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Mashkani B, Jalili Nik M, Rezaee SA, Boostani R. Advances in the treatment of human T-cell lymphotropic virus type-I associated myelopathy. Expert Rev Neurother 2023; 23:1233-1248. [PMID: 37933802 DOI: 10.1080/14737175.2023.2272639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 10/16/2023] [Indexed: 11/08/2023]
Abstract
INTRODUCTION Nearly 2-3% of those 10 to 20 million individuals infected with the Human T-cell lymphotropic virus type-1 (HTLV-1); are predisposed to developing HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP). It is a neuro-inflammatory disease; differentiated from multiple sclerosis based on the presence of typical neurologic symptoms, confirmation of HTLV-1 infection, and other molecular biomarkers. AREAS COVERED A brief review of the epidemiology, host immune responses, and molecular pathogenesis of HAM/TSP is followed by detailed discussions about the host-related risk factors for developing HAM/TSP and success/failure stories of the attempted management strategies. EXPERT OPINION Currently, there is no effective treatment for HAM/TSP. Anti-retroviral therapy, peculiar cytokines (IFN-α), some anti-oxidants, and allograft bone marrow transplantation have been used for treating these patients with limited success. Under current conditions, asymptomatic carriers should be examined periodically by a neurologist for early signs of spinal cord injury. Then it is crucial to determine the progress rate to adapt the best management plan for each patient. Corticosteroid therapy is most beneficial in those with acute myelitis. However, slow-progressing patients are best managed using a combination of symptomatic and physical therapy. Additionally, preventive measures should be taken to decrease further spread of HTLV-1 infection.
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Affiliation(s)
- Baratali Mashkani
- Department of clinical Biochemistry, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad Jalili Nik
- Department of clinical Biochemistry, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Seyed Abdolrahim Rezaee
- Inflammation and Inflammatory Diseases division, Immunology Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Reza Boostani
- Department of Neurology, Mashhad University of Medical Sciences, Mashhad, Iran
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Abstract
PURPOSE OF REVIEW This article reviews current epidemiologic trends, clinical presentations, and diagnostic strategies for central nervous system (CNS) infections in human immunodeficiency virus-negative (HIV) patients immunocompromised by their underlying disease or by receipt of immunosuppressive or immunomodulating therapies. Three patient groups are considered: (1) cancer patients; (2) hematopoietic or solid organ transplantation recipients; and (3) patients with autoimmune or inflammatory conditions requiring therapies that alter the host immune response. RECENT FINDINGS Clinical presentations, associated neuroimaging, and cerebrospinal fluid (CSF) abnormalities differ between immunocompromised and immunocompetent patients. Infections can trigger the emergence of neurotropic antibodies or inflammatory conditions due to treatment with cancer immunotherapies. Unbiased metagenomic assays to identify obscure pathogens help clinicians navigate the increasing range of conditions affecting the growing population of patients with altered immunity. Awareness of clinical presentations and disease and drug-specific risks is important for early diagnosis and intervention in these often life-threatening infections and their noninfectious mimes.
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Affiliation(s)
- Amy A Pruitt
- Department of Neurology, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA.
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Wakabayashi T, Obara H, Seki M, Shinoda M, Kitago M, Yagi H, Abe Y, Matsubara K, Yamada Y, Oshima G, Oki K, Nagoshi N, Watanabe K, Hibi T, Itano O, Hoshino K, Suzuki N, Kuroda T, Kitagawa Y. Myelopathy due to human T-cell leukemia virus type-1 from the donor after ABO-incompatible liver transplantation. Ann Hepatol 2020; 18:397-401. [PMID: 31029562 DOI: 10.1016/j.aohep.2018.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 06/19/2018] [Accepted: 06/19/2018] [Indexed: 02/04/2023]
Abstract
We report the case of a 53-year-old-man who developed human T-cell leukemia virus type-1-associated myelopathy (HAM) after ABO-incompatible liver transplantation for alcoholic liver cirrhosis. The living donor was seropositive for human T-cell leukemia virus type-1 (HTLV-1) and the recipient was seronegative for HTLV-1 before transplantation. After transplantation, the recipient developed steroid-resistant acute cellular rejection, which was successfully treated using anti-thymocyte globulin, and he was eventually discharged. He underwent spinal surgery twice after the transplantation for the treatment of cervical spondylosis that had been present for a period of 9 months before the transplantation. The surgery improved his gait impairment temporarily. However, his gait impairment progressed, and magnetic resonance imaging revealed multiple sites of myelopathy. He was diagnosed with HAM 16 months after the transplantation. Pulse steroid therapy (1000mg) was administered over a period of 3 days, and his limb paresis improved. Presently, steroid therapy is being continued, with a plan to eventually taper the dose, and he is being carefully followed up at our institution. Our case suggests that liver transplantation involving an HTLV-1-positive living donor carries the risk of virus transmission and short-term development of HAM after transplantation.
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Affiliation(s)
- Taiga Wakabayashi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hideaki Obara
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan.
| | - Morinobu Seki
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Masahiro Shinoda
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Minoru Kitago
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hiroshi Yagi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yuta Abe
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kentaro Matsubara
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yohei Yamada
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Go Oshima
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Koichi Oki
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Narihito Nagoshi
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kota Watanabe
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Taizo Hibi
- Department of Transplantation and Pediatric Surgery, Kumamoto University, Kumamoto, Japan
| | - Osamu Itano
- Department of Hepato-Biliary-Pancreatic and Gastrointestinal Surgery, International University of Health and Welfare School of Medicine, Chiba, Japan
| | - Ken Hoshino
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Norihiro Suzuki
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Tatsuo Kuroda
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
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Roc L, de Mendoza C, Fernández-Alonso M, Reina G, Soriano V. Rapid subacute myelopathy following kidney transplantation from HTLV-1 donors: role of immunosuppresors and failure of antiretrovirals. Ther Adv Infect Dis 2019; 6:2049936119868028. [PMID: 31467675 PMCID: PMC6704407 DOI: 10.1177/2049936119868028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 07/16/2019] [Indexed: 12/28/2022] Open
Abstract
Two kidney transplant recipients from a single donor became infected with HTLV-1 (human T-lymphotropic virus type 1) in Spain. One developed myelopathy 8 months following surgery despite early prescription of antiretroviral therapy. The allograft was removed from the second recipient at month 8 due to rejection and immunosuppressors discontinued. To date, 3 years later, this patient remains infected but asymptomatic. HTLV-1 infection was recognized retrospectively in the donor, a native Spaniard who had sex partners from endemic regions. Our findings call for a reappraisal of screening policies on donor–recipient organ transplantation. Based on the high risk of disease development and the large flux of persons from HTLV-1 endemic regions, pre-transplant HTLV-1 testing should be mandatory in Spain.
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Affiliation(s)
- Lourdes Roc
- Microbiology Department, Hospital Miguel Servet, Zaragoza
| | - Carmen de Mendoza
- Puerta de Hierro Research Institute and University Hospital, Majadahonda, Madrid, Spain
| | | | - Gabriel Reina
- Microbiology Department, Clinica Universitaria, Pamplona
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de Mendoza C, Roc L, Benito R, Reina G, Ramos JM, Gómez C, Aguilera A, Rodríguez-Iglesias M, García-Costa J, Fernández-Alonso M, Soriano V. HTLV-1 infection in solid organ transplant donors and recipients in Spain. BMC Infect Dis 2019; 19:706. [PMID: 31399112 PMCID: PMC6688206 DOI: 10.1186/s12879-019-4346-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 07/31/2019] [Indexed: 11/22/2022] Open
Abstract
Background HTLV-1 infection is a neglected disease, despite infecting 10–15 million people worldwide and severe illnesses develop in 10% of carriers lifelong. Acknowledging a greater risk for developing HTLV-1 associated illnesses due to immunosuppression, screening is being widely considered in the transplantation setting. Herein, we report the experience with universal HTLV testing of donors and recipients of solid organ transplants in a survey conducted in Spain. Methods All hospitals belonging to the Spanish HTLV network were invited to participate in the study. Briefly, HTLV antibody screening was performed retrospectively in all specimens collected from solid organ donors and recipients attended since the year 2008. Results A total of 5751 individuals were tested for HTLV antibodies at 8 sites. Donors represented 2312 (42.2%), of whom 17 (0.3%) were living kidney donors. The remaining 3439 (59.8%) were recipients. Spaniards represented nearly 80%. Overall, 9 individuals (0.16%) were initially reactive for HTLV antibodies. Six were donors and 3 were recipients. Using confirmatory tests, HTLV-1 could be confirmed in only two donors, one Spaniard and another from Colombia. Both kidneys of the Spaniard were inadvertently transplanted. Subacute myelopathy developed within 1 year in one recipient. The second recipient seroconverted for HTLV-1 but the kidney had to be removed soon due to rejection. Immunosuppression was stopped and 3 years later the patient remains in dialysis but otherwise asymptomatic. Conclusion The rate of HTLV-1 is low but not negligible in donors/recipients of solid organ transplants in Spain. Universal HTLV screening should be recommended in all donor and recipients of solid organ transplantation in Spain. Evidence is overwhelming for very high virus transmission and increased risk along with the rapid development of subacute myelopathy.
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Affiliation(s)
- Carmen de Mendoza
- Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain.,Universidad CEU-San Pablo, Madrid, Spain
| | | | | | | | | | | | | | | | | | | | - Vicente Soriano
- UNIR Health Sciences School and Medical Centre, Calle Almansa 101, 28040, Madrid, Spain.
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Pruitt AA. Central Nervous System Infections Complicating Immunosuppression and Transplantation. Continuum (Minneap Minn) 2019; 24:1370-1396. [PMID: 30273244 DOI: 10.1212/con.0000000000000653] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE OF REVIEW This article reviews infections associated with cancer treatments and immunosuppressive/immunomodulatory therapies used in both neoplastic and non-neoplastic conditions, including hematopoietic cell transplantation and solid organ transplantation. It provides a clinical approach to the most commonly affected patient groups based on clinicoanatomic presentation and disease-specific risks resulting from immune deficits and drugs received. RECENT FINDINGS The clinical presentations, associated neuroimaging findings, and CSF abnormalities of patients with central nervous system infections who are immunocompromised may differ from those of patients with central nervous system infections who are immunocompetent and may be confused with noninfectious processes. Triggering of brain autoimmunity with emergence of neurotropic antibodies has emerged as a recognized parainfectious complication. New unbiased metagenomic assays to identify obscure pathogens help clinicians navigate the increasing range of conditions affecting the growing population of patients with altered immunity. SUMMARY Despite evidence-based prophylactic regimens and organism-specific antimicrobials, central nervous system infections continue to cause significant morbidity and mortality in an increasing range of patients who are immunocompromised by their conditions and therapies. Multiple new drugs put patients at risk for progressive multifocal leukoencephalopathy, which has numerous imaging and clinical manifestations; patients at risk include those with multiple sclerosis, for whom infection risk is becoming one of the most important factors in therapeutic decision making. Efficient, early diagnosis is essential to improve outcomes in these often-devastating diseases.
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Abstract
Donor-derived infections are defined as any infection present in the donor that is transmitted to 1 or more recipients. Donor-derived infections can be categorized into 2 groups: "expected" and "unexpected" infections. Expected transmissions occur when the donor is known to have an infection, such as positive serology for cytomegalovirus, Epstein Barr virus, or hepatitis B core antibody, at the time of donation. Unexpected transmissions occur when a donor has no known infection before donation, but 1 or more transplant recipients develop an infection derived from the common donor. Unexpected infections are estimated to occur in far less than 1% of solid organ transplant recipients. We will review the epidemiology, risk factors, and approaches to prevention and management of donor-derived viral infectious disease transmission in liver transplantation.
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White SL, Rawlinson W, Boan P, Sheppeard V, Wong G, Waller K, Opdam H, Kaldor J, Fink M, Verran D, Webster A, Wyburn K, Grayson L, Glanville A, Cross N, Irish A, Coates T, Griffin A, Snell G, Alexander SI, Campbell S, Chadban S, Macdonald P, Manley P, Mehakovic E, Ramachandran V, Mitchell A, Ison M. Infectious Disease Transmission in Solid Organ Transplantation: Donor Evaluation, Recipient Risk, and Outcomes of Transmission. Transplant Direct 2019; 5:e416. [PMID: 30656214 PMCID: PMC6324914 DOI: 10.1097/txd.0000000000000852] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 08/15/2018] [Indexed: 12/11/2022] Open
Abstract
In 2016, the Transplantation Society of Australia and New Zealand, with the support of the Australian Government Organ and Tissue authority, commissioned a literature review on the topic of infectious disease transmission from deceased donors to recipients of solid organ transplants. The purpose of this review was to synthesize evidence on transmission risks, diagnostic test characteristics, and recipient management to inform best-practice clinical guidelines. The final review, presented as a special supplement in Transplantation Direct, collates case reports of transmission events and other peer-reviewed literature, and summarizes current (as of June 2017) international guidelines on donor screening and recipient management. Of particular interest at the time of writing was how to maximize utilization of donors at increased risk for transmission of human immunodeficiency virus, hepatitis C virus, and hepatitis B virus, given the recent developments, including the availability of direct-acting antivirals for hepatitis C virus and improvements in donor screening technologies. The review also covers emerging risks associated with recent epidemics (eg, Zika virus) and the risk of transmission of nonendemic pathogens related to donor travel history or country of origin. Lastly, the implications for recipient consent of expanded utilization of donors at increased risk of blood-borne viral disease transmission are considered.
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Affiliation(s)
- Sarah L White
- Central Clinical School, Sydney Medical School, The University of Sydney, Sydney, Australia
| | - William Rawlinson
- Serology and Virology Division, NSW Health Pathology Prince of Wales Hospital, Sydney, Australia
- Women's and Children's Health and Biotechnology and Biomolecular Sciences, University of New South Wales Schools of Medicine, Sydney, Australia
| | - Peter Boan
- Departments of Infectious Diseases and Microbiology, Fiona Stanley Hospital, Perth, Australia
- PathWest Laboratory Medicine, Perth, Australia
| | - Vicky Sheppeard
- Communicable Diseases Network Australia, New South Wales Health, Sydney, Australia
| | - Germaine Wong
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Karen Waller
- Central Clinical School, Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Helen Opdam
- Austin Health, Melbourne, Australia
- The Organ and Tissue Authority, Australian Government, Canberra, Australia
| | - John Kaldor
- Kirby Institute, University of New South Wales, Sydney, Australia
| | - Michael Fink
- Austin Health, Melbourne, Australia
- Department of Surgery, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
| | - Deborah Verran
- Transplantation Services, Royal Prince Alfred Hospital, Sydney, Australia
| | - Angela Webster
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, Australia
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Kate Wyburn
- Central Clinical School, Sydney Medical School, The University of Sydney, Sydney, Australia
- Renal Medicine, Royal Prince Alfred Hospital, Sydney, Australia
| | - Lindsay Grayson
- Austin Health, Melbourne, Australia
- Department of Surgery, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
| | - Allan Glanville
- Department of Thoracic Medicine and Lung Transplantation, St Vincent's Hospital, Sydney, Australia
| | - Nick Cross
- Department of Nephrology, Canterbury District Health Board, Christchurch Hospital, Christchurch, New Zealand
| | - Ashley Irish
- Department of Nephrology, Fiona Stanley Hospital, Perth, Australia
- Faculty of Health and Medical Sciences, UWA Medical School, The University of Western Australia, Crawley, Australia
| | - Toby Coates
- Renal and Transplantation, Royal Adelaide Hospital, Adelaide, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | - Anthony Griffin
- Renal Transplantation, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Greg Snell
- Lung Transplant, Alfred Health, Melbourne, Victoria, Australia
| | - Stephen I Alexander
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
| | - Scott Campbell
- Department of Renal Medicine, University of Queensland at Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Steven Chadban
- Central Clinical School, Sydney Medical School, The University of Sydney, Sydney, Australia
- Renal Medicine, Royal Prince Alfred Hospital, Sydney, Australia
| | - Peter Macdonald
- Department of Cardiology, St Vincent's Hospital, Sydney, Australia
- St Vincent's Hospital Victor Chang Cardiac Research Institute, University of New South Wales, Sydney, Australia
| | - Paul Manley
- Kidney Disorders, Auckland District Health Board, Auckland City Hospital, Auckland, New Zealand
| | - Eva Mehakovic
- The Organ and Tissue Authority, Australian Government, Canberra, Australia
| | - Vidya Ramachandran
- Serology and Virology Division, NSW Health Pathology Prince of Wales Hospital, Sydney, Australia
| | - Alicia Mitchell
- Department of Thoracic Medicine and Lung Transplantation, St Vincent's Hospital, Sydney, Australia
- Woolcock Institute of Medical Research, Sydney, Australia
- School of Medical and Molecular Biosciences, University of Technology, Sydney, Australia
| | - Michael Ison
- Divisions of Infectious Diseases and Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL
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Kawano N, Yoshida S, Kawano S, Kuriyama T, Tahara Y, Toyofuku A, Manabe T, Doi A, Terasaka S, Yamashita K, Ueda Y, Ochiai H, Marutsuka K, Yamano Y, Shimoda K, Kikuchi I. The clinical impact of human T-lymphotrophic virus type 1 (HTLV-1) infection on the development of adult T-cell leukemia-lymphoma (ATL) or HTLV-1-associated myelopathy (HAM) / atypical HAM after allogeneic hematopoietic stem cell transplantation (allo-HSCT) and renal transplantation. J Clin Exp Hematop 2018; 58:107-121. [PMID: 30089749 PMCID: PMC6408177 DOI: 10.3960/jslrt.18011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Because there are limited clinical reports on the impact of human T-lymphotropic virus
type 1 (HTLV-1) on organ transplantation, its effects on the development of adult T-cell
leukemia-lymphoma (ATL), post-transplantation lymphoproliferative disorder (PTLD) and
HTLV-1–associated myelopathy (HAM) or atypical HAM after organ transplantation remain
unclear. We retrospectively analyzed the impact of HTLV-1 in 54 allogeneic hematopoietic stem cell
transplantation (allo-HSCT) cases and 31 renal transplantation cases between January 2006
and December 2016. Among the 54 allo-HSCT cases, nine recipients with ATL tested positive for HTLV-1, and
one was found to be an HTLV-1 carrier. All donors tested negative for HTLV-1. Only one
HTLV-1 carrier did not present with ATL or HAM development after allo-HSCT. Among nine ATL
cases after allo-HSCT, four eventually relapsed due to proliferation of recipient-derived
ATL cells. However, in one ATL case, atypical HAM developed rapidly at 5 months after
allo-HSCT. Among the 31 renal transplantation cases, all donors tested negative for HTLV-1, and only
recipients tested positive. Only one HTLV-1 carrier recipient did not present with ATL or
HAM development after renal transplantation. However, one HTLV-1-negative recipient
developed PTLD in the brain 10 years after renal transplantation. In clinical practice, careful follow-up of HTLV-1 infected recipients after organ
transplantation is important because atypical HAM can develop in ATL patients after
allo-HSCT. Furthermore, to clarify the risk of ATL or HAM development in HTLV-1 infected
recipients, we prospectively followed up our cohort.
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Takajo I, Umekita K, Ikei Y, Oshima K, Okayama A. Adult T-cell Leukemia/Lymphoma as a Methotrexate-associated Lymphoproliferative Disorder in a Patient with Rheumatoid Arthritis. Intern Med 2018; 57:2071-2075. [PMID: 29491299 PMCID: PMC6096007 DOI: 10.2169/internalmedicine.0308-17] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
The patient was a 74-year-old Japanese woman with rheumatoid arthritis (RA) who developed generalized lymphadenopathy with elevated levels of lactase dehydrogenase (LD), and soluble IL-2 receptor (sIL-2R). She was found to be positive for anti-human T-cell leukemia virus type 1 (HTLV-1) antibodies. Her symptoms and laboratory abnormalities spontaneously regressed after the cessation of methotrexate (MTX), suggesting that she had an MTX-associated lymphoproliferative disorder; however, her lymphadenopathy appeared again approximately 14 months later with LD and sIL-2R elevation. A histopathological analysis and Southern blotting of a lymph node biopsy specimen for HTLV-1 provirus supported the diagnosis of adult T-cell leukemia/lymphoma (ATL) (lymphoma type). These data confirmed that an HTLV-1 positive RA patient may develop ATL.
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Affiliation(s)
- Ichiro Takajo
- Department of Rheumatology, Infectious Diseases and Laboratory Medicine, Internal Medicine, Faculty of Medicine, University of Miyazaki, Japan
- Youkikai Ikei Hospital, Japan
| | - Kunihiko Umekita
- Department of Rheumatology, Infectious Diseases and Laboratory Medicine, Internal Medicine, Faculty of Medicine, University of Miyazaki, Japan
| | | | | | - Akihiko Okayama
- Department of Rheumatology, Infectious Diseases and Laboratory Medicine, Internal Medicine, Faculty of Medicine, University of Miyazaki, Japan
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Abstract
: Human T-lymphotropic virus type 1 (HTLV-1) infection is a neglected disease despite roughly 15 million people are chronically infected worldwide. Lifelong less than 10% of carriers develop life-threatening diseases, mostly a subacute myelopathy known as tropical spastic paraparesis (TSP) and a lymphoproliferative disorder named adult T-cell leukemia (ATL). HTLV-1 is efficiently transmitted perinatally (breastfeeding), sexually (more from men to women) and parenterally (transfusions, injection drug user (IDU), and transplants). To date there is neither prophylactic vaccine nor effective antiviral therapy. A total of 327 cases of HTLV-1 infection had been reported at the HTLV-1 Spanish registry until December 2016, of whom 34 had been diagnosed with TSP and 25 with ATL. Overall 62% were Latin American immigrants and 13% were persons of African origin. The incidence of HTLV-1 in Spain has remained stable for nearly a decade with 20-25 new cases yearly. Of the 21 newly diagnosed HTLV-1 cases during year 2016, one was a native Spaniard pregnant woman, and four presented with symptomatic disease, including three with ATL and one with TSP. Underdiagnosis of HTLV-1 in Spain must be high (iceberg model), which may account for the disproportionate high rate of symptomatic cases (almost 20%) and the late recognition of preventable HTLV-1 transmissions in special populations, such as newborns and transplant recipients. Our current estimate is of 10 000 persons living with HTLV-1 infection in Spain. Given the large flux of immigrants and visitors from HTLV-1 endemic regions to Spain, the expansion of HTLV-1 screening policies is warranted. At this time, it seems worth recommending HTLV testing to all donor/recipient organ transplants and pregnant women regardless place of birth. Although current leukoreduction procedures largely prevent HTLV-1 transmission by blood transfusions, HTLV testing of all first-time donors should be cost-effective contributing to unveil asymptomatic unaware HTLV-1 carriers.
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Yoshizumi T, Takada Y, Shirabe K, Kaido T, Hidaka M, Honda M, Ito T, Shinoda M, Ohdan H, Kawagishi N, Sugawara Y, Ogura Y, Kasahara M, Kubo S, Taketomi A, Yamashita N, Uemoto S, Yamaue H, Miyazaki M, Takada T, Maehara Y. Impact of human T-cell leukemia virus type 1 on living donor liver transplantation: a multi-center study in Japan. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 23:333-41. [DOI: 10.1002/jhbp.345] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 03/17/2016] [Indexed: 12/25/2022]
Affiliation(s)
- Tomoharu Yoshizumi
- Department of Surgery and Science; Graduate School of Medical Sciences, Kyushu University; Fukuoka Japan
| | - Yasutsugu Takada
- The Study Group of the Japanese Society of Hepato-biliary-Pancreatic Surgery and Japanese Liver Transplantation Society; Tokyo Japan
| | - Ken Shirabe
- The Study Group of the Japanese Society of Hepato-biliary-Pancreatic Surgery and Japanese Liver Transplantation Society; Tokyo Japan
| | - Toshimi Kaido
- The Study Group of the Japanese Society of Hepato-biliary-Pancreatic Surgery and Japanese Liver Transplantation Society; Tokyo Japan
| | - Masaaki Hidaka
- The Study Group of the Japanese Society of Hepato-biliary-Pancreatic Surgery and Japanese Liver Transplantation Society; Tokyo Japan
| | - Masaki Honda
- The Study Group of the Japanese Society of Hepato-biliary-Pancreatic Surgery and Japanese Liver Transplantation Society; Tokyo Japan
| | - Takashi Ito
- The Study Group of the Japanese Society of Hepato-biliary-Pancreatic Surgery and Japanese Liver Transplantation Society; Tokyo Japan
| | - Masahiro Shinoda
- The Study Group of the Japanese Society of Hepato-biliary-Pancreatic Surgery and Japanese Liver Transplantation Society; Tokyo Japan
| | - Hideki Ohdan
- The Study Group of the Japanese Society of Hepato-biliary-Pancreatic Surgery and Japanese Liver Transplantation Society; Tokyo Japan
| | - Naoki Kawagishi
- The Study Group of the Japanese Society of Hepato-biliary-Pancreatic Surgery and Japanese Liver Transplantation Society; Tokyo Japan
| | - Yasuhiko Sugawara
- The Study Group of the Japanese Society of Hepato-biliary-Pancreatic Surgery and Japanese Liver Transplantation Society; Tokyo Japan
| | - Yasuhiro Ogura
- The Study Group of the Japanese Society of Hepato-biliary-Pancreatic Surgery and Japanese Liver Transplantation Society; Tokyo Japan
| | - Mureo Kasahara
- The Study Group of the Japanese Society of Hepato-biliary-Pancreatic Surgery and Japanese Liver Transplantation Society; Tokyo Japan
| | - Shoji Kubo
- The Study Group of the Japanese Society of Hepato-biliary-Pancreatic Surgery and Japanese Liver Transplantation Society; Tokyo Japan
| | - Akinobu Taketomi
- The Study Group of the Japanese Society of Hepato-biliary-Pancreatic Surgery and Japanese Liver Transplantation Society; Tokyo Japan
| | | | - Shinji Uemoto
- The Study Group of the Japanese Society of Hepato-biliary-Pancreatic Surgery and Japanese Liver Transplantation Society; Tokyo Japan
| | - Hiroki Yamaue
- The Study Group of the Japanese Society of Hepato-biliary-Pancreatic Surgery and Japanese Liver Transplantation Society; Tokyo Japan
| | - Masaru Miyazaki
- The Study Group of the Japanese Society of Hepato-biliary-Pancreatic Surgery and Japanese Liver Transplantation Society; Tokyo Japan
| | - Tadahiro Takada
- The Study Group of the Japanese Society of Hepato-biliary-Pancreatic Surgery and Japanese Liver Transplantation Society; Tokyo Japan
| | - Yoshihiko Maehara
- Department of Surgery and Science; Graduate School of Medical Sciences, Kyushu University; Fukuoka Japan
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Gövert F, Krumbholz A, Witt K, Hopfner F, Feldkamp T, Korn K, Knöll A, Jansen O, Deuschl G, Fickenscher H. HTLV-1 associated myelopathy after renal transplantation. J Clin Virol 2015; 72:102-5. [DOI: 10.1016/j.jcv.2015.09.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 08/25/2015] [Accepted: 09/25/2015] [Indexed: 11/16/2022]
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Ramanan P, Deziel PJ, Norby SM, Yao JD, Garza I, Razonable RR. Donor-transmitted HTLV-1-associated myelopathy in a kidney transplant recipient--case report and literature review. Am J Transplant 2014; 14:2417-21. [PMID: 25138148 DOI: 10.1111/ajt.12849] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 05/20/2014] [Accepted: 05/20/2014] [Indexed: 01/25/2023]
Abstract
Clinical disease due to human T cell lymphotropic virus type 1 (HTLV-1), a retrovirus endemic in certain regions of the world, is rarely reported after solid organ transplantation. In 2009, universal deceased donor organ screening for HTLV-1 was discontinued in the United States. We report the first case of donor-derived HTLV-1-associated myelopathy in a kidney transplant recipient from the United States. The patient, who was HTLV-1-seronegative prior to transplantation, likely acquired HTLV-1 infection from a seropositive organ donor. In this era when screening of donors and recipients for HTLV infection is not mandatory, clinicians should be vigilant in recognizing the risk and potential occurrence of this donor-derived infection in recipients with epidemiologic exposures.
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Affiliation(s)
- P Ramanan
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN; William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
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15
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Pruitt AA, Graus F, Rosenfeld MR. Neurological complications of solid organ transplantation. Neurohospitalist 2013; 3:152-66. [PMID: 24167649 DOI: 10.1177/1941874412466090] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Solid organ transplantation (SOT) is the preferred treatment for an expanding range of conditions whose successful therapy has produced a growing population of chronically immunosuppressed patients with potential neurological problems. While the spectrum of neurological complications varies with the type of organ transplanted, the indication for the procedure, and the intensity of long-term required immunosuppression, major neurological complications occur with all SOT types. The second part of this 2-part article on transplantation neurology reviews central and peripheral nervous system problems associated with SOT with clinical and neuroimaging examples from the authors' institutional experience. Particular emphasis is given to conditions acquired from the donated organ or tissue, problems specific to types of organs transplanted and drug therapy-related complications likely to be encountered by hospitalists. Neurologically important syndromes such as immune reconstitution inflammatory syndrome (IRIS), posterior reversible encephalopathy syndrome (PRES), and posttransplantation lymphoproliferative disorder (PTLD) are readdressed in the context of SOT.
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Affiliation(s)
- Amy A Pruitt
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
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16
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Waggoner JJ, Soda EA, Deresinski S. Rare and emerging viral infections in transplant recipients. Clin Infect Dis 2013; 57:1182-8. [PMID: 23839998 PMCID: PMC7107977 DOI: 10.1093/cid/cit456] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Emerging viral pathogens include newly discovered viruses as well as previously known viruses that are either increasing, or threatening to increase in incidence. While often first identified in the general population, they may affect transplant recipients, in whom their manifestations may be atypical or more severe. Enhanced molecular methods have increased the rate of viral discovery but have not overcome the problem of demonstrating pathogenicity. At the same time, improved clinical diagnostic methods have increased the detection of reemerging viruses in immunocompromised patients. In this review, we first discuss viral diagnostics and the developing field of viral discovery and then focus on rare and emerging viruses in the transplant population: human T-cell leukemia virus type 1; hepatitis E virus; bocavirus; KI and WU polyomaviruses; coronaviruses HKU1 and NL63; influenza, H1N1; measles; dengue; rabies; and lymphocytic choriomeningitis virus. Detection and reporting of such rare pathogens in transplant recipients is critical to patient care and improving our understanding of posttransplant infections.
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Affiliation(s)
- Jesse J Waggoner
- Division of Infectious Diseases and Geographic Medicine, Stanford University Department of Medicine, Stanford, California
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17
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HTLV-1 in solid-organ transplantation: current challenges and future management strategies. Transplantation 2013; 94:1075-84. [PMID: 23060278 DOI: 10.1097/tp.0b013e318263ad7a] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Human T-cell lymphotrophic virus (HTLV)-1 has been reported after solid-organ transplantation, with a related fatal outcome in less than five cases. The natural history of HTLV-1 transmission from donor to recipient is unknown in this setting, because available screening platforms are suboptimal in low-prevalence areas and there is a lack of long-term follow-up. Minimizing organ wastage due to false-positive screening and avoiding donor-derived HTLV-associated diseases remain the goal. To date, only six HTLV-naive organ recipients from four donors (only one had confirmed HTLV) have developed HTLV-associated disease after transplantation. All of these cases were described in countries or from donors from HTLV-endemic regions. To the best of our knowledge, there have been no reported cases of donor-derived HTLV-1-associated death after organ transplantation in the world. Based on data from low-prevalence countries (Europe and the United States) and the current shortage of donor organs, it appears plausible to authorize the decision to transplant an organ without the prior knowledge of the donor's HTLV-1 status. Currently, it is not possible to exclude such transmission and recipients should be informed of the possible inadvertent transmission of this (and other) infections at the time of consent. In those cases where HTLV-1 transmission does occur, there may be a therapeutic window in which use of antiviral agents (i.e., zidovudine and raltegravir) may be of benefit. The development of national/international registries should allow a greater understanding of the extent and consequences of transmission risk and so allow a more evidence-based approach to management.
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In the Literature. Clin Infect Dis 2012. [DOI: 10.1093/cid/cis619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Yoshizumi T, Shirabe K, Ikegami T, Kayashima H, Yamashita N, Morita K, Masuda T, Hashimoto N, Taketomi A, Soejima Y, Maehara Y. Impact of human T cell leukemia virus type 1 in living donor liver transplantation. Am J Transplant 2012; 12:1479-85. [PMID: 22486853 DOI: 10.1111/j.1600-6143.2012.04037.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Human T cell leukemia virus type 1 (HTLV-1) is an endemic retrovirus in southwestern Japan, which causes adult T cell leukemia (ATL) or HTLV-1 associated myelopathy in a minority of carriers. Here, we investigated the impact of HTLV-1 status in living donor liver transplantation (LDLT). Twenty-six of 329 (7.9%) HTLV-1 carriers underwent primary LDLT. One recipient negative for HTLV-1 before LDLT received a graft from an HTLV-1 positive donor. Eight donors were HTLV-1 positive. Twenty-seven recipients (13 male and 14 female; mean age 52.5 years) were reviewed retrospectively. ATL developed in four recipients who ultimately died. The intervals between LDLT and ATL development ranged from 181 to 1315 days. Of the four ATL recipients, two received grafts from HTLV-1 positive donors and two from negative donors. The 1-, 3- and 5-year HTLV-1 carrier survival rates were 91.3%, 78.3% and 66.3%, respectively. Fulminant hepatic failure as a pretransplant diagnosis and a pretransplant MELD score ≥ 15 was identified as risk factors for ATL development in this study (p = 0.001 and p = 0.041, respectively). In conclusion, LDLT can be performed for HTLV-1 positive recipients. However, when fulminant hepatic failure is diagnosed, LDLT should not be performed until further studies have revealed the mechanisms of ATL development.
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Affiliation(s)
- T Yoshizumi
- Department of Surgery and Multidisciplinary Treatment, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
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Ichikawa T, Taura N, Miyaaki H, Matsuzaki T, Ohtani M, Eguchi S, Takatsuki M, Soyama A, Hidaka M, Okudaira S, Usui T, Mori S, Kamihira S, Kanematsu T, Nakao K. Human T-cell leukemia virus type 1 infection worsens prognosis of hepatitis C virus-related living donor liver transplantation. Transpl Int 2012; 25:433-8. [PMID: 22417010 DOI: 10.1111/j.1432-2277.2012.01434.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Severe and life-threatening donor-transmitted human T-cell leukemia virus type 1 (HTLV-1) infections after solid organ transplantation have been reported. However, in HTLV-1-infected recipients, graft and patient survival were not fully evaluated. A total of 140 patients underwent living donor liver transplantation (LDLT). Of these, 47 of 126 adult recipients showed indications of hepatitis C virus (HCV)-related liver disease. The HTLV-1 prevalence rate was 10 of 140 recipients (7.14%) and three of 140 donors (0.02%). In HCV-related LDLT, graft and patient survival was worsened by HTLV-1 infection in recipients (seven cases). The 1-, 3-, and 5-year survival rates in the HCV/HTLV-1-co-infected group were 67%, 32%, and 15%, respectively, and the corresponding rates in the HCV-mono-infected group were 80%, 67%, and 67%, respectively. Only the 5-year survival rates were statistically significant (P=0.04, log-rank method). HTLV-1 infection in recipients is also an important factor in predicting survival in HTLV-1 endemic areas.
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Affiliation(s)
- Tatsuki Ichikawa
- Department of Gastroenterology and Hepatology, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan.
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Nakamura H, Ichikawa T, Nakamura T, Kawakami A, Iwamoto N, Matsuzaki T, Miyaaki H, Yamasaki S, Ida H, Eguchi S, Hayashi T, Nakao K, Kanematsu T, Eguchi K. Macrophage-Dominant Sialadenitis in Human T-Cell Leukemia Virus Type I–Associated Myelopathy After Living-Donor Liver Transplantation. Transplant Proc 2010; 42:2797-9. [DOI: 10.1016/j.transproceed.2010.04.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2009] [Revised: 12/24/2009] [Accepted: 04/08/2010] [Indexed: 01/12/2023]
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Campdelacreu J, Capurro S, Pumarola T. Varón de 52 años con inestabilidad de la marcha. Med Clin (Barc) 2010; 134:260-7. [DOI: 10.1016/j.medcli.2009.05.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2009] [Accepted: 05/15/2009] [Indexed: 10/20/2022]
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Dynamic interaction between STLV-1 proviral load and T-cell response during chronic infection and after immunosuppression in non-human primates. PLoS One 2009; 4:e6050. [PMID: 19557183 PMCID: PMC2698465 DOI: 10.1371/journal.pone.0006050] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2009] [Accepted: 05/25/2009] [Indexed: 11/25/2022] Open
Abstract
We used mandrills (Mandrillus sphinx) naturally infected with simian T-cell leukemia virus type 1 (STLV-1) as a model for evaluating the influence of natural STLV-1 infection on the dynamics and evolution of the immune system during chronic infection. Furthermore, in order to evaluate the role of the immune system in controlling the infection during latency, we induced immunosuppression in the infected monkeys. We first showed that the STLV-1 proviral load was higher in males than in females and increased significantly with the duration of infection: mandrills infected for 10–6 years had a significantly higher proviral load than those infected for 2–4 years. Curiously, this observation was associated with a clear reduction in CD4+ T-cell number with age. We also found that the percentage of CD4+ T cells co-expressing the activation marker HLA-DR and the mean percentage of CD25+ in CD4+ and CD8+ T cells were significantly higher in infected than in uninfected animals. Furthermore, the STLV-1 proviral load correlated positively with T-cell activation but not with the frequency of T cells secreting interferon γ in response to Tax peptides. Lastly, we showed that, during immunosuppression in infected monkeys, the percentages of CD8+ T cells expressing HLA-DR+ and of CD4+ T cells expressing the proliferation marker Ki67 decreased significantly, although the percentage of CD8+ T cells expressing HLA-DR+ and Ki67 increased significantly by the end of treatment. Interestingly, the proviral load increased significantly after immunosuppression in the monkey with the highest load. Our study demonstrates that mandrills naturally infected with STLV-1 could be a suitable model for studying the relations between host and virus. Further studies are needed to determine whether the different compartments of the immune response during infection induce the long latency by controlling viral replication over time. Such studies would provide important information for the development of immune-based therapeutic strategies.
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Increasing utilization of human T-cell lymphotropic virus (+) donors in liver transplantation: is it safe? Transplantation 2009; 87:1180-90. [PMID: 19384165 DOI: 10.1097/tp.0b013e31819ebf76] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Liver transplantation is the best treatment option for endstage liver disease. The human T-cell lymphotrophic virus (HTLV) has been associated with leukemia/lymphoma and progressive neurologic disease. There has, however, been an increased utilization of HTLV (+) grafts with little data available to support or discourage their use. METHODS We performed univariate and multivariate analyses related to graft and patient survival for recipients of HTLV (+) donors and compared them with recipients of HTLV (-) donors using the United Network for Organ Sharing database. Complete analysis of recipient and donor clinical and demographic factors was performed. RESULTS There were 81 adult recipients of HTLV (+) donors and 29,747 HTLV (-) donor recipients. HTLV (+) donors were more likely to be older, women, and black, with a higher average donor risk index and creatinine, and were more likely to be shared nationally. Recipients of HTLV (+) organs were at slightly elevated risk of graft failure (HR=1.39, 95% CI 0.91-2.11) and death (HR=1.20, CI 0.71-2.02) relative to HTLV (-) donor recipients (P=0.12 and 0.5, respectively). The risk decreased after multivariate analysis - graft survival (HR=1.20, CI 0.79-1.83) and patient survival (HR=1.06, CI 0.63-1.79). CONCLUSION Our analysis reveals no statistically significant difference in graft or patient survival between recipients of HTLV (+) and (-) donors. Serious limitations of these data are that serologic testing for HTLV has a high false positive rate and that there was a short follow-up period. Until these issues are addressed, extreme caution should be exercised when using these organs.
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Current world literature. Curr Opin Organ Transplant 2009; 14:211-7. [PMID: 19307967 DOI: 10.1097/mot.0b013e32832ad721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Pluripotent stem cells as new drugs? The example of Parkinson's disease. Int J Pharm 2009; 381:113-21. [PMID: 19782880 DOI: 10.1016/j.ijpharm.2009.03.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2008] [Revised: 02/27/2009] [Accepted: 03/08/2009] [Indexed: 12/31/2022]
Abstract
Cell replacement therapy is a widely discussed novel concept of medical treatment. The increased knowledge in the stem cell field, particularly pluripotent stem cells, potentially provides powerful tools for this therapeutic concept. A large number of disease characterized by the loss of functional cells are potential candidates for cell replacement therapy and, in this regards, Parkinson's disease is of particular interest. It is one of the most prevalent neurodegenerative diseases caused by the loss of dopaminergic neurons in the Substantia nigra pars compacta. Pharmacological therapies are valuable but suffer from the progressive decline of efficacy as the disease progresses. Cell therapy application has emerged about two decades ago as a valid therapeutic alternative and recent advances in stem cell research suggest that pluripotent stem cell transplantation may be a promising approach to replace degenerated neurons in Parkinson's disease. Various sources of pluripotent stem cells (PSC) currently tested in animal models of Parkinson's disease have proven their efficacy in relieving symptoms and restoring damaged brain function. This review summarizes and discusses the important challenges that actually must be solved before the first studies of PSC transplantation can be undertaken into humans.
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