Cytomegalovirus Diagnosis Research Articles

Economic Impact of Post-Transplant Cytomegalovirus (CMV), Including Hematopoietic Stem Cell Transplant (HSCT) and Solid Organ Transplant (SOT) Recipients Experiencing Myelosuppression or Nephrotoxicity

Introduction CMV infection/disease is a cause of morbidity and mortality in HSCT/SOT recipients. Use of existing treatments (Txs) for CMV infection/disease is limited by toxicities (e.g. myelosuppression and nephrotoxicity). Understanding the economic impact of myelosuppression and nephrotoxicity among transplant recipients, notably those receiving Txs for CMV infection/disease, may provide valuable information on quantifying the burden of these comorbidities in this population. Objective To estimate healthcare costs in HSCT/SOT recipients treated for CMV infection/disease including patients (pts) diagnosed with myelosuppression/nephrotoxicity following Tx. Methods A retrospective, longitudinal cohort study using data from a US health claims database (PharMetrics Plus™; 2013–2017) identified HSCT/SOT recipients diagnosed with CMV and a subsequent prescription claim for Tx for CMV (CMV-Tx cohort), in addition to a Control cohort (no claim associated with CMV diagnosis or Tx). HSCT/SOT recipients with diagnosis claims of myelosuppression or nephrotoxicity on or following the date of Tx initiation were evaluated. The index date for CMV-Tx pts was the date of the first prescription claim after CMV diagnosis; the index date was imputed for controls. Healthcare costs for the subgroups were reported during the observation period (time from index date to the end of insurance coverage or data availability). Costs were reported per patient per month (PPPM) to account for varying lengths of observation period. Results There were 1,311 (412 HSCT and 899 SOT) pts in the CMV-Tx cohort. HSCT subgroup: 349 (84.7%) of CMV-Tx pts and 1,050 (63.3%) of controls had myelosuppression; nephrotoxicity was reported for 189 (45.9%) of CMV-Tx pts and 528 (31.8%) of controls. Mean observation periods for the HSCT CMV-Tx and Control cohorts were 13.73 and 15.32 months, respectively. SOT subgroup: 503 (56.0%) of CMV-Tx pts and 425 (20.0%) of controls had myelosuppression; 405 (45.1%) of CMV-Tx pts and 583 (27.4%) of controls had nephrotoxicity. Mean observation periods for the SOT CMV-Tx and Control cohorts were 18.82 and 14.34 months, respectively. Total medical costs for pts in the HSCT and SOT subgroups who had myelosuppression or nephrotoxicity (CMV-Tx and controls) were higher than in the respective HSCT/SOT full cohorts (Table). Inpatient visits were the main driver of costs in both HSCT and SOT subgroups (Table). Conclusions Using data from a large US claims dataset, this study demonstrates the higher economic burden among pts diagnosed and managed for CMV post transplant compared with those without CMV. Among transplant recipients diagnosed with myelosuppression and nephrotoxicity, medical costs were higher than among the overall study population. This further reflects the burden and the need to minimize the impact of these conditions in the post-transplant CMV population.

A Custom-Designed Recombinant Multiepitope Protein for Human Cytomegalovirus Diagnosis

The Human Cytomegalovirus (HCMV) has infected more than 90% of the world population and its prevalence can be related to the individuals geographical and socialeconomic status. Serological tests based on ELISA are pivotal for HCMV diagnosis. Due to the lack of standardization in the production/purification of antigens from viral preparations, ELISA tests are based on several recombinant proteins or peptides. As an alternative, multiepitope proteins may be employed. In this work, we developed a recombinant multiepitope protein (rMEHCMV) for HCMV diagnosis based on conserved and immunodominant epitopes derived from tegument (pp150, pp65 and pp28), glycoprotein gB (pp38) and DNA polymerase subunit (pp52) of HCMV. The rMEHCMV gene was synthesized de novo and overexpressed in Escherichia coli cells. The recombinant protein was purified to homogeneity using a Ni-NTA column. Biophysical analysis of recombinant protein was performed by circular dichroism. A preliminary biological activity test was performed using 12 positive human sera samples by using an in-house IgG ELISA. The following patents database were consulted: Espacenet, Google Patents and the National Institute of Intellectual Property (INPI, Brazil). The recombinant multiepitope protein was successfully expressed in E. coli. The structural data obtained by circular dichroism spectroscopy showed that rMEHCMV is structurally disordered. An in-house IgG ELISA test with rMEHCMV was successfully used to recognized IgG from human serum samples. Together, our results show that rMEHCMV should be considered as a potential antigenic target for HCMV diagnosis.

Risk of opportunistic infection in kidney transplant recipients with cytomegalovirus infection and associated outcomes.

Cytomegalovirus (CMV) infection in kidney transplant recipients has been anecdotally observed with concomitant or subsequent opportunistic infections (OI), but this association has yet to be defined or quantified. Patients who received a renal transplant between 1/1/2005 and 6/30/2014 and developed CMV infection were matched to controls in a ratio of 1:2 and the rates of opportunistic co-infection were calculated within pre-specified time frames (-30days to +90days and -30days to +180days). The primary outcome was composite OI rate, and secondary outcomes included time to OI and patient and graft outcomes. CMV-OI association rates were estimated via conditional logistic regression. There were 2405 patients who received a renal transplant during the study period; 394 cases of CMV infection were identified. These cases were matched to 783 controls for a total of 805 participants. OI occurred in 14 patients in the CMV case group (CMV+) and in 5 patients in the control group (CMV-) in the -30 to +90day time period (3.55% vs 0.64%, OR=5.60, 95% CI: 2.02-12.55). When considering 180-day follow-up, OI occurred in 17 CMV+ patients and 8 CMV- patients (4.3% vs 1%, OR=4.25, 95% CI: 1.83-9.85). Mean time from CMV diagnosis to OI was 33±64days (median 7days). Mortality was 3 times more likely in the group with concomitant OI (CMV+/OI+) as compared to a matched cohort of patients with CMV infection without OI (CMV+/OI-) (unadjusted HR 3.02, 1.64-5.55, Tables 6 and 7). Cumulative survival for CMV+/OI+ patients was significantly worse than CMV+/OI- patients (P<0.01). CMV is associated with a significantly increased risk of co-infection with OI, particularly fungal infections. Clinical suspicion for concomitant OI should drive further workup after a CMV diagnosis. Future studies are needed to better define those patients at highest risk to elucidate subpopulations where the benefits of prophylaxis outweigh the potential risks associated with these therapies.

Reactivation of Latent Cytomegalovirus Infection after Major Surgery: Risk Factors and Outcomes.

Background: Reactivation of latent cytomegalovirus (CMV) infection occurs in previously immunocompetent critically ill individuals and may be associated with increased morbidity and mortality. Our aim was to explore risk factors for and outcomes after CMV reactivation in patients undergoing major surgery. Patients and Methods: We performed a retrospective case control study of patients without underlying immunocompromise who developed post-operative CMV reactivation from 2004-2016. Cases included patients testing positive for CMV by viral load, culture, or histopathology. Controls were matched by age, gender, type, and year of surgery. Results: Sixteen CMV cases were matched to 32 controls. Median age was 65 and median time from surgery to CMV diagnosis was 32 days. Symptoms included fever (94%), hepatitis (75%), myelosuppression (56%), and diarrhea (38%). Despite similar baseline comorbidities, cases were more likely to return to surgery (odds ratio [OR] 6.31; 95% confidence interval [CI], 1.29-30.74), require renal replacement therapy (OR 18.54; 95% CI, 2.36-145.6), total parenteral nutrition (OR 33.0; 95% CI, 6.60-262.37) and corticosteroids (OR 18.78; 95% CI, 4.5-103.9). Length of stay was increased (median 51 vs. 8 days, p = 0.005), co-infections were more common (OR 15.10; 95% CI, 1.89-120.8), and mortality was higher (38% vs. 0%, p < 0.01). Conclusions: Cytomegalovirus reactivation occurs in previously immunocomptent patients post-operatively and is associated with poor outcomes including other infections and mortality. Potential risk factors include prolonged length of stay, surgical complications, and corticosteroid use. It is not clear from our study whether CMV reactivation is a surrogate marker of severe illness and post-operative complications or if CMV reactivation plays a causative role in the development of these adverse outcomes.

One-step scalable fluorescent microgel bioassay for the ultrasensitive detection of endogenous viral miR-US4-5p.

Human cytomegalovirus (hCMV) infection is the leading cause of birth defects in newborns and death in immunosuppressed people. Traditional techniques require time-consuming and costly analyses, and sometimes result in false positive results; thus, a rapid and accurate detection for hCMV infection is necessary. Recently, hcmv-miR-US4-5p was selected as the biomarker for cytomegalovirus diagnosis and follow-up. Herein, we propose a bioassay based on microgels endowed with optical fluorescent oligonucleotide probes for the detection of circulating endogenous hcmv-microRNAs. In particular, a double strand probe, based on the fluorescence recovery after target capture, was conjugated on microgels and the probe density was opportunely optimised. Then, the microgels were directly mixed with the sample. The fluorescence read-out was measured as a function of target concentration at a fixed number of microgels per tube. As a bead-based assay, the performances of optical detection in terms of dynamic working range and limit of detection could be finely tuned by tuning the number of microgels per tube. The limit of detection of the assay could be tuned in the range from 39.1 fM to 156 aM by changing the microgel concentration from 50 μg mL-1 to 0.5 μg mL-1, respectively. The assay results specific for the selected target were stable over a one-year time span and they were not affected by the presence of human serum. Therefore, this bioassay based on microgels might represent a flexible platform that should be able to predict, identify and follow-up several diseases by monitoring freely circulating oligonucleotides in body fluids.

The detection of the cytomegalovirus DNA in the colonic mucosa of patients with ulcerative colitis is associated with increased long-term risk of proctocolectomy: results from an outpatient IBD clinic.

Cytomegalovirus (CMV) infection has been found to be associated with a reactivation of ulcerative colitis (UC) and with an impaired response to medical therapy. In the past, only limited data were available on the long-term outcome for UC patients with positive tissue CMV-PCR in the colonic mucosa. Between January 2010 and April 2015, we performed a qualitative PCR screening for CMV DNA in one biopsy from most actively inflamed rectal mucosa (tCMV-PCR). All tCMV-PCR-positive patients received 900mg of valganciclovir b.i.d. for at least 15days. We analyzed the association of the tCMV-PCR status with the time to steroid-free remission (SFR) and with the risk of proctocolectomy during the further course. One hundred eight consecutive patients (50 women, 58 men, median age 41years, median UC duration 6years) with active UC not responding to anti-inflammatory medication were analyzed. Eight of the 24 tCMV-PCR-positive patients (33.3%) compared to ten of the 84 tCMV-PCR-negative patients (11.9%) underwent proctocolectomy during a median follow-up of 52months (p < 0.005). The median time from CMV diagnosis to colectomy was 501days (median, interquartile range (IQR): 170, 902days) in tCMV-PCR-positive and 958days (IQR: 287, 1328days) in tCMV-PCR-negative patients (p < 0.01). The median time to SFR was 126days in tCMV-PCR-positive patients vs. 63days in tCMV-PCR-negative patients (p < 0.01). The detection of the CMV DNA in the colonic mucosa of patients with active UC is associated with a longer time to steroid-free UC remission and with an increased rate and earlier need of proctocolectomy.

Aqueous tap and rapid diagnosis of cytomegalovirus anterior uveitis: the Reggio Emilia experience.

The diagnosis of cytomegalovirus (CMV) anterior uveitis in immunocompetent patients requires confirmation by polymerase chain reaction (PCR) analysis and/or intraocular antibody index (AI) assay. In this study, we analyzed the different contributions of PCR and AI to CMV diagnosis by performing one single aqueous tap. A retrospective chart review was conducted of HIV-negative patients attending the Ocular Immunology Unit of Azienda Unità Sanitaria Locale - IRCCS, Reggio Emilia, Italy, from March 2015 to April 2018 with a diagnosis of hypertensive anterior granulomatous uveitis compatible with suspected CMV etiology. Diagnosis was confirmed by real-time PCR (RT-PCR) and intraocular antibody production against CMV on aqueous humor samples. Clinical features were compared to antibody titer and diagnostic delay. Twenty-three patients with suspected CMV uveitis (13 males, 10 females, mean age 48 ± 16years) were included in the analysis. AI was positive in 20/23 (87%) samples, and PCR tested positive in 9/23 (39%). By combining both tests, the sensitivity was 100%. Median diagnostic delay was 29months (IQR 9-107). Diagnostic delay and antibody titer were significantly associated with glaucoma (r = 0.714, p < 0.0001; r = 0.476, p = 0.02, respectively). Our data suggest that to improve the diagnostic accuracy of CMV anterior uveitis, PCR and AI are both useful and complimentary. In our series, AI was the most sensitive diagnostic tool. One single aqueous tap is sufficient to achieve 100% sensitivity in CMV diagnosis. Early diagnosis is necessary to prevent the development of glaucoma.

No evidence of obstetrical adverse events after hyperimmune globulin application for primary cytomegalovirus infection in pregnancy: experience from a single centre

To determine the frequency of obstetrical adverse events and clinical outcome in infants following antenatal hyperimmune globulin (HIG) treatment for primary cytomegalovirus (CMV) infection in pregnancy. Data from 50 women including three twin pregnancies were retrospectively evaluated. Primary infection was defined by seroconversion or the presence of CMV-specific IgM and low IgG avidity. All women received two or more infusions of HIG (200U/kg). Congenital CMV (cCMV) infection was diagnosed by detection of CMV in amniotic fluid and/or neonatal urine. We compared gestational age (GA) at birth, head circumference (HC) and birth weight (BW) of infants in our study cohort with those of live-born infants delivered in our clinic between 2015 and 2016. Median gestational age at time of maternal CMV diagnosis was 13weeks. One-hundred-forty-one maternal HIG doses were given. No HIG-related severe adverse reactions occurred. Preterm birth rate was 4.2% (2/47) in singleton pregnancies. None of the neonates had birth weight or head circumference<3rd percentile (<3P) for gestational age. There was no statistically significant difference regarding GA, BW and HC between our study cohort and the total population of live-born infants. The frequency of CMV-related sequelae in infants with cCMV infection was 10.5% (2/19) (one with bilateral hearing loss and one with mild motoric delay), both cases following first trimester maternal infection. Antenatal HIG treatment was well tolerated and not associated with prematurity or decreased birth weight. HIG application might have a favorable effect on the clinical course of congenital CMV infection.

Pp65 antigenemia and cytomegalovirus diagnosis in patients with lupus nephritis: report of a series.

ABSTRACTIntroduction:In contrast to organ transplantation, few studies correlate the monitoring of pp65 antigenemia with a diagnosis of cytomegalovirus (CMV) in patients with systemic lupus erythematosus (SLE).Objective:To highlight the importance of CMV outside transplantation, we monitored pp65 antigenemia in a series of SLE patients.Methods:From March 2015 to March 2016, SLE patients presenting kidney involvement, fever, and an unclear infection at hospital admission were monitored through pp65 antigenemia. The pp65 antigenemia assay, revealed by immunofluorescence, was correlated with clinical and laboratory findings.Results:We included 19 patients with a suspected unclear infection. A positivity for pp65 antigenemia was found in seven patients (36.8%). The mean age was 33.5 ± 11.2 years, 16 (84%) were females, and 16 (84%) were black. Lymphopenia, anemia, and higher scores of SLEDAI were significantly more common in pp65-positive patients. Five patients received antiviral therapy with ganciclovir. Although receiving specific CMV treatment, one patient died because of suspected CMV disease.Conclusions:Pp65 antigenemia might be relevant in SLE patients, and studies with a greater number of patients are needed in order to establish sensitivity and specificity of pp65 antigenemia in different clinical contexts of SLE patients.

Not Your Typical Case of Hemoptysis: A Rare Presentation of Severe CMV Esophagitis

Cytomegalovirus (CMV) infection is rare in immunocompetent individuals but is a major pathogen for immunocompromised patients. The spectrum of disease is broad and includes a range of gastrointestinal diseases. Esophagitis is the second most common gastrointestinal manifestation of CMV infection after colitis. A 40-year-old Chinese woman with end-stage kidney disease on immunosuppression after failed renal transplant was sent from the clinic for urgent initiation of hemodialysis. On initial presentation, she complained of mouth ulcers, which subsequently resolved. During the hospitalization, she developed belching and nausea with food intake, with no dysphagia. She also had multiple bouts of hemoptysis associated with fevers and chills. Tuberculosis was initially suspected, however, a chest x-ray was normal. During one episode of hemoptysis, she developed tachycardia, EKG changes, and an elevated troponin. A computed tomography (CT) angiogram was negative for pulmonary embolism but showed mild esophageal dilatation, wall thickening, and mild pneumomediastinum suggesting possible esophageal perforation. An esophagram was negative for extravasation of contrast but revealed irregular esophageal contour with linear ulcerations. An EGD demonstrated sloughed off severely friable mucosa with spontaneous bleeding, inflammation, and ulcerations throughout the esophagus consistent with severe erosive esophagitis. Given the friability of the esophagus on examination, no biopsies were taken due to the concern for perforation. The patient was started empirically on ganciclovir and intravenous pantoprazole. CMV PCR DNA returned positive and all other serologies were negative. Ganciclovir caused severe leukopenia and was discontinued after seven days of treatment. Subsequently, a repeat EGD was performed and showed a normal esophagus. CMV infection with GI involvement is present in 26% of renal transplant recipients. In our case, biopsies were not performed given concern for perforation; however CMV diagnosis was established based on positive PCR. The most common symptoms of CMV esophagitis are odynophagia, dysphagia, and chest pain. Our patient presented with hemoptysis and esophagitis was incidentally established to be the cause. Given the high prevalence of esophagitis in this population, a high index of suspicion must be maintained even with atypical presentations.FigureFigure

Recent advances in CMV tropism, latency, and diagnosis during aging.

Human cytomegalovirus (CMV) is one of the largest viruses known to cause human diseases. Chronic CMV infection, as defined by anti-CMV IgG serology, increases with age and is highly prevalent in older adults. It has complex biology with significant immunologic and health consequences. This article aims to summarize research findings presented at the 6th International Workshop on CMV and Immunosenescence that relate to advances in the areas of CMV tropism, latency, CMV manipulation of cell metabolism, and T cell memory inflation, as well as novel diagnostic evaluation and translational research of chronic CMV infection in older adults. Information summarized here represents the current state of knowledge in these important fields. Investigators have also identified a number of areas that deserve further and more in-depth investigation, including building more precise parallels between mouse CMV (mCMV) and human CMV (HCMV) research. It is hoped that this article will also stimulate engaging discussion on strategies and direction to advance the science to the next level.

The diagnostic impact generated by the presence of Cytomegalovirus IgM antibodies in pregnancy

Background: Cytomegalovirus (CMV) infection is one of the most common congenital infections and the most frequent cause of mental retardation and non-genetically cause of deafness. The risk of fetal transmission is above 40%. The objectives of this study were to review and improve the CMV diagnosis in pregnancy. Method: 50 pregnant women took part in the study. They were taken in evidence at the virology counseling office. The reason for the need of viral diagnosis came from the fact that the result of previous routine serological testing came out positive for CMV IgM antibodies (Ab). Based on the test result, the gynecologist may normally indicate the termination of the pregnancy. Results: In the virology counseling office the results for CMV IgM Ab test turn out negative in 48 of the 50 (96%) referred pregnant women. In two women CMV IgM Ab test turn out positive. These women also tested positive for CMV IgG Ab test. The pregnant women were also tested for pp65 antigenemia. They presented a four times raise in CMV IgG Ab titer. All the rest were negative for pp65 antigemenia. Conclusion: From the 50 women only two needed to terminate their pregnancies. It is important to test for CMV infection in pregnancy along with other viral, bacterial or parasitic infections, but the indication of pregnancy termination must be taken only after a thorough examination and testing. It would be helpful if CMV tests, as well as all the TORCH tests were supported by the health insurance system.

Adaptive NK Cell Expansion Is Associated with Reduced Relapse of Lymphoid Malignancies after Autologous Hematopoietic Cell Transplant

Introduction: Our group previously reported that latent or reactivated cytomegalovirus (CMV) after hematopoietic cell transplantation (HCT) leads to expansion of a CD56dimCD57+NKG2C+ "adaptive" natural killer (NK) cell subset that displays characteristics of immune memory. Here we report on the impact of these adaptive NK cells on outcomes after autologous (auto) HCT in patients with lymphoid malignancies.Methods: Based on our prior studies in allogeneic transplant, we hypothesized that patients with high absolute numbers of CD56dimCD57+NKG2C+ "adaptive" NK cells at day 28 post auto HCT ("high group") would have lower risk of relapse compared to those with low numbers ("low group"). Secondary outcomes included overall survival (OS) at 2 years and incidence of bacterial, fungal and viral infections 3 months post HCT. Patients with CMV reactivation were excluded because of low incidence (5%). Recursive partitioning was used to differentiate a high (≥1.529 adaptive NK cells/µL, n=88) from low (<1.529 cells/µL, n=25) group based on the largest Gray test statistic at day 28, which predicted the risk of relapse. Kaplan-Meier curves were used to estimate the probability of relapse and disease free survival (DFS) through 2-year post-HCT, and the log-rank test was used for comparisons. Fine-Gray and Cox regression was used to examine the independent effect of factors on relapse and DFS, respectively.Results: Overall, mean age at HCT was 55.8 years, 52% were males and 64% were CMV seropositive. Diagnoses included Hodgkin (13%) and non-Hodgkin lymphoma (36%) and multiple myeloma (51%) [Table 1]. Almost all patients (96%) in the low group vs. 77% in the high group had Karnofsky performance scores (KPS) of 90 or higher at the time of HCT, p=0.04.There were no other differences between the baseline characteristics of the groups. Cumulative incidence of relapse at 2-years was 34% (95% confidence interval [CI] 23-44%) in the high group compared with 70% (95% CI 49-91%) in the low group (p=0.0012). 2-year DFS rates were 63% (95% CI 51-72%) and 30% (95% CI 12-50%), respectively (p=0.0032) [Figure 1]. Overall survival (OS) at 2-years was 87% (95% CI 77-92%) in the high group vs. 84% (95% CI 63-94%) in the low group, p=0.70. Cumulative incidence of bacterial infections (25% vs. 24%, p=0.91), viral infections (2% vs. 0%, p=0.9) or fungal infections at 90 days (4% each, p=0.9) were similar in high and low groups. After adjusting for CMV serostatus, diagnosis, disease status, age, gender, KPS and comorbidity index in multivariate analysis, the high group had significantly lower risk of relapse (hazard ratio [HR] 0.22, 95% CI 0.11-0.46, p<0.0001) and improved DFS (HR 0.28, 95% CI 0.13-0.56, p<0.001) compared with the low group. The protective effect of CD56dimCD57+NKG2C+ NK cells on relapse (HR 0.12, 95% CI 0.05-0.30, p<0.0001) and DFS (HR 0.14, 95% CI 0.06-0.33, p<0.0001) was noted only in CMV seropositive patients, but not in seronegative individuals.Conclusion: We show that patients with lymphoid malignancies with high absolute counts of "adaptive" CD56dimCD57+NKG2C+ NK cells at day 28 post auto HCT had significantly superior DFS and lower risk of relapse compared with patients with low absolute "adaptive" NK cell counts. There was no difference in the risk of bacterial, fungal or viral infections or in OS between the groups. These provocative data suggest that interventions to increase numbers of these adaptive NK cells might provide a novel means of enhancing protection against relapse following auto HCT. [Display omitted] [Display omitted] DisclosuresCichocki:Fate Therapeutics, Inc: Research Funding. Miller:Oxis Biotech Scientific Advisory Board: Membership on an entity's Board of Directors or advisory committees.

Value of immunoglobulin G avidity for primary cytomegalovirus diagnosis in pregnant women compared to nested polymerase chain reaction

Primary human cytomegalovirus (HCMV) infection in pregnancy especially in the first term carries high risks to foetus. Diagnosis depends mainly on laboratory tools as clinical diagnosis is non specific. The aim of the present study was to detect recent infection with HCMV in cohort pregnant Egyptian women in the first trimester by serological detection of specific IgM, IgG and IgG avidity test compared to nested PCR method. This study was performed on consecutive pregnant women. Blood samples were obtained and sera were separated from 120 pregnant women in their first trimester of pregnancy and were screened for anti-CMV IgG, IgM and IgG avidity by ELISA and for HCMV-DNA by PCR. Positive IgG for HCMV was 62.5% and positive IgM was 15%. IgG avidity results showed that low, intermediate and high avidity represented 33.3%, 16.7% and 50%, respectively of IgM positive patients and 42.1%, 38.6% and 19.3%, respectively of IgM negative patients. Detection of HCMV DNA by PCR was positive in one of 24 IgM negative/low IgG avidity, in three of 22 IgM negative/intermediate IgG avidity and in all IgM positive/low IgG avidity patients. Confirmatory testing for primary infection with the combined use of IgG avidity with IgM antibody test in pregnant women during the first trimester is an accurate screening tool. The use of PCR as a diagnostic method can be applied to pregnant women with IgM antibodies and low IgG avidity results or in presence of isolated low or intermediate avidity IgG.

Sensitivity of blood and tissue diagnostics for gastrointestinal cytomegalovirus disease in solid organ transplant recipients.

Gastrointestinal (GI) cytomegalovirus (CMV) disease is the most common manifestation of tissue-invasive CMV infection in solid organ transplant (SOT) recipients, but the diagnostic yields of blood and tissue testing have not been systematically assessed in a large patient cohort. We retrospectively identified consecutive SOT recipients with biopsy-confirmed GI CMV disease who had both tissue and blood (CMV polymerase chain reaction or antigenemia) diagnostic testing performed within 14 days of diagnosis. Descriptive statistics and logistic regression were used to assess the association between patient factors and viremia and the diagnostic yield of tests performed on biopsy specimens. A total of 101 patients (73% donor seropositive/recipient seronegative [D+/R-], 22% recipient seropositive [R+]) had GI CMV disease (58% upper, 22% lower, and 20% both) at a median of 185 days (range, 21-6345 days) post transplant. In multivariate analysis, R+ CMV serostatus (odds ratio [OR] 0.1 [0.0-0.4], P < 0.001) and diagnosis >6 months post transplant (OR 0.3 [0.1-0.9], P = 0.03) were each independently associated with absence of CMV viremia at time of diagnosis. In the subset of patients (n = 29) in whom both histopathology and viral culture were performed on biopsy specimens, 11 (39%) had CMV detected only by culture and had similar clinical characteristics and outcomes to those with positive histopathology (P > 0.05 for all comparisons). The sensitivity of viremia in SOT recipients with GI CMV disease is significantly lower in CMV-seropositive patients and in those >6 months post transplant. Addition of viral culture to endoscopic biopsy specimens significantly increases the diagnostic yield for GI CMV disease.

Evaluation of T Cell Immunity against Human Cytomegalovirus: Impact on Patient Management and Risk Assessment of Vertical Transmission.

Cytomegalovirus (CMV) is one of the most common infectious agents, infecting the general population at an early age without causing morbidity most of the time. However, on particular occasions, it may represent a serious risk, as active infection is associated with rejection and disease after solid organ transplantation or fetal transmission during pregnancy. Several methods for CMV diagnosis are available on the market, but because infection is so common, careful selection is needed to discriminate primary infection from reactivation. This review focuses on methods based on CMV-specific T cell reactivity to help monitor the consequences of CMV infection/reactivation in specific categories of patients. This review makes an attempt at discussing the pros and cons of the methods available.

Postnatal Cytomegalovirus Infection and the Risk for Bronchopulmonary Dysplasia.

Postnatally acquired cytomegalovirus (CMV) is typically benign in term infants but in very low-birth-weight (VLBW) infants can cause pneumonitis and sepsislike illness. Whether postnatal CMV infection results in long-term pulmonary sequelae in these infants is unknown. To investigate the association between postnatal CMV infection and bronchopulmonary dysplasia (BPD) and mortality in a large multicenter cohort of VLBW infants. Conducted between October 2014 and June 2015, this propensity-matched retrospective cohort study involved 101,111 hospitalized VLBW (<1500 g) infants at 348 neonatal intensive care units in the United States from 1997 to 2012. We matched infants with postnatal CMV infection 1:1 to comparison infants using propensity scores, and we used Poisson regression to examine the effect of postnatal CMV on the combined risk for death or BPD at 36 weeks' postmenstrual age. To describe features of postnatal CMV infection, we extracted clinical and laboratory data from 7 days before until 7 days after infants met criteria for postnatal CMV. Postnatal CMV infection was defined as a diagnosis of CMV or detection of CMV from blood, urine, cerebrospinal fluid, or respiratory secretions on or after day of life 21. Infants with a CMV diagnosis or virologic detection of CMV prior to day of life 21 were not considered to have postnatal infection. The primary outcome was death or BPD at 36 weeks' postmenstrual age. Of 101,111 infants, 328 (0.3%) had postnatal CMV infection. We matched a comparison infant to 303 CMV-infected infants (92%) for a final cohort of 606 infants. The median gestational age and birth weight of this cohort were 25 weeks and 730 g, respectively. Postnatal CMV infection was associated with an increased risk for death or BPD at 36 weeks' postmenstrual age (risk ratio, 1.21; 95% CI, 1.10-1.32) and BPD (risk ratio, 1.33; 95% CI, 1.19-1.50). Changes in cardiorespiratory status associated with postnatal CMV infection included a new requirement for vasopressor medications (9%; n = 29), intubation for mechanical ventilation (15%; n = 49), a new oxygen requirement (28%; n = 91), and death (1.2%; n = 4). In VLBW infants, postnatal CMV infection was associated with increased risk for BPD. Further studies are needed to determine the role of preventive measures against CMV in this population.

First-Day Direct Hyperbillirubinemia in an Infant with Congenital Cytomegalovirus Infection

The human cytomegalovirus (CMV) is widely distributed among the human population as one of the most common causes of congenital infection with an incidence of about 0.15-2.0% in developed countries.In this case report we present a female neonate (with a maternal history of flu-like syndrome in 30 weeks of pregnancy) delivered via caesarian section with good reflexes and appropriate APGAR score, without any obvious anomalies. Its cerebrospinal fluid and unigrams were found to be normal. The CMV diagnosis was confirmed by neonate serology (IgM-positive). Additionally, positive results for CMV were obtained from the neonate’s urine polymerase chain reaction test. Therefore, the necessity for differential diagnosis (e.g. hemolysis, ABO RH mismatch, biliary duct obstruction) was eliminated. Treatment with ganciclovir and granulocyte-colony stimulating factor (Gancyclovir induced neutropenia) was provided, as a result of which a dramatic immediate and short-term response was observed.It is proposed that multisystem involvement in congenital CMV should be suspected and medical treatment should be administered especially in life threatening conditions.

CMV Reactivation is Associated with Reduced Relapse Risk, Better Disease-Free Survival and Expansion of Adaptive NK Cells after Reduced Intensity Hematopoietic Cell Transplantation

We have previously shown that while NK cells are the first lymphocyte reconstituting after allogeneic transplantation, these NK cells are immature and functionally hyporesponsive when exposed to tumor targets. Remarkably, this can be reversed by reactivation of human cytomegalovirus (CMV). A distinct population of natural killer (NK) cells with attributes of immunological memory arises specifically in response to acute CMV infection in healthy individuals or reactivation of latent CMV in hematopoietic cell transplantation (HCT) recipients. These adaptive NK cells are defined by expression of the activating receptor NKG2C and maturation marker CD57 and display a heightened capacity for inflammatory cytokine production and cytolysis in response to target cell recognition. Since the differentiation and maturation of NK cells is dependent upon interactions with cells of the myeloid lineage, including antigen-presenting cells, we hypothesized that the expansion of adaptive NK cells could influence relapse risk, particularly after a reduced intensity conditioning (RIC) regimen where residual host myeloid cells may intensify donor adaptive NK cell expansion in response to CMV reactivation after HCT. Thus, we analyzed 1-year relapse rates in 674 allogeneic HCT recipients at the University of Minnesota (470 umbilical cord blood (UCB) and 204 matched sibling donor (MSD)) between 2001-2013 with AML (n=313), ALL (n=187), MDS (n=85), CML (n=28), NHL (n=42), Hodgkins (n=14) and Multiple Myeloma (n=5) segregated by recipient CMV serostatus (270 seronegative and 404 seropositive). Within the CMV seropositive group, 190 individuals experienced CMV reactivation. We observed no association between CMV reactivation and 1-year relapse rates in recipients of myeloablative conditioning (n=366; 16% [10%-22%] for CMV seronegative vs. 18% [12-24%] for CMV seropositive without CMV reactivation vs. 15% [8%-22%] for CMV seropositive recipients with CMV reactivation). In marked contrast, CMV reactivation was associated with lower 1-year relapse rates following RIC (n=308; 35% [27%-43%] for CMV seronegative vs. 30% [20-40%] for CMV seropositive without CMV reactivation vs. 26% [17%-35%] for CMV seropositive with CMV reactivation [p for trend=0.05, Figure 1A]). In multivariate analyses adjusting for recipient CMV status, conditioning regimen, donor type (MSD vs. UCB), diagnosis (AML [shown to be sensitive to NK cell effects] vs. other), gender, disease risk (standard vs. high) and prior autologous transplant, CMV reactivation was independently associated with lower relapse risk (RR=0.6 [0.4-1.0], p=0.06) and increased DFS (RR=0.7 [0.5-1.0], p=0.05) following RIC, but not myeloablative HCT. Although CMV reactivation led to superior DFS within the entire cohort (RR=0.7 [0.6-1.0], p=0.04), CMV reactivation was not independently associated with lower relapse risk (RR=1.0 [0.5-1.8], p=0.88) with myeloablative conditioning. To determine whether the preparative regimen also influenced adaptive NK cell differentiation post-transplant, we analyzed the percentage of CD56dimCD57+NKG2C+ NK cells. Compared to myeloablative recipients, after RIC, the percentage of circulating CD56dimCD57+NKG2C+ NK cells was significantly higher at 4 weeks post-CMV reactivation (8.58% vs. 4.64%, p=0.02), 8 weeks post-CMV reactivation (7.77% vs. 3.84%, p=0.02), and 6 months post-transplant (14.80% vs. 6.29%, p=0.01) (Figure 1B). Our results demonstrate a relationship between CMV reactivation and enhanced graft-versus-leukemia (GVL) in patients treated with RIC. The association between lower relapse risk and in vivo expansion and survival of adaptive NK cells suggests that these cells may be critical to reducing the risk of relapse. Strategies to isolate and expand adaptive NK cells in order to enhance the GVL effect without clinical CMV reactivation are being actively explored. [Display omitted] DisclosuresMiller:Coronado: Speakers Bureau; BioSciences: Membership on an entity’s Board of Directors or advisory committees; SAB: Membership on an entity’s Board of Directors or advisory committees, Speakers Bureau.

Evaluation of Serial Urine Viral Cultures for the Diagnosis of Cytomegalovirus Infection in Neonates and Infants

Cytomegalovirus (CMV) is the most common cause of congenital infection worldwide. Urine viral culture is the standard for CMV diagnosis in neonates and infants. The objectives of this study were to compare the performance of serial paired rapid shell vial cultures (SVC) and routine viral cultures (RVC), and to determine the optimal number of cultures needed to detect positive cases. From 2001 to 2011, all paired CMV SVC and RVC performed on neonates and infants less than 100 days of age were recorded. Testing episodes were defined as sets of cultures performed within 7 days of one another. A total of 1264 neonates and infants underwent 1478 testing episodes; 68 (5.4%) had at least one episode with a positive CMV culture. In episodes where CMV was detected before day 21 of life, the first specimen was positive in 100% (16/16) of cases. When testing occurred after 21 days of life, the first specimen was positive in 82.7% (43/52) of cases, requiring three cultures to reach 100% detection. The SVC was more prone to assay failure than RVC. Overall, when RVC was compared to SVC, there was 86.0% positive agreement and 99.9% negative agreement. In conclusion, three serial urine samples are necessary for detection of CMV in specimens collected between day of life 22 and 99, while one sample may be sufficient on or before day of life 21. Though SVC was more sensitive than RVC, the risk of SVC failure supports the use of multimodality testing to optimize detection.