Tissue-invasive Cytomegalovirus Research Articles

Cytomegalovirus surveillance after antiviral prophylaxis in CMV mismatched transplant patients: Does recurrent cytomegalovirus DNAemia impact patient survival?

Cytomegalovirus (CMV) mismatched, donor IgG-positive/recipient IgG-negative, solid organ transplant recipients (SOTRs) are at high risk of CMV invasive disease. Post-prophylaxis disease is an issue in this population. Some programs employ surveillance after prophylaxis (SAP) to limit the incidence of post-prophylaxis disease. This was a single-center retrospective cohort study that included all CMV mismatched SOTRs from 2003 to 2017. Patients underwent SAP with weekly CMV plasma viral load for 12 weeks. The subjects were classified into three post-prophylaxis DNAemia patterns: no DNAemia, one episode of DNAemia, and multiple episodes of DNAemia. We calculated the cumulative incidence of each DNAemia pattern. We also determined 5-year mortality based on DNAemia pattern stratified by organ transplant type. Post-prophylaxis recurrent DNAemia occurred in 63% of lung recipients and 32% of non-lung recipients (p = .003). Tissue invasive CMV disease was diagnosed in 3% of the population and CMV syndrome was diagnosed in 33%. Recurrent DNAemia was not associated with 5-year mortality. In this cohort, undergoing SAP tissue invasive disease was uncommon and CMV DNAemia recurrence did not have an impact on long-term mortality.

Cytomegalovirus infection in liver-transplanted children.

Cytomegalovirus (CMV) infection is a common complication of liver trans-plantation in children. The CMV serostatus of recipients and donors is the primary risk factor, and prophylaxis or pre-emptive strategies are recommended for high-risk patients. Graft rejection, coinfection and Epstein-Bar virus reactivation, which can lead to post-transplant lymphoproliferative disease, are indirect effects of CMV infection. Assessment of CMV infection viral load should be routinely performed upon clinical suspicion. However, tissue-invasive CMV disease is not associated with CMV viraemia and requires confirmation by tissue pathology. Oral valganciclovir and intravenous ganciclovir are equivalent treatments, and the duration of treatment depends on factors including CMV viral load, tissue pathology, and clinical response. Risk stratification by donor and recipient status prior to transplantation and post-transplantation antiviral prophylaxis or pre-emptive therapy are recommended. Adult guidelines have been established but additional study of the effectiveness of the preventive guidelines in children is needed. This review summarizes the burden, risk factors, clinical manifestations, laboratory evaluation, treatment, and prevention of CMV infection in children after liver transplantation.

An Atypical Subcutaneous Cytomegalovirus Infection Mimicking a Post-transplant Lymphoproliferative Disorder in a Solid Organ Transplant Recipient

: Cytomegalovirus (CMV) infection is a common cause of morbidity and mortality in solid organ transplant recipients and immunocompromised hosts. However, tissue-invasive CMV infection, causing cutaneous or subcutaneous diseases, has been rarely reported in the literature, and proper diagnosis can be easily delayed due to the rarity. Here, we report a rare case of a 45-year-old male renal transplant recipient, presenting with subcutaneous nodules. The nodules were initially suspected as a post-transplant lymphoproliferative disorder (PTLD) on computed tomography (CT) scan. However, biopsy later indicated a CMV infection. Based on the present findings, clinicians and radiologists are suggested to consider CMV infection as a differential diagnosis of subcutaneous nodular lesions in solid organ transplant recipients.

The Trends of Immunohistochemistry for Tissue-Invasive Cytomegalovirus in Gastrointestinal Mucosal Biopsies.

Cytomegalovirus (CMV) immunohistochemistry (IHC) is the most widely used method to diagnose CMV infection/reactivation in tissues in a pathology laboratory. To improve the efficiency of CMV IHC testing by evaluating immunopositive staining trends of tissue-invasive CMV in the gastrointestinal system. A total of 1479 individual orders for CMV IHC on gastrointestinal biopsy specimens from 2016 to 2018 were included. The analysis was performed to identify the significant factors contributory to CMV-positive test results. The overall positivity rate of CMV IHC in our institution was 4.73% (70 of 1479). The positivity rate from physician-requested and pathologist-initiated tests was significantly different (7.54% versus 3.83%, P = .004). Cases with severe inflammation showed a higher positive CMV rate than those with mild inflammation (5.37% versus 2.60%, P = .04). Cytomegalovirus positivity in biopsies from posttransplant patients, inflammatory bowel disease, human immunodeficiency virus (HIV)/common variable immunodeficiency (CVID), cancer, and others was 19.69%, 3.84%, 23.33%, 9.00%, and 2.84%, respectively. The positivity rate among posttransplant, HIV/CVID, or cancer patients was significantly higher than in other populations. Cases tested with multiple tissue blocks generated a higher positivity rate than those with a single block (7.77% versus 3.23%, P < .001). Testing 3 to 4 blocks per case almost tripled the positive CMV detection rate (9.04%). Interestingly, using 5 or more blocks did not further ameliorate the positive CMV detection rate. The data revealed that physician request, immunosuppression, multiple blocks, and severe inflammation were strongly related to positive CMV IHC detection rate. These findings might provide value in helping pathologists manage CMV IHC testing more efficiently.

686. Elevations in TNFα and IL-18 are Associated with Increased Risk of Probable Cytomegalovirus Tissue Invasive Disease in Solid Organ Transplant Recipients

BackgroundHuman cytomegalovirus (CMV) continues to cause significant morbidity and mortality in solid organ transplant (SOT) recipients despite prophylaxis. Tissue invasive CMV disease (TI-CMV) can lead to end-organ damage and graft loss. Diagnosing TI-CMV can be challenging as CMV viral load in the blood does not always correlate with episodes of TI-CMV and therefore definitive diagnosis often requires an invasive procedure such as bronchoscopy or colonoscopy. The purpose of this study was to determine if proinflammatory cytokines, including IL-18, are elevated in SOT recipients with probably TI-CMV as a way to identify patients at risk for this severe form of CMV disease.MethodsThe electronic medical record was searched for adult SOT recipients who were tested for CMV via blood qPCR during an 11-month period.Twenty-nine SOT recipients were identified that had episodes of CMV DNAemia without other concomitant infections during this time period. Patients were divided into those that had probable TI-CMV and those with CMV DNAemia alone, by chart review. Inflammatory cytokines (IFNγ, TNFα, IL-1β, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12p70, IL-13, IL-18, and IL-1RA) were measured in residual plasma from these patients using a commercially available multiplex assay for at least two time points during the study period. Wilcoxon-Rank-Sum, logistic regression, and principal component analysis was performed comparing patients with and without probable TI-CMV.ResultsPatients with probable TI-CMV had significantly higher IL-18, TNFα, and IL-1β than patients with CMV DNAemia alone (p < 0.001, < 0.001, and < 0.05 respectively). When adjusting for transplant type and CMV recipient serostatus, elevations in TNFα (OR 1.43, 95% CI 1.07-1.92) and IL-18 (OR 2.00, 95% CI 1.06-3.75) were associated with increased odds of having probable TI-CMV. In principal component analysis the combination of CMV viral load, IL-18, TNFa, and IL-1β accounted for 80% of the variance in the data.ConclusionTNFα and IL-18 in combination with CMV viral load may be useful in predicting likelihood of TI-CMV. This is important in situations where tissue biopsies are not feasible, and adds to our diagnostic capability for TI-CMV in SOT recipients.Disclosures Stuart C. Ray, MD, miDiagnostics, Inc. (Board Member, Research Grant or Support) Robin K. Avery, MD, Aicuris (Scientific Research Study Investigator)Astellas (Scientific Research Study Investigator)Chimerix (Scientific Research Study Investigator)Merck (Grant/Research Support, Scientific Research Study Investigator)Oxford Immunotec (Scientific Research Study Investigator)Qiagen (Scientific Research Study Investigator)Takeda/Shire (Scientific Research Study Investigator)

Development of cytomegalovirus retinitis after negative conversion of cytomegalovirus antigenemia due to systemic antiviral therapy.

Cytomegalovirus (CMV) antigenemia assays have been widely used as adjunct tests to diagnose tissue invasive CMV diseases, including cytomegalovirus retinitis (CMVR). In this study, we examined CMVR cases to assess the presence of CMV in sera and aqueous humor and antiviral therapy received prior to the onset of CMVR. A total of 37 eyes from 26 different cases of CMVR in patients who visited Hokkaido University Hospital between 2007 and 2015 were enrolled. The diagnosis of CMVR was established based on characteristic ophthalmoscopic findings and the presence of local and/or systemic CMV infection. Among the 26 cases, 3 cases (12%) were HIV-positive, while the other 23 cases (88%) were HIV-negative. The records of clinical and laboratory results were reviewed from clinical charts retrospectively. CMV antigenemia was positive at the onset of CMVR in 14 cases (53.8%) and negative in the other 12 cases. In 9 cases among the antigenemia-negative cases (75.0%), the antigenemia had been previously positive and had turned negative before the onset of CMVR. In 12 of the 14 antigenemia-positive cases (85.7%) and in 8 of the 9 antigenemia-negative cases (88.9%) that were previously positive, systemic antiviral therapies had never been used or had been used before but had been discontinued prior to the onset of CMVR. Even if viremia turns negative, the risk of developing CMVR exists for more than several weeks after the completion of systemic therapy.

COVID-19 and Cytomegalovirus Co-infection: A Challenging Case of a Critically Ill Patient with Gastrointestinal Symptoms

We describe a case of COVID-19 and cytomegalovirus (CMV) co-infection in a critically ill patient.Clinical symptoms simulated mesenteric vascular involvement and intestinal obstruction.The successful management of invasive CMV colitis in a patient with COVID-19 with atypical symptoms is described.

SAT-342 CYTOMEGALOVIRUS INFECTION IN KIDNEY TRANSPLANTS RECIPIENTS: EXPERIENCE OF A SINGLE CENTER

Cytomegalovirus (CMV) is the most common infection after organ transplantation; it can be a major cause of morbidity, mortality. Optimal prevention, diagnosis, and treatment of active CMV infection enhance transplant outcomes. But, the management of CMV varies considerably among transplant centers. We described the incidence, clinical profile, outcome, and risk factors for the development of CMV infection among renal transplant recipients. We studied kidney transplants recipients admitted for CMV infection from January 1998 to September 2018. CMV infection was present if the patient had positive CMV antigenemia or positive PCR CMV. CMV disease was diagnosed if clinical signs and symptoms are associated with CMV infection. About 48 cases of CMV infection was confirmed in our study. The majority of patients were CMV seropositive recipients from seropositive donors (88,8%). Only 29, 16% of our patients had symptomatic CMV infection and 70, 8% had CMV disease. 52, 1% of our recipients developed CMV infection 2 months post-transplantation. Fever was the most common presenting symptoms (97, 2%) and the most common biological disorder were leukopenia (83,3%). Among the 6 who developed tissue-invasive CMV (13,3%), 3 had CMV pneumonitis, 1 has two recurrent episodes of CMV uveitis for, 1 had colitis, and 1 had macrophage activation syndrome induced by CMV during pregnancy. Risk factors that were statistically significant in the development of CMV disease were as follows: recent rejection treatment (p= 0,021) and HLA mismatch (p=0, 05). For the indirect effect of CMV infection, the most frequent was bacterial and fungal coinfections (33, 35%), then we found, graft dysfunction (25%), acute graft rejection (14, 5%), new-onset post-transplant diabetes (6, 25%), post lymphoproliferative disease (1 case, 2, 2%), and mortality incidence was 20%. The cardiovascular events were significantly associated with CMV infection (p=0.02). We also demonstrate a significant association between CMV infection and long term graft function expressed either as graft dysfunction or graft loss: The DFG was lower in CMV infection group in 6 months, 1 year, 2 years and 10 years. The graft loss was significantly superior in patients with CMV infection/disease than patients without CMV (p= 0,05). CMV infection and CMV disease remain an infectious cause of significant clinical problems, morbidity, and mortality. Despite the absence of prophylaxis, the complications associated with CMV infection are usually not higher than in other countries. However, the use of universal prophylaxis and preemptive therapy remains necessary to reduce the hospitalization rate and consequence of CMV infection.

A Phase 3 Active-Controlled Study of Maribavir (MBV) for the Treatment (Tx) of Transplant Recipients with Refractory/Resistant (RR) Cytomegalovirus (CMV): Study Design

Introduction In transplant recipients, CMV infection RR to prior antiviral Tx is associated with significant morbidity and mortality. Existing antivirals are not approved for RR CMV infection and are limited by their toxicities. A prior Phase 2 dose-ranging study of MBV for RR CMV (67% of patients [pts] achieved undetectable CMV DNA within 6 wks) motivated initiation of a Phase 3 trial with the concept of an investigator-assigned (IA) Tx comparator arm. Objective To assess the efficacy and safety of MBV compared with IA anti-CMV therapies in HSCT/SOT recipients with RR CMV infection. Methods In this Phase 3, randomized, open-label, multicenter, active-controlled study (NCT02931539), HSCT/SOT recipients (≥12 years old) with RR CMV infection are randomized 2:1 to MBV (400 mg BID) or IA Tx (ganciclovir [GCV], valganciclovir [VGC], foscarnet [FSC], cidofovir [CDV]) for 8 wks. Pts in the IA Tx group discontinuing Tx early (lack of response and/or intolerance; investigator discretion) are assessed Wks 3–7 to enter MBV rescue arm. Pts are followed for 12 wks after the 8-wk Tx period. Inclusion criteria include: documented CMV infection with screening value ≥2730 IU/mL / ≥910 IU/mL (whole blood / plasma) in 2 consecutive tests ≥1 day apart; current refractory CMV infection: documented failure to achieve >1 log10 decrease in CMV DNA after ≥14 days of the same anti-CMV Tx. Pts with ≥1 genetic mutation associated with GCV/VGC, FSC or CDV resistance must also meet refractory criteria. Pts with tissue invasive CMV disease with CNS involvement including the retina, eg CMV retinitis, are excluded. A central specialty laboratory quantifies plasma CMV DNA (COBAS ‘AmpliPrep/TaqMan' CMV test). The primary efficacy endpoint is confirmed CMV viremia clearance (defined as plasma CMV DNA concentrations Results Planned enrollment is 351 pts across ∼140 sites (North America, Europe, Asia Pacific). Study start, Dec 2016; completion ∼Sep 2020. Conclusions The comparator arm of this Phase 3 study is valid for evaluating efficacy and safety of MBV for RR CMV compared with available anti-CMV Tx, whilst allowing for personalized Tx for pts in the comparator group.

CMV Viral Load Kinetics as Surrogate Endpoints for Antiviral Prophylaxis Trials

<h3>Introduction</h3> The paradigm for preventing clinically significant cytomegalovirus (CMV) infection and CMV disease after hematopoietic cell transplantation (HCT) has shifted from preemptive treatment to antiviral prophylaxis with the approval of letermovir. Previously, our group validated the use of quantitative CMV DNA viral load as a surrogate endpoint for tissue-invasive CMV disease (ASBMT 2018) in the <i>pre-emptive treatment setting</i>. <h3>Objectives</h3> To address whether CMV viral load kinetics could serve as valid surrogate endpoints for CMV disease in the <i>prophylactic setting</i>, we performed CMV viral load testing of frozen serum samples collected during a placebo-controlled randomized trial of ganciclovir (GCV) given at engraftment (Goodrich et al. Ann Intern Med 1993). Because this study pre-dated the approval of ganciclovir, CMV disease occurred in an extremely high proportion of patients, allowing us to link viral load kinetics with CMV disease, which would not be possible in the modern treatment environment. <h3>Methods</h3> We calculated each patient's CMV viral load kinetics (mean, peak, maximum change, percentage of positive viral loads) from samples collected during the first five weeks after randomization and analyzed their value as surrogates for CMV disease by 24 weeks after randomization. First, we tested each marker for fulfillment of the Prentice criteria for valid surrogate endpoints using multivariable logistic regression, including quantifying the degree to which each marker captured the effect of ganciclovir on CMV disease. Secondly, to determine the ability of the viral load markers to predict CMV disease, we developed a ‘SuperLearner' machine learning model and quantified prediction accuracy by cross-validated area under the receiver-operator characteristic curves (cv-AUCs). <h3>Results</h3> Mean, peak, change, and percentage of positive viral loads were significantly higher in the placebo group than in the ganciclovir group. See viral loads by group in Fig 1. Percentage of positive viral load satisfied Prentice criteria as a valid surrogate endpoint for CMV disease by week 24 after randomization (Fig 2). All kinetics explained greater than 80% of ganciclovir's reduction in CMV disease (mean: 86%, peak: 83%, maximum change: 95%, percent positive: 94%). We found that a SuperLearner model that included all four viral load kinetics, CMV donor serostatus, acute graft-versus-host disease, and baseline viral load predicted CMV disease with 91% cv-AUC in the placebo group, 78% in the ganciclovir group, and 82% in the combined groups (Fig 3). <h3>Conclusion</h3> We have shown for the first time in a clinical endpoint-rich, placebo-controlled antiviral prophylaxis trial that CMV viral load kinetics fulfill the Prentice criteria as valid surrogate endpoints and have high predictive value for CMV disease after HCT.

2538 Severe Protein-Losing Enteropathy and CMV Duodenitis in an Immunocompetent Male

INTRODUCTION: Cytomegalovirus (CMV) infection, typically associated with immunodeficiency, has been reported to also occur in immunocompetent patients. CMV infection of the gastrointestinal (GI) tract is uncommon in immunocompetent hosts and typically involves the lower GI tract. We encountered a case of CMV duodenitis associated with severe protein-losing enteropathy in an otherwise healthy male. CASE DESCRIPTION/METHODS: A 27-year-old man with a 2-year history of mild, intermittent non-bloody diarrhea presented with 2 weeks of worsening diarrhea, epigastric pain, nausea, vomiting and poor oral tolerance. His only medication was emtricitabine/tenofovir for HIV pre-exposure prophylaxis, initiated 4 months prior to presentation. Physical examination revealed a tender epigastrium and anasarca. Laboratory evaluation showed WBC 13.2 K/mcL (12.2% monocytes), albumin 1.9 g/dL, AST 64 U/L, ALT 77 U/L, total bilirubin 1.0 mg/dL, INR 1.0, and lipase 346 U/L. Serum HIV antigen/antibody was negative, and CD4 cell count was 873 cells/mcL. Urinalysis was unremarkable and was without proteinuria. Stool studies were negative for common enteric bacterial pathogens, Clostridium difficile, Giardia, and ova/parasites. Fecal calprotectin was elevated at 390 µg/g. MRI/MRCP imaging of the abdomen and pelvis showed a thickened duodenum, and peripancreatic fat stranding and fluid (suggestive of acute pancreatitis), without biliary or pancreatic duct dilation. EGD showed severe duodenitis with diffuse erythema, mucosal denudation, patchy erosions, and nonbleeding ulcerations. Biopsy with immunostain revealed CMV duodenitis. Serum CMV DNA was mildly elevated at 142 IU/mL. Following multidisciplinary discussion, supportive care was provided without antiviral therapy. Over the next month, the patient improved clinically, with normalization of serum albumin, transaminases, and CMV titer. DISCUSSION: Several reports have described tissue invasive CMV infection in immunocompetent patients, primarily involving the colon. CMV duodenitis and pancreatitis are rare, even in immunocompromised patients. Our case describes a healthy man with severe CMV duodenitis resulting in protein-losing enteropathy. CMV likely caused mild acute pancreatitis in our patient as well. A recent systematic review did not support antiviral therapy for immunocompetent patients with CMV. Supportive care with close monitoring may be sufficient; however, further investigation is needed to routinely support this practice.

Determination of Optimal Viral Kinetic Markers for Predicting Antiviral Treatment Effect for the Prevention of Cytomegalovirus (CMV) Disease after Hematopoietic Cell Transplant (HCT) Using Machine Learning and a Novel Non-Parametric Estimation Method

The United States Food and Drug Administration recently issued guidance that CMV DNAemia (quantitative CMV viral load as measured by PCR) could be used in a composite endpoint along with tissue-invasive CMV disease as the primary endpoint in allogeneic HCT CMV prophylaxis trials. However, the specific time points after antiviral treatment initiation at which to measure viral load and the viral load thresholds that most accurately predict clinical CMV disease have not been identified. In order to estimate the treatment effect of an antiviral agent on CMV clinical outcomes, placebo-controlled, randomized trial data with accompanying viral load measurements are needed. Unfortunately, in the modern era of PCR and early preemptive treatment, ethically, placebo-controlled, randomized trials that allow for the development of CMV disease after HCT can no longer be performed. To overcome this limitation, we performed CMV DNA PCR testing on frozen plasma samples collected during the first 100 days post-HCT in the only placebo-controlled, double-blind RCT of ganciclovir for the early treatment of CMV infection after HCT (Goodrich et al. NEJM 1991). We used three analytic methods (Cox proportional hazards models, machine learning, and a novel non-parametric method) to determine which of 14 viral load markers, measured in the first four weeks of treatment, are the most useful surrogates of antiviral treatment for the prevention of CMV disease. All methods identified peak viral load and percentage of positive samples by week 4 as highly associated with or predictive of tissue-invasive CMV disease by week 8 post-randomization. Cox proportional hazards models (Figure 1) yielded significant associations for peak viral load measured by week 4 (HR 1.4, 95% CI 1.1-1.9) and percentage of positive samples by week 4 (HR 1.6, CI 1.1-2.3). The machine-learning ensemble algorithm SuperLearner implemented in R (Figure 2) demonstrated cross-validated area under the receiver-operator curves of at least 75% for peak viral load (75%, CI 62-87%) and percentage of positive plasma samples (77%, CI 63-90%) measured by week 4. Using a novel statistical technique that allows direct estimation of biomarker surrogacy (Parast et al. Stat Med 2017), we estimated that the percentage of ganciclovir treatment effect explained by peak viral load and percentage of positive samples measured by week 4 was greater than 85%—peak viral load 89%, CI 56-100%; percent positive samples 91%, CI 60-100% (Figure 3). Peak viral load and percentage of positive samples by week 4 are highly predictive of CMV disease and the treatment effect of ganciclovir. Our analysis suggests that these may be the best surrogate markers of ganciclovir treatment and introduces novel methods for identifying optimal candidate biomarkers as surrogates for clinical endpoints.

A Novel Cytomegalovirus Prophylaxis Protocol in Cytomegalovirus (CMV) D+/R- Heart Transplant Recipients: A Single-Center Experience

Background We previously reported that after completion of 3 months of prophylactic treatment with valganciclovir in cytomegalovirus (CMV) donor positive, recipient negative (D+/R-) heart transplant patients, there was a high incidence of CMV disease, with six out of seven recipients (86%) developing CMV disease within the next 6 months. A novel, three-tiered CMV prophylactic strategy for D+/R-heart transplant recipients was thus implemented at our center in 2010. The efficacy of this strategy is unknown. Methods We retrospectively reviewed consecutive heart transplants between September 2010 and December 2013. The novel 3-tiered CMV protocol administered to D+/R- patients consisted of: 1) Renally-dosed valganciclovir, starting on post-operative day 5 and continuing for 12 months, if tolerated; 2) CMV Immune Globulin administration through 16 weeks; and 3) Azathioprine rather than mycophenolate mofetil for immunosuppression. The diagnosis of CMV disease, consisting either of the CMV syndrome or tissue-invasive CMV infection, was established according to American Society of Transplantation Guidelines for clinical CMV infection. Results Of seventy-five heart transplant recipients, 17 (23%) were CMV D+/R-. Three of the 17 died of non-CMV causes within the first year. Among the remaining 14 recipients, CMV disease occurred in the first year in 3 (21%) recipients. Following cessation of valganciclovir at one year, another 4 (29%) recipients developed CMV disease within the next 6 months. Conclusion CMV D+/R- heart transplant recipients appear to have a lower incidence of CMV disease in the first year using a novel prophylactic regimen as compared to a historical group at our program. CMV D+/R- patients remain at risk of developing CMV disease with valganciclovir discontinuation, even after a full year of prophylactic treatment. Figure 1

Cytomegalovirus Management in Adult Hematopoietic Stem Cell Transplant Patients with Pre-Engraftment Viremia: A Single-Center, Retrospective, Descriptive Study

BackgroundScant data exist regarding cytomegalovirus (CMV) viremia in hematopoietic stem cell transplant (HSCT) recipients during the pre-engraftment period. The goal of this study was to describe management of CMV in neutropenic adult HSCT patients at our institution, and to assess the possible impact of different quantitative CMV PCR tests (QPCRs).MethodsPost-HSCT monitoring at this center includes weekly CMV QPCR from plasma. Three different QPCR assays were used sequentially during the study period (1/2010–12/2015): two with lower limits of quantification (LLOQ) of 300 and 100 copies/mL through 4/2013, and after that the FDA-approved assay with LLOQ of 137 IU/mL. Medical records of first-time HSCT patients were reviewed. Pre-/peri-engraftment CMV was defined as detectable CMV DNA with [ANC] < 1000 cells/mm3. Information collected included demographics, donor/recipient CMV serostatus, conditioning regimen, CMV QPCR and ANC results, dates of CMV treatment, CMV disease within 100 days, and death within 6 months of HSCT. Data were analyzed with STATA v14.ResultsOf 1151 total HSCT, 76 patients had a positive CMV QPCR when ANC < 1000 cells/mm3. CMV was first detected a median of 12 days (0–48) post-transplant, and was above LLOQ at a median of 28 days (0–49). 71/76 (93%) were treated at a median of 33 days post-transplant (range 4–105 days), most with valganciclovir (40) or ganciclovir (30); 1 received foscarnet initially. 5 patients with low-level viremia were monitored without treatment. At initiation of therapy, median CMV level was 1471 (range 159–22,900) copies or IU/mL and ANC was 1202 (range 28–9680) cells/mm3. Median treatment duration was 34 days (range 9–392). Only 2 patients had possible tissue-invasive CMV disease.ConclusionGanciclovir and valganciclovir were used to treat most pre- and peri-engraftment CMV viremia, despite potential bone marrow toxicity. The LLOQ of different CMV QPCR tests did not affect the viral threshold for starting treatment. The time between first CMV DNA detection (median day +12) and initiation of treatment (median day +33) suggests clinicians waited for CMV DNA and/or ANC to rise before treating. With this deferred-treatment approach, the proportion of patients with tissue-invasive disease remained low.Disclosures All authors: No reported disclosures.

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.

The Value of Tissue Polymerase Chain Reaction Testing for the Diagnosis of Tissue-Invasive Cytomegalovirus Disease Following Allogeneic Hematopoietic Cell Transplantation

Background: CMV disease is a major complication of allogeneic hematopoietic cell transplantation (HCT). Our widely used diagnostic modalities (H&E-based morphology and CMV IHC) are suboptimal in accuracy and frequently equivocal. Furthermore, current therapies for CMV disease are toxic and can cause serious complications such as prolonged neutropenia or progressive renal insufficiency. As a result, more accurate diagnosis that would help avoid potentially toxic treatments in patients who are truly negative for disease is highly desirable. The purpose of this study was to evaluate whether CMV PCR performed on formalin-fixed paraffin-embedded (FFPE) tissue offers additional diagnostic value to H&E/IHC in allogeneic HCT recipients.Methods: Following the approval by our institutional review board, the electronic medical records of all adult patients who underwent an allogeneic HCT at Washington University School of Medicine (St. Louis, MO) between 2010 and 2015 and had a post-transplant upper/lower endoscopy were retrospectively reviewed. An additional inclusion criterion was the availability of CMV DNA PCR on the blood within 7 days of biopsy.FFPE specimens were reviewed by a pathologist who was blinded to clinical and molecular results. The specimens were reviewed for H&E-based morphology and IHC findings. Tissue PCR was performed by a laboratory technician who was blinded to clinical, H&E, and IHC findings.Results: A total of 151 samples were included. Concurrent CMV viremia was present in 38% of cases. According to H&E/IHC results, cases were classified as double-positive (n = 17), double-negative (n = 105), or equivocal (n = 29) (Table 1). In receiver operating characteristic curve analysis for classification of H&E/IHC-concordant cases using tissue PCR, the optimal cycle threshold (Ct) value was 40 (area under the curve = 0.91, P < 0.001, sensitivity 94%, specificity 79%, positive predictive value 42%, and negative predictive value 99%; Figure 1). Using this cutoff, 45% of equivocal cases were classified as negative, suggesting that anti-CMV treatment in almost half of H&E/IHC-equivocal cases is unnecessary and potentially detrimental. Among viremic, H&E/IHC-concordant cases, tissue PCR with a cutoff Ct of 40 had a sensitivity of 100%, specificity of 50%, PPV of 44%, and NPV of 100%. Among non-viremic, H&E/IHC-concordant cases, these numbers were 80%, 91%, 36%, and 99%, respectively. In this analysis on viremic cases, all double-positive and 50% of double-negative cases were classified positive, while 31% of equivocal cases were classified negative. In non-viremic patients, 91% of double-negatives, 20% of double-positives, and 62% of equivocal cases were classified negative.Conclusions: Tissue PCR is a useful adjunct to H&E and IHC, particularly in H&E/IHC-equivocal cases, and can help avoid unnecessary, potentially toxic, anti-CMV treatment in cases without tissue-invasive disease. We propose the following algorithm: (i) If the cost and labor associated with tissue PCR on all patients are prohibitive, start with H&E and IHC. Perform tissue PCR in H&E/IHC-equivocal cases and consider this test also in non-viremic, H&E/IHC-positive cases. In all other cases forgo tissue PCR. (ii) If the cost and labor are not prohibitive, perform PCR on all cases. A negative PCR rules out CMV disease. In PCR-positive cases, use H&E/IHC results and treat only if H&E and IHC are both positive. One limitation of our study is related to using FFPE specimens rather than the real-life fresh tissue. Our results warrant testing in prospective studies. [Display omitted] [Display omitted] DisclosuresDiPersio:Incyte Corporation: Research Funding.

Outcomes in Transplant Recipients Treated With Foscarnet for Ganciclovir-Resistant or Refractory Cytomegalovirus Infection.

Antiviral-resistant or refractory cytomegalovirus (CMV) infection is challenging, and salvage therapies, foscarnet, and cidofovir, have significant toxicities. Several investigational anti-CMV agents are under development, but more information is needed on outcomes of current treatments to facilitate clinical trial design for new drugs. Records of solid organ transplant (SOT) and hematopoietic cell transplant (HCT) recipients at a single center over a 10-year period were reviewed retrospectively to characterize those who had received foscarnet treatment for ganciclovir-resistant or refractory CMV infection. Data were collected on virologic responses, mortality, and nephrotoxicity. Of 39 patients (22 SOT, 17 HCT), 15 had documented ganciclovir resistance mutations and 11 (28%) of 39 had tissue-invasive CMV. Median duration of foscarnet was 32 days. Virologic failure occurred in 13 (33%) of 39 and relapses of viremia occurred in 31%. Mortality was 12 (31%) of 39 and was higher in HCT than SOT (P = 0.001), although ganciclovir resistance was more common in SOT (P = 0.003). Doses of ganciclovir or valganciclovir were low in 10 (26%) of 39 at some time before switching to foscarnet. Renal dysfunction occurred in 20 (51%) of 39 by end of treatment and in 7 (28%) of 25 after 6 months. Outcomes of existing treatment for ganciclovir-resistant or refractory CMV are suboptimal, in terms of virologic clearance, renal dysfunction, and mortality. These data should provide background information for future clinical trials of newer antiviral agents.

Cytomegalovirus infection in autologous stem cell transplant recipients in the era of rituximab

The incidence of cytomegalovirus (CMV) reactivation/disease after autologous stem cell transplant (ASCT) is much lower than that after allogeneic stem cell transplantation. With the recent use of rituximab during cancer chemotherapy or conditioning regimens prior to transplantation, there has been an increasing concern of opportunistic infections including CMV. In the present study, we reviewed the patients undergoing ASCT from December 2007 to December 2013 to identify those developing CMV reactivation/disease. Out of the 978 patients who underwent ASCT at the Karmanos Cancer Institute, 239 patients were tested for symptomatic CMV reactivation based on clinical suspicion. Of the tested patients, 7/239 (2.9%) were documented to have CMV reactivation within 90days of ASCT. The median time to develop CMV viremia was 32days from transplantation. Of the 239 patients tested, CMV viremia was detected in 3 out of 72 patients who received rituximab as compared to 4 out of 167 patients who did not. Three of these seven viremic patients were treated with anti-viral drugs; viremia resolved in all patients at a median of 24days. Three patients were found to develop other bacterial and/or fungal infections following CMV viremia. Two of the seven patients died during 1-year follow-up, due to primary disease progression or Candida sepsis. None of the patients developed proven tissue-invasive CMV disease. The study did not evaluate the incidence of asymptomatic CMV infection/reactivation. Despite prior publications based on limited data, rituximab does not appear to contribute to an increased frequency of symptomatic CMV reactivation following ASCT.

Sensitivity of blood and tissue diagnostics for gastrointestinal cytomegalovirus disease in solid organ transplant recipients.

Gastrointestinal (GI) cytomegalovirus (CMV) disease is the most common manifestation of tissue-invasive CMV infection in solid organ transplant (SOT) recipients, but the diagnostic yields of blood and tissue testing have not been systematically assessed in a large patient cohort. We retrospectively identified consecutive SOT recipients with biopsy-confirmed GI CMV disease who had both tissue and blood (CMV polymerase chain reaction or antigenemia) diagnostic testing performed within 14 days of diagnosis. Descriptive statistics and logistic regression were used to assess the association between patient factors and viremia and the diagnostic yield of tests performed on biopsy specimens. A total of 101 patients (73% donor seropositive/recipient seronegative [D+/R-], 22% recipient seropositive [R+]) had GI CMV disease (58% upper, 22% lower, and 20% both) at a median of 185 days (range, 21-6345 days) post transplant. In multivariate analysis, R+ CMV serostatus (odds ratio [OR] 0.1 [0.0-0.4], P < 0.001) and diagnosis >6 months post transplant (OR 0.3 [0.1-0.9], P = 0.03) were each independently associated with absence of CMV viremia at time of diagnosis. In the subset of patients (n = 29) in whom both histopathology and viral culture were performed on biopsy specimens, 11 (39%) had CMV detected only by culture and had similar clinical characteristics and outcomes to those with positive histopathology (P > 0.05 for all comparisons). The sensitivity of viremia in SOT recipients with GI CMV disease is significantly lower in CMV-seropositive patients and in those >6 months post transplant. Addition of viral culture to endoscopic biopsy specimens significantly increases the diagnostic yield for GI CMV disease.

Resistant cytomegalovirus in intestinal and multivisceral transplant recipients.

Intestinal and multivisceral transplantation can be complicated by cytomegalovirus (CMV)-related viremia and disease. Intravenous ganciclovir (GCV) and oral valganciclovir remain the treatment of choice in this setting. Limited data are available on GCV-resistant (GCV-R) CMV infection in small intestine and multivisceral transplant recipients. A retrospective review was performed on all patients who underwent small intestine or multivisceral transplantation from November 8, 2003 through November 30, 2008. Those with CMV viremia and invasive disease were identified. GCV resistance was suspected in patients who continued to have viremic episodes or invasive disease despite appropriate GCV treatment. Genotypic analyses were performed to detect the presence of GCV resistance genes UL97 and UL54. During the study period, 88 small intestine or multivisceral transplants were performed on 85 patients. Of the 88 transplantations, 16 patients developed CMV viremia with or without end-organ disease (18.2%) and 5.7% developed GCV-R CMV infection. In patients diagnosed with CMV infection, 31.3% (5/16) had GCV-R CMV infection. Of patients with GCV-R CMV infection, 80% (4/5) developed CMV allograft enteritis, resulting in allograft explantation in 3 patients. All patients with GCV-R CMV infection were CMV donor positive/recipient negative. Patients with tissue-invasive CMV disease were 18 times more likely to be infected with GCV-R CMV (95% confidence interval 1.24-260.93; P-value 0.0341). Small intestinal and multivisceral transplant recipients have a higher rate of GCV-R CMV infection compared with other solid organ transplant recipients, which is often associated with tissue-invasive disease and allograft loss.