Pp65 Antigenemia Assay Research Articles

Evaluation of CMV DNA Antigenemia Status in Patients With Allogeneic Bone Marrow Transplant

Purpose: The risk of cytomegalovirus (CMV) reactivation following allogeneic hematopoietic stem cell transplantation (ASCT) reaches 30-50%, and there are numerous diagnostic tests to detect CMV replication. The most common tests used in this group of patients include 65kDa phosphoprotein (pp65) antigenemia immunofluorescence assay and nucleic-acid-based quantitative CMV-DNA polymerase chain reaction (qPCR). Material and Methods: In this study, patients who underwent ASCT and developed CMV positivity from 2009 to 2016 in our hospital were evaluated retrospectively. The study included samples of the same patient with antigenemia and CMV-DNA qPCR test for up to 48 hours. The study aimed to determine the factors affecting CMV DNA antigenemia and compare CMV DNA PCR and pp65 antigenemia immunofluorescence assay. Results: The results of 138 specimens of 39 patients who underwent ASCT were evaluated. The mean value of CMV PCR, which was positive for both tests, was 57.887 copies/ml (70- 1.213.633 copies/ml) and a significant correlation was found between the two tests and the positive samples (p = 0.018). The ROC analysis showed that 322 copies/ml CMV viral load in plasma corresponds to ≥1 antigen-positive cells/200 thousand leukocytes (Sensitivity: 68.5%; Specificity: 31.5%). CMV infection was observed in 32 samples; CMV DNA cut-off values of the reference according to CMV DNA PCR and antigenemia results, compared to the development of CMV infection, presented a significant correlation (p=0.004). Conclusion: Although there is a common agreement between antigenemia and CMV DNA PCR tests, one should keep in mind that the sensitivity of antigenemia test is low especially in the neutropenic period.

Long-term CMV monitoring and chronic rejection in renal transplant recipients.

Cytomegalovirus (CMV) is well established to be an independent risk factor for graft loss after kidney transplantation (KTx). Monitoring for CMV in the chronic phase is not defined in the current guideline. The effects of CMV infection, including asymptomatic CMV viremia, in the chronic phase are unclear. We performed a single-center retrospective study to investigate incidence of CMV infection in the chronic phase, defined as more than 1 year after KTx. We included 205 patients who received KTx between April 2004 and December 2017. The CMV pp65 antigenemia assays to detect CMV viremia were continuously performed every 1-3 months. The median duration of the follow-up was 80.6 (13.1-172.1) months. Asymptomatic CMV infection and CMV disease were observed in 30.7% and 2.9% in the chronic phase, respectively. We found that 10-20% of patients had CMV infections in each year after KTx which did not change over 10 years. The history of CMV infection in the early phase (within 1 year after KTx) and chronic rejection were significantly associated with CMV viremia in the chronic phase. CMV viremia in the chronic phase was significantly associated with graft loss. This is the first study to examine the incidence of CMV viremia for 10 years post KTx. Preventing latent CMV infection may decrease chronic rejection and graft loss after KTx.

Acquisition of Antibody Against Cytomegalovirus After Kidney Transplantation in Seronegative Recipients

Cytomegalovirus (CMV) infection is one of the most important infectious diseases affecting recipients of kidney transplantation (KTx). However, the timing of seroconversion for CMV infection in seronegative recipients remains unclear. We evaluated CMV infections in CMV-seronegative recipients and the time to acquire antibodies against CMV. We conducted a retrospective study of 228 recipients who underwent KTx between March 1988 and February 2018 at the Niigata University Hospital. The anti-CMV IgG antibody profile before and after transplantation was analyzed. Oral acyclovir or valganciclovir was used as prophylactic therapy for at least 6 months after transplantation. Cytomegalovirus infection was defined as CMV viremia detected using the CMV pp65 antigenemia assay. In this study, 50 cases (21.9%) were CMV-seronegative recipients. Over a median follow-up period of 126.7 months, 68% (34/50) of CMV-seronegative recipients experienced CMV viremia or overt disease symptoms as the first episode of CMV infection. The median duration from transplant to CMV infection was 69.0 days (range, 22-7426). All the recipients who experienced CMV infections acquired seroconversion. The median duration from KTx to seroconversion was 7.2 months (range, 2.8-252.3). Almost all CMV-seronegative recipients could acquire anti-CMV IgG antibodies within 2.5 years. In seronegative recipients whose donors were seronegative, no CMV viremia was found, and none developed anti-CMV IgG antibodies. In the clinical practice of CMV-seronegative recipients, we should consider that physicians must closely monitor the occurrence of CMV infection up until 2.5 years after KTx.

Cytomegalovirus Gastroenteritis in Patients with Acute Graft-Versus-Host Disease

Cytomegalovirus Gastroenteritis in Patients with Acute Graft-Versus-Host Disease

Human Cytomegalovirus Is Associated with Lower HCC Recurrence in Liver Transplant Patients.

Human cytomegalovirus (CMV) infection has been reported to compromise liver transplantation (LT) outcomes. Recent studies have shown that CMV has a beneficial oncolytic ability. The aim of this study was to investigate the impact of CMV on tumor recurrence in patients with hepatocellular carcinoma (HCC) who underwent liver transplantation (LT). This retrospective study enrolled 280 HCC patients with LT at our institute between January 2005 and January 2016. Their relevant demographic characteristics, pre- and post-LT conditions, and explant histology were collected. A CMV pp65 antigenemia assay was performed weekly following LT to identify CMV infection. A total of 121 patients (43.2%) were CMV antigenemia-positive and 159 patients (56.8%) were negative. A significantly superior five-year recurrence-free survival was observed among CMV antigenemia-positive patients compared with the CMV-negative group (89.2% vs. 79.9%, p = 0.049). There was no significant difference in overall survival between the positive and negative CMV antigenemia groups (70.2% vs. 75.3%, p = 0.255). The major cause of death was HCC recurrence in CMV antigenemia-negative patients (51.3%), whereas more CMV antigenemia-positive patients died due to other bacterial or fungal infections (58.3%). In the multivariate analysis, the independent risk factors for tumor recurrence included positive CMV antigenemia (p = 0.042; odds ratio (OR) = 0.44; 95% confidence interval (CI) = 0.20–0.97), microscopic vascular invasion (p = 0.001; OR = 3.86; 95% confidence interval (CI) = 1.78–8.36), and tumor status beyond the Milan criteria (p = 0.001; OR = 3.69; 95% CI = 1.77–7.71). In conclusion, in addition to the well-known Milan criteria, human CMV is associated with a lower HCC recurrence rate after LT. However, this tumor suppressive property does not lead to prolonged overall survival, especially in severely immunocompromised patients who are vulnerable to other infections.

One Year of Preemptive Valganciclovir Administration in Children After Liver Transplantation

ObjectivesValganciclovir (VGCV) is used as prophylaxis against cytomegalovirus (CMV) infection after pediatric living donor liver transplantation (LDLT). The purpose of this study was to examine the efficacy of 1 year of preemptive VGCV administration compared with a shorter administration after pediatric LDLT. MethodsVGCV was administered to 56 children who underwent LDLT. CMV and Epstein-Barr virus (EBV) antibody status, pp65 antigenemia, and other laboratory data were assessed at 1 year after LDLT. Patients were divided into the 1-year group (n = 32) (patients who had 1 year of VGCV administration) and the <1-year group (n = 24) (patients who had less than 1 year of VGCV administration). ResultsStudy participants consisted of 34 females and 22 males, with a mean age of 4.2 years at transplant. Regarding pretransplant donor (D)/recipient (R) CMV antibody status, 13 were D positive (+)/R negative (-), 27 were D+/R+, 8 were D-/R+, and 8 were D-/R-. For EBV, 22 were D+/R+, 32 were D+/R-, and 2 were D-/R-. In the 1-year group, only 2 patients (6.5%) developed CMV infection, whereas 8 patients (33.3%) developed CMV infection in the <1-year group. The CMV pp65 antigenemia assay was positive in 2 patients. CMV IgM was positive in 7 patients. One year of preemptive VGCV administration was associated with a lower incidence of CMV infection (P = .008), but not EBV infection. No adverse effects were observed. ConclusionsOne year of preemptive VGCV administration after LDLT is safe and suppresses CMV infection. It was useful after pediatric LDLT.

Screening Donated Blood for Transfusion-Transmissible Cytomegalovirus Infection among Libyans

Human cytomegalovirus (HCMV) is a ubiquitous DNA-containing herpesvirus causes severe and fatal diseases in immunocompromised patients and a prevalent cause of virus-associated birth defects. Blood transfusion donated for neonates, pregnant women, and immunocom-promised patients should be adequately screened for evidences of CMV infection prior to use in clinical management. The effective national programmes for quality-assured screening of donated blood have not yet been fully established, hence this study was undertaken to assess whether any bloodborne-CMV infections pose a significant threat to the safety of the blood supplies. A total of 200 voluntary blood donor subjects admitted to the Blood Bank of Benghazi/Libya were screened for transfusion-transmissible CMV (TT-CMV) using a highly sensitive CMV total IgG and IgM antibody enzyme immunoassay as well as CMV pp65 anti-genemia assays. We determined that the overall seropositivity for IgG antibodies (80.50%) was higher than that of IgM antibodies (39.00%), but only 2 (1.00%) individuals out of these donors were seropositive for the CMV-antigenic protein pp65. The frequency of CMV infection based on gender was incomparable due to the small population number of blood-donated females. According to age, there was not influence of various age groups on prevalence of anti-CMV IgG antibodies, while a progressive increase in seropositivity of CMV-IgM antibodies with age was detected. The age groups were not significantly associated with CMV prevalence. In contrast, only 2 (1.00%) patients were shown to be positive for all three performed assays indicating a recurrent infection. Our findings prove a risk of primary transfusion-associated transmission of CMV and may provide a policy guidance on ensuring safe blood supplies accessible to all patients who require transfusion.

Cytomegalovirus (CMV) infection and risk of mortality in allogeneic hematopoietic stem cell transplantation (Allo-HSCT): A systematic review, meta-analysis, and meta-regression analysis.

Controversy surrounds the potential association between cytomegalovirus (CMV) infection and increased risk of mortality after allogeneic hematopoietic stem cell transplantation (Allo-HSCT). A systematic literature search was conducted using the PubMed, EMBASE, and Web of Science databases, assessing the association between CMV infection, as documented by the pp65 antigenemia assay or by polymerase chain reaction (PCR) using blood specimens, and overall mortality (OM) and nonrelapse mortality (NRM) in the allo-HSCT setting. Pooled effects were estimated using the generic inverse variance random effects model. Heterogeneity was evaluated by Cochrane's Q test and I2 statistics. The source of heterogeneity was investigated by meta-regression and subgroup analyses. Twenty-six of 1367 studies fulfilled eligibility criteria. CMV infection identified by PCR monitoring was significantly associated with an increased risk of OM and NRM (hazard ratio 1.47, 95% confidence interval [1.20-1.81], P≤.001; hazard ratio 1.68, 95% confidence interval [1.14-2.49], P=.05, respectively). In this setting, the use of preemptive antiviral therapy (PET) resulted in a twofold increased risk of OM and NRM. The estimated effect sizes were associated with allo-HSCT modalities. Although our analyses point to an association between CMV infection and an increased risk of OM and NRM in allo-HSCT recipients, the high heterogeneity across studies prevented drawing of robust conclusions on this matter.

Cytomegalovirus Infection: comparison of methodologies for monitoring renal and cardiac transplants

Introduction: Cytomegalovirus (CMV) remains a major cause of morbidity and mortality among solid organ transplant recipients, despite remarkable advances in its diagnosis, prevention and treatment [1]. The two methods that are currently used to monitor CMV infection and disease in these patients are the pp65 antigenemia assay and the quantitative nucleic acid test (QNAT) [2]. The purpose of this study is to compare two different types of QNAT (the Roche COBAS AmpliPrep/COBAS TaqMan CMV test, which is available commercially, and a laboratory-developed RT-PCR test) and one CMV pp65 antigenemia assay. Materials and methods: A total of 49 samples from 32 transplant recipients (28 renal and 4 cardiac transplants) were submitted to these three methodologies. Results: The results showed a significant agreement (concordance rates between 81.6% and 71.4%, and Cohen’s kappa coefficient values between 0.456 and 0.602, p < 0.001) and a moderate to high, significant (p < 0.01), correlation between these methods (Spearman’s coefficient value of 0.769 for pp65 antigenemia and COBAS, 0.546 for pp65 antigenemia and RT-PCR “in-house”, and 0.736 for COBAS and RT-PCR “in-house” comparison). The unexpected good results obtained with antigenemia is a consequence of decades of laboratory’s and operators’ experience with this technique. In addition, one third (33.3%) of all antigenemia positive samples had 1 or 2 positive cells. Discussion and conclusions: The results from this study showed significant agreement and correlation between the three methodologies. Therefore, we conclude that these can be used successfully for monitoring solid organ transplant recipients.

Cytomegalovirus disease in patients with hematopoietic stem cell transplantation, experience over 8 years

ObjectiveCytomegalovirus infection and disease are significant causes of morbidity and mortality among patients with hematopoietic stem cell transplantation. The aim of this study was to assess the frequency of cytomegalovirus infection and characterize the patients who developed the disease. MethodsA retrospective cohort study was performed among adult patients, recipients of allogeneic HSTC between 2008 and 2015. Taking into account the institutional protocol of prophylaxis infections in hematopoietic stem cell transplantation, patients received either preemptive therapy or prophylaxis with valganciclovir. Infection was defined as a positive pp65 antigenemia assay or PCR higher than 500copies/mL. Disease was defined as viremia with evidence of end organ damage. ResultsSeventy patients were included, the median age was 36 years old (IQR 17–62). A total of 93% of the recipients had a positive serology. The Cytomegalovirus infection occurred in 59% of the patients. Eleven patients developed disease (16%), the most frequent manifestation being colitis, followed by pneumonitis and a single case of retinitis. There were no differences between the preemptive therapy or prophylaxis groups. The mean time of onset of the disease was day 94 post-transplant. Three patients developed disease with a viral load lower than 1000copies/mL. ConclusionThe incidence of cytomegalovirus infection after transplantation at our institution is high. It was found that the disease can occur with any level of viral load and is associated with high mortality.

Early Cytomegalovirus Reactivation and Donor Constellation Reduce Early and Late Relapse Incidence of Acute Myeloid Leukemia in a Long-Term Study

IntroductionAfter allogeneic cell transplantation (HCT) for acute myeloid leukemia (AML) relapse remains the main cause of morbidity and mortality. Relapse rates directly translate into patients' overall survival. The connection between early human cytomegalovirus (CMV) replication and reduced leukemic recurrence has first been established by this group (Elmaagacli et. al. Blood 2011), using a pp65-antigenemia assay and confirmed by Green et al. (Blood 2013), Takenaka et al. (BBMT 2015) and others. In a more recent study by Teira et al. (Blood 2016) using PCR to detect reactivation, this effect has been questioned and the controversy remains probably due to methodological differences between studies.MethodsPatients with AML received allogeneic HCT at the Department of Bone Marrow Transplantation of the University Hospital Essen between 10/1997 and 10/2017. All patient-, donor-, HCT- and virology data was prospectively documented and retrospectively analyzed. The immunosuppressive regimen consisted of cyclosporine A and methotrexate. The conditioning was according to physician's choice and included only non-anti-thymocyte globuline (ATG) conditioning regimens. Early supportive and follow-up care was identical for all patients. Patients were followed for up to 60 months. Surviving patients were censored at last follow-up date. Competing risk analysis was performed for calculating cause-specific relapse-incidences with non-relapse mortality as competing risk. CMV titers were measured at the Department of Virology using quantitative PCR (qPCR) and a pp65 antigenemia assay. CMV reactivation was defined as a replication of >500 CMV copies per ml EDTA blood or as >25 pp65 antigen expressing cells per 5×105 white blood cells. If several CMV reactivation episodes occurred, only the interval to the first episode after HCT was analyzed.ResultsA total of 420 consecutive adult patients (median age, 48 years; range, 16-73 years) with AML and HCT were included for analysis. Over 60 months of follow-up, cumulative incidence of CMV reactivation was detected in 28% of patients and AML relapsed in 34%. In this cohort, the sensitivity of qPCR or pp65 detection methods did not differ (p=0.35) with regard to the incidence of CMV reactivation. CMV reactivation associated with significantly reduced AML relapse risk. The relapse incidence (RI) for patients with CMV reactivation was 0.18 (95% Confidence interval (CI), 0.12-0.25) compared to 0.41 (95% CI, 0.35-0.46) for patients without CMV reactivation (p<0.0001). This significant difference was reproduced for prognostic AML subgroups in first complete remission (RI, 0.14 with CMV reactivation versus 0.35 without; p=0.02) and for higher risk AML (RI, 0.20 versus 0.45; p<0.0001). Notably, donor-recipient serostatus constellation significantly (p=0.005) associated with AML relapse reduction, independently of CMV reactivation. CMV positive donors had a RI of 0.40 (95% CI, 0.33-0.46) compared to 0.28 in CMV negative donors (95% CI, 0.22-0.34).DiscussionThis new PCR dataset confirms previous reports (Elmaagacli et al. 2011; Takenaka et al. 2015) of an independent reduction of AML relapse risk after CMV reactivation, using qPCR detection in a homogeneous population of AML patients. While the association between CMV reactivation and early relapse (< day+100) has also been confirmed by Green et al. (Blood 2013) and relapse (>day +100) by Takenaka et al. (BBMT 2015), our data shows that late relapse (>24 months) may occur in patients without CMV reactivation. While the aforementioned studies exclusively used pp65 antigenemia titers as a determinant of CMV reactivation, Teira et al. (Blood 2016) analyzed PCR samples. The sensitivity of CMV reactivation using PCR or pp65 antigen titers was identical in our dataset. With regard to the on-going controversy on the role of CMV reactivation and AML relapse, this data shows a reduction of relapse in the quantitative PCR age. [Display omitted] DisclosuresTurki:Neovii Biotech: Other: subsidies for the costs of travel. Beelen:Medac: Consultancy, Other: Travel Support.

Evidence‐based consensus on opportunistic infections in inflammatory bowel disease

Evidence‐based consensus on opportunistic infections in inflammatory bowel disease

Pp65 antigenemia and cytomegalovirus diagnosis in patients with lupus nephritis: report of a series.

ABSTRACTIntroduction:In contrast to organ transplantation, few studies correlate the monitoring of pp65 antigenemia with a diagnosis of cytomegalovirus (CMV) in patients with systemic lupus erythematosus (SLE).Objective:To highlight the importance of CMV outside transplantation, we monitored pp65 antigenemia in a series of SLE patients.Methods:From March 2015 to March 2016, SLE patients presenting kidney involvement, fever, and an unclear infection at hospital admission were monitored through pp65 antigenemia. The pp65 antigenemia assay, revealed by immunofluorescence, was correlated with clinical and laboratory findings.Results:We included 19 patients with a suspected unclear infection. A positivity for pp65 antigenemia was found in seven patients (36.8%). The mean age was 33.5 ± 11.2 years, 16 (84%) were females, and 16 (84%) were black. Lymphopenia, anemia, and higher scores of SLEDAI were significantly more common in pp65-positive patients. Five patients received antiviral therapy with ganciclovir. Although receiving specific CMV treatment, one patient died because of suspected CMV disease.Conclusions:Pp65 antigenemia might be relevant in SLE patients, and studies with a greater number of patients are needed in order to establish sensitivity and specificity of pp65 antigenemia in different clinical contexts of SLE patients.

Evaluation of diagnostic tests for cytomegalovirus active infection in renal transplant recipients.

Cytomegalovirus (CMV) infection is a main viral infection after kidney transplantation. The diagnostic methods currently employed are pp65 antigenemia and nucleic acid amplification by polymerase chain reaction (PCR) and aim at detecting viral replication. The goal of this study was to evaluate and compare by both methods the incidence of CMV active infection in kidney transplant patients and to establishthe best clinical-laboratory correlation. Thirty sequential kidney transplant recipients were enrolled in a single center prospective cohort study. Peripheral blood samples were drawn from day 15 until the 6th month after transplantation and tested for CMV replication by pp65 antigenemia and quantitative PCR assays (qPCR). Two hundred forty samples were analyzed and the incidence of active infection was similar by both methods. Time elapsed to the first positive test was almost identical but more samples tested positive by qPCR than by antigenemia in a behavior that was almost evenly distributed overtime. Agreement between tests was observed in 217 samples (90.4%; kappa = 0.529; p < 0.001) and in 25 patients the tests were concordant (83.3%; kappa = 0.667; p < 0.001). The evaluation of the diagnostic parameters for CMV replication revealed higher sensitivity for the qPCR test (82.1%) against antigenemia (59.0%). Quantitative PCR was also slightly more accurate than antigenemia. Our data demonstrate that both methods are suitable and have almost equivalent accuracy for the detection of post-transplant cytomegalovirus replication. The choice for either test must take in consideration the demand, execution capability and cost-effectiveness at each institution.

Clinical correlates of pp65 antigenemia monitoring in the first months of post kidney transplant in patients undergoing universal prophylaxis or preemptive therapy

IntroductionHuman cytomegalovirus is a major cause of morbidity in kidney transplant patients. ObjectivesWe aimed to study viral replication and serological response in the first months post kidney transplant in patients undergoing universal prophylaxis or preemptive therapy and correlate the findings with the clinical course of Human cytomegalovirus infection. Patients and methodsIndependent from the clinical strategy adopted for managing Human cytomegalovirus infection, prophylaxis versus preemptive therapy, the pp65 antigenemia assay and serological response were assessed on the day of transplantation, and then weekly during the first three months of post-transplant. ResultsFrom the 32 transplant recipients, 16 were positive for pp65 antigenemia, with a similar incidence rate in each group. There were no positive results in the first three weeks of monitoring; the positivity rate peaked at week eight. There was a trend for a higher and earlier frequency of positivity in the universal prophylaxis group in which the course of the Human cytomegalovirus infection was also more severe. Despite the differences in clinical picture and in the initial immunosuppressant schedule, the serological response was similar in both groups. ConclusionRoutine monitoring during the first three post-transplant months has a positive impact on the early detection of Human cytomegalovirus viral replication allowing for timely treatment in order to reduce morbidity of the disease. The strategy of universal therapy employing intravenous ganciclovir was associated to a worse clinical course of the Human cytomegalovirus infection suggesting that the use of >10 cells/2×105 leukocytes as a cut-off in this setting may be inappropriate.

Cytomegalovirus infection in transplant recipients

Cytomegalovirus infection is a frequent complication after transplantation. This infection occurs due to transmission from the transplanted organ, due to reactivation of latent infection, or after a primary infection in seronegative patients and can be defined as follows: latent infection, active infection, viral syndrome or invasive disease. This condition occurs mainly between 30 and 90 days after transplantation. In hematopoietic stem cell transplantation in particular, infection usually occurs within the first 30 days after transplantation and in the presence of graft-versus-host disease. The major risk factors are when the recipient is cytomegalovirus seronegative and the donor is seropositive as well as when lymphocyte-depleting antibodies are used.There are two methods for the diagnosis of cytomegalovirus infection: the pp65 antigenemia assay and polymerase chain reaction. Serology has no value for the diagnosis of active disease, whereas histology of the affected tissue and bronchoalveolar lavage analysis are useful in the diagnosis of invasive disease.Cytomegalovirus disease can be prevented by prophylaxis (the administration of antiviral drugs to all or to a subgroup of patients who are at higher risk of viral replication) or by preemptive therapy (the early diagnosis of viral replication before development of the disease and prescription of antiviral treatment to prevent the appearance of clinical disease). The drug used is intravenous or oral ganciclovir; oral valganciclovir; or, less frequently, valacyclovir. Prophylaxis should continue for 90 to 180 days. Treatment is always indicated in cytomegalovirus disease, and the gold-standard drug is intravenous ganciclovir. Treatment should be given for 2 to 3 weeks and should be continued for an additional 7 days after the first negative result for viremia.

Analysis of HCMV gN genotypes in patients with HCMV-HIV co-infection

Objective To analyze the distribution of various genotypes of human cytomegalovirus glycoprotein N (HCMV gN) in patients with HIV infection; to investigate the effects of HCMV-HIV co-infection on disease progression and the relationships between HCMV gN genotypes and disease progression. Methods Patients with active HCMV infection were screened out from 359 patients with HIV infection by using the pp65 antigenemia assay. The genes encoding HCMV gN (UL73) were amplified by nested PCR (nPCR). The amplicons were digested by restriction enzymes including MboⅠ, ScaⅠ and SalⅠ. Then, the restricted fragment length polymorphisms were further analyzed on 4% agarose gel. The relationships between HCMV genotypes and the morbidity and mortality of acquired immune deficiency syndrome (AIDS) were investigated via a prospective study. Results Among the 359 patients with HIV infection, 28 subjects were positive for the HCMV pp65 antigenemia assay. The HCMV gN genotypes in 20 patients with active HCMV infection were distributed as: gN-3a (4/20, 20%), gN-1 (4/20, 20%), gN-4d (1/20, 5%), gN-4b (1/20, 5%) and mixed infection (10/20, 50%). Patients with HCMV-HIV co-infection were more likely to develop AIDS during the follow-up period (RR=9.78). Patients harboring HCMV gN-1 and gN-4 genotypes would seem likely to have 4.6 times of chance leading to AIDS-associated death than those harboring other HCMV gN genotypes. Conclusion HCMV infection (especially gN-1 and gN-4 genotypes) might accelerate the progression of HIV infection. Key words: HIV; HCMV; Restricted fragment length polymorphism analysis (RFLP)

Monitoring human cytomegalovirus infection in pediatric hematopoietic stem cell transplant recipients: using an affordable in-house qPCR assay for management of HCMV infection under limited resources.

Quantitative real-time PCR (qPCR) assay is accepted as the method of choice for monitoring human cytomegalovirus (HCMV) infection in hematopoietic stem cell transplant recipients, but the high cost of commercial kits has hampered its use in many developing countries. In this study, an affordable in-house qPCR was used to manage HCMV infection in pediatric patients and the diagnostic value of this method was compared with the conventional pp65 antigenemia assay. A total number of 1179 samples from 82 recipients were used in this study, and the effect of some potential risk factors on HCMV reactivation was evaluated. The qPCR was able to detect HCMV reactivation earlier and with higher sensitivity than antigenemia assay. Forty-six episodes of reactivation were detected in 39 patients, of which all were detected by the qPCR assay, while only 21 episodes were diagnosed by antigenemia. The DNAemia level of 1284 IU/ml plasma was defined as the optimal cutoff value for starting pre-emptive therapy. It was shown that the acute GVHD severity and the relationship of donor and recipient are the most significant risk factors for HCMV reactivation. The data suggest that the antigenemia method for monitoring HCMV reactivation could be substituted by the qPCR assay.

Use of Valacyclovir for the Treatment of Cytomegalovirus Antigenemia after Hematopoietic Stem Cell Transplantation

Background: Cytomegalovirus (CMV) infection remains a cause of morbidity and mortality in patients who have undergone allogeneic hematopoietic cell transplantation (HSCT) despite pre-emptive antiviral therapy. Available treatments have clinically significant toxic effects. Valacyclovir is well tolerated, and limited evidence suggests that Valacyclovir is effective in preventing CMV disease when given as prophylactic treatment. We investigated the efficacy and safety of high dose Valacyclovir compared with Valganciclovir or Foscarnet in the pre-emptive therapy of CMV antigenemia.Methods: In a retrospective single-center study, 61 allogeneic HSCT recipients with an initial episode of CMV antigenemia received pre-emptive therapy with either Valacyclovir (n=15), Valganciclovir (n=16), or Foscarnet (n=30). Patients were treated with either Valacyclovir at 2 g twice-daily, Valganciclovir at 900 mg twice-daily, or Foscarnet at 90 mg/kg twice-daily, with appropriate renal dose adjustments for each drug. Patients were assessed weekly using the pp65 antigenemia assay. Endpoints analyzed include viremia clearance at day 14 and 28, and rates of recurrent antigenemia. Neutrophil counts and creatinine levels were monitored during treatment.Results: Overall, 60/61 (98%) of cases achieved CMV antigenemia clearance by day 28, and no patient developed CMV disease. Valacyclovir achieved similar clearance of CMV viremia compared to Valganciclovir and Foscarnet, at rates of 93.3%, 77.5%, and 79.5% respectively at 14 days (p=0.054; log rank test). After adjusting for age, sex, CMV serological status, donor type, CMV antigen level, GVHD therapy, and conditioning regimen, there were no significant differences in the odds of viral clearance at day 14 in patients who received Valganciclovir (odds ratio (OR) 0.16, 95% confidence interval (CI) 0.01 to 2.14, p=0.17) and Foscarnet (OR 0.21, 95% CI 0.02 to 2.39, p=0.21), compared to Valacyclovir (assigned OR 1.00). Recurrent CMV antigenemia by day 180 after clearance of the initial episode occurred in 34/61 (56%) of patients. Use of Acyclovir was not associated with an increased odds of CMV recurrence, compared to Valganciclovir or Foscarnet, after adjusting for the same covariates in logistic regression models. Foscarnet significantly increased creatinine levels (p=0.009), while Valganciclovir significantly reduced neutrophil counts (p=0.012). Laboratory evaluation revealed no hematopoietic or renal toxicity in patients on Valacyclovir treatment.Conclusion: Pre-emptive treatment with Valganciclovir, Foscarnet and Valacyclovir led to similar clearance of CMV antigenemia and rates of recurrence. High dose Valacyclovir is a potential alternative for pre-emptive CMV treatment in allogeneic HSCT recipients, with an acceptable safety profile. Table 1Response to preemptive cytomegalovirus therapyAll(n=61)Valacyclovir(n=15)Valganciclovir(n=16)Foscarnet(n=30)PMedian viral load (No. of CMV positive cells per million leukocytes, range)3 (1-750)3 (1-140)3 (2-181)3.5 (1-750)0.772Clearance, N (%)0.054Cleared by day 735 (58.3)12 (80.0)11 (68.8)12 (41.4)Cleared by day 1414 (23.3)2 (13.3)2 (12.5)10 (34.5)Cleared by day 218 (13.3)1 (6.7)3 (18.8)4 (13.3)Cleared by day 283 (5.0)0 (0)0 (0)3 (10.3)Recurrent antigenemia, N (%)34 (55.8)7 (46.7)11 (68.8)16 (53.3)0.434Median days to recurrence43.5 (11-173)59 (27-173)42 (14-94)38 (11-163)0.081 DisclosuresOff Label Use: Valacyclovir use for CMV pre-emptive therapy in allogeneic HSCT recipients. Goh:Novartis Pte Ltd: Honoraria, Membership on an entity’s Board of Directors or advisory committees, Research Funding; Jannsen Pharmaceuticals Inc: Research Funding; Bristol-Myres Squibb: Membership on an entity’s Board of Directors or advisory committees; Gilead Sciences: Honoraria, Membership on an entity’s Board of Directors or advisory committees; Hospira Inc: Honoraria, Membership on an entity’s Board of Directors or advisory committees.

An investigation on the relationship between the occurrence of CMV DNAemia and the development of invasive aspergillosis in the allogeneic stem cell transplantation setting

Cytomegalovirus (CMV) infection might increase the risk of fungal superinfection in allogeneic stem cell transplant patients. The potential association between the occurrence of CMV DNAemia and the development of invasive aspergillosis in this clinical setting was investigated. The current retrospective observational study included 167 patients undergoing T cell-replete allogeneic stem cell transplantation. Virological monitoring of active CMV infection was performed by the pp65 antigenemia assay and/or by a plasma real-time PCR assay. A total of 109 out of 167 patients developed CMV DNAemia. Twenty-three patients had proven (n = 4) or probable (n = 19) invasive aspergillosis. The occurrence of CMV DNAemia was not significantly associated with the subsequent development of invasive aspergillosis (P = 0.38). Overall, the duration of the episodes of active CMV infection and the peak level of CMV DNAemia within the episodes were comparable, irrespective of whether invasive aspergillosis developed subsequently or not (P = 0.99; P = 0.70, respectively). Peak CMV DNA load in patients with proven or probable invasive aspergillosis who died was higher (median, 5,461 copies/ml) than that in those who survived (median 1,179 copies/ml) (P = 0.41). The data argue against the existence of an association between the occurrence of CMV DNAemia and the development of invasive aspergillosis, however, CMV replication, particularly at high levels, might aggravate the prognosis of this disease.