Cytomegalovirus Polymerase Chain Reaction Research Articles

How to Diagnose Early 5-Azacytidine-Induced Pneumonitis: A Case Report.

Interstitial pneumonitis is a classical complication of many drugs. Pulmonary toxicity due to 5-azacytidine, a deoxyribonucleic acid methyltransferase inhibitor and cytotoxic drug, has rarely been reported. We report a 67-year-old female myelodysplastic syndrome patient treated with 5-azacytidine at the conventional dosage of 75 mg/m2 for 7 days. One week after starting she developed moderate fever along with dry cough and subsequently her temperature rose to 39.5 °C. She was placed under broad-spectrum antibiotics based on the protocol for febrile neutropenia, including ciprofloxacin 750 mg twice daily, ceftazidime 1 g three times daily (tid), and sulfamethoxazole/trimethoprim 400 mg/80 mg tid. High-resolution computed tomography of the chest disclosed diffuse bilateral opacities with ground-glass shadowing and pleural effusion bilaterally. Mediastinal and hilar lymph nodes were moderately enlarged. polymerase chain reaction for Mycobacterium tuberculosis, Pneumocystis jiroveci, and cytomegalovirus were negative. Cultures including viral and fungal were all negative. A diagnosis of drug-induced pneumonitis was considered and, given the negative bronchoalveolar lavage in terms of an infection, corticosteroid therapy was given at a dose of 1 mg/kg body weight. Within 4 weeks, the patient became afebrile and was discharged from hospital. Development of symptoms with respect to drug administration, unexplained fever, negative workup for an infection, and marked response to corticosteroid therapy were found in our case. An explanation could be a delayed type of hypersensitivity (type IV) with activation of CD8 T cell which could possibly explain most of the symptoms. We have developed a decision algorithm in order to anticipate timely diagnosis of 5-azacitidine-induced pneumonitis, and with the aim to limit antibiotics abuse and to set up emergency treatment.

Big Data, Predictive Analytics, and Quality Improvement in Kidney Transplantation: A Proof of Concept.

We sought proof of concept of a Big Data Solution incorporating longitudinal structured and unstructured patient-level data from electronic health records (EHR) to predict graft loss (GL) and mortality. For a quality improvement initiative, GL and mortality prediction models were constructed using baseline and follow-up data (0-90 days posttransplant; structured and unstructured for 1-year models; data up to 1 year for 3-year models) on adult solitary kidney transplant recipients transplanted during 2007-2015 as follows: Model 1: United Network for Organ Sharing (UNOS) data; Model 2: UNOS & Transplant Database (Tx Database) data; Model 3: UNOS, Tx Database & EHR comorbidity data; and Model 4: UNOS, Tx Database, EHR data, Posttransplant trajectory data, and unstructured data. A 10% 3-year GL rate was observed among 891 patients (2007-2015). Layering of data sources improved model performance; Model 1: area under the curve (AUC), 0.66; (95% confidence interval [CI]: 0.60, 0.72); Model 2: AUC, 0.68; (95% CI: 0.61-0.74); Model 3: AUC, 0.72; (95% CI: 0.66-077); Model 4: AUC, 0.84, (95 % CI: 0.79-0.89). One-year GL (AUC, 0.87; Model 4) and 3-year mortality (AUC, 0.84; Model 4) models performed similarly. A Big Data approach significantly adds efficacy to GL and mortality prediction models and is EHR deployable to optimize outcomes.

Characteristics and prognosis of hepatic cytomegalovirus infection in children: 10 years of experience at a university hospital in Korea.

PurposeStudies on cytomegalovirus (CMV) infections in immunocompetent children are lacking, and minimal information is available in the medical literature on hepatic manifestations and complications of CMV. The aims of this study were to evaluate the clinical characteristics, laboratory data, and prognosis of children with CMV hepatitis, and to investigate its prevalence at a single medical center in Korea over a 10-year period.MethodsOne hundred thirty-two children diagnosed with CMV infection based on specific markers (anti-CMV IgM, CMV polymerase chain reaction in blood and urine, or CMV culture of urine) were included in the study. Clinical and biochemical characteristics, immunological markers, and outcomes of hepatic CMV infection were determined.ResultsThe median age of patients (n=132) was 8.5 months (range, 14 days–11.3 years). Peak total bilirubin and alanine aminotransferase levels in serum ranged from 0.11–21.97 mg/dL, and 5–1,517 IU/L, respectively. Alanine aminotransferase remained elevated from 2–48 weeks. Jaundice was the most common clinical feature of hepatic CMV infection during infancy. The hematologic findings revealed anemia, leukocytosis, and monocytosis in CMV-infected patients. All participants recovered without administration of ganciclovir.ConclusionIn children with CMV hepatitis, fever was the most common symptom at presentation, and jaundice was the most common clinical feature of hepatic CMV infection in infants younger than 3 months of age. Hepatic CMV infection in immunocompetent children is often a self-limited illness that does not require antiviral therapy, as most patients in this study had favorable outcomes.

Failure to Recognize the Diagnosis of Cytomegalovirus Colitis in an Immunocompetent Male: Need for Heightened Index of Suspicion

Background: Cytomegalovirus (CMV) disease affects mainly immunosuppressed individuals such as stem cell and solid organ transplant recipients as well as those patients infected with the human immunodeficiency virus (HIV). Cytomegalovirus colitis has been diagnosed increasingly in normal hosts. Case Presentation: A 65-year-old male with a history of alcohol abuse had been hospitalized for severe bloody diarrhea for three months in an outside hospital; he tested negative for clostridial toxin. He was transferred to our intensive care unit in septic shock and multi-organ failure with bloody diarrhea and a megacolon on computed tomography (CT) scan. Emergency sigmoid colectomy was performed, however, the patient continued to have bloody diarrhea; subsequently, completion sub-total colectomy with ileostomy was performed. On immunohistochemistry a diagnosis of CMV colitis was made; blood CMV polymerase chain reaction (PCR) was positive, the patient tested positive for anti-CMV immunoglobulin (Ig) G but non-IgM antibodies. Ganciclovir was started and the patient's CMV PCR became negative within one week. The patient developed multiple other complications including Aspergillus tracheobronchitis, Pseudomonas aeruginosa sepsis, and Candida krusei pneumonia, but ultimately recovered from the multiple infections. A low natural killer (NK) cell count (<1%) was found on immunologic workup; the patient tested negative for HIV. Conclusion: Cytomegalovirus colitis is a rare disease in the non-immunocompromised host but should be considered in patients with pseudomembranous colitis testing negative for clostridial toxin.

Simultaneous Cytomegalovirus Disease and Novel Influenza A (H1N1) Pneumonia in a Renal Transplant Recipient

Background: Cytomegalovirus (CMV) causes the most common post-transplant systemic viral infection. During infectious epidemics, such as the outbreak of novel influenza A (H1N1), immunocompromised hosts including transplant recipients may be at greater risk for acquiring disease and may have a more serious course. Case Report: We report on a 65-year-old female renal transplant recipient who underwent pre-transplant desensitization with whole plasma exchange, intravenous immunoglobulin (IVIG), and rituximab and developed simultaneous CMV disease and H1N1 pneumonia. With accurate diagnosis (CMV polymerase chain reaction [PCR] and H1N1 isolation from bronchoalveolar lavage), ganciclovir, oseltamivir and IVIG therapy, and temporary withdrawal of immunosuppression, the patient recovered from the life-threatening infection with preservation of graft function. Discussion: Co-infection with multiple pathogens should always be considered in transplant recipients receiving intensified immunosuppression, especially during outbreaks of large epidemics.

Monitoring of cytomegalovirus (CMV) infection in solid organ transplant recipients: quantitation of CMV DNAemia by two real-time polymerase chain reaction assays

&lt;em&gt;Background and aim:&lt;/em&gt; Quantification of cytomegalovirus (CMV) DNAemia is essential in clinical management of post-transplant infection. We evaluated the performances of two quantitative real-time polymerase chain reaction (PCR) assays. &lt;br /&gt;&lt;em&gt;Materials and Methods&lt;/em&gt;: 114 serial whole blood samples collected from 14 actively infected transplant recipients were processed by Abbott RealTime CMV PCR kit (Abbott Molecular) and CMV ELITe MGB™ kit (ELITech Group). The Quality Control for Molecular Diagnostics human CMV panels was also tested. &lt;br /&gt;&lt;em&gt;Results&lt;/em&gt;: Sixteen (14%) samples resulted negative and 59 (51.7%) positive with a quantitative result for both assays. In the 59 samples, the coefficient of correlation was 0.856. Bland-Altman analysis showed a mean difference of &amp;lt;0.11 log10 copies/mL (standard deviation=0.38 log10 copies/mL). The assays gave CMV-DNA loads differing by 1 log10 DNA copies/mL in 57 samples (96.6%) and by &amp;lt;0.5 log10 DNA copies/mL in 48 samples (81.3%). Eleven (9.6%) samples were positive with a quantitative result with Abbott and negative with ELITech. Sixteen (14%) positive samples with a quantitative result for Abbott resulted positive but below the lower limit of quantification (LLQ) for ELITech. Twelve (10.5%) samples resulted negative with ELITech and positive but below the LLQ with Abbott. No samples were positive with ELITech and negative with Abbott. &lt;br /&gt;&lt;em&gt;Conclusions&lt;/em&gt;: The assays showed a good correlation between CMVDNA levels detected and variation in CMV-DNA &amp;lt;0.5 log10 was observed in the majority of the samples. The viral load kinetic profiles of the assays were overlapping in all patients, but Abbott showed higher sensitivity in samples containing lower amount of DNA. The clinical value of this greater sensitivity requires further investigation.

Rhinosinusitis and Parotid Enlargement in a Young African American Man

AyoungAfricanAmericanmanpresentedwith a6-monthhistoryof nasal congestion, facial pressure, purulent rhinorrhea, and hypo-osmia that had not improved despite multiple coursesofantibiotics andsteroids.Hismedical historywassignificant for chronic rhinosinusitis, allergic rhinitis, andasthma, forwhichhetookfluticasonepropionateandsalmeterol (Advair) and albuterol. A review of systems revealed epiphora and ocular crusting for 4 months. Findings on nasal endoscopy includedbilateral turbinate hypertrophy and significant nasal crusting.A computed tomographic (CT) scanof the sinuses revealeddiffusemucosal thickening consistent with pansinusitis (Figure, A). All laboratory results from an autoimmune workup were normal for angiotensin-converting enzyme (ACE) level, antineutrophil cytoplasmic antibodies, antinuclear antibody, and immunoglobulin levels. He had a normal chest radiograph. The patient was lost to follow-up but returned several months later with 6weeks of progressive bilateral parotid swelling (Figure, B). His parotid glands were diffusely enlarged and tender, and his facial function was normal. Radiologically, nomasses or sialoliths were seen (Figure, C). His only associated symptomswere fevers and fatigue. A history of recent tuberculosis exposure was obtained. Test results for SSa/SSb levels, human immunodeficiency virus (HIV), polymerase chain reaction (PCR), mumps titers, rapid plasma reagin, amylase, cytomegalovirus PCR, and quantiferon testing were negative. A superficial parotid biopsy revealed noncaseating granulomatous inflammation (Figure, D). Parotid biopsy specimen D Axial postcontrast CT of neck C Preoperative photograph B Coronal noncontrast CT image A

Valaciclovir to prevent Cytomegalovirus mediated adverse modulation of the immune system in ANCA-associated vasculitis (CANVAS): study protocol for a randomised controlled trial.

BackgroundThe ANCA-associated vasculitides (AAV) are systemic autoimmune inflammatory disorders characterised by necrotising inflammation affecting small to medium-sized blood vessels. Despite improvements in survival, infection and cardiovascular disease remain leading causes of morbidity and mortality.Considerable evidence suggests that CD4 + CD28null T-cell expansions, predominantly seen in Cytomegalovirus (CMV) seropositive individuals, are associated with systemic dysregulation of immune function leading to a heightened risk of infection and cardiovascular disease. In patients with AAV, CD4 + CD28null expansions are driven by CMV and are associated with an increased risk of infection and mortality.The aim of this study is to explore in detail the ways in which CMV modulates the immune system and to determine whether treatment with valaciclovir blocks subclinical CMV reactivation in CMV seropositive AAV patients and ameliorates the CMV-induced adverse effects on the immune system.Methods/designCANVAS is a single-centre prospective open-label randomised controlled proof-of-concept trial of 50 adult CMV seropositive patients with stable AAV. Participants will be randomly allocated to receive valaciclovir orally (2 g QDS or reduced according to renal function) or no additional treatment for 6 months with an additional 6-month follow-up period. The primary outcome is the proportion of patients with CMV reactivation, as assessed by measurable viral load on quantitative blood and urine CMV polymerase chain reaction. The secondary outcomes are safety, change in the proportion of CD4+ CMV-specific T-cell population (defined as CD4 + CD28null cells) and change in soluble markers of inflammation from baseline to 6 months. Further tertiary and exploratory outcomes include persistence of the effect of valaciclovir on the proportion of CD4 + CD28null cells at 6 months post completion of treatment, change in the immune phenotype of CD4+ T cells and change in blood pressure and arterial stiffness parameters from baseline to 6 months.DiscussionThe results of this study will enable larger studies to be conducted to determine whether by controlling subclinical CMV reactivation, we can improve clinical endpoints such as infection and cardiovascular disease. The potential impact of this study is not limited to AAV, as CD4 + CD28null cells have been linked to adverse outcomes in other inflammatory conditions and in the context of an ageing immune system.Trial registrationClinicalTrials.gov Identifier NCT01633476 (registered 29 June 2012).Electronic supplementary materialThe online version of this article (doi:10.1186/s13063-016-1482-2) contains supplementary material, which is available to authorized users.

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.

Ganciclovir and Foscarnet Therapy of Cytomegalovirus-Associated Meningoencephalitis in a Hemodialysis Patient With Liver Transplantation: Case Report

Cytomegalovirus (CMV) infection in patients with liver transplantation (LT) remains a highly prevalent complication with a significant increase in morbidity and mortality. However, CMV-associated meningoencephalitis is rarely diagnosed, and treatment is very difficult. The aim of the present report is to review the experience of successful treatment with combined ganciclovir and foscarnet of CMV-associated meningoencephalitis refractory to ganciclovir alone in a hemodialysis (HD) patient after LT. A 54-year-old woman with end-stage renal disease on HD developed a seizure with loss of consciousness. She had received a liver transplant 4 months before. Blood CMV polymerase chain reaction was positive, and cerebrospinal fluid (CSF) analysis was compatible with viral meningitis. Brain magnetic resonance imaging (MRI) showed extensive dural thickening with enhancement and a round ring-like enhancement in the left centrum semiovale. She was diagnosed with CMV-associated meningoencephalitis. At that time, ganciclovir was started intravenously. After that, there were no improvements in mental state, CSF analysis, or brain MRI. Intravenous foscarnet at reduced dose was added to ganciclovir therapy. With combined ganciclovir and foscarnet, there was a slight improvement in her mental state and brain MRI.

Long-Term Topical Ganciclovir and Corticosteroids Preserve Corneal Endothelial Function in Cytomegalovirus Corneal Endotheliitis.

To report the long-term outcomes of topical ganciclovir (GCV) and corticosteroids as a maintenance therapy for cytomegalovirus (CMV) corneal endotheliitis. This retrospective study included 10 eyes of 9 patients diagnosed with CMV corneal endotheliitis with a minimum 1-year follow-up at a tertiary referral hospital between 2008 and 2014. CMV corneal endotheliitis was defined by corneal edema associated with typical keratic precipitates (KPs) and a positive CMV polymerase chain reaction from aqueous humor taps. Patients receiving long-term topical 0.5% GCV and topical corticosteroids without discontinuation were included. The final corneal condition and endothelial cell density (ECD) were reported. The mean age was 45.6 ± 11.7 years. The mean follow-up duration was 48 ± 25 months. All patients exhibited typical coin-shaped and/or linear KPs. A significant resolution of corneal edema and decreased KPs were achieved within 1 month in all patients after initiating topical 0.5% GCV every 2 hours and topical corticosteroids twice a day. The dose frequency was gradually tapered to GCV 4 times and corticosteroids once or twice a day as a maintenance therapy. All 10 eyes had a clear graft or corneas at the end of this study. The mean ECD was 1630 ± 699 cells per millimeter square before treatment and 1776 ± 834 cells per millimeter square at the end of the study period. Topical 0.5% GCV and corticosteroids as a maintenance regimen without interruption effectively preserved long-term corneal endothelial function.

Resistant cytomegalovirus infection in related donor kidney allograft recipients

To clarify whether cytomegalovirus (CMV) infection can affect the results of living related donor kidney transplantation. A study group included 17 (7.27%) patients (10 men and 7 women; 8 children and 9 adults) aged 3 to 51 years who had developed resistant CMV infection. For comparative analysis, a control group was formed from 113 patients (61 men and 52 women; 40 children and 73 adults) aged 1 to 61 years, whose CMV polymerase chain reaction (PCR) had always been negative, i.e. CMV DNA was absent. The duration of CMV infection episodes was 44 to 232 days. The patients were given valganciclovir in a dose of 450 mg/day. CMV PCR was negative in all the patients at the end of therapy. None of the patients died; one graft was lost. In the control (negative CMV PCR) group, 6 grafts were lost in 113 patients lost and 4 patients died. Statistical analysis showed that the results of related donor kidney transplantation were virtually equal. Suppression of resistant CMV infection can be achieved with the longer use of valganciclovir or its higher dose. CMV infection fails to affect the results of related donor kidney transplantation.

Qualitative Cytomegalovirus Polymerase Chain Reaction From Gastrointestinal Specimens for Diagnosis of Tissue Invasive Disease

Qualitative Cytomegalovirus Polymerase Chain Reaction From Gastrointestinal Specimens for Diagnosis of Tissue Invasive Disease

Is Treatment with Bortezomib for Multiple Myeloma or Amyloidosis Associated with Cytomegalovirus Reactivation?

BackgroundBortezomib (Velcade®) is an inhibitor of the 26S proteasome used as a first line therapy for multiple myeloma, for retreatment of relapsed multiple myeloma and for treatment of AL amyloidosis. An increased incidence of reactivation of herpesviruses including varicella zoster virus (VZV) and herpes simplex virus type 1 (HSV-1) has been reported following administration of bortezomib (Oakervee et al 2005) In addition one study has described an increased incidence of cytomegalovirus (CMV) reactivation in myeloma patients post autografting treated previously with bortezomib when compared to other regimens (Marchesi et al 2014). We noted several cases of CMV viraemia with one case of likely end organ involvement (colitis) among patients given bortezomib. To determine how frequently this association occurs, we introduced a clinical protocol to monitor our patients on bortezomib for CMV infection.MethodsAll patients with myeloma or amyloidosis due their first dose of bortezomib were tested for CMV by polymerase chain reaction (PCR) on whole blood at baseline prior to treatment and then tested every 2 weeks after their initial dose or whenever they re-attended for clinic appointments, regardless of symptoms. Where possible, data on pre- treatment CMV serostatus was also recorded.We applied a protocol for pre-emptive therapy that we use for transplant patients (Atabani et al 2012). Whereas transplant patients with a viral load greater than 3000 genomes/ml (2520 IU/ml) whole blood are treated, bortezomib patients who had CMV levels in excess of 7500 copies/ml were given treatment (either oral valganciclovir or IV ganciclovir) until 2 consecutive blood samples showed undetectable levels.Results60 new bortezomib starters were tested with 43 being tested by CMV PCR at baseline i.e pre-treatment. The characteristics of these patients are shown in table 1 Table 1Patient characteristicsCharacteristicSexMale = 35 Female = 25AgeMedian 63.5 (range 33-89)Underlying diseaseAmyloidosis =39 Multiple myeloma= 21Pre-treatment CMV serostatusIgG positive = 35 IgG negative =17 Unknown= 8CMV viraemia was detected in 14/60 (23%) patients (10 myeloma and 4 amyloidosis) of whom 13 were known to be seropositive showing that the majority of the viraemias seen were reactivations/reinfections rather than primary infections. No CMV viraemia was seen in the seronegative group. Of those who had a true baseline none were positive prior to starting treatment. Of those without a true baseline, 5 had a detectable viraemia on their first blood sample. The course of the viraemia in these 14 patients is shown in figure 1. Five patients (all myeloma) reached the threshold for treatment and all responded to therapy including one patient who had 2 separate CMV reactivations. There were no cases of CMV end-organ disease.SummaryIn our cohort, 14/60 (23%) patients developed a CMV viraemia after starting bortezomib, corresponding to 13/35 (37%) who were initially CMV seropositive. Although we cannot exclude CMV reinfection from an exogenous source, we suggest that most of these were reactivations of latent CMV. Clinically, the majority of these episodes were self limiting although, because we elected to treat those patients who reached a pre-defined threshold of 7500 copies/ml, the true course of viraemia and the risk of subsequent end organ disease is unclear. Further investigation of the incidence of CMV reactivation and its clinical significance is warranted. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Cytomegalovirus reactivation and its clinical impact in patients with solid tumors.

Cytomegalovirus reactivation can be life threatening. However, little evidence on its incidence in solid cancers is available. Therefore our single center Cytomegalovirus polymerase chain reaction database with altogether 890 CMV positive blood serum samples of mainly hematological and oncological patients was retrospectively analyzed to examine the occurrence of Cytomegalovirus reactivation in patients with solid tumors, resulting in 107 patients tested positive for Cytomegalovirus reactivation. Seventeen patients with solid cancer and a positive CMV-PCR test were identified, of which eight patients had clinically relevant CMV disease and received prompt antiviral treatment. Five patients fully recovered, but despite prompt antiviral treatment three patients died. Among these three patients two had significant co-infections (in one case EBV and in the other case Aspergillus) indicating that that CMV reactivation was at least one factor contributing to sepsis. The patient with the EBV co-infection was treated in an adjuvant therapy setting for breast cancer and died due to Cytomegalovirus and Epstein-Barr virus associated pneumonia despite intensive therapy. The other two patients had progressive disease of an underlying pancreatic cancer at the time of CMV diagnosis. One patient died due to attendant uncontrollable Aspergillus pneumonia, the other patient most likely died independent from CMV disease because of massively progressive underlying disease.Cytomegalovirus reactivation and disease might be underestimated in routine clinical practice. In our retrospective analysis we show that approximately 50 % of our patients suffering from solid cancers with a positive Cytomegalovirus polymerase chain reaction also had clinically relevant Cytomegalovirus disease requiring antiviral therapy.

Detection of cytomegalovirus by polymerase chain reaction in aqueous samples from patients with acquired immune deficiency syndrome

Objective To analyze the sensitivity and specificity of polymerase chain reaction (PCR) tests in the detection of cytomegalovirus (CMV) in the diagnosis of patients with acquired immune deficiency syndrome (AIDS), using aqueous humor samples. Methods 25 AIDS patients (including 21 men and 4 women) were studied. The age of the patients varied from 24 to 59 years, with an average of (39.2±9.3) years. The CD4+ T cell count was from 1 to 523 cells/μl, with a medium of 40 cells/μl. They were infected with human immunodeficiency virus(HIV)for a period from 15 days to 9 years with a median of 10 months. They were divided into three groups according to the fundus and treatment, including untreated cytomegalovirus retinitis (CMVR), treated CMVR and control group. There were 10 patients without anti-CMV treatment and 7 patients treated previously with foscarnet or ganciclovir whose eyes were diagnosed CMVR. Control group has 8 patients who had normal fundus or minor retinopathy excluded from CMVR. Approximately 100 μl of aqueous humor was obtained by anterior-chamber paracentesis and PCR was performed in all cases. Results There were CMV DNA in 9 of 10 eyes with untreated CMVR (90.0% sensitivity). Of 7 specimens from eyes with treated CMVR, 3 were CMV PCR positive (42.9% sensitivity). All 8 samples of the control group were negative for CMV DNA, indicating the clinical specificity of our PCR was greater than 99.9% for CMVR. The anterior chamber paracentesis did not cause any complications in our patients except for a patient with subconjunctival hemorrhage. Conclusions The assay had an estimated sensitivity of 90.0% in detecting untreated CMVR and a sensitivity of 42.9% in detecting CMVR that had been treated. The specificity of this assay was greater than 99.9%. Key words: Acquired immunodeficiency syndrome/complications; Cytomegalovirus retinitis/diagnosis; Aqueous humor; Polymerase chain reaction

Congenital nephrotic syndrome: A diagnostic and management dilemma

Congenital nephrotic syndrome (CNS) is characterised by heavy proteinuria, hypoproteinaemia and oedema presenting in the first 3 months of life. We present a 27-day-old female patient admitted to the Inkosi Albert Luthuli Central Hospital with CNS; one of twins and HIV exposed but uninfected. The child had a cytomegalovirus (CMV) polymerase chain reaction (PCR) positive result in the urine, confirmed on two separate occasions. The CMV PCR for qualitative testing of CMV DNA was negative and quantitative testing was not done. CMV retinitis and central nervous system involvement were absent. Despite treatment with gancyclovir, the CNS did not improve. Further management required indomethacin followed by unilateral nephrectomy to decrease administration of albumin infusions to control oedema. Unfortunately, due to loss to follow-up, the patient demised from probable sepsis. We discuss the challenges we faced with respect to the diagnosis and management of CNS in a resource-limited setting where transplantation is not readily available.

Inflammatory Bowel Disease Patients With High-Grade Cytomegalovirus Infection May Benefit From Antiviral Therapy

Introduction: Patients with inflammatory bowel disease (IBD) have an increased risk of cytomegalovirus (CMV) colitis, but can also have incidental CMV identified on mucosal biopsies. Identifying IBD patients with CMV who may benefit from antiviral therapy thus remains a challenge. Increasing evidence support that patients with a “higher grade” of CMV infection may benefit most from antiviral therapy, but there is no consensus in defining high versus low grade infection. We aim to investigate the effect of antiviral treatment in high and low grade infection by CMV cell number. Methods: Patients with IBD and CMV infection were identified by searching the pathology database. Slides were re-reviewed blinded to clinical outcome and the number of CMV cells on immunohistochemical (IHC) staining was quantified. The distribution of CMV cell counts were determined, and patients were stratified into “high grade” and “low grade” infection, based on the median cell number (high grade: > median, low grade: < median). Charts were reviewed for clinical outcomes and laboratory data including serum CMV PCR. Results: Forty-four patients with IBD and CMV by IHC were identified. Cell count ranged from 1 to 25 cells (median 5); high grade infection was defined as ≥5 cells. Serum CMV polymerase chain reaction (PCR) was significantly higher in patients with high vs low grade infection (167 vs 16 copies, p < 0.05). There were no differences in hospitalization rate, length of stay, and inflammatory markers between high and low grade infection, and between treated versus untreated subgroups (Table 1). Although not statistically significant, there was decreased colectomy rate in patients with high CMV load receiving antiviral treatment, compared to patients not receiving treatment (Table 1). The colectomy rates of treated versus untreated patients with low grade CMV appear to be similar.Table 1Conclusion: Our study indicates that serum CMV PCR correlates with colonic CMV burden and may be used to predict CMV colitis with “high grade” CMV infection. Our data suggests that treating patients with high CMV burden (≥5 CMV inclusion cells) may improve important clinical outcomes, notably colectomy. Further studies are warranted.

How to develop an in-house real-time quantitative cytomegalovirus polymerase chain reaction: Insights from a cancer centre in Eastern India

Development of a reliable, cost-effective cytomegalovirus quantitative polymerase chain reaction (QPCR) is a priority for developing countries. Manufactured kits are expensive, and availability can be inconsistent. Development of an in-house QPCR kit that is reliable and quality assured requires significant effort and initial investment. However, the rewards of such an enterprise are manifold and include an in-depth understanding of molecular reactions, and expertise in the development of further low-cost molecular kits. The experience of an oncology centre in Eastern India has been shared. Hopefully, this would provide a brief roadmap for such an initiative. Staff with adequate understanding of molecular processes are essential along with vital infrastructure for molecular research and development.

Cytomegalovirus and other common enteric viruses are not commonly associated with NEC.

Changes in gut microbiota may contribute to NEC, but most studies focus on bacteria. Case reports suggest a link between cytomegalovirus (CMV) or other enteric viruses and NEC, but there are few case series systematically looking at common potential viral causes. We aimed to assess the presence of candidate viruses in blood or stool of a case series of infants with NEC managed in one surgical centre. We identified 22 infants diagnosed with NEC (from November 2011 to March 2014): 17 had suitable blood stored, of whom 14 also had suitable stool samples stored. Blood was analysed with polymerase chain reaction (PCR) for CMV, Epstein-Barr virus (EBV) and adenovirus, and stool by PCR for norovirus, sappovirus, astrovirus, adenovirus and rotavirus. All samples were negative. Although case reports indicate an episodic association of enteric viruses in NEC, the inability to detect any of these viruses in our 17 NEC infants suggests that a viral aetiology is unlikely to be causative for most sporadic forms of NEC.