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Bush R, Johns F, Betty Z, Goldstein S, Horn B, Shoemaker L, Upadhyay K. BK virus encephalitis and end-stage renal disease in a child with hematopoietic stem cell transplantation. Pediatr Transplant 2020; 24:e13739. [PMID: 32412694 DOI: 10.1111/petr.13739] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 03/09/2020] [Accepted: 04/20/2020] [Indexed: 01/07/2023]
Abstract
BK virus encephalitis after HSCT is uncommon. Several reports of native kidney BKVN in patients with HSCT, hematologic malignancies, human immunodeficiency virus infection, and non-renal solid organ transplantation have been described. However, an uncommon combination of BK encephalitis and ESRD of native kidneys secondary to BK virus in a child with HSCT has not been described. We report a 10-year-old boy who presented with a gradually rising serum creatinine during treatment for severe autoimmune hemolytic anemia, which he developed 9 months after receiving an allogeneic HSCT for aplastic anemia. There was no proteinuria or hematuria present. Serum BK virus load was 5 × 106 copies/mL. A renal biopsy showed evidence of BKVN. He developed fever, seizures, and confusion, and the (CSF) showed significant presence of the BK virus (1 × 106 copies/mL) along with biochemical evidence of viral encephalitis. Cerebrospinal fluid cultures were negative. Despite significant clinical symptoms and presence of BK virus in CSF, the magnetic resonance brain imaging findings were minimal. With reduction of immunosuppression, there was resolution of BK encephalitis but BKVN remained resistant to multiple anti-BK virus agents, including leflunomide and cidofovir. He eventually became dialysis-dependent and, 6 years later, received a renal transplant from his mother. This case illustrates that BK virus in severely immunocompromised HSCT recipient may lead to BK encephalitis and BKVN of native kidneys, even without hemorrhagic cystitis, leading to ESRD. Knowledge of such is important for appropriate timely evaluation and management.
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Affiliation(s)
- Rachel Bush
- Division of Pediatric Nephrology, Department of Pediatrics, University of Florida, Gainesville, FL, USA
| | - Felicia Johns
- Division of Pediatric Nephrology, Department of Pediatrics, University of Florida, Gainesville, FL, USA
| | - Zachary Betty
- Division of Pediatric Nephrology, Department of Pediatrics, University of Florida, Gainesville, FL, USA
| | - Steven Goldstein
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, FL, USA
| | - Biljana Horn
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, University of Florida, Gainesville, FL, USA
| | - Lawrence Shoemaker
- Division of Pediatric Nephrology, Department of Pediatrics, University of Florida, Gainesville, FL, USA
| | - Kiran Upadhyay
- Division of Pediatric Nephrology, Department of Pediatrics, University of Florida, Gainesville, FL, USA
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2
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Lee YJ, Glezerman IG, Tamari R, Sauter CS, Prockop SE, Boulad F, Salvatore SP, Seshan SV, Jaimes EA, Giralt SA, Papadopoulos EB, Jakubowski AA, Papanicolaou GA. BK polyoma virus nephropathy in hematopoietic cell transplant recipients. ACTA ACUST UNITED AC 2019. [DOI: 10.1177/2399369319858362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Background: The epidemiology of BK polyoma virus nephropathy in hematopoietic cell transplant recipients is poorly characterized. Kidney dysfunction after hematopoietic cell transplant is often attributed to treatment toxicities and kidney biopsies are rarely performed. Methods: We reviewed pathology-confirmed BK polyoma virus nephropathy cases in adult and pediatric patients who had undergone a hematopoietic cell transplant between 1 January 2015 and 31 December 2017 at our institution. Plasma and urine BK polyoma virus was assessed by a quantitative polymerase chain reaction assay and were obtained at the clinician discretion. Glomerular filtration rate was estimated by the Chronic Kidney Disease Epidemiology Collaboration equation. BK polyoma virus nephropathy was scored by the Banff Working Group Proposal. Results: Eight (7 adult and 1 pediatric) cases of BK polyoma virus nephropathy were identified among 685 hematopoietic cell transplant recipients, 14 of whom had undergone a kidney biopsy. Five patients (62.5%) had received a CD34+-selected peripheral blood hematopoietic cell transplant; two had received a cord blood allograft and one an unmodified peripheral blood hematopoietic cell transplant. Two patients developed acute graft-versus-host disease grade II. Early post–hematopoietic cell transplant BK polyoma viruria was documented with onset at a median of 54 days (range, 6–91) post–hematopoietic cell transplant and median urine BK polyoma viral load was 9.6 log10 copies/mL (range, 8.6–10.0). BK polyoma virus nephropathy was diagnosed at a median of 267 days after hematopoietic cell transplant (range, 133–637). At BK polyoma virus nephropathy diagnosis, all patients had decreased renal function with glomerular filtration rate (median 29 mL/min/1.73 m2; range, 9–98 ) and creatinine (median 2.4 mg/dL; range, 0.8–7.5) ; median plasma BK polyoma viral load was 6.3 log10 copies/mL (range, 5.5–7.1) and median CD4+ lymphocyte count was 82 cell/mcL (range, 21–172). Conclusions: We report eight biopsy-proven BK polyoma virus nephropathies in hematopoietic cell transplant recipients from a single center. BK polyoma virus nephropathy should be considered in hematopoietic cell transplant recipients with worsening kidney function and high BK polyoma viremia.
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Affiliation(s)
- Yeon Joo Lee
- Infectious Diseases Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
| | - Ilya G Glezerman
- Weill Cornell Medical College, New York, NY, USA
- Renal Services, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Roni Tamari
- Weill Cornell Medical College, New York, NY, USA
- Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Craig S Sauter
- Weill Cornell Medical College, New York, NY, USA
- Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Susan E Prockop
- Weill Cornell Medical College, New York, NY, USA
- Pediatric Bone Marrow Transplantation Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Farid Boulad
- Weill Cornell Medical College, New York, NY, USA
- Pediatric Bone Marrow Transplantation Service, Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | - Edgar A Jaimes
- Weill Cornell Medical College, New York, NY, USA
- Renal Services, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sergio A Giralt
- Weill Cornell Medical College, New York, NY, USA
- Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Esperanza B Papadopoulos
- Weill Cornell Medical College, New York, NY, USA
- Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ann A Jakubowski
- Weill Cornell Medical College, New York, NY, USA
- Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Genovefa A Papanicolaou
- Infectious Diseases Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
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3
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Shah A, Kumar V, Palmer MB, Trofe-Clark J, Laskin B, Sawinski D, Hogan JJ. Native kidney BK virus nephropathy, a systematic review. Transpl Infect Dis 2019; 21:e13083. [PMID: 30907978 DOI: 10.1111/tid.13083] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 02/10/2019] [Accepted: 02/15/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND There is a growing base of literature describing BK nephropathy (BKVN) in patients outside of the setting of kidney transplant. Previous systematic reviews of the literature have been limited by methodology or by the scope of patients included. STUDY DESIGN AND METHODS Systematic Review (Prospero # CRD42018088524). SETTING & POPULATION Patients without kidney transplant who had biopsy-proven BKVN. SELECTION CRITERIA FOR STUDIES Full-text articles that describe native BKVN patient cases. ANALYTICAL APPROACH Descriptive synthesis. RESULTS The search identified 630 unique articles of which 51 were included in the final review. Sixty-five cases (including two new cases presented in this review) were identified, all but one occurred in the setting of known immunosuppression. LIMITATIONS The primary limitation was the exclusion of studies that did not fulfill the stringent review criteria. We excluded reports with only a clinical diagnosis of BKVN, such as those with viruria and/or viremia without biopsy. CONCLUSIONS As of May 2018, there are 65 reported cases of BKVN in native kidneys. This represents the most comprehensive description of biopsy-proven BKVN in native kidneys to date. Evaluation for BK nephropathy should be considered in immunocompromised patients who exhibit unexplained renal failure.
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Affiliation(s)
- Ankur Shah
- Division of Nephrology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Vinayak Kumar
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew B Palmer
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Pathology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jennifer Trofe-Clark
- Division of Nephrology, University of Pennsylvania, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Pharmacy Services, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Benjamin Laskin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Division of Nephrology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Deirdre Sawinski
- Division of Nephrology, University of Pennsylvania, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jonathan J Hogan
- Division of Nephrology, University of Pennsylvania, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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4
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Safdar A, Pouch SM, Scully B. Infections in Allogeneic Stem Cell Transplantation. PRINCIPLES AND PRACTICE OF TRANSPLANT INFECTIOUS DISEASES 2018. [PMCID: PMC7121717 DOI: 10.1007/978-1-4939-9034-4_11] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) has become a widely used modality of therapy for a variety of malignant and nonmalignant diseases. Despite advances in pharmacotherapy and transplantation techniques, infection remains one of the most severe and frequently encountered complications of allo-HSCT. This chapter will address the risk factors for development of infection following allo-HSCT, including those related to the host, the conditioning regimen, and the graft, as well as the timing of opportunistic infections after allo-HSCT. The most common bacterial, viral, fungal, and parasitic infections, as well as issues surrounding their diagnostics and treatment, will be discussed. Finally, this chapter will address vaccination and other preventative strategies to be utilized when caring for patients undergoing allo-HSCT.
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Affiliation(s)
- Amar Safdar
- grid.416992.10000 0001 2179 3554Clinical Associate Professor of Medicine, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX USA
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5
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Persistent polyomavirus-associated nephropathy in a patient with GvHD and treatment with the JAK1/2 inhibitor ruxolitinib. Bone Marrow Transplant 2018; 54:762-764. [PMID: 30349038 DOI: 10.1038/s41409-018-0370-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 10/01/2018] [Accepted: 10/01/2018] [Indexed: 11/08/2022]
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6
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The Noninvasive Urinary Polyomavirus Haufen Test Predicts BK Virus Nephropathy in Children After Hematopoietic Cell Transplantation: A Pilot Study. Transplantation 2017; 100:e81-7. [PMID: 26895217 DOI: 10.1097/tp.0000000000001085] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND After hematopoietic cell transplantation (HCT), polyoma-BK virus is associated with hemorrhagic cystitis and also with polyomavirus nephropathy (PVN). However, the true burden of post-HCT PVN is unknown because kidney biopsies are avoided due to their bleeding risk. The novel, noninvasive urinary PV-Haufen test detects PVN in kidney transplant recipients with greater than 95% positive/negative predictive values. We hypothesized that the detection of PV-Haufen in voided urine samples-a positive PV-Haufen test-was also clinically significant after HCT. METHODS We examined 21 suitable urine samples from 14 patients (median age, 15 years; 71.4% male) who were selected from repositories for having varying degrees of BK viremia (range, 0-1.0 × 10 copies/mL), hemorrhagic cystitis (present/absent), and data on kidney function. Urine samples were obtained at a median of 88 days post-HCT. RESULTS The PV-Haufen were detected in 5 of 14 patients (35.7%) and 7 of 21 (33.3%) urine samples, with histologic confirmation of PVN in 1 autopsy specimen. After a median of 285 days post-HCT, patients with PV-Haufen had an increased risk of dialysis-dependent renal failure (P < 0.05). All 3 dialysis-dependent patients had PV-Haufen and died. The presence of urinary PV-Haufen was not significantly correlated with hemorrhagic cystitis. From the 16 urines collected during BK viremia, 43.8% were PV-Haufen-positive, and 56.2% were negative. The PV-Haufen were not present in the 5 urines from patients without concomitant BK-viremia. CONCLUSIONS In this proof-of-concept study, a positive PV-Haufen test was only seen in some patients with BK viremia and was not associated with hemorrhagic cystitis. The detection of PV-Haufen suggests underlying PVN with an increased risk of kidney failure and dialysis.
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7
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Vigil D, Konstantinov NK, Barry M, Harford AM, Servilla KS, Kim YH, Sun Y, Ganta K, Tzamaloukas AH. BK nephropathy in the native kidneys of patients with organ transplants: Clinical spectrum of BK infection. World J Transplant 2016; 6:472-504. [PMID: 27683628 PMCID: PMC5036119 DOI: 10.5500/wjt.v6.i3.472] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 08/25/2016] [Accepted: 09/08/2016] [Indexed: 02/05/2023] Open
Abstract
Nephropathy secondary to BK virus, a member of the Papoviridae family of viruses, has been recognized for some time as an important cause of allograft dysfunction in renal transplant recipients. In recent times, BK nephropathy (BKN) of the native kidneys has being increasingly recognized as a cause of chronic kidney disease in patients with solid organ transplants, bone marrow transplants and in patients with other clinical entities associated with immunosuppression. In such patients renal dysfunction is often attributed to other factors including nephrotoxicity of medications used to prevent rejection of the transplanted organs. Renal biopsy is required for the diagnosis of BKN. Quantitation of the BK viral load in blood and urine are surrogate diagnostic methods. The treatment of BKN is based on reduction of the immunosuppressive medications. Several compounds have shown antiviral activity, but have not consistently shown to have beneficial effects in BKN. In addition to BKN, BK viral infection can cause severe urinary bladder cystitis, ureteritis and urinary tract obstruction as well as manifestations in other organ systems including the central nervous system, the respiratory system, the gastrointestinal system and the hematopoietic system. BK viral infection has also been implicated in tumorigenesis. The spectrum of clinical manifestations from BK infection and infection from other members of the Papoviridae family is widening. Prevention and treatment of BK infection and infections from other Papovaviruses are subjects of intense research.
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8
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Burbach M, Birsen R, Denis B, Munier AL, Verine J, de Fontbrune FS, Peraldi MN. A case of BK virus nephropathy without hemorrhagic cystitis after hematopoietic stem cell transplantation. Ann Hematol 2016; 95:1567-8. [PMID: 27278550 DOI: 10.1007/s00277-016-2725-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 06/02/2016] [Indexed: 01/12/2023]
Affiliation(s)
- Maren Burbach
- Assistance Publique-Hôpitaux de Paris, Service de Néphrologie, Hôpital Saint-Louis, Paris, France
| | - Rudy Birsen
- Assistance Publique-Hôpitaux de Paris, Service des maladies infectieuses, Hôpital Saint-Louis, Paris, France.
| | - Blandine Denis
- Assistance Publique-Hôpitaux de Paris, Service des maladies infectieuses, Hôpital Saint-Louis, Paris, France
| | - Anne-Lise Munier
- Assistance Publique-Hôpitaux de Paris, Service des maladies infectieuses, Hôpital Saint-Louis, Paris, France
| | - Jérôme Verine
- Assistance Publique-Hôpitaux de Paris, Service d'Anatomie Pathologique, Hôpital Saint-Louis, Paris, France.,University Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Flore Sicre de Fontbrune
- Assistance Publique-Hôpitaux de Paris, Service d'Hématologie-Greffe, Hôpital Saint-Louis, Paris, France
| | - Marie-Noelle Peraldi
- Assistance Publique-Hôpitaux de Paris, Service de Néphrologie, Hôpital Saint-Louis, Paris, France.,University Paris Diderot, Sorbonne Paris Cité, Paris, France
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9
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Abstract
Purpose of review Polyomavirus nephropathy (PVN) mainly caused by BK virus (BKV) remains the most common productive viral infection of the kidney. Over the past decade, clinical interest often focused on BK viremia and viruria as the diagnostic mainstays of patient management. The purpose of this review is to discuss viral nephropathy in the context of BK viremia and viruria and new strategies to optimize diagnostic accuracy and patient management. The emerging roles of polyomaviruses in oncogenesis, salivary gland disease, and post-bone marrow transplantation as well as novel Polyomavirus strains are highlighted. Recent findings Areas of investigation include proposals by the Banff working group on the classification of PVN and studies on PVN progression and resolution, including the role cellular immune responses may play during reconstitution injury. New noninvasive strategies to optimize the diagnosis of PVN, that is, the urinary ‘polyomavirus-haufen’ test and mRNA expression levels for BKV in the urine, hold great promise to accurately identify patients with viral nephropathy. Tools are now available to separate ‘presumptive’ from ‘definitive’ disease in various patient cohorts including individuals post-bone marrow transplantation. Recent observations also point to a currently underrecognized role of polyomaviruses in oncogenesis post-transplantation and salivary gland disease in patients with HIV-AIDS. Summary This review summarizes recent studies on PVN and the significance of the BKV strain in disease. Current paradigms for patient management post-(renal) transplantation are discussed in the setting of new observations. Issues that still require clarification and further validation are highlighted.
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10
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Gagneux-Brunon A, Pillet S, Laurent B, Mariat C, Michalet M, Lucht F, Botelho-Nevers E. A case of BK virus nephropathy in a stem cell transplant recipient: a rare or under-recognized cause for Acute Kidney injury. Med Mal Infect 2015; 45:331-4. [PMID: 26144286 DOI: 10.1016/j.medmal.2015.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 05/18/2015] [Accepted: 06/03/2015] [Indexed: 11/29/2022]
Affiliation(s)
- A Gagneux-Brunon
- Service de Maladies Infectieuses et Tropicales, CHU de Saint-Étienne, 42055 Saint-Étienne cedex 2, France; Groupe Immunité des Muqueuses et Agents Pathogènes, EA 3064, Université Jean-Monnet, Université de Lyon, CHU de Saint-Étienne, 42000 Saint-Étienne, France.
| | - S Pillet
- Groupe Immunité des Muqueuses et Agents Pathogènes, EA 3064, Université Jean-Monnet, Université de Lyon, CHU de Saint-Étienne, 42000 Saint-Étienne, France; Laboratoire de Bactériologie et Virologie, CHU de Saint-Étienne, 42055 Saint-Étienne, France
| | - B Laurent
- Laboratoire de Cytologie et Histologie rénale, CHU de Saint-Étienne, 42055 Saint-Étienne, France
| | - C Mariat
- Groupe Immunité des Muqueuses et Agents Pathogènes, EA 3064, Université Jean-Monnet, Université de Lyon, CHU de Saint-Étienne, 42000 Saint-Étienne, France; Service de Néphrologie, Dialyse, Transplantation et Hypertension, CHU de Saint-Étienne, 42055 Saint-Étienne, France
| | - M Michalet
- Service d'Hématologie, Hôpitaux Sud, Hospices Civils de Lyon, 69495 Pierre-Bénite, France
| | - F Lucht
- Service de Maladies Infectieuses et Tropicales, CHU de Saint-Étienne, 42055 Saint-Étienne cedex 2, France; Groupe Immunité des Muqueuses et Agents Pathogènes, EA 3064, Université Jean-Monnet, Université de Lyon, CHU de Saint-Étienne, 42000 Saint-Étienne, France
| | - E Botelho-Nevers
- Service de Maladies Infectieuses et Tropicales, CHU de Saint-Étienne, 42055 Saint-Étienne cedex 2, France; Groupe Immunité des Muqueuses et Agents Pathogènes, EA 3064, Université Jean-Monnet, Université de Lyon, CHU de Saint-Étienne, 42000 Saint-Étienne, France
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11
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Maximova N, Pizzol A, Sonzogni A, Gregori M, Granzotto M, Tamaro P. Polyclonal gammopathy after BKV infection in HSCT recipient: a novel trigger for plasma cells replication? Virol J 2015; 12:23. [PMID: 25886491 PMCID: PMC4335512 DOI: 10.1186/s12985-015-0254-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 01/30/2015] [Indexed: 12/16/2022] Open
Abstract
Background BK polyomavirus infects most of the general population. However, its clinical manifestations are almost exclusively seen in immunocompromised patients, particularly in kidney and hematopoietic stem cell transplantation recipients. Case presentation A 15-y-old female suffering from common B-cell acute lymphoblastic leukaemia underwent hematopoietic stem cell transplantation. The patient had reactivation of BKPyV infection and developed an haemorrhagic cystitis. Three months after transplant, BKPyV viremia and viruria increased and she developed a severe nephropathy associated to a polyclonal gammopathy with high levels of isolated IgM. Conclusion This case report describes a rare and unexpected polyclonal gammopathy developed during a polyomavirus-associated nephropathy confirmed by immunohistochemical and laboratory analyses.
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Affiliation(s)
- Natalia Maximova
- Bone Marrow Transplant Unit, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Via dell'Istria 65/1, 34134, Trieste, Italy.
| | - Antonio Pizzol
- Pediatric Hemato-Oncology Department, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy.
| | - Aurelio Sonzogni
- Department of Pathology, Ospedale Beato Papa Giovanni XXIII, Bergamo, Italy.
| | - Massimo Gregori
- Department of Radiology, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy.
| | | | - Paolo Tamaro
- Pediatric Hemato-Oncology Department, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy.
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12
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Papanicolaou GA, Lee YJ, Young JW, Seshan SV, Boruchov AM, Chittick G, Momméja-Marin H, Glezerman IG. Brincidofovir for polyomavirus-associated nephropathy after allogeneic hematopoietic stem cell transplantation. Am J Kidney Dis 2015; 65:780-4. [PMID: 25600489 DOI: 10.1053/j.ajkd.2014.11.020] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 11/03/2014] [Indexed: 12/16/2022]
Abstract
Polyomavirus-associated nephropathy (PVAN) is common in patients who have undergone kidney transplantation and has been reported in hematopoietic stem cell (HSC) transplant recipients. Aside from reduction of immunosuppression, few therapeutic options exist for treatment of PVAN. We report a case of PVAN in a severely immunocompromised allogeneic HSC transplant recipient that was treated with brincidofovir without reduction of immunosuppression. We review our institutional experience of PVAN in HSC transplantation and discuss the potential use of brincidofovir for treatment.
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Affiliation(s)
- Genovefa A Papanicolaou
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Yeon Joo Lee
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - James W Young
- Department of Medicine, Weill Cornell Medical College, New York, NY; Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Surya V Seshan
- Department of Pathology, Weill Cornell Medical College, New York, NY
| | - Adam M Boruchov
- Saint Francis Hospital and Medical Center and University of Connecticut School of Medicine, Hartford, CT
| | | | | | - Ilya G Glezerman
- Department of Medicine, Weill Cornell Medical College, New York, NY; Renal Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY.
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13
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Abstract
The kidney is subject to a large variety of injurious factors before, during, and after hematopoietic stem cell transplantation (HCT), leading to a high incidence of acute kidney injury in the peritransplant period. Chronic kidney disease is estimated to impact 15% to 20% of HCT recipients. Although renal biopsies may be deferred in the setting of thrombotic microangiopathy, acute self-limited impairment, or slowly progressive functional decline, in many patients renal biopsy yields important diagnostic insight to guide treatment. Light microscopic, immunofluorescence, and ultrastructural analysis often reveals a number of concurrent abnormalities in glomeruli, tubules, interstitium, and vessels. Meta-analysis of the literature reveals that membranous nephropathy is the most commonly reported glomerular lesion in the setting of HCT, followed by minimal change disease. Autopsy and biopsy studies show that clinical criteria lack sensitivity and specificity for renal acute and chronic thrombotic microangiopathy. Viral infection and other causes of interstitial nephritis and tubular injury are important findings in HCT renal biopsies, which in many instances may not be clinically suspected. Given the complexity and variability of HCT protocols, clinicopathologic correlation is needed.
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14
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BK Virus and Its Role in Hematopoietic Stem Cell Transplantation: Evolution of a Pathogen. Curr Infect Dis Rep 2014; 16:417. [PMID: 24942378 DOI: 10.1007/s11908-014-0417-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
We reviewed the literature regarding disease induced by BK virus (BKV) in the hematopoietic stem cell transplant (HSCT) population, particularly hemorrhagic cystitis (HC) and nephritis. The association between BKV and HC has been reported over the past four decades. BKV has been clinically implicated and widely accepted as an etiologic agent of HC and nephritis in HSCT and nephropathy in renal transplant patients. We discuss the potential benefit of early initiation of therapy in patients who fail supportive care alone as well as the different treatment strategies for HC induced by BKV. Treatments that have been used such as cidofovir and leflunomide are accompanied by risks, and the benefits are not as concrete as with other viral illness in the HSCT population.
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15
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Satyanarayana G, Marty FM, Tan CS. The polyomavirus puzzle: is host immune response beneficial in controlling BK virus after adult hematopoietic cell transplantion? Transpl Infect Dis 2014; 16:521-31. [PMID: 24834968 DOI: 10.1111/tid.12233] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 01/22/2014] [Accepted: 02/08/2014] [Indexed: 12/14/2022]
Abstract
BK virus (BKV), a ubiquitous human polyomavirus, usually does not cause disease in healthy individuals. BKV reactivation and disease can occur in immunosuppressed individuals, such as those who have undergone renal transplantation or hematopoietic cell transplantation (HCT). Clinical manifestations of BKV disease include graft dysfunction and failure in renal transplant recipients; HCT recipients frequently experience hematuria, cystitis, hemorrhagic cystitis (HC), and renal dysfunction. Studies of HCT patients have identified several risk factors for the development of BKV disease including myeloablative conditioning, acute graft-versus-host disease, and undergoing an umbilical cord blood (uCB) HCT. Although these risk factors indicate that alterations in the immune system are necessary for BKV pathogenesis in HCT patients, few studies have examined the interactions between host immune responses and viral reactivation in BKV disease. Specifically, having BKV immunoglobulin-G before HCT does not protect against BKV infection and disease after HCT. A limited number of studies have demonstrated BKV-specific cytotoxic T cells in healthy adults as well as in post-HCT patients who had experienced HC. New areas of research are required for a better understanding of this emerging infectious disease post HCT, including prospective studies examining BK viruria, viremia, and their relationship with clinical disease, a detailed analysis of urothelial histopathology, and laboratory evaluation of systemic and local cellular and humoral immune responses to BKV in patients receiving HCT from different sources, including uCB and haploidentical donors.
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Affiliation(s)
- G Satyanarayana
- Division of Infectious Disease, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Infectious Disease, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA; Center for Virology and Vaccine Research, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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16
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BK virus disease after allogeneic stem cell transplantation: a cohort analysis. Biol Blood Marrow Transplant 2014; 20:564-70. [PMID: 24462984 DOI: 10.1016/j.bbmt.2014.01.014] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 01/15/2014] [Indexed: 11/21/2022]
Abstract
The clinical epidemiology of BK virus (BKV) disease after allogeneic hematopoietic stem cell transplantation (HSCT) is not well defined. We evaluated 491 patients transplanted from January 2010 to December 2011 at a single transplant center to assess incidence, severity, and risk factors for BKV disease after HSCT. BKV disease was defined as BKV detection in urine by PCR testing in association with genitourinary symptoms without other concurrent genitourinary conditions. BKV disease occurred in 78 patients (15.9%), for an incidence rate of .47/1000 patient-days (95% confidence interval [CI], .37 to .59); BKV disease was considered severe in 27 patients (5.5%). In multivariate Cox modeling, time-dependent acute graft-versus-host disease (aGVHD) grades II to IV (adjusted hazard ratio [aHR] 4.25; 95% CI, 2.51 to 7.21), cord blood HSCT (aHR 2.28; 95% CI, 1.01 to 5.15), post-transplant mycophenolate use (aHR 3.31; 95% CI, 1.83 to 5.99), and high-dose cyclophosphamide conditioning (aHR 2.34, 95% CI 1.45 to 3.77) were significant predictors of BKV disease. Time-dependent aGVHD grades III to IV (aHR 10.5; 95% CI, 4.44 to 25.0) and cord blood HSCT (aHR 5.40; 95% CI, 1.94 to 15.0) were independent risk factors for severe BKV disease. BKV disease is common and is associated with significant and prolonged morbidity after HSCT. Prospective studies are needed to better define the morbidity of post-HSCT BKV disease and inform the design of prophylaxis and treatment trials.
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Oshrine B, Bunin N, Li Y, Furth S, Laskin BL. Kidney and bladder outcomes in children with hemorrhagic cystitis and BK virus infection after allogeneic hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 2013; 19:1702-7. [PMID: 24060406 DOI: 10.1016/j.bbmt.2013.09.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Accepted: 09/12/2013] [Indexed: 12/16/2022]
Abstract
BK virus (BKV) infection is associated with hemorrhagic cystitis (HC) in hematopoietic stem cell transplantation (HSCT) recipients and nephropathy after kidney transplantation. We assessed the association between BKV and kidney and bladder complications in children developing HC by retrospectively reviewing 221 consecutive pediatric allogeneic HSCT recipients at the Children's Hospital of Philadelphia from 2005 to 2011. We included all patients with BKV PCR testing performed for clinical indication from day 0 until 1 year post-HSCT (N = 68). We assessed the association of any BKV infection (urine and/or blood) or peak BK viremia ≥ 10,000 copies/mL (high viremia) with severe HC (defined as grade IV-bladder catheterization or surgical intervention); the need for dialysis; serum creatinine-estimated glomerular filtration rate at the time of BKV testing, day 100, and day 365; and death. Children with high viremia more likely developed severe HC compared with those with peak viremia < 10,000 copies/mL (21% versus 2%; P = .02). BKV infection of the blood or urine was not associated with the need for dialysis, change in estimated glomerular filtration rate, or mortality. BKV infection is common after pediatric allogeneic HSCT, and plasma testing in those with HC may predict patients who will develop severe bladder injury.
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Affiliation(s)
- Benjamin Oshrine
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
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19
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Sharma SG, Nickeleit V, Herlitz LC, de Gonzalez AK, Stokes MB, Singh HK, Markowitz GS, D'Agati VD. BK polyoma virus nephropathy in the native kidney. Nephrol Dial Transplant 2012; 28:620-31. [PMID: 23249622 DOI: 10.1093/ndt/gfs537] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND While BK polyoma virus nephropathy (PVN) is a well-recognized cause of renal allograft dysfunction, PVN of native kidneys is likely under-recognized. METHODS We present the pathologic features, risk factors and outcomes of eight cases of PVN in native kidneys. RESULTS The cohort included eight males aged 16-73 years (mean 47.4) with an immunocompromised state (mean duration 3.15 years) attributable to: hematologic malignancies (n = 6), for which three had undergone bone marrow transplant; lung transplant (n = 1) and combined tuberculosis and diabetes (n = 1). Seven patients were receiving specific immunosuppressive therapies. Patients were biopsied for acute kidney injury (AKI) with rise in mean creatinine levels from baseline 1.6 to 2.8 mg/dL. Pathology showed BK PVN with characteristic intranuclear inclusions staining positive for SV40 T antigen and negative for JC virus (JCV), with positive serum and/or urine PCR for BK virus. One patient had focal medullary JCV co-infection. Two patients also had renal infiltration by chronic lymphocytic leukemia (CLL). Six patients received specific therapy directed to PVN (cidofovir or leflunomide). Follow-up ranged from 2 to 20 (mean 10) months. Despite marked decrease in serum BK viral copy numbers, creatinine continued to rise in six cases (mean 3.7 mg/dL in four, requiring dialysis in two) and three patients died of malignancy, opportunistic infection or renal failure. Advanced histologic stage of PVN, ineffective antiviral therapy, co-morbidities and persistent immunocompromised state likely contributed to the poor outcomes. CONCLUSION A high level of suspicion in immunocompromised patients is needed to diagnose PVN in an early stage that may respond more favorably to antiviral therapy.
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Affiliation(s)
- Shree G Sharma
- Department of Pathology, ColumbiaUniversity Medical Center, New York, NY, USA.
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Infections in Leukemia and Hematopoietic Stem Cell Transplantation. LEUKEMIA AND RELATED DISORDERS 2012. [PMCID: PMC7178857 DOI: 10.1007/978-1-60761-565-1_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Infections are one of the most common complications in patients diagnosed with leukemia and serve as a major obstacle to treatment. Through the early 1970s, infections were the most common cause of death in patients diagnosed with acute leukemia, but improvement in treatment and supportive care over the past few decades, coupled with expanded prophylaxis and prevention regimens, have led to reduction in both the frequency and severity of infections. Regardless, due in part to an aging cancer population and the diversity of cancer treatments and procedures, infectious diseases remain a major cause of morbidity and mortality in patients with leukemia.
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Raval M, Gulbis A, Bollard C, Leen A, Chemaly R, Shpall E, Lahoti A, Kebriaei P. Evaluation and management of BK virus-associated nephropathy following allogeneic hematopoietic cell transplantation. Biol Blood Marrow Transplant 2011; 17:1589-93. [PMID: 21767514 DOI: 10.1016/j.bbmt.2011.07.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2010] [Accepted: 07/11/2011] [Indexed: 12/16/2022]
Abstract
BK virus nephropathy is a common cause of graft loss in kidney transplant recipients. Cases of BK nephropathy following allogeneic hematopoietic cell transplantation (HCT) are underreported. An increased incidence of BK virus-associated nephropathy is being seen in the setting of more profound and prolonged immunosuppression following solid organ transplantation and HCT. We will review diagnostic and treatment modalities for BK-associated nephropathy following allogeneic HCT.
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Affiliation(s)
- Mihir Raval
- Department of Internal Medicine, University of North Dakota, ND, USA
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Haines HL, Laskin BL, Goebel J, Davies SM, Yin HJ, Lawrence J, Mehta PA, Bleesing JJ, Filipovich AH, Marsh RA, Jodele S. Blood, and not urine, BK viral load predicts renal outcome in children with hemorrhagic cystitis following hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 2011; 17:1512-9. [PMID: 21385622 DOI: 10.1016/j.bbmt.2011.02.012] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2011] [Accepted: 02/16/2011] [Indexed: 12/16/2022]
Abstract
BK virus is a significant cause of hemorrhagic cystitis after hematopoietic stem cell transplantation (HSCT). However, its role in nephropathy post-HSCT is less studied. We retrospectively evaluated clinical outcomes in pediatric HSCT patients with hemorrhagic cystitis. Although most of these patients had very high urine BK viral loads (viruria), patients with higher BK plasma loads (viremia) had significant renal dysfunction, a worse clinical course, and decreased survival. Patients with a peak plasma BK viral load of >10,000 copies/mL (high viremia) were more likely to need dialysis and aggressive treatment for hemorrhagic cystitis compared to patients with ≤ 10,000 copies/mL (low viremia). Conversely, most patients with low viremia had only transient elevations in creatinine, and less severe hemorrhagic cystitis that resolved with supportive therapy. Overall survival (OS) at 1 year post-HSCT was 89% in the low viremia group and 48% in the high viremia group. We conclude that the degree of BK viremia, and not viruria, may predict renal, urologic, and overall outcome in the post-HSCT population.
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Affiliation(s)
- Hilary L Haines
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
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Sanchez-Pinto LN, Laskin BL, Jodele S, Hummel TR, Yin HJ, Goebel J. BK virus nephropathy in a pediatric autologous stem-cell transplant recipient. Pediatr Blood Cancer 2011; 56:495-7. [PMID: 21225938 DOI: 10.1002/pbc.22860] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2010] [Accepted: 09/10/2010] [Indexed: 12/16/2022]
Abstract
BK virus (BKV) is an increasingly identified cause of pathology in immunocompromised transplant recipients. BKV is a well-known cause of graft dysfunction following renal transplantation and has also been reported in the native kidneys of other solid organ recipients. Less commonly, BKV nephropathy occurs in allogeneic stem-cell transplant (SCT) recipients. We now describe the first reported case of BKV nephropathy after pediatric autologous SCT.
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Affiliation(s)
- L Nelson Sanchez-Pinto
- Division of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Abstract
PURPOSE OF REVIEW Several viruses have recently gained importance for the transplant recipient. The purpose of this review is to give an update on emerging viruses in transplantation. RECENT FINDINGS BK virus-associated nephropathy (BKVAN) causes graft loss after kidney transplantation. Immunosuppression lowering strategies have now been shown to have benefit in decreasing the incidence of BKVAN. Guidelines for screening, prevention, and therapy have also been developed. Another polyomavirus, JC virus, is a cause of progressive multifocal leukoencephalopathy and has also gained prominence due to the increasing use of monoclonal antibodies in transplant recipients. The significance of human herpesvirus-6 and -7 continues to be debated in the literature, and new data is available on their association with clinical disease. Finally, newly discovered respiratory viruses, such as human metapneumovirus, bocavirus, KI and WU viruses, have also been described in transplant recipients. Human metapneumovirus appears to cause significant respiratory disease whereas the significance of bocavirus, KI and WU viruses in transplant recipients remains uncertain. SUMMARY Viral infections, such as polyomaviruses, human herpesvirus-6 and -7 and respiratory viruses, are emerging as causes of significant disease in transplantation. Antiviral options for these viruses are limited, and decreasing immunosuppression is the cornerstone of therapy.
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Affiliation(s)
- Deepali Kumar
- Transplant Infectious Diseases, University of Alberta, Edmonton, Alberta, Canada.
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Aoki K, Kotani S, Ichinohe T, Kondo T, Ishikawa T. Acute renal failure associated with systemic polyoma BK virus activation in a patient with peripheral T-cell lymphoma. Int J Hematol 2010; 92:638-41. [PMID: 20924732 DOI: 10.1007/s12185-010-0694-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2010] [Revised: 08/27/2010] [Accepted: 09/13/2010] [Indexed: 12/29/2022]
Abstract
Renal dysfunction associated with polyoma BK virus (BKV) reactivation usually occurs in the setting of profound immunosuppression related to renal transplantation and hematopoietic stem cell transplantation. However, it has been rarely described as a complication during the course of conventional chemotherapy. Here, we report a case of BKV-associated acute renal failure developed in a patient suffering from refractory peripheral T-cell lymphoma, not otherwise specified. After repetitive cycles of salvage chemotherapy, the patient developed fever and urinary frequency, rapidly followed by anuria that necessitated the emergent institution of hemodialysis. Cytologic examination of the urine revealed the presence of decoy cells and positive immunostaining for polyomavirus simian virus 40 antigen. High levels of BKV were detected in urine and plasma with quantitative real-time polymerase chain reaction, strongly suggesting that his renal failure was due to polyoma virus-associated nephropathy. This rare complication should be kept in mind in case of unexplained renal failure developed in immunodeficient patients undergoing cytotoxic chemotherapy.
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Affiliation(s)
- Kazunari Aoki
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawaharacho, Sakyo-ku, Kyoto 606-8507, Japan
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Chatzidimitriou D, Gavriilaki E, Sakellari I, Diza E. Hematopoietic cell transplantation and emerging viral infections. J Med Virol 2010; 82:528-38. [PMID: 20087928 PMCID: PMC7166846 DOI: 10.1002/jmv.21696] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2009] [Indexed: 12/11/2022]
Abstract
Viral infections remain important causes of morbidity and mortality in hematopoietic cell transplant recipients. More recent developments in preparative regimens and graft manipulations, as well as the control of well-recognized post-transplant infections by the introduction of prophylaxis and preemptive strategies, have influenced the timing and the epidemiology of infections. As new pathogens, such as human metapneumovirus (HMPV), human bocavirus, human coronaviruses HCoV-NL63 and HCoV-HKU1, human herpesviruses HHV-6 and HHV-7, and polyomaviruses, have emerged, it is fundamental to determine the significance of the newly discovered viruses and their role in the transplantation field. This article summarizes recent data on epidemiology and laboratory diagnosis of new pathogens, as well as clinical features and management of the associated infectious complications. J. Med. Virol. 82:528-538, 2010. (c) 2010 Wiley-Liss, Inc.
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Affiliation(s)
- D Chatzidimitriou
- 2nd Department of Microbiology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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Hiemenz JW. Management of Infections Complicating Allogeneic Hematopoietic Stem Cell Transplantation. Semin Hematol 2009; 46:289-312. [DOI: 10.1053/j.seminhematol.2009.03.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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