Cytomegalovirus In Bronchoalveolar Lavage Research Articles

Detection of cytomegalovirus in bronchoalveolar lavage fluid from immunocompromised patients with pneumonitis by viral culture and DNA quantification

PurposeTo compare the detection of human cytomegalovirus (HCMV) in bronchoalveolar lavage (BAL) fluid by viral culture and quantitative polymerase chain reaction (qPCR), and to establish a viral load threshold that can identify cases of HCMV replication indicative of pneumonitis. There is currently no universal viral load cut-off to differentiate between patients with and without pneumonitis, and the interpretation of qPCR results is challenging. Methods176 consecutive BAL samples from immunosuppressed hosts with signs and/or symptoms of respiratory infection were prospectively studied by viral culture and qPCR. ResultsConcordant results were obtained in 81.25% of the BAL samples. The rest were discordant, as only 34% of the qPCR-positive BAL samples were positive by culture. The median HCMV load was significantly higher in culture-positive than in culture-negative BAL samples (5038 vs 178 IU/mL). Using a cut-off value of 1258 IU/mL of HCMV in BAL, pneumonia was diagnosed with a sensitivity of 76%, a specificity of 100%, a VPP of 100% and VPN of 98%, and HCMV was isolated in 100% of the BAL cultures. ConclusionWe found that a qPCR-negative was a quick and reliable way of ruling out HCMV pneumonitis, but a positive result did not always indicate clinically significant replication in the lung. However, an HCMV load in BAL fluid of ≥ 1258 IU/mL was always associated with disease, whereas < 200 IU/mL rarely so.

2199. Herpesviridae lung reactivation and infection in patients with severe Covid-19 or influenza virus pneumonia: a comparative study

Abstract Background Lung reactivations of Herpesviridae, herpes simplex virus (HSV) and cytomegalovirus (CMV) have been reported in Covid-19 patients. Whether or not those viral reactivations are more frequent than in other patients is not known. Methods Retrospective monocentric cohort study of 145 patients with severe Covid-19 pneumonia requiring invasive mechanical ventilation and who were tested for HSV and CMV in bronchoalveolar lavage performed during fiberoptic bronchoscopy for ventilator-associated pneumonia suspicion. Rates of HSV and CMV lung reactivations, and HSV bronchopneumonitis were assessed and compared with an historical cohort of 89 patients with severe influenza pneumonia requiring invasive mechanical ventilation. Results Among the 145 Covid-19 patients included, 50% and 42 % had HSV and CMV lung reactivations, respectively; whereas among the 89 influenza patients, 63% and 28% had CMV lung reactivations, respectively. Cumulative incidence of HSV lung reactivation (taking into account extubation and death as competing events) was higher in influenza than in Covid-19 patients (p = 0.03, see figure 1), whereas the rate of HSV bronchopneumonitis was similar in both groups (31% and 25%, respectively). Cumulative incidence of CMV lung reactivation (taking into account extubation and death as competing events) was similar in Covid-19 and influenza patients (p=0.07). Outcomes of patients with HSV or CMV lung reactivations were similar to that of patients without, whatever the underlying conditions, i.e., in Covid-19 patients, in influenza patients, or when all patients were grouped. Estimated cumulative incidence of herpes simplex virus (HSV) lung reactivation, extubation or death in Covid-19 and influenza patients, taking into account only the first event that occurred. p values for differences between Covid-19 and influenza patients were 0.03 for HSV reactivation, 0.53 for death and 0.87 for extubation. Conclusion HSV and CMV lung reactivations are frequent in Covid-19 patients, but not more frequent than in patients with influenza-associated severe pneumonia, despite a higher severity of illness at intensive care unit (ICU) admission of the latter and a longer duration of mechanical ventilation of the former. Although no impact on outcome of HSV and CMV lung reactivations was detected, the effect of antiviral treatment against these Herpesviridae remains to be determined in these patients. Disclosures CHARLES-EDOUARD LUYT, MD PhD, AdvanzPharma: Honoraria|Aerogen: Honoraria|Merck: Honoraria.

Herpesviridae lung reactivation and infection in patients with severe COVID-19 or influenza virus pneumonia: a comparative study

BackgroundLung reactivations of Herpesviridae, herpes simplex virus (HSV) and cytomegalovirus (CMV) have been reported in COVID-19 patients. Whether or not those viral reactivations are more frequent than in other patients is not known.MethodsRetrospective monocentric cohort study of 145 patients with severe COVID-19 pneumonia requiring invasive mechanical ventilation and who were tested for HSV and CMV in bronchoalveolar lavage performed during fiberoptic bronchoscopy for ventilator-associated pneumonia suspicion. Rates of HSV and CMV lung reactivations, and HSV bronchopneumonitis were assessed and compared with an historical cohort of 89 patients with severe influenza pneumonia requiring invasive mechanical ventilation.ResultsAmong the 145 COVID-19 patients included, 50% and 42% had HSV and CMV lung reactivations, respectively, whereas among the 89 influenza patients, 63% and 28% had HSV and CMV lung reactivations, respectively. Cumulative incidence of HSV lung reactivation (taking into account extubation and death as competing events) was higher in influenza than in COVID-19 patients (p = 0.03), whereas the rate of HSV bronchopneumonitis was similar in both groups (31% and 25%, respectively). Cumulative incidence of CMV lung reactivation (taking into account extubation and death as competing events) was similar in COVID-19 and influenza patients (p = 0.07). Outcomes of patients with HSV or CMV lung reactivations were similar to that of patients without, whatever the underlying conditions, i.e., in COVID-19 patients, in influenza patients, or when all patients were grouped.ConclusionsHSV and CMV lung reactivations are frequent in COVID-19 patients, but not more frequent than in patients with influenza-associated severe pneumonia, despite a higher severity of illness at intensive care unit admission of the latter and a longer duration of mechanical ventilation of the former. Although no impact on outcome of HSV and CMV lung reactivations was detected, the effect of antiviral treatment against these Herpesviridae remains to be determined in these patients.

A CONFUSING CASE OF PNEUMONIA IN A PATIENT WITH HUMAN IMMUNODEFICIENCY VIRUS

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: The incidence of acquired immunodeficiency syndrome (AIDS) related opportunistic infections has declined dramatically following the introduction of potent antiretroviral therapy. However, pulmonary infections remain a significant cause of morbidity and mortality (1). The spectrum of pulmonary disease that can affect patients with human immunodeficiency virus (HIV) is wide and includes opportunistic infection with many bacterial, fungal, viral, and parasitic organisms (2). Herein, we present a rare case of pneumonia caused by four different pathogens: Strongyloides Stercoralis, Pneumocystis Jirovecii (PCP), Cytomegalovirus (CMV) and Pseudomonas Aeruginosa. CASE PRESENTATION: A 65-year-old female from Mexico with a past medical history of HIV presents to the emergency department with subacute dyspnea, mild hemoptysis, melena, and fatigue. She was non-compliant with her anti-retroviral therapy. Her CD4 count was <20 cells/uL with a HIV PCR of 1,690,000 copies/mL. CBC demonstrated normocytic anemia (hemoglobin: 6.0 g/dl); hemolysis was excluded. Her Pa02 was 60 mmHg on room air. A computed tomography (CT) scan of the chest with contrast (image) revealed diffuse bilateral ground-glass opacities with diffuse interlobular septal thickening. Severe enteritis and colitis were seen on the CT abdomen/pelvis with contrast. The patient was empirically started on levofloxacin, metronidazole, intravenous (IV) trimethoprim-sulfamethoxazole and prednisone. Sputum cultures were positive for pan sensitive Pseudomonas Aeruginosa. Bronchoalveolar lavage (BAL), upper and lower endoscopy were performed. Blood and BAL CMV PCR were positive. She was subsequently started on IV ganciclovir. BAL PCP PCR was high. Several days later, numerous Strongyloides Stercoralis larvae were seen in the BAL and on the duodenal biopsy. Daily ivermectin was initiated. The patient progressed to septic shock requiring IV norepinephrine and her oxygenation worsened. The patient refused escalation of care and decided to proceed with comfort measures. The patient passed away within a few hours. DISCUSSION: Prior to the era of potent antiretroviral therapy, parasitic pulmonary infections were more commonly seen than they are today (2). Immunocompromised patients are at high risk for systemic strongyloidiasis which presents as either disseminated strongyloidiasis or hyper infection syndrome (3). Aside from HIV, our patient was empirically started on prednisone for PCP treatment which might have contributed to worsening systemic strongyloidiasis and therefore worsening clinical status. For severe disease, patients should be started on daily ivermectin along with empiric antibiotic therapy with activity against gram-negative bacteria. CONCLUSIONS: We describe a rare case of HIV related pneumonia caused by four different pathogens. Reference #1: Boyton RJ. Infectious lung complications in patients with HIV/AIDS. Curr Opin Pulm Med. 2005 May;11(3):203-7. Reference #2: Skalski JH, Limper AH. Fungal, Viral, and Parasitic Pneumonias Associated with Human Immunodeficiency Virus. Semin Respir Crit Care Med. 2016;37(2):257. Reference #3: Celedon JC, Mathur-Wagh U, Fox J, Garcia R, Wiest PM. Systemic strongyloidiasis in patients infected with the human immunodeficiency virus. A report of 3 cases and review of the literature. Medicine (Baltimore). 1994;73(5):256 DISCLOSURES: No relevant relationships by Ahmad Al-Shyoukh, source=Web Response No relevant relationships by Laith Derbas, source=Web Response No relevant relationships by Ashraf Gohar, source=Web Response No relevant relationships by Raed Qarajeh, source=Web Response No relevant relationships by Moustafa Younis, source=Web Response

Cytomegalovirus Viral Load in Bronchoalveolar Lavage to Diagnose Lung Transplant Associated CMV Pneumonia.

The diagnostic yield for cytomegalovirus (CMV) polymerase chain reaction (PCR) viral load in bronchoalveolar lavage (BAL) or in plasma to diagnose CMV pneumonia in lung transplant recipients remains uncertain and was investigated in a large cohort of consecutive lung transplant recipients. Bronchoscopies within the first year of lung transplantation with CMV detectable in BAL by PCR (ie, viral load, ≥273 IU/mL) were included (66 recipients; 145 bronchoscopies); at each bronchoscopy episode, 2 independent experts reviewed clinical and laboratory information to determine whether the patient at that time fulfilled the criteria for CMV pneumonia per current international recommendations. Corresponding plasma CMV PCR viral load determined at time of the bronchoscopy (n = 126) was also studied. Optimal CMV PCR viral load cutoff for CMV pneumonia diagnosis was determined using receiver operating characteristics. CMV was detected in BAL with CMV PCR in 145 episodes, and 34 (23%) of these episodes fulfilled the criteria for CMV pneumonia. The area under the curve-receiver operating characteristics for CMV in BAL was 90% at the optimum cutoff (4545 IU/mL) with a corresponding sensitivity of 91% and specificity of 77% (in plasma the corresponding values were 274 IU/mL, 63% and 76%, respectively). CMV PCR viral load in BAL had a high performance to diagnose CMV pneumonia in lung transplant recipients; plasma CMV viral load did not reliably aid as a diagnostic tool.

Cytomegalovirus disease and infection in lung transplant recipients in the setting of planned indefinite valganciclovir prophylaxis

The optimal method of both predicting and preventing cytomegalovirus (CMV) disease in lung transplant recipients remains unclear. In particular, the most appropriate duration of CMV prophylaxis post transplant is unresolved. We report herein our experience with a planned indefinite regimen of valganciclovir prophylaxis and monitoring of quantitative CMV load in bronchoalveolar lavage (BAL) fluid. We performed a single-center observational study with both prospective and retrospective components. The included patients (n = 128) received a planned regimen of indefinite valganciclovir prophylaxis post transplant, regardless of donor (D)/recipient (R) CMV serostatus. Real-time polymerase chain reaction assay for detection of CMV in BAL was prospectively performed over a 1-year period. Clinical data were reviewed retrospectively; median follow-up was 24.8 months (range 1-93 months). Sixty-five patients (50.6%) discontinued valganciclovir prophylaxis, either temporarily or permanently, with a primary cause of mild leukopenia. Six cases of CMV disease were identified (4.7%), with no significant difference between those who were on continuous prophylaxis or not (4.6% vs. 4.9%; P = non-significant [ns]). However, those who discontinued prophylaxis showed an increased incidence of laboratory-detected CMV infection (40.7% vs. 12.7%; P = 0.001). High-risk D+/R- patients did not demonstrate a significantly increased incidence of CMV disease (8.1% vs. 3.3% other serotypes; P = ns). Three patients (2.3%) developed valganciclovir-resistant CMV disease. Molecular detection of CMV in BAL fluid was significantly more sensitive than shell vial culture. However, BAL CMV viral load was not predictive of subsequent disease development. Extended valganciclovir prophylaxis for all lung transplant recipients led to a low incidence of CMV disease and resistance. In such low-incidence populations, routine quantitation of CMV in BAL did not confer significant clinical benefit over non-quantitative methods in prediction of CMV disease onset.

169 Clinical Significance of Cytomegalovirus (CMV) Detected by RT-PCR in Bronchoalveolar-Lavage Fluid of Stable Lung Transplant Recipients

Purpose: Cytomegalovirus (CMV) may play a major role in the development of bronchiolitis obliterans syndrome (BOS). Study aim was to assess the outcome of CMV-DNA positive LTx outpatients in bronchoalveolar lavage (BAL) during surveillance. Methods and Materials: A single-center retrospective cohort study was performed between 9-2007 and 2-2010. Pts who underwent at least 3 BAL (surveillance months 3, 6 and 12 plus indication tests) were included. CMV-DNA load in BAL by PCR had a cut-off of 500 copies/mL. CMV pp65 antigenemia was detected in peripheral blood leukocytes. A 3-months prophylaxis with ganciclovir/ valgangciclovir was applied in all but low-risk pts. No antiviral treatment was administered in case of an isolated positive CMV-PCR in BAL. Results: 103 LTx-pts underwent 1100 BAL (87% SSLTx, median 49 years, 41% female, 32% COPD, 23% IPF, 28% CF). F/u was median 639 (interquartiles 495-780) d. 155 BAL (14%) were CMV-PCR pos of whom 23 (2%) % had a simultaneous CMV-antigenemia in blood. 1, 17, 28, 29 and 21 % of BALs were CMV-PCR-pos in months 0-3, 4-6, 7-12, 12-24 and 24 respectively. 53 (51%) of all pts had at least one positive CMV-PCR in BAL during f/u. A CMV-seropositive donor proved to be a independent risk factor for CMV-positivity in BAL (p 0.001 hazard ratio 1.8). 7 patients died median 494 (IQR 482-641) d after LTx, no death was CMV-related. 58/103 (56%) pts underwent a course of rejection treatment during the first year. Neither CMV-BAL-positivity, positive antigenemia nor positivity in both tests had a significant effect on rejection or BOS-free survival (p 0.055 for the latter). Pts with BAL-CMV detection developed significantly more frequently CMV-antigenemia in blood after one year (44 vs. 5% respectively, log-rank p 0.001). Conclusions: Detection of CMV-BAL is a frequent phenomenon after LTx after the first 3 postoperative months. Detection of CMV in BAL by PCR did not correlate with rejection free and BOS free survival. We conclude that monitoring CMV-DNA in BAL is of limited clinical value after LTx.

Clinical Utility of Cytomegalovirus Viral Load in Bronchoalveolar Lavage in Lung Transplant Recipients

The utility of cytomegalovirus (CMV) viral load (VL) by quantitative hybrid capture assay (Q-HCA) was investigated in bronchoalveolar lavage (BAL) from lung transplant recipients and compared with BAL cultures and blood VL. Forty-three consecutive BAL samples from 27 lung transplant recipients were analyzed. All samples had shell vial (SV) cultures in addition to Q-HCA. Histopathology was done on all lung tissues, and immunohistochemistry (IHC) in those with positive CMV cultures. Fifteen (56%) lung transplant recipients had both positive BAL SV cultures and BAL VL. Five of 15 had CMV pneumonitis with a VL in BAL >500 000 copies/mL (mean: 1638 450). Ten patients without CMV pneumonitis had VL in BAL <500 000 copies/mL (mean 81 820, p = 0.002). High VL in BAL and blood invariably meant CMV pneumonitis, but 2 patients with CMV pneumonitis had high BAL VL but relatively low blood VL. Initial CMV seronegativity was associated with pneumonitis (4/5 vs. 1/10; p = 0.004) and higher BAL CMV VL (p = 0.03). High CMV BAL or blood VL did not correlate with acute rejection or development of bronchiolitis obliterans syndrome (BOS). High CMV VL in BAL in lung transplant recipients is strongly associated with CMV pneumonitis, and may be more predictive than peripheral blood viral load.

Cytomegalovirus (CMV) infection in infants may result intractable stridor

We found ten cases of human cytomegalovirus (CMV) infection who were intractable stridor. Their symptoms were not improved by the treatment with aminophyllin nor beta stimulants. They were admitted repeatedly complaining of stridor, fever and diarrhea. In two cases, the immunological findings showed a decrease of bacterial sterilizing activity of the neutrophils. Additionally, blood count showed leukocytosis more than 15,000/ul in all cases. Total serum IgE and specific IgE antibodies to many antigens were not elevated. Transaminase was elevated. Chest X-p findings of interstitial pneumonia or atelectasis continued for a long time in some cases. Virological examinations revealed high concentrations of specific IgM or CF antibodies against CMV in all cases. CMV DNA in saliva were examined by polymerase chain reaction (PCR) with primer sets for the immediate early (IE) region of CMV and showed positive in seven cases. CMV in bronchoalveolar lavage (BAL) was isolated in two cases, and CMV PCR in BAL was positive in three cases. The sequence of the CMV-PCR products showed almost same sequence except one point mutation in bp 1203. We considered that CMV infections in infants may induce stridor for a long period.

Application of polymerase chain reaction to the detection of cytomegalovirus in bronchoalveolar lavage from lung transplant recipients

The use of polymerase chain reaction (PCR) for the detection of cytomegalovirus (CMV) in bronchoalveolar lavages (BAL) of immunocompromised patients was evaluated. Firstly, PCR was compared to conventional cell culture (CCC) and shell vial assay (SVA) in 65 BAL received in our laboratory on a routine basis. Sensitivity and specificity of the PCR were 100% and 87.2% respectively. The PCR method was then applied to the monitoring of 55 BAL from nine lung transplant recipients. The data illustrate the excellent sensitivity of PCR. However the predictive value of the test for the occurrence of a symptomatic infection was weak.

Search for human herpesvirus 6 and human cytomegalovirus in bronchoalveolar lavage from patients with human immunodeficiency virus-1 and respiratory disorders.

Virus isolation and viral DNA detection by the polymerase chain reaction were used to investigate the presence of human herpesvirus 6 (HHV-6) and human cytomegalovirus (HCMV) in bronchoalveolar lavage from 34 human immunodeficiency virus-1 (HIV-1)-infected patients with respiratory disorders. The aim was to assess the presence of reactivated HHV-6 in lung tissues for a subsequent evaluation of the frequency of virus involvement in respiratory clinical manifestations in the course of HIV-1 infection. Bronchoalveolar lavage samples were tested for the presence of HCMV, as a routine investigation within a protocol monitoring opportunistic infections in symptomatic HIV-1 patients. Whereas HCMV DNA was detected by the polymerase chain reaction in 12 bronchoalveolar lavage specimens, 10 of which were also positive for virus isolation, all samples were negative for HHV-6 by both virological procedures. The HHV-6 DNA finding in bronchoalveolar lavage from an HIV-1-seronegative patient with renal carcinoma, investigated accidentally together with the bronchoalveolar lavage specimens from HIV-1 seropositive patients, stressed the HHV-6 polymerase chain reaction-negative results in the bronchoalveolar lavage samples under study. It is concluded that the lung may be a target organ for HCMV infection in HIV-1-seropositive patients affected by respiratory symptoms but that this does not seem to be the case for HHV-6.

Search for human herpesvirus 6 and human cytomegalovirus in bronchoalveolar lavage from patients with human immunodeficiency virus‐1 and respiratory disorders

Search for human herpesvirus 6 and human cytomegalovirus in bronchoalveolar lavage from patients with human immunodeficiency virus‐1 and respiratory disorders

Diagnosis of Cytomegalovirus in Bronchoalveolar Lavage by Polymerase Chain Reaction, in Comparison with Virus Isolation and Detection of Viral Antigen

Bronchoalveolar lavage (BAL) products from 52 immunocompromised patients with symptoms of pulmonary infection was examined for cytomegalovirus (CMV) by virus isolation, polymerase chain reaction (PCR) and detection of CMV antigen by immunofluorescence or immunoperoxidase staining after short-term incubation in tissue culture and directly in BAL cells. We found that PCR detected all cases positive by virus isolation (15/52 samples) and the result was obtained within 5 h. PCR detected more cases of CMV than did virus isolation (22/52 samples). Positive PCR and negative virus isolation were consistent with probable CMV infection in 3/7 patients when other clinical and laboratory parameters of CMV infection were considered. The negative predictive value of PCR was high; none of 30 patients negative by PCR developed CMV pneumonia within the subsequent 2 months. Detection of CMV antigen after short-term incubation was rapid enough to be used in clinical practice, specific (100%) and with a sensitivity of 60%. Demonstration of CMV antigen in alveolar cells was highly specific (100%) but had too low a sensitivity (26.7%) to be used as the only rapid method. Our conclusion is that a combination of PCR and detection of CMV antigen after short-term incubation and directly in alveolar cells is optimal for rapid identification of CMV.

Cytomegalovirus Is Frequently Isolated in Bronchoalveolar Lavage Fluid of Bone Marrow Transplant Recipients without Pneumonia

We prospectively studied the presence of cytomegalovirus in bronchoalveolar lavage through virus isolation in 21 bone marrow transplant recipients before and after transplantation. All 14 lavage specimens collected before bone marrow transplantation were negative for cytomegalovirus. During the period from 20 to 90 days after transplantation, 12 of 24 lavage specimens (50%) from 14 patients without lung problems were positive for cytomegalovirus. Cytomegalovirus was isolated from 4 of 10 lavage specimens (40%) in 7 patients with pneumonia during the same interval. We conclude that culture for cytomegalovirus in bronchoalveolar lavage fluid is not a reliable method for establishing the virus's causative role in pneumonia soon after bone marrow transplantation. Among 14 patients in whom bronchoalveolar lavage was done at an asymptomatic stage, 6 of 9 patients with cytomegalovirus and none of 5 without cytomegalovirus in the lavage fluid later developed pneumonia. All of the patients subsequently developing pneumonia also had acute graft-versus-host disease, suggesting an immunopathologic mechanism, possibly triggered by cytomegalovirus, for cytomegalovirus-associated pneumonia.

DNA hybridization for detection of human cytomegalovirus in bronchoalveolar lavage and pharynx biopsy

A simplified hybridization procedure was used for detection of cytomegalovirus (CMV) in human specimens. The probe was a 32P-labelled cloned DNA fragment of CMV strain AD169. This probe did not hybridize to DNA from uninfected cells or other herpesviruses (herpes simplex virus, Epstein-Barr virus). Specific hybridization was obtained with unselected bronchoalveolar lavage specimens, but the sensitivity of the test (33%) was lower than that of culture (80%) and immunofluorescence (60%) assays which are routinely performed in our laboratory. The detection procedure was also carried out with pharynx biopsy specimens which had been kept frozen at -70 degrees C. CMV DNA was detected in 14% of tumour specimens and only in 1.7% of control specimens (p less than 0.05). The indications of DNA hybridization for CMV diagnosis are discussed.