Cytomegalovirus DNA PCR Research Articles

Evaluation of CMV DNA Antigenemia Status in Patients With Allogeneic Bone Marrow Transplant

Purpose: The risk of cytomegalovirus (CMV) reactivation following allogeneic hematopoietic stem cell transplantation (ASCT) reaches 30-50%, and there are numerous diagnostic tests to detect CMV replication. The most common tests used in this group of patients include 65kDa phosphoprotein (pp65) antigenemia immunofluorescence assay and nucleic-acid-based quantitative CMV-DNA polymerase chain reaction (qPCR). Material and Methods: In this study, patients who underwent ASCT and developed CMV positivity from 2009 to 2016 in our hospital were evaluated retrospectively. The study included samples of the same patient with antigenemia and CMV-DNA qPCR test for up to 48 hours. The study aimed to determine the factors affecting CMV DNA antigenemia and compare CMV DNA PCR and pp65 antigenemia immunofluorescence assay. Results: The results of 138 specimens of 39 patients who underwent ASCT were evaluated. The mean value of CMV PCR, which was positive for both tests, was 57.887 copies/ml (70- 1.213.633 copies/ml) and a significant correlation was found between the two tests and the positive samples (p = 0.018). The ROC analysis showed that 322 copies/ml CMV viral load in plasma corresponds to ≥1 antigen-positive cells/200 thousand leukocytes (Sensitivity: 68.5%; Specificity: 31.5%). CMV infection was observed in 32 samples; CMV DNA cut-off values of the reference according to CMV DNA PCR and antigenemia results, compared to the development of CMV infection, presented a significant correlation (p=0.004). Conclusion: Although there is a common agreement between antigenemia and CMV DNA PCR tests, one should keep in mind that the sensitivity of antigenemia test is low especially in the neutropenic period.

Haploidentical Donor Transplants with Cytokine Release Syndrome Have Increased Risk of Clinically Significant Early CMV Reactivation Compared with Matched Donor Transplants Receiving Post-Transplant Cyclophosphamide

Background: Post-transplant cyclophosphamide (PTCy) enables safe haploidentical stem cell transplantation by reducing graft-versus-host-disease (GVHD) but is associated with an increased risk of reactivation of Cytomegalovirus (CMV). PTCy has more recently been adopted for matched-donor transplants, where early CMV reactivation may also be more common. This suggests that CMV reactivation is a function of PTCy rather than donor source. However, other studies comparing the rates of CMV in transplants using PTCy-based prophylaxis suggested disparity in donor source may contribute to CMV reactivation. Aim: The goal of this single-centre, retrospective study was to determine if donor type had any impact on CMV reactivation in the setting of PTCy-based GVHD prophylaxis. Methods: The Alfred Hospital Bone Marrow Transplantation Unit has used PTCy for GVHD prophylaxis in both haploidentical and matched-donor allogeneic stem cell transplants (alloSCT) since 2015. A local database search identified 119 allogeneic peripheral blood alloSCT recipients receiving PTCy-based GVHD prophylaxis between February 2015 and December 2022. Matched-donor alloSCTs also received cyclosporin from Day +5 while haploidentical alloSCTs also received tacrolimus and mycophenolate from Day +5. One patient was excluded due to CMV viremia at the time of transplant. Recipients who were CMV seropositive received therapeutic dose valganciclovir 900 mg twice daily from the start of conditioning until the day prior to stem cell infusion. Prophylactic valganciclovir (900 mg daily) was planned upon engraftment for seropositive recipients and those receiving stem cells from a seropositive donor. CMV DNA PCR was performed weekly for the first 100 days post-transplant and beyond when clinically indicated. CMV viremia was defined as any positive CMV PCR (> 34.5 copies/mL) within the first 100 days post-transplant. Therapeutic valganciclovir was initiated for CMV viral loads (VL) > 1,000 copies/mL or earlier for rapidly rising VLs. Cytokine release syndrome (CRS) was defined as fever > 38 degrees Celsius between stem cell infusion and PTCy on Day +3 without an alternate explanation and graded according to CTCAE criteria. CMV donor and recipient negative transplants were excluded from the analysis of the impact of donor disparity on CMV reactivation. Statistical analyses included Fisher's Exact test, one-way ANOVA and Binomial Logistic Regression. Results: Transplant characteristics according to donor source were similar apart from conditioning intensity, where recipients of haploidentical stem cells were more likely to receive myeloablative conditioning (Table 1). The cumulative incidence of moderate-severe chronic GVHD was significantly higher in matched sibling transplants but overall, 12-month GVHD-free and relapse-free survival were similar. As previously reported, CRS (overall and grades II-IV) was significantly more common in haploidentical transplants. Day 100 CMV viremia rates were not statistically different between donor groups. However, haploidentical transplants trended for earlier CMV reactivation (p=0.08), and were significantly more likely to rise above 250 copies/mL (Table 1 and Figure 1). Consequently, haploidentical transplant recipients received significantly more anti-CMV therapy (p=0.009). Multivariable analysis identified haploidentical donor as a major risk factor for CMV > 250 (odds ratio, OR 1.24, p=0.011) and > 1,000 copies/mL (OR 1.41, p=0.032) while transplant for AML/MDS was negatively associated with CMV > 250 (OR 0.19, p=0.009) and CMV > 1,000 copies/mL (OR 0.16, p=0.003). CRS was significantly associated with CMV > 1,000 copies/mL (OR 3.33, p=0.032) but this was no longer significant in multivariable analysis due to the association with haploidentical donor transplantation. Conclusion: This single-center retrospective comparison of PTCy-based transplants shows that haploidentical transplants have increased risk of early and clinically significant reactivation of CMV. Potential explanations include increased immunosuppression with mycophenolate and the presence of CRS, where inflammatory cytokines may de-repress the CMV major immediate early promoter. Selecting this high-risk group (haploidentical transplants with CRS) may be a cost-effective use of letermovir, which can be initiated prior to engraftment.

Cytomegalovirus (CMV) as a cause of exacerbation of ulcerative colitis (UC). An approach to diagnosis and management

Cytomegalovirus (CMV) reactivation may be a cause of acute exacerbations in patients with severe ulcerative colitis (UC). Patients with exacerbation of symptoms by CMV have greater morbidity and mortality rate.The present study was conducted to evaluate the prevalence of CMV infection in UC patients by endoscopic examination, histopathological examination and CMV DNA PCR of colonic mucosal biopsy tissue and also to identify the associated risk factors and clinical outcomes.

S2176 Co-Occurrence of Two Rare Diseases: CMV Colitis in a Patient With Clozapine-Included Ischemic Colitis

Introduction: CMV (Cytomegalovirus) colitis is a well-recognized disease in immunocompromised patients, however, there are case reports and series describing the disease in immunocompetent hosts. Given its rarity, its characteristics are yet to be well defined. We present a case of CMV colitis in an immunocompetent patient who likely had concomitant ischemic colitis from clozapine. Case Description/Methods: A 68-year-old female with PMH of Schizophrenia on Clozapine, chronic constipation presented to the emergency department with 1 day of bloody diarrhea and NBNB vomiting. On arrival, she was noted to be tachycardic and tachypneic with a physical exam revealing diffuse abdominal tenderness and hypoactive bowel sounds. Initial labs were notable with leukocytosis of 19 K/ul with bands. Serum lactate, renal function, and liver function tests were normal. Clozapine level was elevated at 1143 ng/dl. Computed Tomography Angiography of the abdomen showed severe colitis of the entire descending colon. Working diagnosis at that point was Infectious colitis, inflammatory colitic, and ischemic colitis. She completed 5 days of antibiotics despite negative Gastrointestinal panel PCR with some relief of symptoms. Colonoscopy planned on day 6 was postponed due to acute delirium, which required the initiation of a new anti-psychotic. Colonoscopy on day 28 showed a 10 cm area of non-bleeding ulcerated mucosa at the splenic flexure. Histopathology reports which became available 1 week later showed colonic mucosa with ulceration, granulation tissue, acute inflammation, and rare CMV-positive cells. HIV test which was then obtained was negative, and CMV DNA PCR was 52 IU/ml. She was subsequently started on Valgancyclovir and discharged without any acute events with a plan for a follow-up colonoscopic examination. Discussion: CMV is a common virus with positive serology in upwards of 2-thirds of the general population. However, it rarely manifests in immunocompetent hosts. CMV colitis in immunocompetent hosts has been described mostly as a superinfection in patients with primary gastrointestinal disorders. Destruction of colonic mucosa from the ischemic colitis caused by clozapine likely allowed for CMV to establish the infection in our patient. It is thought that the anticholinergic manifestation in the gastrointestinal tracts which causes constipation and luminal dilation leads to decreased capillary circulation. Treatment usually involves discontinuation of the drug and supportive care.

Impact of antimetabolite discontinuation following cytomegalovirus or BK polyoma virus infection in kidney transplant recipients.

Cytomegalovirus (CMV) and BK polyoma virus (BKV) infection following kidney transplantation have been associated with allograft dysfunction and allograft loss. Reduction in immunosuppression is a mainstay of management yet has been associated with increased risk of rejection. According to international consensus guidelines, one approach to management of these viral infections is to discontinue the antimetabolite. Little is known surrounding long-term outcomes in these patients, and it remains unclear if consideration should be given to resuming the antimetabolite as variable re-escalation strategies have been reported. The objective was to describe episodes of rejection and identify risk factors for rejection following antimetabolite withdrawal after CMV or BKV DNAemia in kidney transplant recipients. This single-center, retrospective review evaluated adult kidney transplant recipients with a serum CMV or BKV DNA PCR ≥500 copies/ml who underwent antimetabolite discontinuation. The primary outcome assessed was the incidence of biopsy-proven acute rejection (BPAR). One hundred fifty-nine patients were included. Overall, 14 patients (8.8%) experienced BPAR at a median of 1.6 years after antimetabolite discontinuation. Compared to CMV, discontinuation after BKV DNAemia was associated with a higher incidence of BPAR. Characteristics observed more frequently in patients with BPAR included younger age, female sex, higher initial viral load, and development of de novo donor-specific antibody (DSA). These findings suggest that antimetabolite discontinuation after CMV or BKV DNAemia in kidney transplant recipients is a reasonable and safe approach. Further prospective studies investigating optimal immunosuppression management following CMV or BKV DNAemia in kidney transplant recipients are warranted.

924. Cytomegalovirus (CMV) Retinitis during Maintenance Chemotherapy for Acute Lymphoblastic Leukemia

Abstract Background Acute leukemia patients are at risk for cytomegalovirus (CMV) retinitis following hematopoietic stem cell transplantation, though the disease can also occur in non-transplant adult leukemia patients. Emerging data suggest a shift to pediatric-inspired chemotherapy regimens in adults with acute lymphoblastic leukemia (ALL) can lead to increasing cytopenias and impaired functional immunity, placing these patients at risk for this opportunistic infection. Here we describe a case of CMV retinitis in an ALL patient following a lower-intensity regimen during maintenance chemotherapy. Methods Chart review. Results A 55-year-old male with ALL presented to his optometrist with complaints of visual changes including “fogginess” and “floaters”. The patient had completed 8 cycles of dose-adjusted etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab (EPOCH-R) and achieved complete remission. He had been on maintenance chemotherapy with 6-mercaptopurine, vincristine, methotrexate, and prednisone (POMP) for 2 months at the time of symptom onset. He was referred to his local ophthalmologist who had concerns for bilateral, zone 1 CMV retinitis based on fundoscopic exam (Figure 1). Vitreous aspiration was performed and CMV DNA PCR returned positive at 1.6 million IUs/ml. Peripheral blood CMV DNA PCR was also positive at 1133 IU/ml. He was started on combination therapy with intravitreal ganciclovir injections and oral valganciclovir 900 mg twice daily (Figure 2). The patient received 14 intravitreal injections with resultant stability of his eye exam, though he remained on induction valganciclovir for 5 months due to persistent blood CMV DNAemia. Letermovir was added to help suppress his peripheral CMV DNAemia and he attained partial vision recovery. Figure 1. Fundoscopic images Conclusion CMV retinitis is an uncommon and highly morbid infection that can occur during maintenance chemotherapy in adult non-transplant ALL patients. Early identification of the disease is imperative as delay can result in blindness or further systemic CMV disease. Treatment is challenging, involving systemic and intravitreal antiviral therapy, serial ophthalmologic exams, serum CMV monitoring, and close coordination with the treating hematologist. Disclosures Michael Boeckh, MD PhD, AlloVir (Consultant)Ansun Biopharma (Grant/Research Support)Astellas (Grant/Research Support)EvrysBio (Consultant, Other Financial or Material Support, Options to acquire equity, but have not exercised them)Gilead Sciences (Consultant, Grant/Research Support)GlaxoSmithKline (Consultant)Helocyte (Consultant, Other Financial or Material Support, Options to acquire equity, but have not exercised them)Janssen (Grant/Research Support)Kyorin (Consultant)Merck (Consultant, Grant/Research Support)Moderna (Consultant)Symbio (Consultant)Takeda (formerly known as Shire) (Consultant, Grant/Research Support)VirBio (Consultant, Grant/Research Support) Ryan Cassaday, MD, Amgen (Grant/Research Support, Advisor or Review Panel member)Kite/Gilead (Grant/Research Support, Advisor or Review Panel member)Merck (Grant/Research Support)Pfizer (Grant/Research Support, Advisor or Review Panel member)Seagen (Other Financial or Material Support, Spouse is employee and hold stock)Vanda Pharmaceuticals (Grant/Research Support)

Mathematical Modeling of Within-Host, Untreated, Cytomegalovirus Infection Dynamics after Allogeneic Transplantation.

Cytomegalovirus (CMV) causes significant morbidity and mortality in recipients of allogeneic hematopoietic cell transplantation (HCT). Whereas insights gained from mathematical modeling of other chronic viral infections such as HIV, hepatitis C, and herpes simplex virus-2 have aided in optimizing therapy, previous CMV modeling has been hindered by a lack of comprehensive quantitative PCR viral load data from untreated episodes of viremia in HCT recipients. We performed quantitative CMV DNA PCR on stored, frozen serum samples from the placebo group of participants in a historic randomized controlled trial of ganciclovir for the early treatment of CMV infection in bone marrow transplant recipients. We developed four main ordinary differential Equation mathematical models and used model selection theory to choose between 38 competing versions of these models. Models were fit using a population, nonlinear, mixed-effects approach. We found that CMV kinetics from untreated HCT recipients are highly variable. The models that recapitulated the observed patterns most parsimoniously included explicit, dynamic immune cell compartments and did not include dynamic target cell compartments, consistent with the large number of tissue and cell types that CMV infects. In addition, in our best-fitting models, viral clearance was extremely slow, suggesting severe impairment of the immune response after HCT. Parameters from our best model correlated well with participants’ clinical risk factors and outcomes from the trial, further validating our model. Our models suggest that CMV dynamics in HCT recipients are determined by host immune response rather than target cell limitation in the absence of antiviral treatment.

Outcomes of Cytomegalovirus Monitoring in Autologous Transplantation: A Single Institution Experience

Introduction: Identification of patients seropositive for cytomegalovirus (CMV) prior to stem cell transplant (SCT) is a well-accepted practice across institutions designed to reduce a known cause of morbidity and mortality in this population, but the role of monitoring and preemptive approaches to CMV identification and treatment are controversial and not standardized in autologous transplantation. The preemptive approach necessitates the use of significant resources and requires persistent patient involvement. Patients undergoing autologous SCT are at a relatively low risk for CMV reactivation, especially those seronegative for CMV at the time of transplant. Here, we show that the necessity of routine monitoring of autologous transplant patients is of minimal clinical value.Methods: To determine the efficacy of the CMV monitoring protocol currently in place at our institution in detecting patients who would later develop CMV reactivation and disease following autologous SCT, we retrospectively analyzed the charts of 218 adult patients between 11/1/14 and 8/1/19 who underwent transplant at St. Louis University Hospital. No patients underwent CD34 selected stem cell infusions. The protocol stipulated the following: CMV IgG/IgM and CMV DNA PCR prior to preparative regimen followed by weekly CMV DNA PCR to day +30 . We correlated the predictive ability of positive results on any of these screening tests to identify whether patients would later develop quantifiable CMV DNA PCR positivity, clinical manifestations of CMV disease, and/or require pharmacologic treatment for CMV.Results: Quantifiable pre-BMT DNA PCR was positive in only 0.46% of patients, and 97.79% of patients were DNA PCR negative prior to transplant. CMV IgG was positive in 56.4% patients, and only 22.1% of patients in this group went on to develop a quantifiable post-transplant PCR. Of the remaining 43.6% of patients initially testing negative for CMV IgG, no patients went on to develop a quantifiably positive post-transplant PCR. Regardless of seropositivity, only 0.08% of the 1,191 PCRs performed during the study period were found to be quantifiable. Further, no patients in our cohort developed CMV disease or required CMV treatment during the monitoring period. This trend persisted despite stratification by age, diagnosis, transplant number, and preparative regimen.Conclusion: When clinically-significant CMV is defined by cases requiring treatment or the development of end-organ disease, no screening tests performed elicited clinical action. Laboratory-based CMV surveillance, based on our data, has minimal diagnostic implications and represents an overly-stringent practice in a set of patients already utilizing a substantial share of healthcare resources. We believe that pre-transplant screening for CMV IgM serology and CMV DNA PCR can be safely eliminated in the autologous SCT population at our institution while CMV IgG still plays a role in determining candidacy for CMV-negative blood products. We also propose the elimination of serial post-transplant monitoring with DNA PCR in patients without clinical signs, symptoms, or pathologic findings suggestive of CMV disease. We have changed the protocol to test for CMV PCR only if there are clinical scenarios that indicate a utility, such as prolonged fever post-transplant, unexplained cytopenias, or unexplained pneumonitis, colitis, or hepatitis. By extension, other centers should consider determining the necessity of CMV screening in their autologous transplant population given the potential resource conservation and reduction in healthcare expenditures. DisclosuresFesler: abbvie: Consultancy, Speakers Bureau; incyte: Consultancy, Speakers Bureau; sanofi: Speakers Bureau; morphosys: Speakers Bureau; epizyme: Consultancy; jazz: Consultancy; Skipta: Consultancy; Best Doctors: Consultancy; Aptitude Health: Consultancy; Care Dx: Consultancy; Opinionsite: Consultancy. Goldenberg: Seattle Genetics: Membership on an entity's Board of Directors or advisory committees.

S2852 Tissue Invasive Cytomegalovirus Enteritis With Gastric Outlet Obstruction in an Immunocompetent Patient

INTRODUCTION: Cytomegalovirus (CMV) usually causes asymptomatic or mononucleosis-like syndrome in immunocompetent individuals. We present a case of severe tissue invasive gastrointestinal CMV in an immunocompetent individual complicated by gastric outlet obstruction. CASE DESCRIPTION/METHODS: A 72-year-old man with a history of hypertension presented with vomiting, postprandial abdominal pain, and hematochezia for one week. He had also lost 40lbs in three months. Physical examination was normal except for epigastric tenderness. The previous colonoscopy done 5 years ago was normal. No personal or family history of inflammatory bowel disease, gastrointestinal malignancy, or lymphoma. He had never had immunosuppressive therapy, organ transplantation, or any other biological agent. Initial blood work revealed Hemoglobin 10.9 g/dl, AST 64 IU/l, ALT 83 IU/l, and ALP 350 IU/l. His HIV and Tuberculosis screening were negative. Ultrasound and CT scan of the abdomen and pelvis were normal except for increased gallbladder wall thickness (3mm). An Esophagogastroduodenoscopy (EGD) revealed esophagitis, pyloric channel ulcer, and duodenal ulcer. Colonoscopy revealed an ulcer at the ileocecal valve. The biopsy of all the ulcers revealed ulcerated mucosa, architectural distortion, and reactive epithelial atypia suspicious of CMV infection which was later confirmed by immunohistochemical staining (IHC) [Figure 1]. Quantitative CMV DNA PCR analysis showed levels of 1739 IU/ml. He was started on intravenous ganciclovir while inpatient and sent home on oral valganciclovir for 21 days. His symptoms improved significantly after treatment. CMV DNA levels decreased to 1230 IU/ml post-treatment. The patient returned with symptoms of gastric outlet obstruction a few months later which were getting worse. His barium X-ray revealed a delayed gastric emptying time with pyloric stenosis and partial malrotation of the small bowel [Figure 2]. A repeat EGD revealed pyloric stenosis with an inner diameter of 11 mm, which was dilated endoscopically. The biopsy taken from an antral ulcer was negative for CMV on IHC staining. There were no other signs of prior CMV infection on the EGD. DISCUSSION: The gastric outlet obstruction in the patient is likely a long term sequela of CMV. Due to the undertreatment and delay in diagnosis, CMV infections can lead to long term and potentially life-threatening complications. Therefore, gastrointestinal CMV should be considered in immunocompetent patients and aggressively treated.Figure 1.: Medium power (100×) Immunohistochemical staining for CMV with hematoxylin counter-stain. A representative high power view demonstrating strong focal CMV immunoreactivity.Figure 2.: Barium Xray reveals pyloric stenosis (black arrow) and malrotation with the first loop of jejunum to the right.

2591. The Role of Neutralizing Antibodies (nAb) Against Cytomegalovirus (CMV) Epithelial Cell-entry in Patients with Self-limited (SL) CMV infection after Hematopoietic Cell Transplantation (HCT)

BackgroundCMV transmission after HCT occurs in 20–30% of CMV-seronegative recipients with CMV-seropositive donors (i.e., CMV D+/R−) and a distinct subset develop transient CMV DNAemia without progression to culture positivity in the absence of antivirals (BMT 1992; 9:221; J Med Virol 2019; 91:1128). The mechanism of SL CMV infection is unknown but may involve nAb, which have been implicated in primary viral clearance, including nAb that inhibit viral epithelial and endothelial cell-entry via CMV pentameric complex (PC). We aimed to describe viral kinetics and the influence of nAb on CMV infection progression in SL CMV-infected patients and controls within a unique cohort from the pre-antiviral era.MethodsWeekly serum samples from 456 CMV D+/R− allogeneic HCT patients collected between 1978–95 were screened using quantitative CMV DNA PCR. Patients with CMV DNAemia in the first 100 days after HCT followed by a sustained return to undetectable levels without positive surveillance CMV cultures were defined as having SL CMV infection. SL CMV-infected patients were matched 1:1:1 to CMV-infected controls (patients with CMV infection by culture in the same period after HCT ± 14 days) and non-infected controls (patients without CMV DNA or culture positivity) to compare viral kinetics and nAb. A modified nAb assay was used to evaluate serum nAb activity against CMV PC-mediated cell entry (Vaccine 2008; 26:5760; JID 2019; in press).ResultsWe identified 9 patients with SL CMV infection and baseline demographics are shown (Table 1). SL CMV-infected patients had a median of 21 days (range 7–54 days) until first positive CMV DNAemia. The median peak CMV DNAemia was 94.2 IU/mL (range 40.2–225.9 IU/mL) and 46,118 IU/mL (range 1,132–284,362 IU/mL) in SL CMV-infected and CMV-infected controls respectively. There was no difference in nAb titers between groups at infection day 0 or in the preceding 4 weeks (Figure 1, Figure 2).ConclusionnAb against CMV PC-mediated cell entry did not appear to play a critical role in viral clearance in SL CMV infection after CMV D+/R- allogeneic HCT. Our study illustrates the potential for clearance of relatively low CMV DNAemia after HCT without the addition of antivirals. CMV-specific T-cell immunity or innate immune mechanisms may be more important in early viral control. Disclosures All authors: No reported disclosures.

3240 Cytomegalovirus Gastritis in an Immunocompetent Patient

INTRODUCTION: Cytomegalovirus (CMV) is a large enveloped virus of the Herpes virus family. CMV frequently infects humans and can establish latent infection after an acute infection. In immune-compromised patients, CMV can have neurological, cutaneous, gastrointestinal (GI), cardiac or ocular manifestations and can cause severe organ dysfunction leading to significant morbidity and mortality. The colon and the stomach are the common sites of GI infection. CASE DESCRIPTION/METHODS: 54 year old female with no prior medical history presented to the hospital with complaints of shortness of breath for the last 3 days and was noted to be in rapid atrial fibrillation. Patient was admitted and subsequently found to have severe mitral valve stenosis and moderate to severe tricuspid regurgitation. The patient was seen by Cardio-thoracic surgery and underwent mitral valve replacement and tricuspid ring annuloplasty. During the post-operative period, the patient was found to have blood in her stool and was evaluated by the gastroenterology service. In evaluating her GI bleed, she underwent an upper endoscopy. Findings on upper endoscopy included, small hiatus hernia and a single small ulcer in the incisura of the stomach. An area of gastritis was found in the antrum/body of the stomach. The mucosa appeared nodular and edematous. Biopsies were taken from the antrum and showed gastric antral type mucosa with reactive gastropathy. CMV viral inclusions were present in the gastric pit epithelial cells, confirmed on immunostain for CMV. HIV and quantiferon gold tests were negative and the patient was not known to be on any immunosuppressive therapies. Serum CMV DNA PCR was tested on 2 subsequent days which showed 4858 IU/ml and 5548 IU/mL respectively. DISCUSSION: CMV infection of the GI tract is a common manifestation of CMV disease in the immunocompromised patients such as Acquired immunodeficiency syndrome, organ/ bone marrow transplantation and other condition requiring chronic immunosuppressive therapy. CMV of the GI tract is rare in an immunocompetent patient and only few cases have been reported so far. Presenting symptoms include odynophagia/dysphagia, epigastric pain, nausea/vomiting, GI bleeding. However, in up to 7% of cases it can be asymptomatic. Endoscopic features of CMV infection include macroscopic normal mucosa, diffuse erythema, nodules, pseudotumors, erosions and ulcers. Detection of intranuclear inclusions, also known as “owl's eye,” is the hallmark of CMV infection.

1501 Double Whammy: Checkpoint Inhibitor and CMV-Induced Colitis

INTRODUCTION: Immune checkpoint inhibitors (ICIs) such as nivolumab have become a common treatment for several types of malignancies, especially metastatic disease. Diarrhea and enterocolitis are known side effects of these drugs. Here we present a case of a patient who developed ICI associated colitis who was later diagnosed with superimposed Cytomegalovirus colitis. CASE DESCRIPTION/METHODS: A 75-year-old male with past medical history pertinent for squamous cell carcinoma of the neck and base of tongue treated with nivolumab. His treatment was interrupted due to the development of chronic diarrhea possibly related to immune checkpoint inhibitor therapy (nivolumab). Immunotherapy was discontinued and the patient was started on a high dose of steroids with initial clinical response and symptom control. He was admitted to the hospital two months later with signs of shock with hematochezia and profound diarrhea. Computed Tomography (CT) of his abdomen upon admission showed severe colitis. Blood cultures were positive for Streptococcus infantarium (previously known as Streptococcus bovis) likely translocation from severe immunotherapy-induced colitis. His hemodynamics improved with fluid resuscitation and antibiotic therapy; however his diarrhea did not resolve. He then underwent colonoscopy which demonstrated circumferential, uninterrupted, extensive and severe inflammation (Figures 1 and 2) with the procedure terminated prematurely to avoid risk of perforation. Pathology of colonic biopsies showed positive immunostaining for Cytomegalovirus (CMV), and the patient tested positive for CMV DNA PCR, confirming acute active infection. He was started on valganciclovir and his steroid regimen was tapered with significant improvement of his diarrhea. DISCUSSION: Immune checkpoint inhibitors are monoclonal antibodies that target downregulators of the anti-neoplastic immune response. There are currently seven FDA approved ICIs, including Nivolumab. Immune-mediated colitis and diarrhea are the most common side effects associated with these drugs. One third of patients treated with ICIs will experience gastrointestinal adverse effects and 1-2% of patients on nivolumab will experience diarrhea. Although is not common, infection can coexist and in the setting of persistent and recurrent diarrhea it has to be ruled out.

Single-center experience with use of letermovir for CMV prophylaxis or treatment in thoracic organ transplant recipients.

Cytomegalovirus (CMV) infection is common in thoracic organ transplant recipients. Valganciclovir and ganciclovir are used for both prophylaxis and treatment of this infection, but intolerance and treatment failure are common. Letermovir has been demonstrated to reduce the risk of CMV infection when used for prophylaxis in allogeneic hematopoietic cell transplantation. However, there are no data on its efficacy in thoracic organ transplantation. We examined the use of letermovir for either CMV prophylaxis (primary and secondary) or treatment in heart and lung transplant recipients at our institution from February 1, 2018, through December 31, 2018. Nine total patients received letermovir at our institution (8 lung transplant, 1 heart transplant) during the study period. Letermovir was prescribed for CMV prophylaxis in eight patients (primary prophylaxis in two patients and secondary prophylaxis in 6 patients), and for treatment of CMV DNAemia in two cases. One patient received letermovir for both secondary prophylaxis and treatment on separate occasions. Three out of 8 (37.5%) patients receiving letermovir for prophylaxis developed CMV DNAemia during prophylaxis. One patient treated for CMV disease had clinical failure with a sharp rise in serum CMV DNA PCR. The other patient treated for low-grade CMV DNAemia initially had a slight rise in CMV DNA PCR, but has since had a sustained response. No major side effects were experienced, and 2 patients reported minor side effects. Letermovir was well tolerated with only minor side effects reported; however, the rate of development of CMV DNAemia on prophylaxis was considerable. Further study of the dosing and efficacy of letermovir for CMV prophylaxis or treatment in thoracic organ transplant recipients is warranted.

DETECTION OF CMV DNA IN INTRAOCULAR FLUID SAMPLES IN PATIENTS CLINICALLY DIAGNOSED WITH VIRAL UVEITIS BY MOLECULAR METHODS

Background: Latent Cytomegalovirus (CMV) infections may be reactive in consequence of immunosuppression. Recently, CMV-associated uveitis cases have also been reported in immunocompetent individuals. Aim: The aim of this study was to obtain epidemiological data by evaluating CMV DNA PCR results, clinical characteristics and risk factors of patients diagnosed with viral uveitis. Methods: Between the years 2011-2017, anterior chamber fluid samples of 35 patients with viral uveitis sent from the ophthalmology clinic to the Virology Laboratory were included in this study. CMV DNA real-time PCR results were evaluated. Results: CMV DNA positivity was detected in 9 (26%) of the 35 patients. CMV DNA positivity was highest (13%) in over 60 years (p=0.02). Acute recurrent uveitis in 44% (4/9) of patients, single eye involvement in 78% (7/9) and anterior uveitis in 44% (4/9) were found. Conclusion: In this study, CMV DNA positivity was detected in 26% of the patients with viral uveitis. Considering the presentations of a small number of cases related to CMV uveitis in our country, this study is important due to being the most comprehensive study in our country.

Determination of Optimal Viral Kinetic Markers for Predicting Antiviral Treatment Effect for the Prevention of Cytomegalovirus (CMV) Disease after Hematopoietic Cell Transplant (HCT) Using Machine Learning and a Novel Non-Parametric Estimation Method

The United States Food and Drug Administration recently issued guidance that CMV DNAemia (quantitative CMV viral load as measured by PCR) could be used in a composite endpoint along with tissue-invasive CMV disease as the primary endpoint in allogeneic HCT CMV prophylaxis trials. However, the specific time points after antiviral treatment initiation at which to measure viral load and the viral load thresholds that most accurately predict clinical CMV disease have not been identified. In order to estimate the treatment effect of an antiviral agent on CMV clinical outcomes, placebo-controlled, randomized trial data with accompanying viral load measurements are needed. Unfortunately, in the modern era of PCR and early preemptive treatment, ethically, placebo-controlled, randomized trials that allow for the development of CMV disease after HCT can no longer be performed. To overcome this limitation, we performed CMV DNA PCR testing on frozen plasma samples collected during the first 100 days post-HCT in the only placebo-controlled, double-blind RCT of ganciclovir for the early treatment of CMV infection after HCT (Goodrich et al. NEJM 1991). We used three analytic methods (Cox proportional hazards models, machine learning, and a novel non-parametric method) to determine which of 14 viral load markers, measured in the first four weeks of treatment, are the most useful surrogates of antiviral treatment for the prevention of CMV disease. All methods identified peak viral load and percentage of positive samples by week 4 as highly associated with or predictive of tissue-invasive CMV disease by week 8 post-randomization. Cox proportional hazards models (Figure 1) yielded significant associations for peak viral load measured by week 4 (HR 1.4, 95% CI 1.1-1.9) and percentage of positive samples by week 4 (HR 1.6, CI 1.1-2.3). The machine-learning ensemble algorithm SuperLearner implemented in R (Figure 2) demonstrated cross-validated area under the receiver-operator curves of at least 75% for peak viral load (75%, CI 62-87%) and percentage of positive plasma samples (77%, CI 63-90%) measured by week 4. Using a novel statistical technique that allows direct estimation of biomarker surrogacy (Parast et al. Stat Med 2017), we estimated that the percentage of ganciclovir treatment effect explained by peak viral load and percentage of positive samples measured by week 4 was greater than 85%—peak viral load 89%, CI 56-100%; percent positive samples 91%, CI 60-100% (Figure 3). Peak viral load and percentage of positive samples by week 4 are highly predictive of CMV disease and the treatment effect of ganciclovir. Our analysis suggests that these may be the best surrogate markers of ganciclovir treatment and introduces novel methods for identifying optimal candidate biomarkers as surrogates for clinical endpoints.

351. It Is Not Always Tuberculosis: Cytomegalovirus Polyradiculopathy and Encephalitis in Two Filipino Men With Advanced HIV Infection

BackgroundPolyradiculopathy (PRP) and encephalitis are neurologic syndromes associated with 1% of cytomegalovirus (CMV) disease among patients with advanced HIV infection. Untreated patients die within 8 weeks. This case series and literature review highlights the clinical and laboratory features integral to the prompt diagnosis and treatment of these rare but serious manifestations of CMV disease among AIDS patients.MethodsWe document CMV PRP and encephalitis in two HIV-seropositive men seen in a tertiary hospital in the Philippines. Both patients presented with bilateral leg weakness, paresthesias, hyporeflexia, and urinary retention associated with confusion and memory lapses. In the two cases described, diagnosis of CMV disease was delayed because it was not immediately entertained. Tuberculosis involving the nervous system was first ruled out.ResultsThe first case was a 31-year-old male with a baseline CD4 count of 9 cells/mm3 who presented with signs and symptoms of bilateral leg weakness and paresthesias 3 weeks after initiation of antiretrovirals (ART). CMV viremia was detected by PCR. Ganciclovir was initiated late, and he subsequently died of multiorgan failure. The second case is a 29-year-old male with a baseline CD4 count of 2 cells/mm3. CMV DNA PCR was detected in the CSF. He died prior to initiation of anti-CMV therapy.ConclusionCMV-related neurologic complications are uncommon, but often fatal when appropriate anti-CMV therapy is not initiated promptly. The diagnosis of CMV PRP should be considered in patients with advanced immunosuppression presenting with ascending paraplegia, areflexia, and urinary retention with typical CSF abnormalities (polymorphonuclear pleocytosis, elevated protein concentration, and hypoglycorrhachia).Table 1. Summary of Presenting Signs and Symptoms of the Two Cases in Comparison to the 103 Patients with CMV PRP in Anders and Goebel’s ReviewSign or SymptomAnders and Goebel [2]Case 1Case 2Lower limb weakness100%PresentPresentLower limb areflexia100%PresentPresentUrinary retention94%PresentPresentParesthesia79%PresentPresentSensory loss (legs)72%PresentPresentFecal incontinence67%AbsentAbsentLumbar pain36%AbsentAbsentBabinski sign16%AbsentAbsentDisclosures All authors: No reported disclosures.

The significance of cytomegalovirus in children with pneumonia admitted for mechanical ventilation.

The pathogenic role of cytomegalovirus (CMV) among children with pneumonia is not clear. We describe the outcome of children on mechanical ventilation with 'probable' CMV-related pneumonitis (CMV DNA polymerase chain reaction [PCR] positive as well as clinical and imaging features of CMV on ganciclovir) and children with pneumonia and CMV infection (CMV DNA PCR-positive without clinical and imaging features of CMV and not on ganciclovir therapy) at a paediatric intensive care unit in South Africa between 2011 and 2013. CMV viral loads were measured in non-bronchoscopic bronchoalveolar lavage fluid (NBBALF), plasma and whole-blood samples. Of the 97 children enrolled, 38 had CMV-related pneumonitis, 27 had pneumonia and CMV infection and 32 had pneumonia without CMV infection (negative CMV DNA PCR). Survival in the three groups was respectively 73.7% (P < 0.05), 92.6% (P < 0.05) and 88.0%. The difference in outcome could be accounted for by variance in the prevalence of human immunodeficiency virus (HIV) infection (respectively 60.5% and 29.6%, P < 0.05). A higher CMV viral load in NBBALF and plasma was seen in cases of CMV-related pneumonitis than in pneumonia with CMV infection: respectively log 5.20 vs. log 4.10 (P < 0.05) and 4.56 vs. 3.47 (P < 0.05). HIV-infected children on mechanical ventilation with CMV-related pneumonitis on ganciclovir have poor outcomes. Randomised placebo-controlled studies on ganciclovir are required.

Efficacy and safety of an extemporaneous preparation of 2% ganciclovir eye drops in CMV anterior uveitis

BackgroundTo evaluate the efficacy and safety of an extemporaneous preparation of 2% ganciclovir topical eye drops in cytomegalovirus (CMV) anterior uveitis because many studies have confirmed the benefits of topical...

“Targeted” Screening for Cytomegalovirus (CMV)-Related Hearing Loss: It’s Time for Universal CMV Screening in the NICU!

BackgroundCongenital CMV infection is the leading cause of non-genetic sensorineural hearing loss in infancy. Antiviral therapy has been shown to improve hearing outcomes, and thus “targeted” CMV screening for newborns who do not pass the hearing screen has been recommended. Diagnosis of congenital CMV infection requires that the infant be tested for CMV in the first 3 weeks of age. Our objective was to determine when infants in the neonatal intensive care unit (NICU) have their first hearing screen performed and thus inform the practice of targeted screening for determination of CMV-related hearing loss.MethodsRetrospective review of the electronic health records of all infants admitted to the Level 4 outborn NICU at Nationwide Children’s Hospital, Columbus, OH from August 2016 to May 2017. Demographic and clinical data were obtained, and the age that the first hearing screen was performed was assessed.ResultsDuring the 10 month study period, 362 infants were admitted to the NICU and had a first hearing screen performed. The majority of neonates (204, 56%) had a first hearing screen performed in the first 3 weeks of age. However, 158 (44%; median birth weight [IQR], 1072 g [747–1766]; median gestational age [IQR], 28 weeks [25–32]) infants received the first hearing screen at >3 weeks of age when a positive CMV PCR or culture cannot distinguish congenital infection from intrapartum/postnatal acquisition of CMV. Of the 158 infants, 20 (13%) did not pass the first hearing screen (13, unilateral; 7, bilateral), and subsequently, 9 of them did pass a second hearing screen. However, 11 of the 20 infants did not pass a second hearing screen and had urine CMV PCR testing, and 1 (9%) was positive. This latter infant’s newborn dried blood spot CMV DNA PCR was negative so a diagnosis of congenital CMV infection was not possible.ConclusionTargeted screening in the NICU for CMV-related hearing loss is problematic as a substantial number of infants do not have a hearing screen performed until after 21 days of age, thus representing a missed opportunity for diagnosis of congenital CMV infection and institution of antiviral therapy if indicated. Our findings support universal CMV screening of neonates on admission to the NICU.Disclosures O. Adunka, MED-EL Corporation: Consultant, Consulting fee, Educational grant and Research support; Advanced Bionics: Consultant, Consulting fee and Licensing agreement or royalty; Advanced Cochlear Diagnostics: President, Ownership interest; AGTC Corporation: Consultant, Consulting fee

Cytomegalovirus Infection in Pediatric Haploidentical Hematopoietic Stem Cell Transplantation at a Single Center

Introduction : Clinical aspects and risk factors of Cytomegalovirus (CMV) reactivation and diseases are an emerging interest in recent investigation fields of hematopoietic stem cell transplantation (HSCT). Several risk factors and clinical manifestations of CMV infection have been reported in numbers of previous reports. Monitoring of viral replication and timely given antiviral agents have resulted in a decreased incidence of CMV-related death recently. However, CMV in still a major cause of infectious complications after HSCT. Specially in haploidentical HSCT setting, clinical manifestations and associated risk factors have been rarely reported. This study is conducted to identify risk factors and clinical aspects of CMV reactivation and disease in pediatric haploidentical HSCT.Methods : We retrospectively reviewed the medical records of 92 pediatric patients who underwent haploidentical HSCT using ex vivo T cell-depleted grafts at Asan Medical Center between December, 2004 and June, 2016. After haploidentical HSCT, all recipients were monitored for CMV infection by CMV pp65 antigen and/or CMV-PCR. Both recipient and donor were screened for CMV serology before the HSCT. During the study period, methodologic changes in ex vivo T cell depletion and CMV prophylaxis policy have been modulated with the course of time. During the 1st study period (Group I, n=19), CD3+ T cell was depleted without CMV prophylaxis while ganciclovir for CMV prophylaxis was given with CD3+ T cell depletion during the 2nd period (Group II, n=16). The T cells expressing alpha-beta T cell receptor (TCRαβ) was depleted during the 3rd period (Group III, n=57) with ganciclovir prophylaxis.Results : Of the 92 patients, 49 (53.3%) developed CMV reactivation after haploidentical HSCT. CMV reactivation significantly reduced in group II and III compared to group I (84±8.4% vs 46±5.9%; p<0.001). Patients with chronic graft-versus-host-disease (GVHD) also experienced more reactivation (p=0.041). In the multivariate analysis, difference of study group was the only variable predicted the occurrence of CMV reactivation (Group I vs Group III; hazard ratio, 3.728; 95% confidence interval (CI), 1.910-7.278). CMV disease was developed in 16/92 (17.4%) patients during the study period (16/49, 32.7% among CMV reactivation patients). The peak CMV pp65 antigen level, peak CMV DNA-PCR level, and duration of CMV antigenemia were significantly higher in patients with CMV disease (p=0.024, p=0.009, p=0.046, respectively). In univariate analysis, the peak CMV pp65 antigen level (p=0.020), and duration of CMV antigenemia (p=0.05) were associated with increased occurrence of CMV disease. In multivariate analysis, CMV disease significantly increased in patients with high CMV pp65 antigenemia greater than 40/200,000 cells (hazard ratio, 3.568; 95% CI 1.062-12.594). CMV diseases included retinitis in 12 (75%), pneumonitis in 3 (25%), gastritis, colitis, and encephalitis in 1 (8.3%) each, respectively. Of the 16 patients, 3 patients (2 pneumonitis, 1 encephalitis) died of CMV disease.Conclusions : Our study demonstrated that ganciclovir prophylaxis has effectively reduced the occurrence of CMV reactivation in ex vivo T cell depleted haploidentical HSCT. In addition, close monitoring of CMV pp65 antigen and timely preemptive management is important to prevent CMV related death. DisclosuresNo relevant conflicts of interest to declare.