Developed Cytomegalovirus Disease Research Articles

P208 Comparison of two assays for CMV specific cell mediated immunity in the recipients of liver transplantation

Aim To prevent serious problem due to cytomegalovirus (CMV) infection, antiviral prophylaxis is commonly used in recipients of solid-organ transplants. To predict which patient will develop CMV disease, CMV-specific cell-mediated immunity can be measured by Quantiferon-CMV, ELISpot assay, cytokine profiling, intracellular cytokine staining and tetramer staining. We were comparing Quantiferon-CMV and ELISpot assay in the recipient of liver transplantation in Korea, in which most people are seropositive. Methods We prospectively included 35 patients who will receive antiviral prophylaxis for liver transplantation in a tertiary university hospital. We had tested interferon-gamma level following in vitro stimulation with CMV antigen using two assays – EliSpot IFN-γ CMVspot (CMVspot) (Autoimmun Diagnostika, Germany) and Quantiferon-CMV (QF-CMV) (Qiagen, Australia). Blood samples of recipient collected before liver transplantation and CMVspot, CF-CMV and CMV IgM/IgG assay (BioMerieux, Germany) were performed simultaneously. For detection of CMV viremia, real-time PCR was performed using CMV R-gene kit (BioMerieux, France). The testing and interpretation were performed according to the manufacturer’s recommendation. Results The agreement rate of two assays was overall 51.5%. Although CMVspot results showed 32 recipients has CMV-specific cell-mediated immunity, 17 patients show reactive results in the QF-CMV assay. The 28 patients show the reactive result of CMVspot pp65 and the 13 patients show reactive results of CMVspot IE-1. Two samples were failing during the process of CMVspot on the sample reception and interpretation step and seven samples were interpreted indeterminate because of low mitogen reactivity in QF-CMV. All patients had a positive result of CMV IgG before transplantation and 16 patients had CMV viremia episode after transplantation. Conclusions To choose the method for testing cell-mediated immunity for CMV, laboratory have to concern about the characteristics of assays and regional seropositive prevalence. The results of two commercial assays can be different at one time for testing. Further evaluation was proceeding for accurate prediction of CMV disease after solid-organ transplantation.

Cytomegalovirus infection in living-donor and cadaveric lung transplantations.

Cytomegalovirus (CMV) infection remains a major cause of morbidity after lung transplantation. Some studies have reported prognostic factors for the postoperative development of CMV infection in cadaveric lung transplantation (CLT), but no research has been performed in living-donor lobar lung transplantation (LDLLT). Therefore, we analysed the possible risk factors of post-transplant CMV infection and the differences between LDLLT and CLT. The development of CMV disease and viraemia in 110 patients undergoing lung transplantation at Kyoto University Hospital in 2008-2015 were retrospectively assessed. The prognostic factors in the development of CMV infection and the differences between LDLLT and CLT were analysed. Among 110 patients, 58 LDLLTs and 52 CLTs were performed. The 3-year freedom rates from CMV disease and viraemia were 92.0% and 58.5%, respectively. There was no difference in the development of CMV infection between LDLLT and CLT (disease: 94.6% vs 91.0%, P = 0.58 and viraemia: 59.3% vs 57.2%, P = 0.76). In preoperative anti-CMV immunoglobulin status, R-D+ recipients (recipient: negative, donor: positive) and R-D- recipients (recipient: negative, donor: negative) tended to have higher and lower cumulative incidences, respectively, of CMV infection (disease: P = 0.34 and viraemia: P = 0.24) than that with R+ recipients (recipient: seropositive). Significantly lower cumulative incidence of CMV viraemia was observed in patients receiving 12-month prophylactic medication (70.6% vs 36.8%, P < 0.001). Twenty-eight patients (25.5%) had early cessation of anti-CMV prophylaxis due to toxicity; however, the extended prophylaxis duration did not increase the incidence of early cessation (P = 0.88). These trends were seen in both LDLLT and CLT. We found that there was no difference in the development of CMV infection between LDLLT and CLT. Twelve-month prophylaxis protocol provides beneficial effect without increased toxicity also in LDLLT.

Cytomegalovirus Reactivation Is Associated with Increased Risk of Late-Onset Invasive Fungal Disease after Allogeneic Hematopoietic Stem Cell Transplantation: A Multicenter Study in the Current Era of Viral Load Monitoring

Opportunistic infections such as cytomegalovirus (CMV) reactivation and invasive fungal disease (IFD) cause significant morbidity and mortality to recipients of hematopoietic stem cell transplant (HSCT). We aimed to characterize the risk and relationship of CMV reactivation post-HSCT to IFD in the current era of CMV viral load monitoring using highly sensitive plasma DNA. A multicenter, retrospective, cohort study was conducted of consecutive patients undergoing allogeneic HSCT from January 2006 to December 2010 in Melbourne, Australia. CMV reactivation was defined as detection of plasma CMV DNA ≥ 546 IU/mL or development of CMV disease. IFD was classified in accordance with current international consensus guidelines. Of the 419 study participants, the median age was 44 years (IQR, 34 to 54), and CMV reactivation occurred in 106 participants (25%) at a median time of 56 days (IQR, 45 to 79). Thirty-eight participants (9.1%) were identified with 41 cases of IFD (n = 22 proven, n = 8 probable, n = 11 possible) at a median time of 76 days (IQR, 24 to 344). The incidence of IFD was higher in participants with CMV reactivation compared with no CMV reactivation (15% versus 7%, P = .012). In a multivariate analysis CMV reactivation remained an independent risk factor for IFD (hazard ratio, 3.7; 95% CI, 1.6 to 8.5; P = .002). The cumulative incidence of all IFD in patients with and without CMV reactivation using a competing risk regression was a hazard ratio of 2.2 (95% CI, 1.2 to 4.1; P = .017) and for late-onset IFD was a hazard ratio of 3.95 (95% CI, 1.7 to 9; P = .001). The median time to IFD onset was longer in participants with than without CMV reactivation (184 versus 37 days, P = .03). The peak viral load, detection of any level of viremia, and experiencing more than 1 episode of CMV reactivation were not associated with development of IFD. CMV reactivation in HSCT recipients in the post-transplant period is associated with an increased risk of developing late-onset IFD. Further research is warranted to understand the interaction between these 2 important infectious complications.

Simultaneous pancreas/kidney transplant recipients are predisposed to tissue-invasive cytomegalovirus disease and concomitant infectious complications.

Infections have increased in simultaneous pancreas/kidney transplant recipients (SPKTRs) with cytomegalovirus (CMV) infection being the most important viral infection with adverse impact on patient and allograft outcomes. We studied all primary SPKTRs and deceased-donor kidney transplant recipients (KTRs) between 2008 and 2015 for the development of CMV infection. A total of 21/62 SPKTRs (33.9%) and 90/335 KTRs (26.9%) were diagnosed with CMV infection. A control group of 41 SPKTRs without CMV infection was used for comparison. SPKTRs showed an increased incidence of CMV infection compared with KTRs. SPKTRs were more likely to develop CMV disease, CMV pneumonia, recurrent CMV infection, higher initial and peak CMV loads, and more need for intravenous antiviral therapy compared with KTRs (P<.05). High-risk CMV serostatus (D+R-) and 2 HLA-B/-DR mismatches increased the risk of CMV infection in SPKTRs (P<.05). No differences were observed for patient and allograft outcomes (P>.05). SPKTRs with CMV infection were more likely to show concomitant Epstein-Barr virus (EBV) viremia compared with SPKTRs without CMV infection (P<.05). SPKTRs with CMV infection showed higher incidences of concomitant BK polyomavirus-associated nephropathy, EBV viremia, and sepsis compared with KTRs with CMV infection (P<.05). Our results suggest a higher incidence and more severe course of CMV infection in SPKTRs compared with KTRs. The increased incidence of concomitant infectious complications among SPKTRs with CMV infection suggests an overall impaired immunity, and calls for more intense screening.

Pre-emptive Therapy for Cytomegalovirus in Post-transplantation Liver Patients With Donor-Positive/Recipient-Negative Serostatus

IntoductionInfection by cytomegalovirus (CMV) is a major cause of morbidity among immunosuppressed patients, especially after solid organ transplantation. The risk of CMV after organ transplantation is strongly related to the serology of the donor and the recipient. The objective of this study was to analyze the outcomes and costs of pre-emptive therapy in patients after liver transplantation with donor-positive/recipient-negative (D+/R−) serostatus. MethodsThis retrospective study analyzed all patients who underwent liver transplantation with CMV serostatus D+/R− between January 2012 and December 2015. The service protocol adopts pre-emptive therapy. The outcomes and costs of this therapy are described. ResultsOf the 119 patients undergoing liver transplantation, 19 were D+/R− and entered the main analysis. Of these, 7 had positive polymerase chain reaction (PCR) results, and 1 developed CMV disease. Of the 6 patients who received no treatment, none developed CMV disease. Analyzing costs, pre-emptive therapy for these patients generated service savings of R$32,346.00. ConclusionsAlthough outcomes of universal prophylaxis and pre-emptive therapy are similar, pre-emptive therapy save on costs and have to be considered in patients with high-risk CMV disease after liver transplantation.

(983) - Impact of Prolonging CMV Prophylaxis in High Risk (CMV D+/R-) Lung Transplant Recipients

Purpose Cytomegalovirus (CMV) seronegative recipients receiving a seropositive allograft (D+/R-) are at a high risk of developing CMV disease. Our program increased the duration of CMV prophylaxis from 6 to 9 months in May 2013. Here, we present the impact on the incidence of CMV infection, disease, side effects and other factors. Methods Retrospective cohort of 241 CMV (D+/R-) transplanted from January 1, 2008 to December 31, 2017. Blood CMV testing was done according to protocol. All patients received ganciclovir/valganciclovir as prophylaxis. We recorded the incidence and timing of CMV infection and disease up to 6 months after cessation of prophylaxis. CMV infection was defined as detectable CMV-viremia in the absence of symptoms. CMV disease was defined as CMV syndrome or tissue-invasive disease. Side effects of prophylaxis were recorded. Results 9-month prophylaxis both delayed and decreased the rate of CMV disease (Figure 1) with no difference in the rate of CMV infection (Figure 1). The rate of biopsy-proven acute cellular rejection was lower in the extended 9 month prophylaxis group, although not statistically significant (Table 1). There was no difference in the rate of adverse effects or development of CMV resistance between the two groups. Conclusion Extending duration of CMV-prophylaxis from 6 to 9 months resulted in a delayed and decreased incidence of CMV disease in our lung transplant population. The incidence of CMV infection, and ganciclovir resistance and side effects were similar between the two groups. Our results suggest that extending CMV prophylaxis in the highest risk CMV D+/R- group is effective in reducing CMV-disease.

Epidemiology of infections following haploidentical peripheral blood hematopoietic cell transplantation.

BackgroundThe use of T‐cell replete haploidentical hematopoietic cell transplant (haplo‐HCT) has increased substantially since the introduction of post‐transplant cyclophosphamide (PTCy) regimens. Limited data exist concerning infectious complications of haplo‐HCT utilizing mobilized peripheral blood (PB) hematopoietic cells.MethodsThis retrospective cohort study included all adult patients at our institution undergoing PB haplo‐HCT with PTCy between June 2009 and June 2015. Infections were microbiologically confirmed. Invasive fungal infections (IFI) classified as “proven” or “probable” by standard definitions were included.ResultsIn total, 104 patients were identified. Median follow‐up was 218 days (range: 6–1576). A total of 322 episodes of infection were recorded. Eighty‐nine percent of patients experienced at least one infection. Median time to first infection was 22 days. Patients experiencing at least one bacterial, viral, and IFI were 62%, 72%, and 6%, respectively. The majority (69%) of bacterial infections were caused by enteric organisms. Seven cases of Staphylococcus aureus infection were recorded, with one bacteremia case. Cytomegalovirus (CMV) viremia occurred in 54/71 (76%) at‐risk patients at a median time of 24 days. Sixteen (15%) patients developed CMV disease. Nineteen percent (20/104) of patients developed BK polyomavirus‐associated cystitis. Six (6%) patients experienced a total of seven IFI. Infection was the primary cause of death for 12% (6/51) of patients and was a secondary cause for 41%.ConclusionIn PB haplo‐HCT patients, a high incidence of CMV viremia and disease was observed. Infections with enteric bacteria were common. Fungal and staphylococcal infections were uncommon. Further studies are needed to compare infectious complications in haplo‐HCT with other transplant modalities.

HLA-mismatched haploidentical transplantation using low-dose anti-thymocyte globulin (ATG: thymoglobulin)

ABSTRACTObjectives: To clarify optimal strategies for human leukocyte antigen (HLA)-mismatched haploidentical hematopoietic stem cell transplantation (HSCT).Methods: Twelve patients who underwent HSCT from a haploidentical related donor using low-dose thymoglobulin were analyzed retrospectively. Thymoglobulin was added to conditioning regimens at 2.5 mg/kg/day for 2 days (days −4 and −3). Prophylaxis against graft-versus-host disease (GVHD) was performed with cyclosporine and methotrexate.Results: The median age of the patients was 33 years. Six patients had previous allogeneic HSCT, and HSCT was performed in non-remission for nine patients. All patients but one, who died due to early infection, achieved neutrophil engraftment at a median of 17 days with complete donor-type chimerism. Acute and chronic GVHD were observed in six and five patients, respectively, but no patients died of GVHD-associated complication. No one developed cytomegalovirus disease, but Epstein–Barr virus-related lymphoproliferative disorder was observed in one patient. Long-term survival in remission without immunosuppressive agents are observed in two patients who underwent HSCT in remission, but the majority of patients who underwent HSCT in non-remission experienced disease progression.Conclusion: Haploidentical HSCT could be performed with thymoglobulin at 5 mg/kg, with the balance between GVHD and relapse rate. The dose reduction of thymoglobulin may be considered for advanced hematological malignancy.

Cytomegalovirus disease in inflammatory bowel disease: epidemiology and disease characteristics in a large single-centre experience.

Patients with inflammatory bowel disease (IBD) show an increased risk of developing cytomegalovirus (CMV) disease because of immunosuppressive medication and malnutrition. Here, we aimed to investigate the prevalence and clinical characteristics of CMV disease in our cohort of IBD patients. We carried out a retrospective analysis of 1023 IBD patients treated at our IBD clinic at the University Hospital Zurich between 2007 and 2014. CMV disease was defined as a positive immunohistochemistry for CMV and 14 patients were identified. The prevalence of CMV disease in our IBD cohort was 1.37%. Twelve patients had ulcerative colitis and two had Crohn's disease with colonic involvement. All patients who developed CMV disease received immunosuppressive medication or, as in one case, had HIV infection. The most used immunosuppressive medications were steroids and azathioprine. The most common therapeutic strategy was the consecutive use of ganciclovir and valganciclovir. Ten patients recovered and two were treatment refractory; among these, one required colectomy and two had a relapse. CMV disease may influence the clinical course of IBD. There is probably an association between CMV disease and IBD-specific medication. Risk factors, epidemiology and therapeutic strategy need to be further investigated.

Monitoring of intracellular adenosine triphosphate in CD4(+) T cells to predict the occurrence of cytomegalovirus disease in kidney transplant recipients.

The measurement of intracellular concentrations of adenosine triphosphate (iATP) in phytohemagglutinin-stimulated CD4(+) T cells constitutes a surrogate marker for post-transplant cell-mediated immunity (CMI). This assay has shown suboptimal accuracy for predicting infection after kidney transplantation (KT). We hypothesize that its predictive capacity depends on the specific contribution of the CMI to host-pathogen interactions. We assessed iATP levels in 100 KT recipients at baseline and months 1, 3, and 6 (363 measurements). No association was found between iATP at month 1 and the risk for overall or bacterial infection, although such association was evident for cytomegalovirus (CMV) disease (multivariate-adjusted hazard ratio [per 50-unit increment]: 0.83; P-value = 0.048). There were no significant differences in mean iATP between stable patients (319.4 ng/ml) and those developing overall (304.1 ng/ml) or bacterial infection (346.9 ng/ml) over the 45 days following monitoring. However, iATP was significantly lower in patients who developed CMV disease (223.5 ng/ml; P-values <0.002). The optimal cutoff (265 ng/ml) for predicting CMV disease in patients not receiving antiviral prophylaxis yielded sensitivity, specificity, positive, and negative predictive values of 85.7%, 68.3%, 15.2%, and 98.6%, respectively. In conclusion, a non-pathogen-specific monitoring of CMI by means of iATP informs the risk of CMV disease in KT recipients.

Valganciclovir As Prophylactic Treatment Option to Reduce Length of Stay on High Risk (D+/R-) Patients after Solid Organ Transplantation

This study aims to perform a length of stay (LOS) analysis between intravenous (IV) preemptive ganciclovir (GCV) and prophylactic oral valganciclovir (VGCV) for high-risk (D+/R-) cytomegalovirus (CMV) patients who underwent solid organ transplantation (SOT). A retrospective analysis was performed in the Brazilian Hospital Information System (SIH/SUS) database to assess the main Brazilian transplantation centers. The analysis was based on 2014 data. Based on a literature review, the Brazilian incidence of CMV infection (96.4%) was applied in the patient-population database number. It was assumed that 3.6% represents D+/R- patients and underwent to prophylactic treatment to avoid CMV infection. Development of CMV disease after treatment was not considered in the analysis. Average LOS for transplantation procedure was calculated from SIH/SUS database - 11 days. Preemptive treatment LOS data was taken from reference institutions guidelines – 21 days, considering that patients will need a twice a day infusion through 21 days. Prophylaxis with VGCV did not require hospitalization due to oral administration. It was considered the biggest transplantation center in Brazil/São Paulo, Hospital of Kidney and Hypertension, where a total of 687 SOT were performed in 2014. Results were expressed by hospitalized days avoided per patient due to VGCV treatment. Patient’s population results were calculated multiplying per patient results by the number of patients treated per institution. Applying the incidence rate of D+/R- (3.6%) in the hospital considered, around 25 D+/R- patients underwent prophylactic treatment. Treatment with GCV would require a total of 32 hospitalization days per patient compared to 11 days with VGCV. Therefore, treatment with VGCV would result in a LOS reduction of 21 days per patient and 519 days at the institution when compared to GCV. Prophylactic oral VGCV for patients who underwent SOT can effectively reduce LOS in the hospital.

Does cytomegalovirus viral load in stem-cell transplant recipients matter?

The question of cytomegalovirus (CMV) viral load on outcome after allogeneic stem-cell transplantation has been discussed since the development of quantitative techniques for assessing CMV DNA more than 15 years ago. Emery and colleagues did groundbreaking work in this area that was published in 2000 showing that initial viral load and the rate of viral load increase were predictive of subsequent development of CMV disease in diff erent types of transplant recipients. However, most patients were not given pre-emptive antiviral therapy. Ljungman and colleagues studied recipients of stem-cell transplants who were receiving PCR-based pre-emptive antiviral therapy and were unable to show an eff ect of pretreatment viral load on the risk for CMV disease but that the rate of decrease in viral load predicted development of CMV disease during later CMV replication episodes. Other studies have also addressed this question, providing support for viral load on outcome development of CMV disease, but data for hard endpoints such as survival are lacking. Why is this question important? New drugs against CMV are urgently needed because presently licensed antiviral drugs have important side-eff ects. Until now, regulatory authorities have required hard clinical endpoints in pivotal studies such as survival or development of CMV disease. However, due to developments in the fi eld of CMV management (eg, in pre-emptive therapy) the frequency of these complications has decreased to levels that make it very diffi cult to do such trials because of the large number of patients required. Establishment of a surrogate endpoint such as viral load for studies of CMV would therefore be of major importance, such as is the case for HIV and HCV. A report in The Lancet Haematology by Margaret Green and colleagues provides important information in this regard. First, they used a standardised assay using the international standard to analyse their material. Second, they noted a clear viral-load dependent negative eff ect on outcome measured by hard endpoints such as overall and non-relapse mortality. Third, they identifi ed that commencement of antiviral therapy when CMV replication has started might be too late, because even low viral loads had a negative eff ect on outcome. The fi ndings of this study therefore support the use of viral load as an important study endpoint in future clinical trials and that prevention of CMV replication rather than pre-emptive therapy should be the goal when managing recipients of stem-cell transplants. The limitation of this study is its retrospective design. However, prospective studies of CMV prophylaxis are ongoing and verifi cation of the fi ndings from Green and colleagues’ retrospective study might be possible through analysis of the data from these studies.

Figuring Out When to Stop Anti-CMV Prophylaxis After Lung Transplantation

Lung transplant recipients are at high risk for developing cytomegalovirus (CMV) disease. Current guidelines recommend that all CMV seropositive

Infectious Complications Following Small Bowel Transplantation.

Microbiological spectrum and outcome of infectious complications following small bowel transplantation (SBT) have not been thoroughly characterized. We performed a retrospective analysis of all patients undergoing SBT from 2004 to 2013 in Spain. Sixty-nine patients underwent a total of 87 SBT procedures (65 pediatric, 22 adult). The median follow-up was 867 days. Overall, 81 transplant patients (93.1%) developed 263 episodes of infection (incidence rate: 2.81 episodes per 1000 transplant-days), with no significant differences between adult and pediatric populations. Most infections were bacterial (47.5%). Despite universal prophylaxis, 22 transplant patients (25.3%) developed cytomegalovirus disease, mainly in the form of enteritis. Specifically, 54 episodes of opportunistic infection (OI) occurred in 35 transplant patients. Infection was the major cause of mortality (17 of 24 deaths). Multivariate analysis identified retransplantation (hazard ratio [HR]: 2.21; 95% confidence interval [CI]: 1.02-4.80; p = 0.046) and posttransplant renal replacement therapy (RRT; HR: 4.19; 95% CI: 1.40-12.60; p = 0.011) as risk factors for OI. RRT was also a risk factor for invasive fungal disease (IFD; HR: 24.90; 95% CI: 5.35-115.91; p < 0.001). In conclusion, infection is the most frequent complication and the leading cause of death following SBT. Posttransplant RRT and retransplantation identify those recipients at high risk for developing OI and IFD.

Comparison of Subcutaneous versus Intravenous Alemtuzumab for Graft-versus-Host Disease Prophylaxis with Fludarabine/Melphalan–Based Conditioning in Matched Unrelated Donor Allogeneic Stem Cell Transplantation

The objective of this study was to compare infusion-related reactions and outcomes of using subcutaneous (subQ) alemtuzumab versus intravenous (i.v.) alemtuzumab as graft-versus-host disease (GVHD) prophylaxis for matched unrelated donor stem cell transplantations. Outcomes include incidence of cytomegalovirus (CMV)/Epstein-Barr (EBV) viremia, development of CMV disease or post-transplantation lymphoproliferative disorder, fatal infections, acute and chronic GVHD, time to engraftment, relapse rate, and survival. We conducted a retrospective study of all adult matched unrelated donor stem cell transplantations patients who received fludarabine/melphalan with subQ or i.v. alemtuzumab in combination with tacrolimus as part of their conditioning for unrelated donor transplantation at New York-Presbyterian/Weill Cornell Medical Center from January 1, 2012 to March 21, 2014. Alemtuzumab was administered at a total cumulative dose of 100 mg (divided over days −7 to −3). Forty-six patients received an unrelated donor stem cell transplantation with fludarabine/melphalan and either subQ (n = 26) or i.v. (n = 20) alemtuzumab in combination with tacrolimus. Within the evaluable population, 130 subQ and 100 i.v. alemtuzumab doses were administered. For the primary outcome, ≥grade 2 infusion-related reactions occurred in 11 (8%) versus 25 (25%) infusions in the subQ and i.v. cohorts, respectively (P = .001). Overall, 12 injections (9%) in the subQ arm versus 26 infusions (26%) in the i.v. arm experienced an infusion-related reaction of any grade (P = .001). There were no significant differences between the subQ and i.v. arms in rates of reactivation of CMV/EBV, development of CMV disease or post-transplantation lymphoproliferative disorder, fatal infections, acute and chronic GVHD, relapse, or survival. Subcutaneous administration of alemtuzumab for GVHD prophylaxis was associated with fewer infusion-related reactions compared with i.v. administration in the SCT setting. Incidences of acute and chronic GVHD were similar between both arms. There was also no difference in reactivation of CMV/EBV viremia, development of CMV disease or post-transplantation lymphoproliferative disorder, fatal infections, relapse, or survival.

Association of CMV-Specific T Cell-Mediated Immunity with CMV DNAemia and Development of CMV Disease in HIV-1–Infected Individuals

BackgroundAmong HIV-1–infected individuals, cytomegalovirus (CMV) reactivation and disease occur in the setting of advanced immunosuppression. The value of a standardized assessment of CMV-specific T-cell mediated immunity by the CMV QuantiFERON assay (CMV-QFT) has not yet been thoroughly investigated in HIV-1–infected subjects.MethodsProspective, longitudinal study in 153 HIV-1–infected subjects with a CD4+ T cell count < 350/μL who simultaneously underwent CMV-QFT, CMV serology testing and CMV-DNA quantification. Factors associated with CMV-QFT were evaluated. Clinical screening for CMV manifestations was then performed every 3 months.ResultsAmong the 141 CMV IgG-seropositive individuals the CMV-QFT assay yielded reactive results in 84% (118/141), negative results in 15% (21/141) and indeterminate (negative mitogen IFN-gamma response) results in 1% (2/141) of subjects. The mean actual CD4+ T cell count was significantly higher in CMV-QFT reactive subjects, when compared to CMV-QFT non-reactive individuals (183 ± 102 vs. 126 ± 104 cells/μL, P = 0.015). A significantly lower proportion of CMV-QFT reactive vs. non-reactive patients displayed CMV DNAemia > 100 copies/mL (23% (27/118) vs. 48% (11/23), P = 0.02). Furthermore, a statistically significant inverse association between mitogen IFN-gamma response and CMV-DNAemia > 1000 copies/mL was observed (P < 0.001). During the observational period, 5 CMV end-organ manifestations were observed. In three of the CMV cases the CMV-QFT yielded indeterminate results.ConclusionsWhile CMV-QFT reactivity indicates CMV-specific immunity, indeterminate results due to negative mitogen IFN-gamma response might reflect HIV-1-induced immunodeficiency. Thus, dependency upon CD4+ T cell count should be considered when interpreting CMV-QFT results.

Effect of long-term prophylaxis in the development of cytomegalovirus-specific T-cell immunity in D+/R- solid organ transplant recipients.

This study aimed to characterize the dynamics of acquisition of cytomegalovirus (CMV)-specific cell-mediated immunity (CMI) in CMV donor positive/recipient negative solid organ transplant (SOT) patients receiving long-term antiviral prophylaxis, and to determine whether development of CMI confers protection against CMV disease. A prospective multicenter study was conducted in Spain from September 2009 to September 2012. Whole blood specimens were prospectively collected at 30, 90, 120, 200, and 365 days after SOT, and CMI was determined by enumeration of CMV pp65 and IE-1-specific CD69(+) /interferon-γ-producing CD8(+) and CD4(+) T cells by flow cytometry for intracellular cytokine staining. As part of a simultaneous clinical trial, patients received either early prophylaxis (in the first 3 days after transplantation) in the first period of the study or delayed prophylaxis (initiated at day 14) during the second period of the study. The impact of the dynamics of acquisition of CMV-specific CMI on the incidence of CMV disease was evaluated by Kaplan-Meier survival analysis. A total of 95 SOT recipients were recruited. CMV infection and disease occurred in 38 (40%) and 26 (27.4%) patients, respectively. The proportion of patients achieving any detectable CMV-specific CMI response at each of the different monitoring points was higher in liver transplant recipients, as compared to kidney or heart transplant recipients. The presence of any detectable response at day 120 or 200 was protective against the development of CMV disease (positive predictive values 92% and 93%, respectively). The rate of acquisition of CMV-specific CMI in SOT recipients undergoing antiviral prophylaxis differed significantly between different SOT populations. Patients developing any detectable CMI response were protected against the occurrence of CMV disease.

Pregnancy-related hemophagocytic lymphohistiocytosis associated with cytomegalovirus infection: A diagnostic and therapeutic challenge

ObjectiveHemophagocytic lymphohistiocytosis (HLH) is a disorder characterized by uncontrolled mature histiocyte proliferation, hemophagocytosis, and hypercytokinemia. We describe a previously healthy pregnant patient who presented in the third trimester of pregnancy with HLH. Case ReportA 35-year-old woman presented at 38 weeks' gestation with pyrexia, jaundice, severe anemia, elevated liver enzymes, and lactate dehydrogenase suggestive of HELLP (hemolysis, elevated liver enzyme, low platelet) syndrome. Unfortunately, her condition deteriorated and she was ventilated in the intensive care unit despite delivery of the baby and administration of dexamethasone. She developed microangiopathic hemolytic anemia, thrombocytopenia, and renal impairment suggestive of thrombotic thrombocytopenic purpura/hemolytic uremic syndrome. However, she was refractory to plasma exchange, intravenous immunoglobulin, and broad-spectrum antibiotics. HLH was eventually diagnosed from biochemical and bone marrow findings. An extensive search for possible causes yielded negative results. She improved significantly with intravenous dexamethasone and cyclosporine A and was transferred out of the intensive care unit. Unfortunately, she developed cytomegalovirus disease 2 weeks later, which improved transiently with intravenous ganciclovir; later, however, she succumbed to multidrug-resistant nosocomial infections, rapidly progressive cytomegalovirus disease, and multiorgan failure. ConclusionThis case highlights the challenges and difficulties involved in the diagnosis and management of pregnancy-related HLH. Immunosuppressive treatment for HLH can precipitate life-threatening opportunistic infections, which need to be promptly diagnosed and treated.

Use of Valacyclovir for the treatment of cytomegalovirus antigenemia after hematopoietic stem cell transplantation.

BackgroundValacyclovir has been used for prophylaxis against cytomegalovirus (CMV) infection after hematopoietic stem cell transplantation (HSCT). We investigated the efficacy and safety of high-dose Valacyclovir as pre-emptive therapy in patients with CMV antigenemia after HSCT.MethodsIn a retrospective single center study of 61 patients, we compared the rates of viral clearance, recurrent antigenemia and adverse events in patients with pp65 CMV antigenemia who received high dose Valacyclovir (n = 15), Valganciclovir (n = 16), and Foscarnet (n = 30).ResultsOverall, 60/61 (98 %) of cases achieved CMV antigenemia clearance by day 28, and no patient developed CMV disease. After adjusting for age, sex, diagnosis, CMV serological status, donor type, CMV antigen level, graft-versus-host disease (GVHD) therapy, and conditioning regimen, there were no significant differences in the rates of viral clearance at day 14 in patients who received Valganciclovir (0.18, 95 % confidence interval (CI) 0.01 to 2.15, p = 0.17) and Foscarnet (OR 0.22, 95 % CI 0.03 to 2.40, p = 0.22), compared with Valacyclovir (assigned OR = 1.00). Recurrent antigenemia by day 180 after clearance of the initial CMV episode occurred in 34/61 (56 %) of patients. Using the multivariate model adjusting for the same covariates, there were also no significant differences in secondary episodes of CMV between treatment groups. With regards to adverse effect monitoring, Foscarnet led to significantly increased creatinine levels (P = 0.009), while Valganciclovir led to significant decrease in neutrophil counts (P = 0.012).ConclusionHigh dose Valacyclovir is a potential alternative to Valganciclovir and Foscarnet in the stable post-HSCT patient who has cytopenia and is not keen for inpatient treatment of CMV antigenemia.

Can Leflunomide Play a Role in Cytomegalovirus Disease Prophylaxis besides its Antirheumatic Effects?

Leflunomide, a disease-modifying antirheumatic drug (DMARD), has shown effectiveness in many autoimmune disorders and can suppress cytomegalovirus (CMV) disease in humans. Thus, it is possible for leflunomide to play a role in CMV prophylaxis or pre-emptive therapy in high-risk patients in addition to its application as a DMARD for autoimmune disorders. We describe two adult patients who developed CMV disease after administration of low-dose leflunomide. One patient was successfully treated with an increasing leflunomide dosage, resulting in a long-term suppression of serum CMV viral load.