Failure in generating hemopoietic stem cells is the primary cause of death from cytomegalovirus disease in the immunocompromised host

Restoration of murine cytomegalovirus (MCMV) induced myelosuppression by AS101

Infection with cytomegalovirus (CMV) continues to be one of the most common complications following allogeneic bone marrow transplantation. The gravest danger for the host occurs when the virus is reactivated as a result of immunosuppression. In this report we studied the effects of sublethal murine cytomegalovirus (MCMV) infection on the hemopoietic system including bone marrow (BM) cellularity, production of colony stimulating factor (CSF) and interleukin-6 (IL-6) and the development of granulocyte-macrophage colony forming units (CFU-GM), and BM stromal cell viability. Our findings show that the virus infection led to a significant decrease in the number of BM cells and in the production levels of CSF and IL-6. There was also a decrease in the number of stromal cells, as reflected by the number of colony forming unit fibroblasts (CFU-F), and in the relative number of CFU-GM progenitors. Treatment of MCMV infected mice with the immunomodulator AS101 [ammonium trichloro (dioxyethylene 0-0')tellurate] restored significantly CSF and IL-6 production by BM cells to levels of uninfected control mice as well as the number of CFU-F and stromal cell elements which consequently led to the restoration of the total number of BM cells. Results presented here indicate that AS101 may have immunomodulatory effects on MCMV mediated myelosuppression. Administration of AS101 to patients with CMV associated BM damage may improve the restoration of their BM function.

Infection with human cytomegalovirus enhances bacterial adhesiveness and invasiveness in permissive and semipermissive cells

The effect of human cytomegalovirus (HCMV) infection on adhesiveness and invasiveness of Salmonella typhimurium was examined in cells permissive (human embryo fibroblasts (HE)), semipermissive (A549) and nonpermissive (HEp-2) for the virus. Preinfection of the cells with HCMV induced enhanced adhesiveness and invasiveness of bacteria in the permissive HE cells. In the semipermissive A549 cells, where HCMV immediate-early (IE) mRNA transcripts and IE proteins were detected, a significant effect on the initial phase of invasiveness, the adherence phase, was demonstrated. HCMV had no effect on invasiveness of S. typhimurium in nonpermissive HEp-2 cells. Neither HCMV IE transcripts nor IE proteins could be detected in these cells.

Bone marrow atrophy induced by murine cytomegalovirus infection

Acute, sublethal infection of mice with murine cytomegalovirus (MCMV) resulted in up to 80% decreases in the number of cells recoverable from the bone marrow, and a decrease in peripheral blood leucocyte counts during the first week of infection. Depopulation of the leucopoietic areas of the marrow was evident from examination of histological sections. The severity of bone marrow atrophy in MCMV-infected mice of different strains correlated with previously described genetically determined sensitivity to MCMV disease. Although the phenomenon only occurred when mice were inoculated with infectious virus preparations, fewer than one in 10(5) marrow cells were productively infected, suggesting that atrophy was not due to lytic infection of large numbers of bone marrow cells. Interestingly, increases in serum colony-stimulating activity were observed and these were proportional to the severity of bone marrow atrophy. After MCMV infection, we observed increases in the proportions of cells expressing some B-cell and myeloid cell markers and a decrease in the proportion of cells expressing an erythroid cell marker. There was no change in the frequency of marrow cells expressing mature T-cell markers. The numbers of myeloid lineage-committed progenitor cells (GM-CFU) in the marrow decreased 10- to 20-fold in BALB/c nu/+ mice, while there was a threefold decrease in their numbers in BALB/c nu/nu mice. In addition, increases in serum colony-stimulating activity were greater in BALB/c nu/+ mice than in BALB/c nu/nu mice. Our results suggest that growth factors produced after MCMV infection may accelerate the maturation and migration of cells from the marrow to sites of virus replication and inflammation, thus accounting for the depletion in numbers of marrow cells observed soon after MCMV infection.

Tumor necrosis factor alpha promotes replication and pathogenicity of rat cytomegalovirus

We investigated the role of tumor necrosis factor alpha (TNF-alpha) in the pathogenesis of rat cytomegalovirus (RCMV) infection. TNF-alpha levels found in the sera of radiation-immunosuppressed rats in the course of infection (> 350 pg/ml) correlated with the development of RCMV disease. Administration of anti-TNF-alpha antibodies strongly reduced the severity of pneumonia and led to a reduction in virus titers. In immunocompetent rats, anti-TNF-alpha antibodies also significantly suppressed viral replication. Conversely, administration of TNF-alpha augmented RCMV replication and aggravated the disease signs. In vitro, TNF-alpha enhanced RCMV replication in the macrophage, whereas a reduction of viral replication was observed in fibroblasts, indicating that the effect on viral replication is cell type specific. Besides activation of viral replication and exacerbation of RCMV disease, TNF-alpha also favored lymphoid and hematopoietic tissue reconstitution after irradiation, which may contribute to antiviral resistance and survival. This finding demonstrates the protean nature of TNF-alpha, with both beneficial and adverse effects for the host. Our results suggest that TNF-alpha plays an important role in modulating the pathogenesis of RCMV infection.

The conditions of primary infection define the load of latent viral genome in organs and the risk of recurrent cytomegalovirus disease

Recurrence of cytomegalovirus (CMV) from latency is a frequent cause of disease in immunocompromised patients. To date, there is no explanation for the diversity in the clinical manifestations. Primary infection can occur perinatally or later in life, and inevitably results in latent infection. Seropositivity for antibodies against CMV is indicative of latent infection, but is insufficient as a predictor for the risk of recurrence. As a model for this important medical problem, we compared the risks of murine CMV recurrence from latency established after neonatal primary infection and after infection at adult age. The risk of CMV recurrence was high only after neonatal infection. The copy number of latent viral genome in tissues was identified as the key parameter that determines the overall and organ-specific risks of recurrence. Latent CMV burden and risk of recurrence were related to the extent of virus multiplication during primary infection. The presence of latent CMV in multiple organs provides the molecular basis for stochastic events of recurrence in single organs or in any combination thereof. These findings are discussed as a concept of multifocal CMV latency and recurrence. It provides a rationale for the diversity in the clinical outcome of CMV disease.

Cytomegaloviral virus infection in bone marrow transplantation recipients: strategies for prevention and treatment

Cytomegalovirus is major infectious pathogen following allogeneic bone marrow transplantation. In infected recipients, the virus is generally detected between 4 and 10 weeks after transplantation. Historically, CMV disease developed in 30-40% of seropositive recipients, the predominante manifestation being interstitial pneumonitis, which was generally lethal. Therapeutic interventions are discussed with special reference to the use of antiviral therapy for both treatment and prevention of CMV disease. The strategies developed in the bone marrow transplantation population to treat or prevent the development of CMV disease can be extrapolated to other patients groups who are immunosuppressed and at risk for developing clinical manifestations of CMV infection.

Risk factors for cytomegalovirus and severe bacterial infections following liver transplantation: a prospective multivariate time-dependent analysis

Risk factors for cytomegalovirus and severe bacterial infections were studied prospectively by univariate, multivariate and time-dependent Cox model analysis in 79 consecutive liver transplant patients treated with selective bowel decontamination. Cytomegalovirus infection occurred in 39 patients (49%) and was symptomatic in 22 patients. Twenty-six patients (33%) developed at least one of 43 documented severe bacterial infections. In a multivariate analysis of risk factors for all cytomegalovirus infections, the cytomegalovirus seronegative recipient-cytomegalovirus seropositive donor group was the highest risk group (P < 0.001). Using the same analysis for risk factors for symptomatic cytomegalovirus infections, a prolonged prothrombin time (P < 0.005), a diagnosis of acute fulminant hepatitis as the underlying liver disease (P < 0.01) and a cytomegalovirus seronegative patient receiving a liver from a seropositive donor (P < 0.001) were significant. The treatment with OKT3 therapy (P < 0.008) and hepatic artery thrombosis (P < 0.02) were found to be significant risk factors in a time-dependent univariate analysis but were not independent risk factors when multivariate analysis was utilized. Significant risk factors for major bacterial infections (P < 0.03) using univariate analysis included a prolonged anesthesia, anhepatic and surgical times, as well as the transfusion of large amounts of fresh frozen plasma or autologous blood. In a multivariate analysis, only the transfusion of large amounts of fresh frozen plasma (P < 0.04) was a significant independent risk factor. Cytomegalovirus infection was a risk factor for the development of severe bacterial infections (P < 0.03) in a multivariate time-dependent analysis.

Pathogenicity of murine cytomegalovirus for newborn mice: analysis with the attenuated mutants

Mutants (ts21, rev21, and rec21w) of murine cytomegalovirus (MCMV) with reduced ability to kill newborn mice have been isolated from the Smith strain (wild type; wt). The postulated mutations for these mutants are as follows; a mutation(s) responsible for temperature sensitivity (ts); a mutation(s) responsible for attenuation (att); a mutation(s) which modifies temperature sensitivity (mts); and a mutation(s) responsible for modified growth characteristics (mgc). Genotypes of the mutants have been proposed from their phenotypes; ts21 (ts, att, mts+, mgc+); rev21 (ts, att, mts, mgc+) or (ts+, att, mts+, mgc); and rec21w (ts+, att, mts+, mgc+). Inoculation of 2.0 x 10(4) plaque forming units (PFU) of wt intraperitoneally into mice resulted in lethal infection accompanying intraperitoneal hemorrhage and pathognomonic changes in the target organs. Such changes were less in rec21w-infected mice than in wt-infected mice, and almost absent in ts21- and rev21-infected mice, on the sixth day after inoculation. The lesser damage to the organs correlated with poor growth of these viruses in the corresponding organs. On the other hand, in the case of rec21w-infected mice, virus titer in the target organs was almost equivalent to that of wt-infected mice. The growth characteristic of rec21w in the liver was also similar to that of wt. Nevertheless, damage to the organs by rec21w was less than that by wt. Comparison of the phenotypic characteristics between rec21w and wt demonstrated that att affects the ability of MCMV to induce the organ damage without affecting viral growth. Similar comparison between ts21 and rec21w revealed that ts affects the growth of MCMV in most organs.

Restoration of viral immunity in immunodeficient humans by the adoptive transfer of T cell clones

The adoptive transfer of antigen-specific T cells to establish immunity is an effective therapy for viral infections and tumors in animal models. The application of this approach to human disease would require the isolation and in vitro expansion of human antigen-specific T cells and evidence that such T cells persist and function in vivo after transfer. Cytomegalovirus-specific CD8+ cytotoxic T cell (CTL) clones could be isolated from bone marrow donors, propagated in vitro, and adoptively transferred to immunodeficient bone marrow transplant recipients. No toxicity developed and the clones provided persistent reconstitution of CD8+ cytomegalovirus-specific CTL responses.

Hematopoietic stem cell deficiency resulting from cytomegalovirus infection of bone marrow stroma

Cytomegalovirus (CMV) recurrence from latency is a major risk factor in bone marrow transplantation (BMT). Owing to the immunodepletive treatment, ablation of the immune control of latent CMV is responsible for recurrence and cytopathogenic spread of the virus in vital tissues. There is increasing evidence for reconstituting bone marrow being itself a target tissue of CMV. By inhibiting post-transplantation hematopoiesis, CMV is causal for maintenance of the immunocompromised state, which leads to a prolonged phase of persistent virus replication. Based on results in a murine model of BMT and concurrent CMV infection, we discuss possible mechanisms of CMV-mediated bone marrow graft failure. It is concluded that an irremediable damage of bone marrow stroma by CMV is responsible for a reduced rate of regeneration of the marrow-repopulating, pluripotent stem cell.

Persistence of cytomegalovirus in human long-term bone marrow culture: relationship to hemopoiesis

Using pre-established human long-term marrow culture (LTMC), we studied cytomegalovirus (CMV) replication in this system after in vitro infection of nonadherent cells obtained from these cultures with CMV AD-169. After infection with 5 immediate-early antigen foci/cell CMV was detectable for 63-123 days (peak titer 2.0 x 10(3)-1.3 x 10(9)) in the supernatants of LTMC. Lower MOI resulted in a delay in the detection and longer persistence of CMV in LTMC although peak titers were unchanged. CMV infection was associated with destruction of the stromal layer, appearance of a subset of large (23 microns) CMV-infected mononuclear cells in the nonadherent fraction, and early differentiation of nonadherent cells into a homogenous population of macrophage-like cells. CMV infection resulted in a reduction and premature disappearance of committed progenitors (BFU-E, CFU-GM) in LTMC. Persistence of CMV in LTMC was linked to ongoing hemopoiesis. Human bone marrow may be an important site for CMV replication during acute infection and CMV persistence.

Cytotoxic infection of hematopoietic stem and committed progenitor cells by the parvovirus minute virus of mice. Propagation of an acute myelosuppression in culture

We have investigated the ability of two strains of the parvovirus minute virus of mice to impair mouse hematopoiesis in vitro. We found that the BFU-E and CFU-GM committed progenitors, CFU-Mix pluripotent progenitor, as well as the CFU-S12d, one of the most primitive hematopoietic precursors of the stem cell compartment detectable by colony technique, were similarly inhibited in their proliferative capacity by the immunosuppressive strain MVMi, but not by the prototype virus MVMp. The inhibitory effect correlated with the input of purified MVMi and was reversed by neutralizing MVM antiserum, showing that cytotoxic mechanisms underlying infectious MVMi replication and not operating in MVMp-infected cells were responsible for the reproductive death of hematopoietic precursors. In agreement with this, myeloid nonadherent cells of long-term bone marrow cultures were selectively permissive for MVMi but not for MVMp replication, as judged by viral DNA synthesis, the expression of the nonstructural cytotoxic NS-1 protein, and virus propagation in these cells. Altogether, the suppressive effects mediated by the MVMi cytotoxic infection define a wide lympho-myelotropism not previously reported for this virus. The MVM-mouse model highlights the role that unsuspected virus-hematopoietic compartment interactions may play in bone marrow failures of immunocompromised animal or human hosts.

Multi-step pathogenesis of AIDS--role of cytomegalovirus

Human immunodeficiency virus (HIV) has been shown to be the initial aetiological agent of the acquired immune deficiency syndrome (AIDS). The recent clinical, epidemiologic, pathological, immunological and molecular data presented in this review point to a multi-step pathogenesis of AIDS involving HIV as an initial cause leading to reactivation of cytomegalovirus (CMV), human herpesvirus-6 (HH-6) and other immunosuppressive organisms. Although the onset of CMV reactivation is not precisely known, it may be related to the transition from AIDS-related complex to AIDS. The molecular interactions between CMV and HIV occur in both directions. Although transcriptional activation of HIV by CMV infection (possibly via induction of NF chi B) is better known, the enhancement of CMV replication by HIV is clinically as important. The interactions between HIV or simian immunodeficiency virus (SIV) and CMV appear to be more specific than between HIV or SIV and other herpes viruses, and are also cell-type-dependent. CMV-induced immune suppression (possibly of variable magnitude with different strains) may be an additional co-factor in AIDS. In a rhesus monkey model, the interaction of SIV with rhesus CMV appears contributory to the reproduction of the full-blown simian AIDS. Patients with AIDS and disseminated CMV infection display the maximum activation of HIV p24 antigenaemia and the greatest deficiency of CD8+ T lymphocytes. Defects in CD4+ and CD8+ T cells, including HIV- and CMV-specific cytotoxic T cells, are crucially important in the progression to terminal AIDS and are related not only to HIV but also to CMV and HH-6 infections of lymphocytes.(ABSTRACT TRUNCATED AT 250 WORDS)

Rescue of myeloid lineage-committed preprogenitor cells from cytomegalovirus-infected bone marrow stroma

The effect of murine cytomegalovirus on myelopoiesis was studied in long-term bone marrow culture to find an in vitro correlate for the lethal virus interference with bone marrow reconstitution (W. Mutter, M. J. Reddehase, F. W. Busch, H.-J. Bühring, and U. H. Koszinowski, J. Exp. Med. 167:1645-1658, 1988). The in vitro generation of granulocyte-monocyte progenitors (CFU-GM) discontinued after infection of the stromal cell layer, whereas the proliferation and differentiation of CFU-GM to granulocyte-monocyte colonies remained unaffected. A protocol was established to probe the functional integrity of earlier hematopoietic cells. Pre-CFU-GM (the progenitors of the CFU-GM) could be recovered from an infected bone marrow donor culture by transfer onto an inductive recipient stromal cell layer. Thus, at least in vitro, infection of bone marrow stroma appears to be the only cause of the defect in myelopoiesis.

Efficacious control of cytomegalovirus infection after long-term depletion of CD8+ T lymphocytes

Although the relative contribution of different immune effector functions to clearing tissues of cytomegalovirus is controversial, the contribution of CD8+ T lymphocytes has generally been accepted as essential. In this report, we show that under certain conditions the CD8+ T-lymphocyte subset can be dispensable for clearance of cytomegalovirus. Mice depleted of the CD8+ T-lymphocyte subset eliminated infectious virus with a clearance kinetics similar to that of normal mice. Adoptive transfer studies revealed that the limitation of virus spread required the cooperation between the CD4+ subset and other cells. Comparison between protective functions generated in fully immunocompetent and in CD8- mice demonstrated that elimination of the CD8+ subset before infection altered the quality of the antiviral immune response. The compensatory protective activity gained by CD4+ cells in CD8- mice was absent in normal mice recovering from virus infection.

Animal cytomegaloviruses

Cytomegaloviruses are agents that infect a variety of animals. Human cytomegalovirus is associated with infections that may be inapparent or may result in severe body malformation. More recently, human cytomegalovirus infections have been recognized as causing severe complications in immunosuppressed individuals. In other animals, cytomegaloviruses are often associated with infections having relatively mild sequelae. Many of these sequelae parallel symptoms associated with human cytomegalovirus infections. Recent advances in biotechnology have permitted the study of many of the animal cytomegaloviruses in vitro. Consequently, animal cytomegaloviruses can be used as model systems for studying the pathogenesis, immunobiology, and molecular biology of cytomegalovirus-host and cytomegalovirus-cell interactions.

An animal model for therapeutic intervention studies of CMV infection in the immunocompromised host

An experimental rat model to study acute cytomegalovirus infections is described. Eight-week old male Brown Norway rats, immunosuppressed by total body irradiation, were infected with rat cytomegalovirus (RCMV). The effects of infection were determined by survival rates and the presence of virus or viral components in different organs was assayed by plaque test, immunoperoxidase staining, dot-blot DNA hybridization and in situ DNA hybridization. At days 10-post infection nearly 90% of the animals had died. Spleen, liver and bone marrow were heavily infected. Interstitial pneumonia was observed. Pathological findings strongly resembled the full scale of lesions in human CMV infections. Anti-RCMV hyperimmune serum was effective against mortality from RCMV infection and viral spread to lungs and liver was prevented. This model is appropriate for studies on the pathogenesis and antiviral therapy of CMV infections in the immunocompromised host.

Treatment of acquired immune deficiency syndrome (AIDS)-related pneumonitis with foscarnet: a double-blind placebo controlled study

A double-blind placebo controlled trial of foscarnet was conducted in 32 Human Immunodeficiency Virus (HIV) antibody positive male homosexuals with a presumed AIDS pneumonia. The study was designed to evaluate the importance of treating cytomegalovirus (CMV) as a possible lung pathogen of these patients and as a toxicity study of foscarnet. Trial subjects were randomised to receive either foscarnet or placebo as a continuous intravenous infusion for 2 weeks along with conventional therapy against Pneumocystis carinii (PC) pneumonia. Bronchoscopy or post-mortem showed PC to be present in 24 patients and the bronchoalveolar lavage fluid had early antigen foci of CMV in nine, five of these being double infections. The incidence of CMV infection in this group of patients was not sufficiently high to prove or disprove that treatment of CMV speeds recovery or improves prognosis in AIDS pneumonias. Overall however foscarnet was well tolerated with a slight increase in adverse reactions in the treated groups. This agent is therefore a relatively non-toxic drug to use in the treatment of established CMV disease.

Site-restricted persistent cytomegalovirus infection after selective long-term depletion of CD4+ T lymphocytes

We have established a murine model system for exploring the ability of a CD4 subset-deficient host to cope with cytomegalovirus infection, and reported three findings. First, an antiviral response of the CD8 subset of T lymphocytes could be not only initiated but also maintained for a long period of time despite a continued absence of the CD4 subset, whereas the production of antiviral antibody proved strictly dependent upon help provided by the CD4 subset. Second, no function in the defense against infection could be ascribed as yet to CD4-CD8- T lymphocytes, which were seen to accumulate to a new subset as a result of depletion of the CD4 subset. This newly arising subset did not substitute for CD4+ T lymphocytes in providing help to B lymphocytes, and was also not effective in controlling the spread of virus in host tissues. As long as a function of these cells in the generation and maintenance of a CD8 subset-mediated response is not disproved, caution is indicated with concern to an autonomy of the CD8 subset. Third, even though with delay, the CD8+ effector cells raised in the CD4 subset-deficient host were able of clear vital tissues from productive infection and to restrict asymptomatic, persistent infection to acinar glandular epithelial cells in salivary gland tissue.