Infections In Transplant Patients Research Articles

Characterization of the Polyproline Region of the Hepatitis E Virus in Immunocompromised Patients

Little is known about virus adaptation in immunocompromised patients with chronic genotype 3 hepatitis E virus (HEV3) infections. Virus-host recombinant strains have been isolated recently from chronically infected patients. The nature and incidence of such recombinant events occurring during infections of solid-organ transplant (SOT) recipients are essentially unknown. The polyproline region (PPR) of strains isolated from SOT patients was sequenced during the acute-infection phase (n = 59) and during follow-up of patients whose infections became chronic (n = 27). These 27 HEV strains included 3 (11%) that showed recombinant events 12, 34, 48, or 88 months after infection. In one strain, parts of the PPR and the RNA-dependent RNA polymerase were concomitantly inserted. In the second, a fragment of a human tyrosine aminotransferase (TAT) gene was inserted first, followed by a fragment of PPR. A fragment of the human inter-α-trypsin inhibitor (ITI) gene was inserted in the third. All the inserted sequences were rich in aliphatic and basic amino acids. In vitro growth experiments suggest that the ITI insertion promoted more vigorous virus growth. In silico studies showed that the inserted sequences could provide potential acetylation, ubiquitination, and phosphorylation sites. We found that recombinant events had occurred in the HEV PPR in approximately 11% of the strains isolated from chronically infected transplant patients followed up in Toulouse University Hospital. These inserted fragments came from the HEV genome or a human gene and could enhance virus replication. Importance: Hepatitis E virus (HEV) can cause chronic infections in immunocompromised patients, including solid-organ transplant (SOT) recipients. Two strains that had undergone recombination with human ribosomal genes were described recently. The strains with inserted sequences replicated better in vitro. Little is known about the frequency of such recombinant events or how such an insertion enhances replication. We therefore investigated 59 SOT patients infected with HEV and found 3 strains with 4 recombinant events in 27 of these patients whose infection became chronic. The 4 inserted sequences were of different origins (human gene or HEV genome), but all were enriched in aliphatic and basic amino acids and provided potential regulation sites. Our data indicate that recombinant events occur in approximately 11% of strains isolated from chronically infected patients. The structures of the inserted sequences provide new clues as to how the inserted sequences could foster virus replication.

Diarrhea in peripheral stem cell transplant recipients: a developing country's experience.

We aimed to determine the frequency and microbiological causes of diarrhea occurring during the first 100 days in allogeneic (allo-) and autologous (auto-) stem cell transplantation (SCT) patients. A total of 452 patients who underwent transplantation due to hematological or solid organ malignancy were included. From the administration of the conditioning regimen up to day 100 post-transplant, diarrhea cases lasting at least three days with a minimum of three episodes per day were evaluated. Cases of diarrhea were observed in 94 patients out of 227 subjects who received allo-SCT and in 107 patients out of 225 who received auto-SCT. The incidence rate of diarrhea in both patients undergoing autologous and allogeneic transplant was 47.5% and 41.4%, respectively. The cause of the diarrhea could be detected in 20.5% of auto-SCT patients and in 30.8% of allo-SCT patients. Parasitic infections were frequently observed in both autologous and allogeneic transplant patients in the first 20 days. In the late period, significantly more patients developed diarrhea in the allo-SCT recipient group than in the auto-SCT recipients due to graft versus host disease (GVHD) and cytomegalovirus (CMV) colitis. This study revealed the causes of diarrhea and the prevalence and factors of parasitic infections in transplant patients in Turkey. All causative factors of diarrhea should be considered in detail, feces analyses should be evaluated for each patient, and endoscopic biopsy samples should be obtained when required in immunosuppressive patients undergoing stem cell transplantation.

Recurrent Mycobacterium haemophilum in a renal transplant recipient

Mycobacterium haemophilum is a rare isolate of non-tuberculous Mycobacterium which has been reported to affect immunocompromised patients. We report a case of a 32-year-old renal transplant patient with M. haemophilum infection initially involving his left sinus which was treated with appropriate antimicrobial therapy for thirteen months. Two weeks after cessation of antibiotics the infection rapidly recurred in his skin and soft tissues of his hands and feet. This case highlights the difficult diagnostic and therapeutic implications of atypical infections in transplant patients. To our knowledge this is the first reported case of relapsed M. haemophilum infection in a renal transplant recipient.

Duplex realtime PCR method for Epstein–Barr virus and human DNA quantification: its application for post-transplant lymphoproliferative disorders detection

IntroductionThe quantification of circulating Epstein–Barr virus (EBV) DNA is used to monitor transplant patients as an early marker of Post-Transplant Lymphoproliferative Disorders (PTLD). So far no standardized methodology exists for such determination. ObjectiveOur purpose was to develop and validate a real-time PCR assay to quantify EBV DNA in clinical samples from transplant recipients. MethodsA duplex real-time PCR method was developed to amplify DNA from EBV and from a human gene. The EBV load was determined in peripheral blood mononuclear cells (PBMC), plasma and oropharyngeal tissue from 64 non-transplanted patients with lymphoid-hypertrophy (Non-Tx), 47 transplant recipients without PTLD (Tx), 54 recipients with PTLD (Tx-PTLD), and 66 blood donors (BD). WinPEPI, version 11.14 software was used for statistical analysis. ResultsAnalytical validation: the intra and inter-assays variation coefficients were less than 4.5% (EBV-reaction) and 3% (glyceraldehyde 3-phosphate dehydrogenase – GAPDH reaction). Linear ranges comprised 107–10 EBV genome equivalents (gEq) (EBV-reaction) and 500,000–32 human gEq (GAPDH-reaction). The detection limit was 2.9 EBV gEq (EBV-reaction). Both reactions showed specificity. Application to clinical samples: higher levels of EBV were found in oropharyngeal tissue from transplanted groups with and without PTLD, compared to Non-Tx (p<0.05). The EBV load in PBMC from the groups of BD, Non-Tx, Tx and Tx-PTLD exhibited increasing levels (p<0.05). In BD, PBMC and plasma, EBV loads were undetectable. ConclusionsThe performance of the assay was suitable for the required clinical application. The assay may be useful to monitor EBV infection in transplant patients, in particular in laboratories from low-income regions that cannot afford to use commercial assays.

Human Herpes Virus 6 Reactivation and Disease After Allogeneic Hematopoietic Stem Cell Transplantation

Background Human herpesvirus type 6 (HHV-6) is a member of the beta herpesvirus subfamily (genus Roseolovirus) and two distinct variants have been described: types A and B. HHV-6 infection is recognized as the cause of a febrile disease and exanthem subitum in early childhood. The infection rarely causes serious events in healthy individuals, but viral reactivation in immunocompromised patients is frequently associated with severe clinical manifestations. Above all HHV-6 is increasingly recognized as an opportunistic and potentially life-threatening pathogen in recipients of allogeneic hematopoietic stem cell transplantation (AlloSCT). Approximately 60% of solid organ transplant and 40% of patients undergoing alloSCT experience HHV-6 reactivation, mainly of variant B. Reported clinical manifestations of HHV-6 infection in transplanted patients are skin rash, interstitial pneumonia, bone marrow suppression and encephalitis. Moreover, some clinical reports suggest that HHV-6 can facilitate the occurrence of severe clinical complications of alloSCT, increasing transplant-related mortality. Methods From January 2009 to February 2013, we retrospectively evaluated 54 consecutive adult patients (median age 50 years) who developed positivity to HHV-6 after alloSCT for high-risk hematological malignancies. Stem cell donors were family haploidentical (37), HLA identical sibling (8), unrelated volunteer (6), cord blood (3). The viral load was determined by quantitative PCR (Nanogen Advanced Diagnostic S.r.L) in cell-free body fluids such as plasma, bronchoalveolar lavage (BAL), cerebrospinal fluid (CSF), bone marrow (BM) aspirates or in gastrointestinal biopsies. Results Median time from alloSCT to HHV-6 reactivation was 34 days (range: 0-705). Thirty-one patients presented HHV-6 positive in plasma, 9/54 in BM, 33/54 in gut biopsies or BAL, 7/54 in CSF. At the time of viral positivity all pts were receiving acyclovir as viral prophylaxis except five. Twenty-nine patients had acute graft versus host disease (GvHD). Twenty-two out of these twenty-nine patients experienced a grade III-IV acute GvHD, requiring high dose steroids in twenty-six cases. A concomitant CMV positivity was detected in 15/54 patients. The median absolute count of CD3+ lymphocytes was 262 cells/mcl. In 52/54 cases we reported HHV-6 clinical manifestations: fever (43), skin rash (22), hepatitis (19), diarrhoea (24), encephalitis (10), BM suppression (18), delayed engraftment (11). HHV-6 positivity led to antiviral pharmacological treatment in 37/54 cases, using as first choice therapy foscarnet. Amongst the total fifty-four patients with documented HHV-6 positivity thirty-one solved the clinical event. However the mortality rate was relatively high in this population (only 30% of patients were alive), mainly related to severe infections or GvHD. A better overall survival is significantly associated with CD3+ cells higher than 200/mcl (p-value 0.011) and time after alloSCT more than 2 months (p-value 0.035). In this analysis the overall survival was not significantly influenced by steroids administration, presence of acute GvHD, plasma viral load and organ involvement. Conclusions This retrospective study further demonstrates the correlation between HHV-6 reactivation and high morbidity and mortality rates in patients after alloSCT. Despite HHV-6 detection typically occurred in the first month after AlloSCT, a better immune reconstitution has the potential to improve the outcome. The regular monitoring of HHV-6 DNA, using a real-time PCR assay, may be useful for identifying active HHV-6 infection and for the introduction of a pre-emptive treatment, possibly reducing the incidence of the most severe clinical complications. Disclosures: Bonini: MolMed SpA: Consultancy.

Cytomegaloviruses: From Molecular Pathogenesis to Intervention

Many health professionals rely on journal articles to keep up with advances in their field because textbooks are often 1–2 years out of date by the time they come to press, and are far more expensive than the occasional PDF downloaded from a university library Web site. This 2-volume text on cytomegalovirus (CMV) is costly and cites data from before 2012, but provides a solid foundation on which to apply new findings. Volume I is mainly focused on the basic science of and related animal experiments on CMV; volume II is aimed at the clinical reader, again with chapters on relevant animal model studies. Each chapter reads as a short review article, and is easily digestible. Many well-recognized experts in this field contributed content, which should be reassuring to the reader. The text and referencing style are easy to read and the figures and tables are illustrative and helpful. The volumes come in a compact size, making them convenient to carry, and also are downloadable as eBooks. Volume I gives in-depth overviews of primate and murine CMVs, CMV metabolomics, miRNAs, and proteomics. Most of the chapters are dedicated to viral gene expression and function and virus interaction with human host cells, describing immune response, aspects of viral tropism, entry, pathogenesis, and latency. The terminology used in Volume I is specialized and may be difficult for readers who do not work in these fields. Volume II covers essential clinical background: the epidemiology of CMV infections in pregnancy, CMV infections in solid and bone marrow transplants, CMV therapy and drug resistance, diagnostic methods, and vaccine development. Additional chapters describe the host immune response to CMV infection, and mechanisms of infection in specific targets, such as the placenta. Chapters in both volumes are detailed and clearly written; the editors are to be commended on maintaining this standard. However, additional detail and discussion (i.e., pros and cons) about alternative targets for CMV PCR monitoring of transplant patients, such as pp65 antigen and pp67 mRNA versus DNA, would have been helpful. Also, an in-depth chapter on the characteristics of reinfecting or superinfecting strains of CMV in various clinical situations would be useful; such strains are frequently referred to without description throughout the clinical text. Perhaps one surprising omission on the clinical side is a chapter comparing and contrasting the various clinical guidelines for the treatment of CMV infections in transplant patients; this would highlight differences in how published data are interpreted. Chapter II.23, Putative Disease Associations with Cytomegalovirus: a Critical Survey, explores the possible role of CMV as an etiologic agent for specific clinical syndromes, including glioblastomamultiforme, cardiovascular disease, and the role that CMV may play in immunosenescence. This makes fascinating and educational reading, especially in how the authors tease out the relevant (and irrelevant) evidence for and against these potential etiologic roles. The price tag is considerable, although the 2 volumes can be purchased separately (http://www.horizonpress.com/hsp/supplementary/cmv2/cmv2-vol1-vol2.html). As a medical–clinical virologist, I find Volume II to be a useful reference text. Those working on the basic virology of CMV may consider Volume I a useful addition to their libraries. These volumes give comprehensive, yet succinct overviews of the current state of knowledge of many aspects of CMV and are detailed enough to satisfy most readers.

Hepatitis C Virus Load in Seropositive Liver and Kidney Transplant Recipients by Quantitative Real-Time PCR Before and After Transplantation

Background: Hepatitis C virus (HCV) infection is one the major health concern among the infected transplant patients. Considering several complications of the disease in them, pre and post-transplantation studies should be performed for monitoring of the infection, as well as, developing new treatment protocols. Objectives: The current study was conducted to determine the Hepatitis C Virus RNA level among seropositive liver and kidney transplant recipients in Namazi Hospital; the main transplantation center in southern Iran. Materials and Methods: RNAs were extracted from 105 serum samples of seropositive liver and kidney transplant recipients and analyzed by Real-time PCR assay using a set of primers. Results: HCV RNA was detected in a total of 46/105 (43.8%) recipients’ serum samples [39/46 (84.8%) males and 7/46 (15.2%) females]. Moreover, 8/46 (17.4%) and 38/46 (82.6%) were kidney and liver recipients, respectively. The copy number of HCV RNA, measured by the Real-time PCR assay, ranged from 5 × 102 to 3.14 × 109 copies/mL; Median 2.37 × 105 copies/mL and 1.7 × 103 to 9.44 × 104 copies/mL; Median 2.89 × 104 copies/mL in liver and renal transplant patients, respectively. The comparison of viral load between liver pre transplant recipients group and post transplant counterpart indicated that the copy number of HCV RNA was significantly higher in the post transplant recipients (P = 0.033). The prevalence of the viral nucleic acid was significantly higher in males than in females (P = 0.026). Similarly, with regards to the age groups, the prevalence of HCV RNA was significantly higher in age group ≥ 45 years than age group < 45 years (P = 0.028). Conclusions: Considering the results, it can be concluded that HCV RNA detection is strongly suggested in transplant patients group to determine the prevalence of the disease and their responses to antiviral therapy and diagnosis of drug resistance. In addition, continuous and regular surveillance of HCV RNA level in such patients is highly recommended in order to better manage the complications of graft loss and reduce the mortality rate. Further studies are needed to find new therapeutic methods to lower the incidence of infection of new healthy allograft tissues in HCV RNA positive recipients.

Sporotrichosis in Renal Transplant Patients

The current report describes two renal transplant recipients who presented with sporotrichosis. In addition, the authors review the general aspects of sporotrichosis in renal transplant recipients reported in the literature. Sporotrichosis is a rare fungal infection in transplant patients and has been reported primarily in renal transplant recipients not treated with antifungal prophylaxis. Extracutaneous forms of sporotrichosis without skin manifestations and no previous history of traumatic injuries have been described in such patients and are difficult to diagnose. Renal transplant recipients with sporotrichosis described in the present report were successfully treated with antifungal therapy including amphotericin B deoxycholate, lipid amphotericin B formulations, fluconazole and itraconazole.

Peripheral Blood Leukocytes and Serum Nested Polymerase Chain Reaction Are Complementary Methods for Monitoring Active Cytomegalovirus Infection in Transplant Patients

Human cytomegalovirus is an important cause of morbidity and mortality in immunocompromised patients. Qualitative polymerase chain reaction (PCR) has proven to be a sensitive and effective technique in defining active cytomegalovirus infection, in addition to having low cost and being a useful test for situations in which there is no need for quantification. Real-time PCR has the advantage of quantification; however, the high cost of this methodology makes it impractical for routine use. To apply a nested PCR assay to serum (sPCR) and to evaluate its efficiency to diagnose active cytomegalovirus infection compared with PCR of peripheral blood leukocytes (L-PCR). Samples of 37 patients were prospectively evaluated. An internal control was created and applied to sPCR to exclude false-negative results. In total, 21 patients (57%) developed active cytomegalovirus infection. After analyzing the two methods for the diagnosis of active infection, higher sensitivity and negative predictive value of the L-PCR versus sPCR (100% versus 62%), and higher specificity and positive predictive value of sPCR versus L-PCR (81% versus 50% and 72%, respectively) were observed. Discordant results were observed in 11 patients who were L-PCR-positive but sPCR-negative for active cytomegalovirus infection, five of whom developed clinical symptoms of cytomegalovirus. Clinical symptoms were observed in 14 patients, 12 of whom were diagnosed with active infection by nested L-PCR (P=0.007) and seven by nested sPCR (P=0.02). Higher specificity and a positive predictive value for sPCR were observed. Nested L-PCR and sPCR were considered to be complementary methods for the diagnosis and management of symptomatic cytomegalovirus infection.

Strongyloides stercoralis infection in transplanted patients.

Patient:Male, 36Final Diagnosis:StrongyloidiasisSymptoms:Abdominal pain • anorexia • eosinophilia • fever • letargy • weight lossMedication:—Clinical Procedure:—Specialty:Infectious diseasesObjective:Challenging differential diagnosis, rare diseaseBackground:Strongyloidiasis is a worldwide infection, infecting approximately 100 million people in more than 70 countries. It is common in Southeast Asia, Latin America, Papua New Guinea and some parts of the United States. Malnutrition, cancer, organ transplantation, hemodialysis and prolonged use of corticosteroids increase the risk of this opportunistic infection. Undiagnosed and untreated, its mortality rate can be high.Case Report:We present a 36 year old Black man with history of malignant hypertension and glomerulonephritis who had chronic eosinophilia and vague, poorly localized abdominal pain and tenderness. He received three deceased donor kidney transplants, two of them failed and the third one succeeded. However, after transplantation, his abdominal pain and discomfort increased, became anorexic, lost weight and developed fever and lethargy. Duodenal aspirate examination was positive for strongyloides stercoralis. Immunosuppressant medications were discontinued and he was treated with thiabendazole. In spite of treatment, his condition deteriorated and he expired.Conclusions:Due to low sensitivity of stool and serological examinations, diagnosis of strongyloidiasis often is delayed. A high index of suspicion and prompt diagnosis and treatment are essential in decreasing the morbidity and mortality of this infection. Before organ transplantation, every attempt should be made to find the cause of peripheral blood eosinophilia and in endemic areas and among patients coming from countries where the infection is known to exist, organ recipients and donors should be screened for parasitic infections including strongyloidiasis

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Introduction: C. difficile represents an important opportunistic infection in transplant patients. In the critical care setting, the severity of illness combined with the lack of data to guide treatment practices poses a particular clinical challenge in this population. We characterize treatment patterns and outcomes for C. difficile infection in transplant patients in the intensive care unit, including initial antibiotic regimen and clinical cure rate. Hypothesis: Due to a lack of specific guidelines for patients with transplantations, varying antibiotics would be used to treat C. difficile infection in critically ill patients with resulting variations in cure rates. Methods: A retrospective chart review was conducted of patients admitted to the intensive care unit between June 2009 and June 2011. Adult patients diagnosed with C. difficile infection and a history of solid organ or bone marrow transplantation were included. Clinical cure was defined as resolution of diarrhea by day six of treatment. Patients were stratified based on infection severity as defined by the IDSA/SHEA clinical guidelines. Outcomes were analyzed using the Chi-squared test. Results: Forty patients were included in the analysis. Metronidazole (n=16), vancomycin (n=18), and a combination of vancomycin and metronidazole (n=6) were initial antibiotic treatments. Clinical cure was seen in 21 (52.5%) patients. Metronidazole was most commonly used in mild to moderate infection (71.4%), vancomycin was most commonly used in severe infection (55.6%), and combination therapy was most common in severe with complications (66.7%). Based on initial treatment regimen, 66.7% of patients on a vancomycin regimen, 50% of patients on metronidazole, and 33.3% on combination therapy achieved a clinical cure, with no significant difference found between groups (p = 0.32). Conclusions: Cure rates observed were lower than those documented in non-critically ill and non-transplant patients. Based on our findings, it would seem reasonable to start all critically ill transplant patients who develop C. difficile infection on vancomycin, but the poor overall cure rates suggest optimal first line therapy still needs to be defined for this challenging population.

Quantification of cytomegalovirus DNA by a fully automated real-time PCR for early diagnosis and monitoring of active viral infection in solid organ transplant recipients

BackgroundQuantification of cytomegalovirus (CMV) DNA by real-time PCR is currently considered an alternative diagnostic approach for the evaluation of active infection in transplant patients. The pp65 antigenemia assay has been used as reference test for monitoring active CMV infection and guiding preemptive therapy in transplant recipients. However, this assay suffers from some limitations: need for immediate processing of the samples, labour-intensive process, lack of standardization and subjective result interpretation. ObjectivesThe aim of this study was to evaluate the performance of a new commercially available real-time PCR assay coupled with a fully automated DNA extraction system (COBAS Ampliprep/COBAS Taqman CMV Test, Roche Diagnostics) for the detection of CMV-DNA in plasma comparing it with pp65 antigenemia assay for monitoring active CMV infection in solid organ transplant recipients (SOTRs). Study designA total of 266 consecutive samples from 45 SOTRs were monitored with pp65 antigenemia and in parallel with CMV-DNA quantitation by real-time PCR assay. ResultsFifty-eight samples resulted PCR-positive, 163 negative and for 45 samples the CMV-DNA values obtained were below the lower limit of quantification (<150copies/ml); pp65 antigen was detected in 47 samples and resulted negative in 219 specimens. Concordance between the two evaluations was 76.7%; also a good correlation was observed (r=0.718). Considering the existing treatment criteria based on pp65 antigenemia evaluation corresponding to pp65 levels≥20 positive cells/200,000, preemptive therapy was administered to four asymptomatically infected patients. The corresponding cut-off value of CMV-DNA load calculated for discrimination between self-clearing infections and those requiring therapy was 2500copies/ml (or 2275IU/ml). ConclusionThe fully automated real-time PCR from Roche provided specific and sensitive results and represented a rapid and simple assay for the evaluation and monitoring of CMV infection in SOTRs. Further studies are required to validate the threshold level for the initiation of preemptive therapy.

Subacute cytomegalovirus appendicitis in a renal transplant recipient

Cytomegalovirus (CMV) infections in transplant patients is a well-known disease. We describe the first case, to our knowledge, documenting CMV appendicitis in a renal transplant patient, and its clinical presentation, diagnosis, and treatment.

Prophylaxis of fungal infections in transplant patients

Fungi are an important cause of infection in patients undergoing solid organ transplantation and bone marrow or hematopoietic stem cell transplantation (BMT/HSCT). The incidence and mortality of fungal infections differ according to the organ and the time since transplantation. In the first 30 days after transplantation, yeast (primarily Candida spp.) predominate. After the first month, filamentous fungi, such as Aspergillus spp., are the most frequent agents of infection (1-6). In BMT/HSCT patients, however, invasive aspergillosis has two peaks of incidence: one at one month post-transplantation and another approximately 90 days after the transplant if the patient develops chronic graft versus host disease (7,8). Among solid organ transplantation, liver and lung transplant have the highest risk for fungal infection due to underlying diseases, surgical techniques and the graft itself (4,9). Antifungal prophylaxis use is well established following some transplant types, such as BMT/HSCT and liver (10,11). However, few studies have evaluated heart and pancreas transplants. One of the major challenges is the prevention of filamentous fungal infections, especially by Aspergillus spp., in high-risk patients, such as those who have undergone an allogeneic BMT and developed chronic graft versus host disease or undergone a lung transplantation (12,13). To standardize the use of primary prophylaxis in transplant patients, we analyzed the literature related to the following transplants: liver, kidney, heart, lung, and HSCT. The IDSA (Infectious Diseases Society of America) system was used to determine the levels of evidence.

JC Polyomavirus Infections in Transplant Patients

The polyomavirus JC virus (JCV) is a small nonenveloped DNA virus that asymptomatically infects about 80% of healthy adults and establishes latency in the kidney tissue. In case of immunodeficient hosts, JCV can lytically infect the oligodendrocytes, causing a fatal demyelinating disease, known as Progressive Multifocal Leukoencephalopathy (PML). Although the reactivation of another human polyomavirus, BK Virus (BKV), is relatively common and its association with the Polyomavirus Associated Nephropathy (PVAN) following renal transplantation is assessed, JCV replication and its impact on graft function and survival is less well studied. In addition, none of the performed studies ruled out the hypothesis that JCV could be associated with certain post-transplantation clinical syndromes. Thus, monitoring of Polyomaviruses infection, especially during the first 24 months post-transplantation, is recommended.

Molecular Networks Involved in the Immune Control of BK Polyomavirus

BK polyomavirus infection is the important cause of virus-related nephropathy following kidney transplantation. BK virus reactivates in 30%–80% of kidney transplant recipients resulting in BK virus-related nephropathy in 1%–10% of cases. Currently, the molecular processes associated with asymptomatic infections in transplant patients infected with BK virus remain unclear. In this study we evaluate intrarenal molecular processes during different stages of BKV infection. The gene expression profiles of 90 target genes known to be associated with immune response were evaluated in kidney graft biopsy material using TaqMan low density array. Three patient groups were examined: control patients with no evidence of BK virus reactivation (n = 11), infected asymptomatic patients (n = 9), and patients with BK virus nephropathy (n = 10). Analysis of biopsies from asymptomatic viruria patients resulted in the identification of 5 differentially expressed genes (CD3E, CD68, CCR2, ICAM-1, and SKI) (P < 0.05), and functional analysis showed a significantly heightened presence of costimulatory signals (e.g., CD40/CD40L; P < 0.05). Gene ontology analysis revealed several biological networks associated with BKV immune control in comparison to the control group. This study demonstrated that asymptomatic BK viruria is associated with a different intrarenal regulation of several genes implicating in antiviral immune response.

DETECTION OF HUMAN HERPESVIRUSES 6 AND 7 DNA IN THE SALIVA OF RENAL TRANSPLANTED PATIENTS AND HEALTHY INDIVIDUALS FROM RIO DE JANEIRO, BRAZIL

In this study, we have sought to verify the prevalence ofhuman herpesviruses 6 and 7 (HHV-6, HHV-7) in the saliva of renal transplanted patients from Rio de Janeiro State, Brazil, and compare results with those of healthy subjects, since Roseolovirus DNA detection in body fluids from transplanted patients has been associated with often misdiagnosed chronic symptoms, organ rejection and even death. The studied group was composed by 120 individuals: 60 were renal transplanted patients and 60 were healthy subjects attending the Hospital Universitario Pedro Ernesto, for odontological follow-up. Saliva specimens were submitted to a multiplex nested polymerase chain reaction (PCR) to detect the presence of HHV-6A, HHV-6B and HHV-7. The total Roseolovirus DNA prevalence was 56.7% for transplanted patients and 23.3% for healthy individuals (p<0.001). For immunossupressed patients, the PCR detected a HHV-6A prevalence of 16.7% in transplanted, HHV-6B in 26.6% and HHV-7 DNA was revealed in 13.3% of the studied cases. In healthy subjects, HHV-6A was found in 5% of the samples, HHV-6B in 6.7% and HHV-7 in 11.7%. Multiple infections were observed in 12/60 (20%) individuals. No co-infection was demonstrated for healthy subjects, reinforcing the idea that imunnossuppression can favor reactivation and possibly transactivation among herpesviruses (P<0.001). Statistically significant differences were recorded for HHV6A and B infections in transplanted patients, when compared with healthy individuals (p<0.05). No statistically significant differences were observed regarding HHV-7 infection. Clinical symptoms and laboratorial findings were not specifically associated with patients shedding any of the studied viruses. Our results showed relevant differences in Roseolovirus prevalence among the two studied groups, suggesting a potential role for those viruses in disturbing host homeostasys that can compromise life quality. Although PCR methodology proved to be a useful tool for Roseolovirus detection, the standardization of samples and procedures is necessary to evaluate possible a pathogenic behavior among different agents in order to analyze their role in the post-transplant scenario. DOI: http://dx.doi.org/10.17525/vrr.v16i1-2.49

Human Herpes Virus-6 and Clinical Manifestations After Allogeneic Hematopoietic Stem Cell Transplantation

Abstract 1960 BACKGROUND:Human herpesvirus 6 (HHV-6) is increasingly recognized as an opportunistic and potentially life-threatening pathogen in recipients of allogeneic Hematopoietic Stem Cell Transplantation (HSCT). Reported clinical manifestations of HHV-6 infection in transplanted patients are skin rash, interstitial pneumonia, bone marrow suppression and encephalitis. Moreover, an increasing number of clinical reports suggest that HHV-6 can facilitate the occurrence of other severe clinical complications of allogeneic HSCT, including Graft-versus-Host Disease (GvHD), ultimately increasining transplant-related mortality. Still, the actual incidence of HHV-6 infection in recipients of HSCT and the causative link between infection and clinical complications remain elusive, mostly due to the small and heterogeneous patient cohorts analyzed to date. METHODS:From January 2009 to July 2011, we retrospectively evaluated 43 consecutive adult patients (median age 51 years) who developed positivity to HHV-6 after allogeneic HSCT for high-risk hematological malignancies. Stem cell donor was for 30 patients family haploidentical, for 5 an HLA identical sibling, and for 8 an unrelated volunteer (1 of which cord blood). The viral load was determined by quantitative PCR in cell-free body fluids such as plasma, bronchoalveolar lavage, cerebrospinal fluid, bone marrow aspirates or in gastrointestinal biopsies. At the time of positivity all patients were receiving acyclovir as viral prophylaxis except 5. Sixteen patients had clinical acute GvHD at time of HHV-6 positivity (grade III-IV in 14), and 33 were profoundly immunosuppressed with variable association of 2–4 immunosuppressive drugs (steroids included). Moreover concomitant CMV positivity was detected in 11 patients, while a severe neutropenia in 12. RESULTS:Median time from allogeneic HSCT to HHV-6 reactivation was 36 days (range: 7–625). In 19 patients HHV-6 was detected in plasma, with a median viral load of 19,454 cp/mL (34-4,524,600); 15 had concomitant fever, 5 skin rash of new onset, 4 impaired liver function, and 5 developed cytopenia subsequently to the infection. In 7 patients HHV-6 was detected in the bone marrow: the median viral load was 163’800 cp/mL (568-1’552’982). In 8 patients, all febrile, HHV-6 was observed in bronchoalveolar lavage samples with a median of 4’149 cp/mL (85–39250). In 16 patients, 10 with documented gut aGvHD, 11 with diarrhoea, HHV-6 was detected in gastrointestinal biopsies with a median of 7’510 cp/mL (120-4’524’600). HHV-6 was found in cerebrospinal fluid in 4 cases (all within 30 days after HSCT); the median viral load was 29’352 cp/mL (4’508-1’552’982); all these patients experienced encephalitis with confusion and anxiety, 2 suffered seizures and 3 showed abnormal findings on brain MRI. Amongst patients with organ localizations of HHV-6 only 28% had concomitant plasma positivity. HHV-6 positivity led to antiviral pharmacological treatment only when associated with clinical manifestations (n=21), using as first choice therapy foscarnet. Amongst the total 43 patients with documented HHV-6 positivity 11 completely solved the clinical event, whereas 19 (44%) died. CONCLUSIONS:HHV-6 infection/reactivation is associated with high morbidity and mortality in patients who undergo allogeneic HSCT. HHV-6 infection typically occurred close to the time of neutrophil engraftment. HSCT from an HLA-mismatched donor and steroid administration were associated with increased risk of active HHV-6 infection. Development of encephalitis was associated with high HHV-6 viral load. The regular monitoring of HHV-6 DNA in allogeneic HSCT recipients, using a real-time PCR assay, may be useful for identifying active HHV-6 infection and for the introduction of a pre-emptive treatment, possibly reducing the incidence of the most severe clinical complications. Disclosures:No relevant conflicts of interest to declare.

Endemic and opportunistic infections in Brazilian solid organ transplant recipients

To evaluate the frequency and clinical features of endemic and other opportunistic infections in liver or kidney transplant recipients in four transplant centres in different geographical areas of Brazil. Retrospective analysis of medical and laboratory records of four transplant centres on endemic and other opportunistic infections in liver or kidney transplant recipients. Analyses were performed with spss statistical software. From 2001 to 2006, 1046 kidney and 708 liver transplants were registered in all centres. The average age was 42 years. Among 82 (4.7%) cases with infections, the most frequent was tuberculosis (2.0%), followed by systemic protozoal infections (0.7%), toxoplasmosis (0.4%) and visceral leishmaniasis (0.3%). Systemic fungal infections occurred in 0.6%, of which 0.4% were cryptococcosis and 0.2% were histoplasmosis. Dengue was the only systemic viral infection and was registered in two cases (0.1%), of which one was classified as the classic form and the other as dengue haemorrhagic fever. Nocardiosis was described in one case (0.05%). The infectious agents most frequently associated with diarrhoea were Blastocystis sp., Schistosoma mansoni and Strongyloides stercoralis. Opportunistic Infections in transplant patients have a wide spectrum and may vary from asymptomatic to severe infections with high mortality. A better understanding of the epidemiology of endemic pathogens and clinical manifestations can contribute to the establishment of an early diagnosis as well as correct treatment aimed at decreasing morbidity and mortality.

Perspective: emerging challenges in the treatment of influenza and parainfluenza in transplant patients.

Influenza, respiratory synctial virus, and parainfluenza are common respiratory infections in immunocompromised transplant recipients, causing significant morbidity and mortality in this patient population. This paper focuses on influenza and parainfluenza virus infections in transplant patients with emphasis on the pandemic 2009 H1N1 influenza infection. Current antiviral treatment recommendations for influenza and parainfluenza in immunocompromised patients as well as novel investigational therapeutic approaches currently being tested in the clinic are discussed. In addition to the morbidity and mortality caused by these viruses, the development of multidrug resistance leading to transmission of resistant viruses is of great public health concern. The development of effective new therapies for influenza and parainfluenza in these high-risk patients is needed with randomized placebo-controlled studies to assess their clinical utility.