)-dependent pathways induce IFN-I production in CMV-infected plasmacytoid dendritic cells; however, the initial burst of IFN-I that occurs within the first few hours in vivo is TLR independent and emanates from stromal cells. Here we show that primary human endothelial cells mount robust IFN-I responses to human CMV that are dependent upon cyclic GMP-AMP synthase (cGAS), STING, and interferon regulatory factor 3 (IRF3) signaling. Disruption of STING expression in endothelial cells by clustered regularly interspaced short palindromic repeat (CRISPR)-Cas9 revealed that it is essential for the induction of IFN-I and restriction of CMV replication. Consistently, STING was necessary to mount the first phase of IFN-I production and curb CMV replication in infected mice. Thus, DNA sensing through STING is critical for primary detection of both human and mouse CMV in nonhematopoietic cells and drives the initial wave of IFN-I that is key for controlling early viral replication in vivo. Cytomegalovirus (CMV) is one of the most common viral pathogens, with the majority of people contracting the virus in their lifetime. Although acute infection is mostly asymptomatic in healthy persons, significant pathology is observed in immunocompromised individuals, and chronic CMV infection may exacerbate a myriad of inflammatory conditions. Here we show that primary human endothelial cells mount robust IFN-I responses against CMV via a cGAS/STING/IRF3 pathway. Disruption of STING expression by CRISPRs revealed an essential role in eliciting IFN-I responses and restricting CMV replication. Consistently, in mice, STING is necessary for the first phase of IFN-I production that limits early CMV replication. Our results demonstrate a pivotal role for the cGAS-STING pathway in the initial detection of CMV infection.

ОЦЕНКА ПОКАЗАТЕЛЕЙ ЛИПИДНОГО МЕТАБОЛИЗМА У РОЖЕНИЦ И ИХ НОВОРОЖДЕННЫХ ПРИ ЦИТОМЕГАЛОВИРУСНОЙ ИНФЕКЦИИ

In order to study the lipid metabolism of a mother–newborn system, there were examined 35 women in labor who had the exacerbation of chronic cytomegalovirus infection with the titer of IgG antibodies to cytomegalovirus 1:1600 in the III trimester of gestation and the same number of newborns (the main group). The control group consisted of 35 healthy pregnant women and their newborns. In maternal blood plasma and neonatal umbilical cord blood, total cholesterol content, triglyceride, lipoproteid cholesterol of high (HDL) and low (LDL) density were studied; in the membrane of erythrocytes the concentration of arachidonic acid and lysophosphatidylcholine was examined. It was found that in comparison with the control group at exacerbation of cytomegalovirus infection during gestation there was a significant transformation of lipid metabolism not only in the mother´s blood, but in the blood of the umbilical cord of newborn children, which was revealed through the reduction of the content of total cholesterol (in mother it was by 21%, in the newborn it was by 35%, p<0.001) and cholesterol of LDL (in mother by 24%, in the newborn by 36%, p<0.001); through an increase in the concentration of triglycerides (in mother by 28%, in newborn by 21%, p<0.001); cholesterol of HDL (in mother by 24%, in the newborn by 46%, p<0.001) and chaotropic fractions of phospholipid bilayer of membranes of red blood cells – lysophosphatidylcholine (in mother by 69%, in the newborn by 76%, p<0.001); arachidonic acid (in mother by 62%, in the newborn by 34%, p<0.001). The disturbance of the lipid composition contributes to pathogenesis of CMV infection and allows further conceptual approaches to prevention and treatment of viral infection during pregnancy. The study results suggest the feasibility and necessity of including drugs with antioxidant, antihypoxic action and the ability to regulate lipid metabolism in the complex therapy of pregnant women.

Suppressive effects of sirtinol on human cytomegalovirus (hCMV) infection and hCMV-induced activation of molecular mechanisms of senescence and production of reactive oxygen species

Substantial evidence suggests that chronic human cytomegalovirus (hCMV) infection contributes significantly to T-cell immunosenescence and adverse health outcomes in older adults. As such, it is important to search for compounds with anti-hCMV properties. Studies have shown that resveratrol, a sirtuin activator, suppresses hCMV infection. Here we report suppressive effects of sirtinol, a sirtuin antagonist, on hCMV infection and its cellular and molecular consequences. Human diploid fibroblast WI-38 cells were infected by hCMV Towne strain in the absence or presence of sirtinol. hCMV replication was measured using qPCR. Senescent phenotype was determined by senescence-associated β galactosidase (SA-β-Gal) activity. Expression of hCMV immediate early (IE) and early (E) proteins and senescence-associated proteins (pRb and Rb, p16INK4, and p53) and production of reactive oxygen species (ROS) were assessed using standard laboratory assays. The results demonstrated that sirtinol suppressed hCMV infection as well as hCMV-induced activation of molecular mechanisms of senescence and ROS production. While underlying molecular mechanisms remain to be elucidated, these findings indicate sirtinol as a novel and potent anti-hCMV agent with the potential to be developed as an effective treatment for chronic hCMV infection and its cellular and molecular consequences that are important to ageing and health of older adults.

Postmortem diagnosis of cytomegalovirus and accompanying other infection agents by real-time PCR in cases of sudden unexpected death in infancy (SUDI)

As an opportunistic pathogen with high mortality rates, Cytomegalovirus (CMV) may lead to fatal disseminated CMV infection of the premature and newborn; thus necessitating the demonstration of CMV-DNA with clinical history and/or histopathological findings of CMV infection and defining other bacterial and viral infection agents with real-time polymerase chain reaction (RT-PCR) in udden unexpected death in infancy (SUDI) cases as we aimed in this study.314 (144 female, 170 male) SUDI cases were prospectively investigated from January 2013 to January 2015 in Istanbul Forensic Medicine Institution. The study includes 87 tissue samples of 39 cases for post-mortem histopathological examination of interstitial pneumonia, myocarditis, meningitis, encephalitis, hepatitis, colitis or tubulointerstitial nephritis and/or accompanying chronic sialadenitis.CMV-DNA was found positive in 35 (40.2%) salivary gland, 19 (21.8%) lung, 1 (1.1%) tonsil, and 1 (1.1%) brain tissues. CMV sialadenitis and/or CMV pneumonia associated with other viral and/or bacterial agents were detected in 23 (60%) of 39 infant cases.The demonstration of CMV-DNA would significantly clarify the cause of death and collection of epidemiological data in SUDI cases with clinical history and histopathological findings of CMV infection accompanying chronic CMV sialadenitis. Furthermore, CMV suppresses the immune system, and may predispose to other bacterial and/or viral infections in these cases. Post-mortem molecular investigations are useful in explaining cause of death in SUDI with a suspicion of infection in forensic autopsies.

Cytomegalovirus infection accelerates epigenetic aging

Epigenetic mechanisms such as DNA methylation (DNAm) have a central role in the regulation of gene expression and thereby in cellular differentiation and tissue homeostasis. It has recently been shown that aging is associated with profound changes in DNAm. Several of these methylation changes take place in a clock-like fashion, i.e. correlating with the calendar age of an individual. Thus, the epigenetic clock based on these kind of DNAm changes could provide a new biomarker for human aging process, i.e. being able to separate the calendar and biological age. Information about the correlation of the time indicated by this clock to the various aspects of immunosenescence is still missing. As chronic cytomegalovirus (CMV) infection is probably one of the major driving forces of immunosenescence, we now have analyzed the correlation of CMV seropositivity with the epigenetic age in the Vitality 90+ cohort 1920 (122 nonagenarians and 21 young controls, CMV seropositivity rates 95% and 57%, respectively). The data showed that CMV seropositivity was associated with a higher epigenetic age in both of these age groups (median 26.5 vs. 24.0 (p<0.02, Mann–Whitney U-test) in the young controls and 76.0 vs. 70.0 (p<0.01) in the nonagenarians). Thus, these data provide a new aspect to the CMV associated pathological processes.

Prevalence and risk factors of cytomegalovirus infection among HIV-infected and HIV-exposed uninfected infants in Nigeria.

Cytomegalovirus (CMV) co-infection increases morbidity and mortality in human immunodeficiency virus (HIV) disease. There has been no study on CMV infection and its risk factors among Nigerian HIV-infected and/or HIV-exposed uninfected infants. This was a cross-sectional cohort study at the Federal Medical Center, Makurdi, between January 2012 and March 2013. Acute CMV infection among consecutive three-month- old HIV-infected and HIV-exposed uninfected infants was determined using the enzyme-linked immunosorbent assay of the CMV immunoglobulin M (IgM). The relationship between acute CMV infections in the infants and the potential risk factors was tested using logistic regression analyses. The prevalence of acute CMV infection was 41.4% (91/220), including 12.1% (11/91) and 87.9% (80/91) among the HIV-infected and the HIV-exposed uninfected infants, respectively. In multivariate logistic regression analyses, oropharyngeal candidiasis in the infants, HIV co-infection in the infants, maternal mastitis during breastfeeding, and the absence of maternal chronic CMV infections significantly increased the risk of acute CMV in the young infants. In our setting, concerted efforts to prevent and/or promptly treat oropharyngeal candidiasis and mastitis during breastfeeding may reduce the burden of CMV among HIV-infected and HIV-exposed uninfected infants. Public enlightenment on the mode of CMV transmission and its prevention is also important.

CLINICOLABORATORY diagnostic CRITERIA FOR CHRONIC CYTOMEGALOVIRUS INFECTION IN EARLY AGE CHILDREN

Aim. To determine the clinicolaboratory diagnostic criteria for chronic cytomegalovirus infection among children of early age, so as to optimize diagnosis in conditions of children’s polyclinic. Materials and methods. The object of the study included immunocompromised children with verified cytomegalovirus infection (CMVI) using the method of qualitative saliva and urinary PCR by means of the test-system produced by “Central Scientific Research Institute of Epidemiology”, “AmpliSens CMV-screen/monitor-FL” (Moscow) (61 patients, total sampling). Patients aged 3-6 months (13 %), 6-12 months (21 %), 1-3 years (43 %), 3-7 years (23 %) were sent from Perm polyclinics to receive consultations, clarify the diagnosis and correct the therapy. Results. According to statistical reports of Perm children’s polyclinics for 2013, frequency of CMVI diagnosis in the group of early age children who frequently fall ill (23,1 %) was stated that makes half of cases of the other intrauterine infections (44,7 %). The group of immunocompromised ambulatory patients (61 children aged 3 months to 7 years) with verified chronic CMVI was examined. Clinicolaboratory secondary immunodeficiency (SID) markers from birth or the first months of life were revealed. A marked dysbiotic status of oropharynx associated with Epstein-Barr infection and type 6 herpesviral infection was diagnosed in 54,1 % of cases. Conclusions. Immunopathological syndromes were presented as infectious (77 %), lymphoproliferative (54,1 %) and allergic (44,3 %).

The inverted CD4:CD8 ratio is associated with gender-related changes in oxidative stress during aging

Aging has been associated with increased generation of free radicals as well as immunosenescence. Previous studies have identified older individuals with inverted T CD4:CD8 cell ratio and increased immunity to cytomegalovirus (CMV). Here, we investigated markers of oxidative stress and antioxidant defences in older individuals with inverted CD4:CD8 T-cell ratio. Sixty-one subjects were identified with inverted CD4:CD8 ratio. Older individuals with a CD4:CD8 ratio <1 had increased levels of plasma advanced oxidation protein products (AOPP) and ferric reducing ability of plasma (FRAP), but reduced levels of thiobarbituric acid reactive substances (TBARS) as compared to subjects with normal CD4:CD8 ratio. The CMV IgG serology was negatively correlated with CD4:CD8 ratio. These markers were more evident among elderly men than women. Our data suggest a close relationship between chronic CMV infection and oxidative profile in older individuals in the midst of its influence on the peripheral T-cell subsets.

Anti-CMV-IgG positivity of donors is beneficial for alloHSCT recipients with respect to the better short-term immunological recovery and high level of CD4+CD25high lymphocytes.

Hematopoietic stem cell transplantation from anti-cytomegalovirus immunoglobulin G (anti-CMV-IgG) positive donors facilitated immunological recovery post-transplant, which may indicate that chronic CMV infection has an effect on the immune system. This can be seen in the recipients after reconstitution with donor lymphocytes. We evaluated the composition of lymphocytes at hematologic recovery in 99 patients with hematologic malignancies post hematopoietic stem cell transplantation (HSCT). Anti-CMV-IgG seropositivity of the donor was associated with higher proportions of CD4+ (227.963 ± 304.858 × 106 vs. 102.050 ± 17.247 × 106 cells/L, p = 0.009) and CD4+CD25high (3.456 ± 0.436 × 106 vs. 1.589 ± 0.218 × 106 cells/L, p = 0.003) lymphocytes in the blood at hematologic recovery. The latter parameter exerted a diverse influence on the risk of acute graft-versus-host disease (GvHD) if low (1.483 ± 0.360 × 106 vs. 3.778 ± 0.484 × 106 cells/L, p < 0.001) and de novo chronic GvHD (cGvHD) if high (3.778 ± 0.780 × 106 vs. 2.042 ± 0.261 × 106 cells/L, p = 0.041). Higher values of CD4+ lymphocytes in patients who received transplants from anti-CMV-IgG-positive donors translated into a reduced demand for IgG support (23/63 vs. 19/33, p = 0.048), and these patients also exhibited reduced susceptibility to cytomegalovirus (CMV), Epstein–Barr virus (EBV) and/or human herpes 6 virus (HHV6) infection/reactivation (12/50 vs. 21/47, p = 0.032). Finally, high levels (≥0.4%) of CD4+CD25high lymphocytes were significantly associated with better post-transplant survival (56% vs. 38%, four-year survival, p = 0.040). Donors who experience CMV infection/reactivation provide the recipients with lymphocytes, which readily reinforce the recovery of the transplanted patients’ immune system.

Randomized Trial of a Novel CMV Vaccine (CMVPepVax) after Allogeneic HCT: Elevated CMV-Specific Immune Response, Reduction in Chronic GvHD and CMV Reactivation Only in Vaccine Arm Patients

▪Background: Cytomegalovirus (CMV) infection causes significant complications in recipients of hematopoietic cell transplant (HCT). Preemptive anti-viral therapy limits CMV viremia and disease, though its use is associated with toxicity, delayed immune reconstitution, and risk of late-onset CMV disease. We developed a novel CMV vaccine (CMVPepVax) based on the HLA-A*0201 pp65495-503 CD8+T-cell epitope (NLVPMVATV) fused with the Tetanus toxin P2 epitope (tt830-843:QYIKANSKFIGITE). The vaccine was formulated with PF03512676 (1.0 mg), a synthetic single-stranded phosphorothioate DNA containing CpG motifs provided by Pfizer Inc. In a Phase 1b healthy volunteer trial, CMVPepVax was found to be safe and immunogenic [LaRosa et al. 2012]. We report on clinical results demonstrating reliable safety, reduced CMV reactivation and chronic (c)GVHD in HCT recipients injected with CMVPepVax compared to randomized observational HCT recipients.Objectives: The primary study objective was safety, with secondary objectives including immunologic responses of HCT recipients to CMVPepVax measured by pentamer assay, prevention of CMV reactivation, and clinical outcome.Patients and methods: Eligible recipients (R+) wereCMV seropositive, HLA-A*0201, between 18-75 years (y) receiving allogeneic T-replete HCT for hematologic malignancy from matched-related (MRD) or 8/8 and 7/8 matched unrelated donors (MUD), excluding those with acute leukemia not in remission. Patients were reassessed on day (d)28 for eligibility and randomized unless they failed to engraft, experienced pre-d28 CMV reactivation or grade 3-4 acute (a)GVHD, received prednisone >1mg/kg/day within 7d of immunization, or had ongoing non-hematologic toxicity (CTCAE >=grade 3). Randomization was stratified by donor (D) CMV serostatus D- vs D+. Patients randomized to the vaccine arm (VA) received CMVPepVax on d28 and d56. Patients randomized to the observation arm (OA) were followed as per standard of care. All patients were monitored for safety/toxicity, CMV-related events, and immune recovery.Results: As of July 2014, of 36 planned patients, 30 patients were enrolled and followed for at least 100d. The median age was 50y (range: 20-76y), with balanced gender accrual. All patients received peripheral blood stem cell grafts, while hematologic diagnosis, pre-HCT conditioning regimens, and GVHD prophylaxis were similar in the VA vs OA. Vaccinations were well tolerated in all 14 patients, and no patient met the safety stopping rule per-protocol. Of three VA patients who developed serious adverse events (SAE), 2 were unrelated and only one was probable (Grade 1 fever), while 8 patients experienced SAE in the OA. The frequency and severity of unrelated AE was similar between arms across all organ systems. None of 6 monitored vaccine recipients developed anti-dsDNA antibodies. In 9 VA patients who reached d180 without reactivation, increases in CMVpp65 pentamer levels after 1st and 2ndinjections were compared to 10 OA patients, using generalized estimating equations. The model indicates an average 6.5fold positive vaccine effect (p=0.02). While this pilot trial was not powered to detect reduced CMV reactivation, we observed a ~5-fold lower rate of CMV reactivation in the VA (1/14 =7%) compared to the OA (6/16=37%, p=0.09) by d100. aGVHD occurred post-randomization in 6/16 (grade II; 5, III: 1) subjects on the OA, and in 2/14 subjects (grade II: 2) on the VA (p = 0.2). An unexpected and striking finding was differing rates of cGVHD in patients who reached d180 in the VA (1/11) vs. OA (7/12, p=0.03). Noteworthy is that the vaccine formulation is more likely to stimulate TH1 responses, yet TH2 immunity is mechanistically associated with cGVHD. An interesting, but unexplained difference in relapse was observed in the OA (3/16) vs VA (0/14) patients, though the observation period is short. Recent observations relating CMV reactivation and reduced relapse have driven strong interest in a mechanistic understanding of the phenomena observed in this trial related to CMV vaccine or the adjuvant, PF03512676.Conclusions: Trial results indicate safety of injecting CMVPepVax in HCT recipients on d28 and d56, no increase in aGVHD, and reduced CMV reactivation associated with vaccine-stimulated immunity. Compelling observations of reduced cGVHD and relapse will be further tested in a recently NIH-funded multi-institution expanded accrual phase 2 trial. DisclosuresMerson:Pfizer Inc.: Employment.

P-124 YI Severe Colonic Stricture in Immunosuppressed Patient with Chronic Cytomegalovirus Colitis

Chronic granulomatous disease (CGD) is a primary immunodeficiency due to a defect in phagocyte NADPH oxidase resulting in recurrent life-threatening bacterial and fungal infections, commonly with catalase positive organisms. These patients may present with an inflammatory bowel disease phenotype and frequently have severe intestinal disease. Bone marrow transplantation is curative for CGD, but chronic immunosuppression places patients at higher risk for disseminated infections including cytomegalovirus (CMV). We present a case of CMV colitis resulting in severe stricture formation in a post-transplant patient. A 6 year old boy with history of CGD diagnosed at age 21 months after presenting with multiple infections and colitis underwent 2 autologous bone marrow transplantations. He later developed several months of bloody diarrhea, intermittent fever, and severe abdominal pain. Infectious stool studies were negative. EGD and flexible sigmoidoscopy revealed epithelial damage in his antrum, duodenum, and colon with increased apoptosis and cytopathic changes in his colon with positive CMV tissue PCR and immunostain. Initial differential diagnosis included Graft versus Host disease and CMV colitis. Imaging at the time revealed diffuse circumferential bowel wall thickening with pericolonic fat. He continued to have profuse bloody diarrhea as well as diffuse abdominal pain. Subsequently, he was treated with IV Ganciclovir and Foscarnet, as well as bowel rest. Follow up flexible sigmoidoscopy biopsies remained CMV tissue PCR positive. With antiviral treatment, his symptoms resolved, and he tolerated enteral feeds with a normal stooling pattern again. Two months following therapy, he returned with progressive, severe distinct episodes of diffuse abdominal pain. The pain was worse with defecation and passing flatus and pain improved on Miralax. CT scan demonstrated a long segment of submucosal bowel wall thickening involving the descending colon. Subsequent barium enema reproduced the patient's episodic pain symptoms and revealed a pinpoint focal colonic stricture at the level of the splenic flexure. Ultimately, surgical resection of 20cm of colon revealed ulceration with chronic inflammation and granulation tissue with scattered capillary endothelial cells with viral cytopathic changes consistent with CMV and highlighted by immunohistochemical stains. CMV is an opportunistic pathogen that results in systemic disease through blood circulation and subsequent invasion of endothelial cells of several organ tissues. CMV infection typically remains latent in immunocompetent individuals, however, it is critical to evaluate for the virus in the immunosuppressed patient, where the infection can be reactivated. The GI tract is a common site for CMV disease, often resulting in esophagitis or colitis. Typical symptoms include watery diarrhea that progresses to rectal bleeding, abdominal pain, fatigue, fever, or even toxic megacolon. While CMV has been previously implicated in complicating severe steroid-refractory inflammatory bowel disease, this is the first report of colonic stricture secondary to chronic CMV infection in an immunosuppressed patient.

Colesevelam and colestipol: novel medication resins in the gastrointestinal tract.

We report the morphologic description of the bile acid sequestrants (BAS) colesevelam and colestipol, as well as the largest series of cholestyramine. Histologically similar medication resins from 4 institutions were prospectively collected over 1 year (26 specimens, 15 patients). Comorbidities included hyperlipidemia (4/15), hypertension (4/15), inflammatory bowel disease (4/15), coronary artery disease (3/15), diarrhea (7/15), hypothyroidism (2/15), and ischemic bowel (1/15). Sites of involvement included the esophagus (1/26), stomach (1/26), small intestine (1/26), ileocecal valve (1/26), and colorectum (22/26). Associated histologic diagnoses included normal (8/26), chronic mucosal injury (11/26), acute inflammation (9/26), erosion/ulceration (6/26), and cytomegalovirus (2/26). The BAS resins were histologically indistinguishable from each other; they were all eosinophilic on hematoxylin and eosin (H&E) and lacked internal "fish-scales." To validate these observations, respective medications were submitted for histologic processing; the processed medications were identical to those in the patient specimens. Rare, irregular "fracture" lines presented diagnostic pitfalls by mimicking the true "fish-scales" of Kayexalate and sevelamer. Clues to the correct identification of BAS include recognition that the "fracture" lines were subtle, irregular, and restricted to large fragments or thick sections, likely representing a processing artifact. Moreover, Kayexalate is violet on H&E and black on acid fast bacillus, and sevelamer characteristically displays a 2-tone color on H&E and is magenta on acid fast bacillus. An association with inflammatory injury was seen (15/26). We believe that the BAS are innocent bystanders in complicated patients, although we cannot exclude their ability to cause mucosal injury in specific settings.