Detection Of Cytomegalovirus Research Articles

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

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

Clinical characteristics and outcomes of pediatric patients with CMV DNA detection in bronchoalveolar lavage fluid.

Cytomegalovirus (CMV) infection can cause severe pulmonary disease in immunocompromised patients. There are no standard diagnostic criteria for CMV pulmonary disease beyond histopathology findings on lung tissue, which is challenging to obtain in pediatric patients. Bronchoalveolar lavage (BAL) fluid is easier to obtain. Since CMV remains latent after primary infection and can potentially reactivate due to any inflammatory response, CMV detection in BAL specimen may not indicate acute CMV pulmonary disease. Thus, we describe the clinical manifestations and outcomes of pediatric patients with CMV detection in BAL fluid. We reviewed the clinical, radiologic, and laboratory data of patients <19 years old with a BAL specimen positive for CMV during a 5-year period. Thirty-four encounters in 29 patients were found with CMV detected in their BAL specimen. Half (17/34) of the encounters were in immunocompromised patients. CMV, polymerase chain reaction (PCR) was the most common positive test. Forty-seven percent of the patients had other infections detected in BAL specimens. The majority of patients were never treated for CMV and resolved their acute respiratory illness. Only one patient had probable CMV pulmonary disease. CMV is frequently recovered from BAL specimens but does not usually indicate acute CMV pulmonary disease. We would suggest that other diagnoses be considered first, even if CMV is recovered. Pediatr Pulmonol. 2017;52:112-118. © 2016 Wiley Periodicals, Inc.

Rare detection of cytomegalovirus in severe fetal malformations in China

BackgroundCytomegalovirus (CMV) is a significant cause of fetal abnormalities in developed world. Whether this could be applied in developing world remains unknown. ObjectivesTo investigate CMV infection in severe fetal malformations in China. Study designDuring 2007–2014, 436 fetuses (237 males) with severe malformations and terminated pregnancy at median gestational age of 26+1 weeks were enrolled. CMV DNA was detected in fetal kidneys and other tissues by real-time PCR, and CMV IgG and IgM were measured by ELISA. ResultsCMV DNA was positive in kidneys and other tissues of seven (1.60%) fetuses. Hematoxylin-eosin staining showed intranuclear and intracytoplasmic inclusion bodies in kidneys of three fetuses, which was also positive for CMV antigens in immunohistochemistry. CMV DNA was found in 5 (6.1%) of 82 fetuses with central nervous system anomalies, 1 (11.1%) of 9 fetuses with abdominal anomalies, 1 (0.59%) of 168 fetuses with multiple congenital malformations, and none of fetuses with other anomalies (177). Of 293 pregnant women with plasma available, 279 (95.2%) were CMV IgG positive only and 6 (2.1%) were CMV IgG and IgM positive. Of 5 mothers with infected fetuses 1 (20%) was CMV IgG and IgM positive, while 5 (1.7%) of 288 mothers with uninfected fetuses were positive respectively (P=0.099). ConclusionsCongenital CMV infection in fetuses with severe congenital malformations is rare, indicating no close association between CMV infection and severe fetal malformations in China. Maternal screening for CMV may have minimal value in identifying fetal malformations in developing world.

Immunohistochemical detection of human cytomegalovirus, Epstein-Barr virus and human papillomavirus in invasive breast carcinoma in Egyptian women: A tissue microarray study

Background and aim: Breast cancer is the commonest malignant tumor and a common cause of cancer death in women all overthe world. Some recent studies attributed breast cancer to viral infection. This study aimed to evaluate the expression of HCMV,EBV and HPV in invasive carcinoma of the breast among the Egyptian women by immunohistochemistry and whether there is arelationship between the prognostic factors of breast carcinoma and these viruses. Patients and methods: This retrospective study included 107 selected cases of invasive breast carcinoma. Slides cut from tissuemicroarray prepared blocks were stained immunohistochemically for HCMV, EBV and HPV antigens. The association of suchviruses with the clinicopathological features, tumor recurrence and patient death was evaluated statistically. Result: HCMV, EBV and HPV were present in 43.9%, 10.3% and 24.3% of cases respectively. HCMV was associatedsignificantly with the tumor grade, mitotic count (P = .01), IDC, ER, PR, Her2/neu and molecular subtype (P = .032, .002, .02,.005, .003) respectively. EBV was associated with the tumor size, stage and histological type (P = . 025, .005, .009) respectively.HPV wasn’t associated with any of the clinicopathological characteristics. None of these viruses was associated with the tumorrecurrence or patient death. Conclusion: HCMV and EBV might be contributing factors for the development and behavioural alteration of breast carcinoma,representing potential tools for the detection of specific therapies for this cancer. Further studies on a larger number of casesusing other techniques such as CISH for specific typing of the viruses especially HPV can add more information.

Histologic detection of cytomegalovirus and its application in gastrointestinal cytomegalovirus infection

To investigate the clinical and pathologic features of gastrointestinal cytomegalovirus (CMV) disease, and the histological detection of CMV. Forty-one gastrointestinal tissues were obtained from 35 patients suspected for gastrointestinal CMV disease. The pathologic changes of these specimens were evaluated by immunohistochemistry and in situ hybridization for CMV, and these were compared to serologic detection methods. CMV was detected in 23/41 tissues. There were 32 serologic CMV DNA tests at the time of biopsies or operations. Compared with histological detection, the sensitivity and specificity of serologic CMV DNA tests were 73.7% and 69.2% respectively. Gastrointestinal histological detection of CMV has important clinical application. HE staining combined with immunohistochemistry and/or in situ hybridization detection is a reliable method to detect CMV.

Analytical performances of real-time PCR by Abbott RealTime CMV with m2000 for the detection of cytomegalovirus in urine

Congenital cytomegalovirus (CMV) infection is the leading cause of sensoneurinal disability due to infectious congenital disease. The diagnosis of congenital CMV infection is based on the search of CMV in the urine within the first two weeks of life. Viral culture of urine is the gold standard. However, the PCR is highly sensitive and faster. It is becoming an alternative choice. The objective of this study is the validation of real-time PCR by Abbott RealTime CMV with m2000 for the detection of cytomegalovirus in urine. Repeatability, reproducibility, detection limit and inter-sample contamination were evaluated. Urine samples from patients (n=141) were collected and analyzed simultaneously in culture and PCR in order to assess the correlation of these two methods. The sensitivity and specificity of PCR were also calculated. The Abbott RealTime CMV PCR in urine is an automated and sensitive method (detection limit 200 UI/mL). Fidelity is very good (standard deviation of repeatability: 0.08 to 0.15 LogUI/mL and reproducibility 0.18 LogUI/mL). We can note a good correlation between culture and Abbott RealTime CMV PCR (kappa 96%). When considering rapid culture as reference, real-time PCR was highly sensitive (100%) and specific (98.2%). The real-time PCR by Abbott RealTime CMV with m2000 is optimal for CMV detection in urine.

The Immunology of Posttransplant CMV Infection: Potential Effect of CMV Immunoglobulins on Distinct Components of the Immune Response to CMV.

The immune response to cytomegalovirus (CMV) infection is highly complex, including humoral, cellular, innate, and adaptive immune responses. Detection of CMV by the innate immune system triggers production of type I IFNs and inflammatory cytokines which initiate cellular and humoral responses that are critical during the early viremic phase of CMV infection. Sustained control of CMV infection is largely accounted for by cellular immunity, involving various T-cell and B-cell subsets. In solid organ transplant patients, global suppression of innate and adaptive immunities by immunosuppressive agents limits immunological defense, including inhibition of natural killer cell activity with ongoing lowering of Ig levels and CMV-specific antibody titers. This is coupled with a short-term suppression of CMV-specific T cells, the extent and duration of which can predict risk of progression to CMV viremia. CMV immunoglobulin (CMVIG) preparations have the potential to exert immunomodulatory effects as well as providing passive immunization. Specific CMVIG antibodies and virus neutralization might be enhanced by modulation of dendritic cell activity and by a decrease in T-cell activation, effects which are of importance during the initial phase of infection. In summary, the role of CMVIG in reconstituting specific anti-CMV antibodies may be enhanced by some degree of modulation of the innate and adaptive immune responses, which could help to control some of the direct and indirect effects of CMV infection.

Molecular detection of cytomegalovirus in pregnant women referred for the triple marker test

The study was carried out to correlate and analyze the cytomegalovirus (CMV) infection in pregnant women who had come for triple marker screening. Fifty blood samples were collected from women in the age group of 20 to 40 years and were tested for the detection of CMV by serum analysis with PCR and serological examination by ELISA technique. PCR and serological examination can detect CMV in serum samples and distinguish primary infection and recurrent infection. Twenty six per cent (13/50) blood samples from women showed PCR positivity for CMV infection. Serological examination of a 27 year old woman showed a negative IgG and a positive IgM, indicating a recent infection with CMV. Journal of Diagnostic Pathology 2015;10(1):23-33

Comparison of the Artus RotorGene and COBAS Ampliprep/COBAS TaqMan Platforms for the Detection of Cytomegalovirus: Experience of a Tertiary Care Center

Cytomegalovirus (CMV) is a member of the Herpesviruses family. CMV infection rarely causes serious disease in otherwise healthy individuals, however, infection/reactivation among immunocompromised patients, including those undergoing hematopoietic stem cell transplantation (HSCT), can be critical and is associated with high rates of morbidity and mortality. The detection of CMV in blood using real-time polymerase chain reaction (qPCR) methods is the most sensitive and specific technique providing for a well-determined preemptive treatment cutoff. This study compares the performance of two new CMV qPCR platforms, COBAS(®) Ampliprep/COBAS(®) TaqMan(®) (Roche Molecular Diagnostics) and Artus RotorGene (QIAGEN). A total of 99 patients referred for CMV testing at AUBMC were tested using the Artus CMV RG PCR kit and the COBAS AmpliPrep/COBAS TaqMan CMV kit as per the manufacturers' recommendations. The difference between the two methods was within the allowable error for 97 out of 99 specimens (98%), with a correlation coefficient r = 0.80. The Artus CMV RG PCR Kit and the COBAS AmpliPrep/COBAS TaqMan CMV kit are both acceptable assays that can be used for the sensitive detection and quantitation of CMV mainly in peripheral blood specimens.

New PCR diagnostic systems for the detection and quantification of porcine cytomegalovirus (PCMV)

Pigs are frequently infected with porcine cytomegalovirus (PCMV). Infected adult animals may not present with symptoms of disease, and the virus remains latent. However, the virus may be transmitted to human recipients receiving pig transplants. Recently, it was shown that pig-to-non-human-primate xenotransplantations showed 2 to 3 times lower transplant survival when the donor pig was infected with PCMV. Therefore, highly sensitive methods are required to select virus-free pigs and to examine xenotransplants. Seven previously established PCR detection systems targeting the DNA polymerase gene of PCMV were examined by comparison of thermodynamic parameters of oligonucleotides, and new diagnostic nested PCR and real-time PCR systems with improved parameters and high sensitivity were established. The detection limit of conventional PCR was estimated to be 15 copies, and that of the nested PCR was 5 copies. The sensitivity of the real-time PCR with a TaqMan probe was two copies. An equal efficiency of the newly established detection systems was shown by parallel testing of DNA from sera and blood of six pigs, identifying the same animals as PCMV infected. These new diagnostic PCR systems will improve the detection of PCMV and therefore increase the safety of porcine xenotransplants.

Seroprevalence and Molecular Detection of Human Cytomegalovirus in HIV Positive Patients Attending Some Selected Hospitals in Kaduna State, Nigeria

Seroprevalence and Molecular Detection of Human Cytomegalovirus in HIV Positive Patients Attending Some Selected Hospitals in Kaduna State, Nigeria

Clinical spectrum, diagnostic criteria, and polymerase chain reaction of aqueous humor in viral and toxoplasma detection in Fuchs' uveitis syndrome.

Aim:The aim of this study is to describe the clinical features and diagnostic criteria of Fuchs’ uveitis (FU) and to determine whether it has an association with virus and toxoplasma in the aqueous humor during cataract surgery.Setting and Design:This is a prospective, case–control study.Materials and Methods:Patients with FU (n = 25), anterior uveitis (n = 15), and no uveitis (normal) (n = 50) were included based on predefined inclusion and exclusion criteria for all three groups. Polymerase chain reaction (PCR) of aqueous humor and serum for rubella, herpes simplex virus (HSV), cytomegalovirus (CMV), varicella-zoster virus (VZV), and toxoplasma was done using conventional uniplex PCR.Statistical Analysis:It was done using SPSS software using Chi-square test for categorical variables, and P < 0.05 was considered statistically significant.Results:Ninety patients were enrolled in the study in three groups, comparable for age, gender, and laterality of ocular involvement. All patients had diffuse keratic precipitates in FU group (P = 0001) with none having posterior synechiae (P = 0.046) which was statistically significant when compared to anterior uveitis patients. Iris nodules were noted in one case in both groups. Serum and aqueous PCR was negative for detection of VZV, CMV, toxoplasma, and rubella in all groups. PCR for HSV was positive in one patient in “normal” group but was not statistically significant.Conclusion:Our study shows that diagnosis of FU is mainly clinical. There appears to be no role of aqueous humor testing for viruses by PCR to aid in etiological diagnosis.

Evaluation of the Automated QIAsymphony SP/AS Workflow for Cytomegalovirus DNA Extraction and Amplification from Dried Blood Spots

Objective: Human cytomegalovirus (CMV) can be considered the most important agent of congenital infection. Long-term sequelae of congenital infection occur in about 15% of infants asymptomatic at birth. To avoid long-term sequelae or to reduce their burden, it is necessary to identify infected children for early interventions. CMV DNA can be detected in dried blood spots (DBSs). DBSs have been used in several studies for the retrospective diagnosis of congenital CMV (CCMV). It has been proposed to use DBSs for the newborn screening of CMV infection; however, manual methods are not suitable for newborn screening of CCMV. Methods: We evaluated in an off-label application the use of an automated instrument, the QIAsymphony SP/AS, in combination with the artus CMV QS-RGQ kit and the RotorGene Q real-time polymerase chain reaction system. Results: We analyzed 100 DBSs from newborns positive or negative for plasma CMV DNA with a 94% concordance in positive samples. Conclusions: We show that the QIAsymphony SP/AS and RotorGene Q workflow is suitable for CMV DNA extraction and detection from DBSs and that the system correctly identified newborns at risk of late sequelae due to CMV infection.

Immunostaining Detection of Cytomegalovirus in Gastrointestinal Biopsies: Clinicopathological Correlation at a Large Academic Health System.

BackgroundCytomegalovirus (CMV) infection can be asymptomatic in healthy individuals but may cause serious complications in immunocompromised patients. We investigated the clinicopathological correlation of CMV in gastrointestinal (GI) biopsies at our institute between January 1, 2013 and December 31, 2015.MethodsA total of 105 non-neoplastic GI biopsies tested positive for CMV by immunohistochemistry (IHC). The IHC results were stratified as “true positive” if > 2 cells stained, or “rare positive” if only 1 - 2 cells stained. Clinical information including comorbidities, serum CMV viral loads, and treatment was reviewed and correlated.ResultsOverall 1% of all GI biopsies were positive for CMV by immunostaining. The most frequently involved organ was colon, followed by esophagus, stomach, ileum and duodenum. When > 2 cells were stained positive, serum CMV viral loads were positive in 52.2%, negative in 17.2%, and not tested in 27.6% of cases. When only 1 - 2 cells stained positive, CMV viral loads were positive in 23.4%, negative in 25.5%, and not tested in 51.1% of cases. We further showed that clinical management of CMV differs based on both pathological findings and underlying diseases.ConclusionsThe role of CMV in GI biopsies remains controversial. We propose an algorithm of performing CMV immunostaining based on clinicopathological correlation.

Comparative evaluation of whole blood versus plasma for quantitative detection of cytomegalovirus using an automated system

Peripheral blood samples were separated into aliquots of whole blood and plasma and tested using an automated PCR system. More positive results were obtained from plasma (43), compared to whole blood (34). Plasma results did not correlate well with those in whole blood and tended to produce higher viral loads.

Molecular Detection of Human Cytomegalovirus (HCMV) Among Infants with Congenital Anomalies in Khartoum State, Sudan.

Human Cytomegalovirus (HCMV) infection still represents the most common potentially serious viral complication in humans and is a major cause of congenital anomalies in infants. This study is aimed to detect HCMV in infants with congenital anomalies.Study subjects consisted of infants born with neural tube defect, hydrocephalus and microcephaly.Fifty serum specimens (20 males, 30 females) were collected from different hospitals in Khartoum State. The sera were investigated for cytomegalovirus specific immunoglobin M (IgM) antibodies using enzyme-linked immunosorbent assay (ELISA), and for Cytomegalovirus DNA using polymerase chain reaction (PCR).Out of the 50 sera tested, one patient’s (2%) sample showed HCMV IgM, but with no detectable DNA, other 4(8.2 %) sera were positive for HCMV DNA but with no detectable IgM.Various diagnostic techniques should be considered to evaluate HCMV disease and routine screening for HCMV should be introduced for pregnant women in this setting. It is vital to initiate further research work with many samples from different area to assess prevalence and characterize HCMV and evaluate its maternal health implications.

Postnatal Cytomegalovirus Infection and the Risk for Bronchopulmonary Dysplasia.

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

Antigenemia and real time polymerase chain reaction for diagnosis of cytomegalovirus disease in HIV infected adults

Cytomegalovirus (CMV) infection is frequent in HIV adults. It is unknown usefulness of quantitative methods for diagnosing the CMV disease in Chilean patients. To determine the performance of antigenemia and real time polymerase chain reaction (rtPCR) in the diagnosis of CMV disease in Chilean HIV adults. Detection of CMV by viral isolation (AVR), antigenemia and quantitative rtPCR in HIV adults. The 102 adults with suspected CMV disease had lower LTCD4 count and higher HIV viral load than 77 patients without suspicion (p < 0.05). Antigenemia and PCR were positive in 47 (46.1%) and 37 (36.3%) adults with clinical suspicion and in 2 (2.6%) and 4 (5.2%) of 77 without suspicion. The sensitivity, specificity, positive and negative predictive value of antigenemia and RPCtr were 92%, 80%, 72% and 95% and 72%, 95%, 92% and 80%, respectively. The cutoff values were ≥ lcell (+) and ≥ 5.5 log10 copies/2 x 10(6) cells. CMV was isolated in 6/179 patients (3.4%), all symptomatic. Positivity of antigenemia and rtPCR are similar for diagnosing CMV disease in Chilean HIV adults. AVR is inappropriate as a gold standard for its low performance.

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

Cytomegalovirus Immunoglobulin for Prophylaxis and Treatment of Cytomegalovirus Infection in the (Val)Ganciclovir Era: A Single-Center Experience.

Evidence concerning the effectiveness of anti-cytomegalovirus immunoglobulin (CMVIg) following lung transplantation in the era of new antiviral agents is limited and controversial. At-risk patients (donor seropositive/recipient seronegative [D+/R-] and R+) received valganciclovir for 3 months (R+) or 6 months (D+/R). CMVIg (2 mg/kg) was given to D+/R- patients on days 1, 4, 8, 15, and 30 post-transplant, then monthly for a further year. Patients with valganciclovir-induced leukopenia were switched to CMVIg (2 mg/kg) prophylaxis. Tissue-invasive disease was treated with intravenous ganciclovir with CMVIg (2 mg/kg) every other day for 1 week and then weekly until discharge. Of 159 patients analyzed, 26 (17%) were D+/R-. Cytomegalovirus (CMV) viremia was more frequent in D+/R- recipients than in R+ patients (61% vs. 35%; P<0.05), but developed at a similar time (mean 10±6 vs. 11±7 months) and resolved in all cases following treatment. One patient developed clinical and laboratory signs of CMV syndrome (fever >38°C), leukopenia, and detection of CMV in blood. Ten patients developed tissue-invasive disease after completion of prophylaxis (5 pneumonitis and 5 gastrointestinal disease); all were successfully treated with combined intravenous ganciclovir and CMVIg. None of the 18 donor seropositive/recipient seronegative patients who were switched from valganciclovir to CMVIg for persistent leukopenia developed CMV viremia during treatment. No cases of CMV infection or disease were attributable to ganciclovir-resistant strains. During follow-up, 44 patients died (4/26 R+/D- [15%], 40/133 R+ [30%), none directly due to CMV infection. Combined prophylaxis with valganciclovir and CMVIg delayed CMV viremia and tissue-invasive disease in D+/R- lung transplant recipients, and prevented CMV-related mortality and development of ganciclovir resistance. CMVIg monotherapy prophylaxis was effective in R+ patients with ganciclovir-related toxicity.