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Morado-Aramburo O, Hasbun R. Solid organ transplant-related central nervous system infections. Curr Opin Infect Dis 2024; 37:192-200. [PMID: 38602163 DOI: 10.1097/qco.0000000000001016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
PURPOSE OF REVIEW Central nervous system (CNS) infections in solid organ transplant (SOT) recipients may present atypical or nonspecific symptoms. Due to a wider range of infectious agents compared with immunocompetent hosts, diagnosis is challenging. This review categorizes CNS infections in SOT recipients by cause. RECENT FINDINGS New studies have reported new data on the epidemiology and the risk factors associated with each specific pathogen described in this review. Additionally, we included the treatment recommendations. SUMMARY The latest findings give us an insight into the different pathogens causing infectious neurologic complications in SOT recipients.
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Affiliation(s)
- Oscar Morado-Aramburo
- Division of Infectious Diseases, Department of Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, USA
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2
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Schulze Lammers FC, Bonifacius A, Tischer-Zimmermann S, Goudeva L, Martens J, Lepenies B, von Karpowitz M, Einecke G, Beutel G, Skripuletz T, Blasczyk R, Beier R, Maecker-Kolhoff B, Eiz-Vesper B. Antiviral T-Cell Frequencies in a Healthy Population: Reference Values for Evaluating Antiviral Immune Cell Profiles in Immunocompromised Patients. J Clin Immunol 2022; 42:546-558. [PMID: 34989946 PMCID: PMC9015970 DOI: 10.1007/s10875-021-01205-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/23/2021] [Indexed: 11/30/2022]
Abstract
Viral infections and reactivations are major causes of morbidity and mortality after hematopoietic stem cell (HSCT) and solid organ transplantation (SOT) as well as in patients with immunodeficiencies. Latent herpesviruses (e.g., cytomegalovirus, Epstein-Barr virus, and human herpesvirus 6), lytic viruses (e.g., adenovirus), and polyomaviruses (e.g., BK virus, JC virus) can cause severe complications. Antiviral drugs form the mainstay of treatment for viral infections and reactivations after transplantation, but they have side effects and cannot achieve complete viral clearance without prior reconstitution of functional antiviral T-cell immunity. The aim of this study was to establish normal ranges for virus-specific T-cell (VST) frequencies in healthy donors. Such data are needed for better interpretation of VST frequencies observed in immunocompromised patients. Therefore, we measured the frequencies of VSTs against 23 viral protein-derived peptide pools from 11 clinically relevant human viruses in blood from healthy donors (n = 151). Specifically, we determined the VST frequencies by interferon-gamma enzyme-linked immunospot assay and classified their distribution according to age and gender to allow for a more specific evaluation and prediction of antiviral immune responses. The reference values established here provide an invaluable tool for immune response evaluation, intensity of therapeutic drugs and treatment decision-making in immunosuppressed patients. This data should make an important contribution to improving the assessment of immune responses in immunocompromised patients.
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Affiliation(s)
- Friederike C Schulze Lammers
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, DE, Germany
| | - Agnes Bonifacius
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, DE, Germany
| | - Sabine Tischer-Zimmermann
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, DE, Germany
| | - Lilia Goudeva
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, DE, Germany
| | - Jörg Martens
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, DE, Germany
| | - Bernd Lepenies
- Institute for Immunology & Research Center for Emerging Infections and Zoonoses, University of Veterinary Medicine Hannover, Hannover, DE, Germany
| | | | - Gunilla Einecke
- Department of Nephrology, Hannover Medical School, Hannover, DE, Germany
| | - Gernot Beutel
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, DE, Germany
| | - Thomas Skripuletz
- Department of Neurology, Hannover Medical School, Hannover, DE, Germany
| | - Rainer Blasczyk
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, DE, Germany
| | - Rita Beier
- Department of Pediatric Hematology and Oncology, Hannover Medical School, Hannover, DE, Germany
| | - Britta Maecker-Kolhoff
- Department of Pediatric Hematology and Oncology, Hannover Medical School, Hannover, DE, Germany
| | - Britta Eiz-Vesper
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, DE, Germany.
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3
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Vazirani J, Crowhurst T, Morrissey CO, Snell GI. Management of Multidrug Resistant Infections in Lung Transplant Recipients with Cystic Fibrosis. Infect Drug Resist 2021; 14:5293-5301. [PMID: 34916813 PMCID: PMC8670859 DOI: 10.2147/idr.s301153] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 11/26/2021] [Indexed: 12/12/2022] Open
Abstract
Cystic fibrosis (CF) is an inherited multisystem disease characterised by bronchiectasis and chronic respiratory infections which eventually cause end stage lung disease. Lung transplantation (LTx) is a well-established treatment option for patients with CF-associated lung disease, improving survival and quality of life. Navigating recurrent infections in the setting of LTx is often difficult, where immune suppression must be balanced against the constant threat of infection. Sepsis/infections are one of the major contributors to post-LTx mortality and multiresistant organisms (eg, Burkholderia cepacia complex, Mycobacterium abscessus complex, Scedosporium spp. and Lomentospora spp.) pose a significant threat to survival. This review will summarize current and novel therapies to assist with the management of multiresistant bacterial, mycobacterial, viral and fungal infections which threaten the CF LTx cohort.
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Affiliation(s)
- Jaideep Vazirani
- Lung Transplant Service, Department of Respiratory Medicine, The Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - Thomas Crowhurst
- Lung Transplant Service, Department of Respiratory Medicine, The Alfred Hospital and Monash University, Melbourne, VIC, Australia.,Department of Medicine, The University of Adelaide, Adelaide, SA, Australia
| | - C Orla Morrissey
- Department of Infectious Diseases, The Alfred Hospital and Monash University, Melbourne, Vic, Australia
| | - Gregory I Snell
- Lung Transplant Service, Department of Respiratory Medicine, The Alfred Hospital and Monash University, Melbourne, VIC, Australia
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4
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Prezioso C, Grimaldi A, Landi D, Nicoletti CG, Brazzini G, Piacentini F, Passerini S, Limongi D, Ciotti M, Palamara AT, Marfia GA, Pietropaolo V. Risk Assessment of Progressive Multifocal Leukoencephalopathy in Multiple Sclerosis Patients during 1 Year of Ocrelizumab Treatment. Viruses 2021; 13:v13091684. [PMID: 34578264 PMCID: PMC8473394 DOI: 10.3390/v13091684] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 08/20/2021] [Accepted: 08/23/2021] [Indexed: 11/22/2022] Open
Abstract
Background: Progressive multifocal leukoencephalopathy (PML) caused by the JC virus is the main limitation to the use of disease modifying therapies for treatment of multiple sclerosis (MS). Methods: To assess the PML risk in course of ocrelizumab, urine and blood samples were collected from 42 MS patients at baseline (T0), at 6 (T2) and 12 months (T4) from the beginning of therapy. After JCPyV-DNA extraction, a quantitative-PCR (Q-PCR) was performed. Moreover, assessment of JCV-serostatus was obtained and arrangements’ analysis of non-coding control region (NCCR) and of viral capsid protein 1 (VP1) was carried out. Results: Q-PCR revealed JCPyV-DNA in urine at all selected time points, while JCPyV-DNA was detected in plasma at T4. From T0 to T4, JC viral load in urine was detected, increased in two logarithms and, significantly higher, compared to viremia. NCCR from urine was archetypal. Plasmatic NCCR displayed deletion, duplication, and point mutations. VP1 showed the S269F substitution involving the receptor-binding region. Anti-JCV index and IgM titer were found to statistically decrease during ocrelizumab treatment. Conclusions: Ocrelizumab in JCPyV-DNA positive patients is safe and did not determine PML cases. Combined monitoring of ocrelizumab’s effects on JCPyV pathogenicity and on host immunity might offer a complete insight towards predicting PML risk.
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Affiliation(s)
- Carla Prezioso
- IRCSS San Raffaele Roma, Microbiology of Chronic Neuro-Degenerative Pathologies, 00163 Rome, Italy
- Department of Public Health and Infectious Diseases, “Sapienza” University of Rome, 00185 Rome, Italy; (G.B.); (F.P.); (S.P.)
- Correspondence: (C.P.); (V.P.)
| | - Alfonso Grimaldi
- Multiple Sclerosis Clinical and Research Unit, Fondazione Policlinico di Tor Vergata, 00133 Rome, Italy; (A.G.); (D.L.); (C.G.N.); (G.A.M.)
| | - Doriana Landi
- Multiple Sclerosis Clinical and Research Unit, Fondazione Policlinico di Tor Vergata, 00133 Rome, Italy; (A.G.); (D.L.); (C.G.N.); (G.A.M.)
- Department of Systems Medicine, Tor Vergata University, 00133 Rome, Italy
| | - Carolina Gabri Nicoletti
- Multiple Sclerosis Clinical and Research Unit, Fondazione Policlinico di Tor Vergata, 00133 Rome, Italy; (A.G.); (D.L.); (C.G.N.); (G.A.M.)
- Department of Systems Medicine, Tor Vergata University, 00133 Rome, Italy
| | - Gabriele Brazzini
- Department of Public Health and Infectious Diseases, “Sapienza” University of Rome, 00185 Rome, Italy; (G.B.); (F.P.); (S.P.)
| | - Francesca Piacentini
- Department of Public Health and Infectious Diseases, “Sapienza” University of Rome, 00185 Rome, Italy; (G.B.); (F.P.); (S.P.)
| | - Sara Passerini
- Department of Public Health and Infectious Diseases, “Sapienza” University of Rome, 00185 Rome, Italy; (G.B.); (F.P.); (S.P.)
| | - Dolores Limongi
- IRCCS San Raffaele Roma, Telematic University, 00163 Rome, Italy;
| | - Marco Ciotti
- Laboratory of Virology, Polyclinic Tor Vergata Foundation, 00133 Rome, Italy;
| | - Anna Teresa Palamara
- Department of Infectious Diseases, Istituto Superiore di Sanità, 00161 Rome, Italy;
- Laboratory Affiliated to Institute Pasteur Italia-Cenci Bolognetti Foundation, Department of Public Health and Infectious Diseases, “Sapienza” University of Rome, 00185 Rome, Italy
| | - Girolama Alessandra Marfia
- Multiple Sclerosis Clinical and Research Unit, Fondazione Policlinico di Tor Vergata, 00133 Rome, Italy; (A.G.); (D.L.); (C.G.N.); (G.A.M.)
- Department of Systems Medicine, Tor Vergata University, 00133 Rome, Italy
- Unit of Neurology, IRCCS Istituto Neurologico Mediterraneo NEUROMED, 86077 Pozzilli, Italy
| | - Valeria Pietropaolo
- Department of Public Health and Infectious Diseases, “Sapienza” University of Rome, 00185 Rome, Italy; (G.B.); (F.P.); (S.P.)
- Correspondence: (C.P.); (V.P.)
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5
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Progressive multifocal leukoencephalopathy in patients treated with rituximab: a 20-year review from the Southern Network on Adverse Reactions. LANCET HAEMATOLOGY 2021; 8:e593-e604. [PMID: 34329579 DOI: 10.1016/s2352-3026(21)00167-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 06/02/2021] [Accepted: 06/03/2021] [Indexed: 12/13/2022]
Abstract
Progressive multifocal leukoencephalopathy (PML) is a serious and usually fatal CNS infection caused by the John Cunningham virus. CD4+ and CD8+ T-cell lymphopenia, resulting from HIV infection, chemotherapy, or immunosuppressive therapy, are primary risk factors for PML. Following its introduction in 1997, the immunomodulatory anti-CD20 monoclonal antibody, rituximab, has received regulatory approval worldwide for treatment of non-Hodgkin lymphoma, rheumatoid arthritis, chronic lymphocytic leukaemia, granulomatosis with polyangiitis, microscopic polyangiitis, and pemphigus vulagris. Rituximab leads to prolonged B-lymphocyte depletion, potentially allowing John Cunningham viral infection to occur. Six unexpected cases of PML infection developing in rituximab-treated patients were first reported in 2002. We review 20 years of information on clinical findings, pathology, epidemiology, proposed pathogenesis, and risk-management issues associated with PML infection developing after rituximab treatment. Since the first case series report of 52 cases of rituximab-associated PML among patients with non-Hodgkin lymphoma or chronic lymphocytic leukaemia in 2009, updated and diligent pharmacovigilance efforts have provided reassurance that this fatal toxicity is a rare clinical event with concurring causal factors. International harmonisation of safety warnings around rituximab-associated PML should be considered, with these notifications listing rituximab-associated PML under a section titled warnings and precautions as is the case in most countries, rather than a boxed warning as is the case in the USA.
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6
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Ahye N, Bellizzi A, May D, Wollebo HS. The Role of the JC Virus in Central Nervous System Tumorigenesis. Int J Mol Sci 2020; 21:ijms21176236. [PMID: 32872288 PMCID: PMC7503523 DOI: 10.3390/ijms21176236] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/22/2020] [Accepted: 08/24/2020] [Indexed: 12/14/2022] Open
Abstract
Cancer is the second leading cause of mortality worldwide. The study of DNA tumor-inducing viruses and their oncoproteins as a causative agent in cancer initiation and tumor progression has greatly enhanced our understanding of cancer cell biology. The initiation of oncogenesis is a complex process. Specific gene mutations cause functional changes in the cell that ultimately result in the inability to regulate cell differentiation and proliferation effectively. The human neurotropic Polyomavirus JC (JCV) belongs to the family Polyomaviridae and it is the causative agent of progressive multifocal leukoencephalopathy (PML), which is a fatal neurodegenerative disease in an immunosuppressed state. Sero-epidemiological studies have indicated JCV infection is prevalent in the population (85%) and that initial infection usually occurs during childhood. The JC virus has small circular, double-stranded DNA that includes coding sequences for viral early and late proteins. Persistence of the virus in the brain and other tissues, as well as its potential to transform cells, has made it a subject of study for its role in brain tumor development. Earlier observation of malignant astrocytes and oligodendrocytes in PML, as well as glioblastoma formation in non-human primates inoculated with JCV, led to the hypothesis that JCV plays a role in central nervous system (CNS) tumorigenesis. Some studies have reported the presence of both JC viral DNA and its proteins in several primary brain tumor specimens. The discovery of new Polyomaviruses such as the Merkel cell Polyomavirus, which is associated with Merkel cell carcinomas in humans, ignited our interest in the role of the JC virus in CNS tumors. The current evidence known about JCV and its effects, which are sufficient to produce tumors in animal models, suggest it can be a causative factor in central nervous system tumorigenesis. However, there is no clear association between JCV presence in CNS and its ability to initiate CNS cancer and tumor formation in humans. In this review, we will discuss the correlation between JCV and tumorigenesis of CNS in animal models, and we will give an overview of the current evidence for the JC virus’s role in brain tumor formation.
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7
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Crowhurst T, Koszyca B, Holmes M, Holmes-Liew CL. Progressive multifocal leukoencephalopathy in a lung transplant recipient presenting with memory impairment: Case report and literature review. Transpl Infect Dis 2020; 22:e13293. [PMID: 32291834 DOI: 10.1111/tid.13293] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 03/31/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Progressive multifocal leukoencephalopathy (PML) is a rare demyelinating disease of the central nervous system caused by JC virus (JCV). The disease occurs in the setting of significant immunocompromise and has now been reported in many different settings, although only very rarely after lung transplantation. The mortality rate is high and therapeutic options are limited. CASE PRESENTATION We report a case of a 66-year-old man who presented with non-specific memory disturbance at 19 months after lung transplantation for chronic hypersensitivity pneumonitis. He had required methylprednisolone for acute allograft rejection but achieved good graft function. Physical examination was unremarkable. CT revealed hypodensity in the left frontal lobe. MR demonstrated significant hyperintense white-matter abnormalities on T2-weighted and fluid-attenuated inversion recovery (FLAIR) sequences, mainly focused on the periventricular region adjacent the frontal horn of the left lateral ventricle. Brain biopsy confirmed PML. The patient had his immunosuppression reduced but then developed antibody-mediated rejection four months later. Despite re-escalation of immunosuppression, he remains neurologically stable on mirtazapine at eight months post-diagnosis. CONCLUSIONS This very rare case highlights the challenges presented by PML, especially in the lung transplant population. It reveals the difficult balance between reducing immunosuppression to protect the brain versus prevention of lung allograft rejection. It clearly highlights the need for improved therapeutic modalities.
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Affiliation(s)
- Thomas Crowhurst
- Discipline of Medicine, University of Adelaide, Adelaide, SA, Australia.,SA Lung Transplant Service, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Barbara Koszyca
- SA Pathology, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Mark Holmes
- Discipline of Medicine, University of Adelaide, Adelaide, SA, Australia.,SA Lung Transplant Service, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Chien-Li Holmes-Liew
- Discipline of Medicine, University of Adelaide, Adelaide, SA, Australia.,SA Lung Transplant Service, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA, Australia
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8
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Godbole MM, Barr PM. Complete recovery of late onset progressive multifocal leukoencephalopathy related to treatment with chemoimmunotherapy: A case report. Leuk Res 2020; 90:106309. [PMID: 32004701 DOI: 10.1016/j.leukres.2020.106309] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 01/19/2020] [Accepted: 01/20/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Manasi M Godbole
- Department of Internal Medicine, Rochester General Hospital, NY, United States.
| | - Paul M Barr
- Department of Hematology-Oncology, Wilmot Cancer Center/Strong Memorial Hospital, Rochester, NY, United States
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9
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Kirincich J, Basic-Jukic N, Radic J, Lovric-Kujundzic S, Kastelan Z. A Kidney Transplant Recipient With Fulminant Progressive Multifocal Leukoencephalopathy-Immune Reconstitution Inflammatory Syndrome: A Rare Clinical Outcome and Review of the Literature. EXP CLIN TRANSPLANT 2019; 18:242-246. [PMID: 31580233 DOI: 10.6002/ect.2018.0227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Progressive multifocal leukoencephalopathy is a devastating disease affecting the central nervous system that may be seen in immunocompromised patients. We present a case of a kidney transplant recipient who received tacrolimus, mycophenolic acid, and prednisone and who developed motor deficits, altered cognition, and speech abnormalities, which culminated in a coma. The diagnosis was made by detecting John Cunningham polyomavirus DNA with polymerase chain reaction and observing characteristic findings on magnetic resonance imaging. Soon after immunosuppressive therapy was withdrawn, the patient's clinical status deteriorated due to immune reconstitution inflammatory syndrome, and prednisone was administered. Unfortunately, the patient died about 9 months after onset of symptoms. This case serves to illustrate the fulminant progression of progressive multifocal leukoencephalopathy and the possible complications that may arise when treating it.
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Affiliation(s)
- Jason Kirincich
- >From the Department of Nephrology, Arterial Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Zagreb, Croatia
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10
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Progressive multifocal leukoencephalopathy in a renal transplant patient. J Neurovirol 2019; 25:612-615. [PMID: 31069707 DOI: 10.1007/s13365-019-00749-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 03/28/2019] [Accepted: 04/03/2019] [Indexed: 12/20/2022]
Abstract
End-stage renal disease (ESRD) has a major impact on health and affects more than 600,000 people in the USA. The current mainstay treatments include dialysis and kidney transplantation (KT), and patients who have received KT have a higher quality of life and a lower mortality risk than those on chronic dialysis. Therefore, KT is considered the more preferred treatment modality for patients with ESRD. However, even though KT results in a higher long-term survival rate, the use of immunosuppressants is associated with various complications, including opportunistic infections and malignancies, which may lead to a higher risk of death in the first year after transplantation. Progressive multifocal leukoencephalopathy (PML) is a rare complication following KT, with an incidence of 0.027% in KT recipients. We present a case of PML following immunosuppressant therapy in a patient who received KT.
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11
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Windpessl M, Burgstaller S, Kronbichler A, Pieringer H, Kalev O, Karrer A, Wallner M, Thaler J. Progressive Multifocal Leukoencephalopathy Following Combined Rituximab-Based Immune-Chemotherapy for Post-transplant Lymphoproliferative Disorder in a Renal Transplant Recipient: A Case Report. Transplant Proc 2018; 50:881-883. [PMID: 29661457 DOI: 10.1016/j.transproceed.2018.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Accepted: 01/17/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Transplant recipients are at risk of developing progressive multifocal leukoencephalopathy (PML), an opportunistic infection due to reactivation of JC virus. Post-transplant lymphoproliferative disorders (PTLDs) represent a common malignancy in this population, and antiCD20-therapy has become an established component of its treatment. CASE PRESENTATION We describe the first case of a renal allograft transplant recipient with PTLD who received rituximab-based immune-chemotherapy and developed PML shortly thereafter. Despite early suspicion and diagnosis, the disease ran a relentlessly progressive course, and the patient succumbed to his illness shortly thereafter. CONCLUSION PML should be strongly suspected whenever unusual neurologic symptoms appear in the context of immunosuppression. Clinicians and patients should be aware of the potential for PML after rituximab therapy.
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Affiliation(s)
- M Windpessl
- Department of Internal Medicine IV, Hematology, Oncology and Nephrology, Academic Teaching Hospital Wels-Grieskirchen, Wels, Austria.
| | - S Burgstaller
- Department of Internal Medicine IV, Hematology, Oncology and Nephrology, Academic Teaching Hospital Wels-Grieskirchen, Wels, Austria
| | - A Kronbichler
- Department of Internal Medicine IV, Nephrology and Hypertension, Medical University of Innsbruck, Innsbruck, Austria
| | - H Pieringer
- Academic Research Unit, 2nd Department of Medicine, Kepler University Hospital, Med Campus III, Linz, Austria; Paracelsus Private Medical University, Salzburg, Austria
| | - O Kalev
- Department of Neuropathology, Kepler University Hospital, Neuromed Campus, Linz, Austria
| | - A Karrer
- Department of Radiology, Academic Teaching Hospital Wels-Grieskirchen, Wels, Austria
| | - M Wallner
- Department of Internal Medicine IV, Hematology, Oncology and Nephrology, Academic Teaching Hospital Wels-Grieskirchen, Wels, Austria
| | - J Thaler
- Department of Internal Medicine IV, Hematology, Oncology and Nephrology, Academic Teaching Hospital Wels-Grieskirchen, Wels, Austria
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12
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Ramos Martínez A, Pintos Pascual I, Múñez Rubio E. [Infections in immunocompromised patients (II). The transplanted patient]. Medicine (Baltimore) 2018; 12:3245-3252. [PMID: 32287906 PMCID: PMC7143593 DOI: 10.1016/j.med.2018.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Los receptores de los diferentes tipos de trasplante presentan un riesgo elevado de infección. En los trasplantados de precursores hematopoyéticos predominan las infecciones nosocomiales. Durante el periodo posprendimiento temprano (30-100 días tras la infusión del trasplante), la incidencia de infección es más elevada en pacientes con enfermedad de injerto contra huésped. En el pulmón pueden aparecer lesiones nodulares por infección fúngica invasora o bien un patón difuso habitualmente secundario a infección vírica o a neumonía por P. jirovecii. Después de los primeros 100 días persiste un moderado riesgo de infección por microorganismos convencionales y oportunistas, como la infección tardía por CMV. Los avances en las técnicas quirúrgicas y el empleo de calcineurínicos han reducido la mortalidad por infecciones en trasplantados de órgano sólido. Durante el primer mes, son frecuentes las infecciones nosocomiales; entre el primer y sexto mes son más frecuentes las infecciones oportunistas dependientes de la inmunidad celular y a partir de sexto mes el riesgo baja y predominan las infecciones comunitarias semejantes a las de los pacientes inmunocompetentes.
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Affiliation(s)
- A. Ramos Martínez
- Unidad de Enfermedades Infecciosas. Servicio de Medicina Interna. Hospital Universitario Puerta de Hierro. Madrid. España
- Autor para correspondencia.
| | - I. Pintos Pascual
- Servicio de Medicina Interna. Hospital Universitario Fundación Jiménez Díaz. Madrid. España
| | - E. Múñez Rubio
- Unidad de Enfermedades Infecciosas. Servicio de Medicina Interna. Hospital Universitario Puerta de Hierro. Madrid. España
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13
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Maillart E, Taoufik Y, Gasnault J, Stankoff B. Leucoencefalopatia multifocale progressiva. Neurologia 2018. [DOI: 10.1016/s1634-7072(18)89404-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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14
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A Difficult Decision: Atypical JC Polyomavirus Encephalopathy in a Kidney Transplant Recipient. Transplantation 2017; 101:1461-1467. [PMID: 27367472 DOI: 10.1097/tp.0000000000001275] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND A number of cerebral manifestations are associated with JC polyomavirus (JCPyV) which are diagnosed by detection of JCPyV in cerebrospinal fluid (CSF), often with the support of cerebral imaging. Here we present an unusual case of a kidney transplant patient presenting with progressive neurological deterioration attributed to JCPyV encephalopathy. METHODS Quantitative polymerase chain reaction JCPyV was used prospectively and retrospectively to track the viral load within the patient blood, urine, CSF, and kidney sections. A JCPyV VP1 enzyme-linked immunosorbent assay was used to measure patient and donor antibody titers. Immunohistochemical staining was used to identify active JCPyV infection within the kidney allograft. RESULTS JC polyomavirus was detected in the CSF at the time of presentation. JC polyomavirus was not detected in pretransplant serum, however viral loads increased with time, peaking during the height of the neurological symptoms (1.5E copies/mL). No parenchymal brain lesions were evident on imaging, but transient cerebral venous sinus thrombosis was present. Progressive decline in neurological function necessitated immunotherapy cessation and allograft removal, which led to decreasing serum viral loads and resolution of neurological symptoms. JC polyomavirus was detected within the graft's collecting duct cells using quantitative polymerase chain reaction and immunohistochemical staining. The patient was JCPyV naive pretransplant, but showed high antibody titers during the neurological symptoms, with the IgM decrease paralleling the viral load after graft removal. CONCLUSIONS We report a case of atypical JCPyV encephalopathy associated with cerebral venous sinus thrombosis and disseminated primary JCPyV infection originating from the kidney allograft. Clinical improvement followed removal of the allograft and cessation of immunosuppression.
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Rastogi A, Gulati N, Bihari C, Chaudhary A, Bansal K, Sasturkar S, Thapar S, Pamecha V. JC Virus-Related Progressive Multifocal Leukoencephalopathy After Living-Donor Liver Transplant: A Rare Case. EXP CLIN TRANSPLANT 2017; 17:414-417. [PMID: 28800720 DOI: 10.6002/ect.2016.0242] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Progressive multifocal leukoencephalopathy caused by polyoma JC virus is a rare and severe demyelinating disease of the central nervous system. It occurs in immunocompromised patients and is scarcely reported in liver transplant recipients. Brain biopsy demonstrating demyelination with presence of foamy macrophages, relative preservation of axons, astrogliosis, and typical polyomavirus inclusions in the enlarged oligodendroglial nuclei is essential for diagnosis. Here, we report a case of JC virus-associated progressive multifocal leukoencephalopathy in a living-donor liver transplant recipient who was transplanted for hepatitis C virus-related decompensated cirrhosis. Brain biopsy with immunohistochemistry confirmed the diagnosis of progressive multifocal leukoencephalopathy secondary to JC virus. JC virus related-progressive multifocal leukoencephalopathy is associated with extremely poor prognosis. Awareness and consideration of this entity in liver transplant recipients who present with sudden progressive neurologic manifestations can help in prompt diagnosis and timely treatment.
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Affiliation(s)
- Archana Rastogi
- From the Department of Pathology, Institute of Liver and Biliary Sciences, Delhi, India
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16
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Assetta B, Atwood WJ. The biology of JC polyomavirus. Biol Chem 2017; 398:839-855. [PMID: 28493815 DOI: 10.1515/hsz-2016-0345] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 04/20/2017] [Indexed: 02/06/2023]
Abstract
JC polyomavirus (JCPyV) is the causative agent of a fatal central nervous system demyelinating disease known as progressive multifocal leukoencephalopathy (PML). PML occurs in people with underlying immunodeficiency or in individuals being treated with potent immunomodulatory therapies. JCPyV is a DNA tumor virus with a double-stranded DNA genome and encodes a well-studied oncogene, large T antigen. Its host range is highly restricted to humans and only a few cell types support lytic infection in vivo or in vitro. Its oncogenic potential in humans has not been firmly established and the international committee on oncogenic viruses lists JCPyV as possibly carcinogenic. Significant progress has been made in understanding the biology of JCPyV and here we present an overview of the field and discuss some important questions that remain unanswered.
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Seppälä H, Virtanen E, Saarela M, Laine P, Paulín L, Mannonen L, Auvinen P, Auvinen E. Single-Molecule Sequencing Revealing the Presence of Distinct JC Polyomavirus Populations in Patients With Progressive Multifocal Leukoencephalopathy. J Infect Dis 2017; 215:889-895. [PMID: 28453853 DOI: 10.1093/infdis/jiw399] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Accepted: 08/18/2016] [Indexed: 12/15/2022] Open
Abstract
Background Progressive multifocal leukoencephalopathy (PML) is a fatal disease caused by reactivation of JC polyomavirus (JCPyV) in immunosuppressed individuals and lytic infection by neurotropic JCPyV in glial cells. The exact content of neurotropic mutations within individual JCPyV strains has not been studied to our knowledge. Methods We exploited the capacity of single-molecule real-time sequencing technology to determine the sequence of complete JCPyV genomes in single reads. The method was used to precisely characterize individual neurotropic JCPyV strains of 3 patients with PML without the bias caused by assembly of short sequence reads. Results In the cerebrospinal fluid sample of a 73-year-old woman with rapid PML onset, 3 distinct JCPyV populations could be identified. All viral populations were characterized by rearrangements within the noncoding regulatory region (NCCR) and 1 point mutation, S267L in the VP1 gene, suggestive of neurotropic strains. One patient with PML had a single neurotropic strain with rearranged NCCR, and 1 patient had a single strain with small NCCR alterations. Conclusions We report here, for the first time, full characterization of individual neurotropic JCPyV strains in the cerebrospinal fluid of patients with PML. It remains to be established whether PML pathogenesis is driven by one or several neurotropic strains in an individual.
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Affiliation(s)
- Hanna Seppälä
- Department of Virology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Elina Virtanen
- Department of Virology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mika Saarela
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - Pia Laine
- Institute of Biotechnology, DNA Sequencing and Genomics Laboratory, University of Helsinki, Finland
| | - Lars Paulín
- Institute of Biotechnology, DNA Sequencing and Genomics Laboratory, University of Helsinki, Finland
| | - Laura Mannonen
- Department of Virology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Petri Auvinen
- Institute of Biotechnology, DNA Sequencing and Genomics Laboratory, University of Helsinki, Finland
| | - Eeva Auvinen
- Department of Virology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Sauer R, Gölitz P, Jacobi J, Schwab S, Linker RA, Lee DH. Good outcome of brain stem progressive multifocal leukoencephalopathy in an immunosuppressed renal transplant patient: Importance of early detection and rapid immune reconstitution. J Neurol Sci 2017; 375:76-79. [DOI: 10.1016/j.jns.2017.01.046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 12/20/2016] [Accepted: 01/13/2017] [Indexed: 12/23/2022]
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Boucher A, Herrmann JL, Morand P, Buzelé R, Crabol Y, Stahl JP, Mailles A. Epidemiology of infectious encephalitis causes in 2016. Med Mal Infect 2017; 47:221-235. [PMID: 28341533 DOI: 10.1016/j.medmal.2017.02.003] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 02/17/2017] [Indexed: 10/19/2022]
Abstract
We performed a literature search in the Medline database, using the PubMed website. The incidence of presumably infectious encephalitis is estimated at 1.5-7 cases/100,000 inhabitants/year, excluding epidemics. Infectious encephalitis and immune-mediated encephalitis share similar clinical signs and symptoms. The latter accounts for a significant proportion of presumably infectious encephalitis cases without any established etiological diagnosis; as shown from a prospective cohort study where 21% of cases were due to an immune cause. Several infectious agents are frequently reported in all studies: Herpes simplex virus (HSV) is the most frequent pathogen in 65% of studies, followed by Varicella-zoster virus (VZV) in several studies. Enteroviruses are also reported; being the most frequent viruses in two studies, and the 2nd or 3rd viruses in five other studies. There are important regional differences, especially in case of vector-borne transmission: Asia and the Japanese encephalitis virus, Eastern and Northern Europe/Eastern Russia and the tick-borne encephalitis virus, Northern America and Flavivirus or Alphavirus. Bacteria can also be incriminated: Mycobacterium tuberculosis and Listeria monocytogenes are the most frequent, after HSV and VZV, in a French prospective study. The epidemiology of encephalitis is constantly evolving. Epidemiological data may indicate the emergence and/or dissemination of new causative agents. The dissemination and emergence of causative agents are fostered by environmental, social, and economical changes, but prevention programs (vaccination, vector controls) help reduce the incidence of other infectious diseases and associated encephalitis (e.g., measles).
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Affiliation(s)
- A Boucher
- Maladies infectieuses, CHU de Lille, 59000 Lille, France
| | - J L Herrmann
- Microbiologie, CHU de Garches, 92380 Garches, France
| | - P Morand
- Virologie, CHU Grenoble Alpes, 38700 La Tronche, France
| | - R Buzelé
- Médecine interne, centre hospitalier de Saint-Brieuc, 22027 Saint-Brieuc, France
| | - Y Crabol
- Médecine interne, centre hospitalier Vannes-Aufray, 56000 Vannes, France
| | - J P Stahl
- Maladies infectieuses, CHU Grenoble Alpes, Grenoble - "European Study Group for the Infections of the Brain (ESGIB)", 38700 La Tronche, France.
| | - A Mailles
- Direction des maladies infectieuses, santé publique France - "European Study Group for the Infections of the Brain (ESGIB)", 94410 Saint-Maurice, France
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20
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Fillatre P, Crabol Y, Morand P, Piroth L, Honnorat J, Stahl JP, Lecuit M. Infectious encephalitis: Management without etiological diagnosis 48hours after onset. Med Mal Infect 2017; 47:236-251. [PMID: 28314470 PMCID: PMC7131623 DOI: 10.1016/j.medmal.2017.02.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 02/22/2017] [Indexed: 12/18/2022]
Abstract
Introduction The etiological diagnosis of infectious encephalitis is often not established 48 hours after onset. We aimed to review existing literature data before providing management guidelines. Method We performed a literature search on PubMed using filters such as “since 01/01/2000”, “human”, “adults”, “English or French”, and “clinical trial/review/guidelines”. We also used the Mesh search terms “encephalitis/therapy” and “encephalitis/diagnosis”. Results With Mesh search terms “encephalitis/therapy” and “encephalitis/diagnosis”, we retrieved 223 and 258 articles, respectively. With search terms “encephalitis and corticosteroid”, we identified 38 articles, and with “encephalitis and doxycycline” without the above-mentioned filters we identified 85 articles. A total of 210 articles were included in the analysis. Discussion Etiological investigations must focus on recent travels, animal exposures, age, immunodeficiency, neurological damage characteristics, and potential extra-neurological signs. The interest of a diagnosis of encephalitis for which there is no specific treatment is also to discontinue any empirical treatments initially prescribed. Physicians must consider and search for autoimmune encephalitis.
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Affiliation(s)
- P Fillatre
- Service de maladies infectieuses et réanimation médicale, CHU Pontchaillou, 35000 Rennes, France
| | - Y Crabol
- Médecine interne, CHBUA site de Vannes, 56017 Vannes, France
| | - P Morand
- Virologie, CHU Grenoble Alpes, 38043 Grenoble cedex 9, France
| | - L Piroth
- Infectiologie, CHU de Dijon, 21000 Dijon, France
| | - J Honnorat
- Inserm U1028, CNRS UMR5292, équipe neuro-oncologie et neuro-inflammation (Oncoflam), centre de recherche en neurosciences (CRNL), université Lyon 1, 69500 Bron, France
| | - J P Stahl
- Service d'infectiologie, CHU de Grenoble, 38043 Grenoble cedex 9, France.
| | - M Lecuit
- Institut Pasteur, Biology of Infection Unit, CNR CCOMS Listeria, Inserm U1117, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Department of Infectious Diseases and Tropical Medicine, Necker-Enfants-Malades University Hospital, Institut Imagine, Assistance Publique-Hôpitaux de Paris, Paris, France
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Davydovskaya MV, Khachanova NV, Evdoshenko EP, Pronin IN, Boiko AN, Zakharova MN, Alifirova VM, Turova EA, Malkova NA, Sivertseva SA, Tsukurova LA, Skoromets AA, Solodun IY. [Recommendations on the algorithms for drug choice and risk management plan in the treatment of patients with remitting multiple sclerosis with natalizumab]. Zh Nevrol Psikhiatr Im S S Korsakova 2017; 116:79-97. [PMID: 28139616 DOI: 10.17116/jnevro201611610279-97] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- M V Davydovskaya
- Pirogov Russian National Research Medical University, Moscow, Russia; Center of Coordination and Clinical Examination of Medical Drugs, Moscow Department of Public Health, Moscow, Russia
| | - N V Khachanova
- Pirogov Russian National Research Medical University, Moscow, Russia; Center of Coordination and Clinical Examination of Medical Drugs, Moscow Department of Public Health, Moscow, Russia
| | - E P Evdoshenko
- Center of Coordination and Clinical Examination of Medical Drugs, Moscow Department of Public Health, Moscow, Russia; City Center of Multiple Sclerosis And Autoimmune Diseases at Hospital #31, Moscow, Russia
| | - I N Pronin
- Burdenko Research Institute of Neurosurgery, Moscow, Russia
| | - A N Boiko
- Pirogov Russian National Research Medical University, Moscow, Russia
| | | | | | - E A Turova
- Siberian Regional Hospital #1, Yekaterinburg, Russia
| | - N A Malkova
- Novosibirsk State Medical University, Novosibirsk, Russia
| | | | - L A Tsukurova
- Research Institute - Ochapovsky Regional Hospital #1, Krasnodar, Russia
| | - A A Skoromets
- Pavlov St. Petersburg State Medical University, St. Petersburg, Russia
| | - I Yu Solodun
- Center of Coordination and Clinical Examination of Medical Drugs, Moscow Department of Public Health, Moscow, Russia
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Sundbom P, Hubbert L, Serrander L. Progressive multifocal leukoencephalopathy after heart transplantation: 4 years of clinically stable infection on low-dose immunosuppressive therapy. Oxf Med Case Reports 2017; 2017:omx003. [PMID: 28473916 PMCID: PMC5410880 DOI: 10.1093/omcr/omx003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 01/01/2017] [Accepted: 01/19/2017] [Indexed: 12/22/2022] Open
Abstract
Progressive multifocal leukoencephalopathy (PML), caused by reactivation of JC-virus is a relatively rare complication seen in patients with compromised immune system. There are no evidence-based treatment available and prognosis is poor. Withdrawal of immunosuppressant can result in further neurological deterioration and for patients with solid organ transplantations, fatal graft rejection. We report a 52-year-old women that presented with seizures within 1 month after heart transplantation. Initial diagnosis was vascular disease. After clinical deterioration 10 months after transplantation, further examinations led to the diagnosis. Minimizing tacrolimus, to a concentration of 2 ng/ml, and extensive physical therapy has improved the physical capacity of the patient. The patient has now been clinically stable for 4 years and extended survival for 5 years. This case adds to the limited adult cases of PML within the population of heart transplant recipients and the need for increased awareness to minimize diagnosis delay.
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Affiliation(s)
- Per Sundbom
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Laila Hubbert
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Lena Serrander
- Department of Infectious Diseases and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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Bonatti H, Sifri CD, Larcher C, Schneeberger S, Kotton C, Geltner C. Use of Cidofovir for Cytomegalovirus Disease Refractory to Ganciclovir in Solid Organ Recipients. Surg Infect (Larchmt) 2017; 18:128-136. [DOI: 10.1089/sur.2015.266] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Hugo Bonatti
- Department of Surgery, University of Maryland, Shore Health System, Easton, Maryland
- Department for Visceral, Transplant and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - Costi D. Sifri
- Department of Medicine, Division of Infectious Diseases and International Health, University of Virginia Health System, Charlottesville, Virginia
| | | | - Stefan Schneeberger
- Department for Visceral, Transplant and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - Camille Kotton
- Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Dropulic LK, Lederman HM. Overview of Infections in the Immunocompromised Host. Microbiol Spectr 2016; 4:10.1128/microbiolspec.DMIH2-0026-2016. [PMID: 27726779 PMCID: PMC8428766 DOI: 10.1128/microbiolspec.dmih2-0026-2016] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Indexed: 12/12/2022] Open
Abstract
Understanding the components of the immune system that contribute to host defense against infection is key to recognizing infections that are more likely to occur in an immunocompromised patient. In this review, we discuss the integrated system of physical barriers and of innate and adaptive immunity that contributes to host defense. Specific defects in the components of this system that predispose to particular infections are presented. This is followed by a review of primary immunodeficiency diseases and secondary immunodeficiencies, the latter of which develop because of a specific illness or condition or are treatment-related. The effects of treatment for neoplasia, autoimmune diseases, solid organ and stem cell transplants on host defenses are reviewed and associated with susceptibility to particular infections. In conclusion, an approach to laboratory screening for a suspected immunodeficiency is presented. Knowledge of which host defects predispose to specific infections allows clinicians to prevent, diagnose, and manage infections in their immunocompromised patients most effectively.
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Affiliation(s)
- Lesia K Dropulic
- The National Institutes of Health, National Institute of Allergy and Infectious Diseases, Division of Intramural Research, Bethesda, MD 20892
| | - Howard M Lederman
- Departments of Pediatrics, Medicine, and Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD 21287
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Abstract
Progressive multifocal leukoencephalopathy is a rare, highly fatal demyelinating brain infection caused by the JC virus. This infection is associated with immunosuppressive agents and is emerging in the transplant population. There has never been a documented case of progressive multifocal leukoencephalopathy in a transplant recipient receiving sirolimus. We present a study, in which the JC virus was found in a 68-year-old man who had received a postorthotopic heart transplant 3 years earlier and who was receiving sirolimus and prednisone for immunosuppression. We review the clinical presentation, diagnosis, current treatment options, and the outcomes of progressive multifocal leukoencephalopathy in transplant recipients.
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SantaCruz KS, Roy G, Spigel J, Bearer EL. Neuropathology of JC virus infection in progressive multifocal leukoencephalopathy in remission. World J Virol 2016; 5:31-37. [PMID: 26870672 PMCID: PMC4735552 DOI: 10.5501/wjv.v5.i1.31] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Revised: 10/10/2015] [Accepted: 12/15/2015] [Indexed: 02/05/2023] Open
Abstract
AIM: To investigate the neuropathology of the brain in a rare case of remission following diagnosis of progressive multifocal leukoencephalopathy (PML).
METHODS: Consent from the family for an autopsy was obtained, clinical records and radiograms were retrieved. A complete autopsy was performed, with brain examination after fixation and coronal sectioning at 1 cm intervals. Fourteen regions were collected for paraffin embedding and staining for microscopic analysis. Histologic sections were stained with Luxol blue, hematoxylin/eosin, and immunostained for myelin basic protein, neurofilament, SV40 T antigen and p53. The biopsy material was also retrieved and sections were stained with hematoxylin/eosin and immunostained for SV40 and p53. Sections were examined by American Board of Pathology certified pathologists and images captured digitally.
RESULTS: Review of the clinical records was notable for a history of ulcerative colitis resulting in total colectomy in 1977 and a liver transplant in 1998 followed by immune-suppressive therapy. Neurological symptoms presented immediately, therefore a biopsy was obtained which was diagnosed as PML. Immunotherapy was adjusted and clinical improvement was noted. No subsequent progression was reported. Review of the biopsy demonstrated atypical astrocytes and enlarged hyperchromatic oligodendroglial cells consistent with JC virus infection. Strong SV40 and p53 staining was found in glial cells and regions of dense macrophage infiltration were present. On gross examination of the post-mortem brain, a lesion in the same site as the original biopsy in the cerebellum was identified but no other lesions in the brain were found. Microscopic analysis of this cerebellar lesion revealed a loss of myelin and axons, and evidence of axonal damage. This single burned-out lesion was equivocally positive for SV40 antigen with little p53 staining. Examination of thirteen other brain regions found no other occult sites.
CONCLUSION: Our study reveals residual damage, rare macrophages or other inflammation and minimal evidence of persistent virus. This case demonstrates the possibility of complete remission of PML.
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Hirsch HH, Babel N, Comoli P, Friman V, Ginevri F, Jardine A, Lautenschlager I, Legendre C, Midtvedt K, Muñoz P, Randhawa P, Rinaldo CH, Wieszek A. European perspective on human polyomavirus infection, replication and disease in solid organ transplantation. Clin Microbiol Infect 2015; 20 Suppl 7:74-88. [PMID: 24476010 DOI: 10.1111/1469-0691.12538] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Accepted: 12/27/2013] [Indexed: 01/15/2023]
Abstract
Human polyomaviruses (HPyVs) are a growing challenge in immunocompromised patients in view of the increasing number of now 12 HPyV species and their diverse disease potential. Currently, histological evidence of disease is available for BKPyV causing nephropathy and haemorrhagic cystitis, JCPyV causing progressive multifocal leukoencephalopathy and occasionally nephropathy, MCPyV causing Merkel cell carcinoma and TSPyV causing trichodysplasia spinulosa, the last two being proliferative skin diseases. Here, the current role of HPyV in solid organ transplantation (SOT) was reviewed and recommendations regarding screening, monitoring and intervention were made. Pre-transplant screening of SOT donor or recipient for serostatus or active replication is currently not recommended for any HPyV. Post-transplant, however, regular clinical search for skin lesions, including those associated with MCPyV or TSPyV, is recommended in all SOT recipients. Also, regular screening for BKPyV replication (e.g. by plasma viral load) is recommended in kidney transplant recipients. For SOT patients with probable or proven HPyV disease, reducing immunosuppression should be considered to permit regaining of immune control. Antivirals would be desirable for treating proven HPyV disease, but are solely considered as adjunct local treatment of trichodysplasia spinulosa, whereas surgical resection and chemotherapy are key in Merkel cell carcinoma. Overall, the quality of the clinical evidence and the strength of most recommendations are presently limited, but are expected to improve in the coming years.
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Affiliation(s)
- H H Hirsch
- Transplantation and Clinical Virology, Department of Biomedicine (Haus Petersplatz), University of Basel, Basel, Switzerland; Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
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Ohara H, Kataoka H, Nakamichi K, Saijo M, Ueno S. Favorable outcome after withdrawal of immunosuppressant therapy in progressive multifocal leukoencephalopathy after renal transplantation: Case report and literature review. J Neurol Sci 2014; 341:144-6. [DOI: 10.1016/j.jns.2014.03.048] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 02/20/2014] [Accepted: 03/25/2014] [Indexed: 02/03/2023]
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Carson KR, Newsome SD, Kim EJ, Wagner-Johnston ND, von Geldern G, Moskowitz CH, Moskowitz AJ, Rook AH, Jalan P, Loren AW, Landsburg D, Coyne T, Tsai D, Raisch DW, Norris LB, Bookstaver PB, Sartor O, Bennett CL. Progressive multifocal leukoencephalopathy associated with brentuximab vedotin therapy: a report of 5 cases from the Southern Network on Adverse Reactions (SONAR) project. Cancer 2014; 120:2464-71. [PMID: 24771533 DOI: 10.1002/cncr.28712] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 02/17/2014] [Accepted: 02/27/2014] [Indexed: 11/10/2022]
Abstract
BACKGROUND Brentuximab vedotin (BV) is an anti-CD30 monoclonal antibody-drug conjugate that was approved in 2011 for the treatment of patients with anaplastic large cell and Hodgkin lymphomas. The product label indicates that 3 patients who were treated with BV developed progressive multifocal leukoencephalopathy (PML), a frequently fatal JC virus-induced central nervous system infection. Prior immunosuppressive therapy and compromised immune systems were postulated risk factors. In the current study, the authors reported 5 patients who developed BV-associated PML, including 2 immunocompetent patients. METHODS Case information was obtained from clinicians (4 patients) or a US Food and Drug Administration database (1 patient). RESULTS All 5 patients had lymphoid malignancies. Two patients with cutaneous T-cell lymphomas had not previously received chemotherapy. PML developed after a median of 3 BV doses (range, 2 doses-6 doses) and within a median of 7 weeks after BV initiation (range, 3 weeks-34 weeks). Presenting findings included aphasia, dysarthria, confusion, hemiparesis, and gait dysfunction; JC virus in the cerebrospinal fluid (2 patients) or central nervous system biopsy (3 patients); and brain magnetic resonance imaging scans with white matter abnormalities (5 patients). Four patients died at a median of 8 weeks (range, 6 weeks-16 weeks) after PML diagnosis. The sole survivor developed immune reconstitution inflammatory syndrome. CONCLUSIONS PML can develop after a few BV doses and within weeks of BV initiation. Clinicians should be aware of this syndrome, particularly when neurologic changes develop after the initiation of BV treatment. The decision to administer BV to patients with indolent cutaneous lymphomas should be based on consideration of risk-benefit profiles and of alternative options.
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Affiliation(s)
- Kenneth R Carson
- Division of Medical Oncology, Washington University School of Medicine, St Louis, Missouri
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Mungunkhuyag M, Harada M, Abe T, Fujita K, Matsui N, Kaji R. Longitudinal monitoring with multiple MR techniques in a case of progressive multifocal leukoencephalopathy associated with multiple myeloma. Magn Reson Med Sci 2014; 13:55-9. [PMID: 24492738 DOI: 10.2463/mrms.2013-0037] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease of the brain caused by the JC virus in immunocompromised patients. We report characteristic features of proton MR spectroscopy, 3-dimensional pseudo-continuous arterial spin labeling imaging, and diffusion tensor imaging in a 53-year-old patient with PML. The utility of multi-modal magnetic resonance techniques for longitudinal monitoring was indicated by their reevaluation over time and consideration of their relation to prognosis.
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Affiliation(s)
- Majigsuren Mungunkhuyag
- Department of Radiology, Institute of Health Biosciences, The University of Tokushima Graduate School
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Rinaldo CH, Hirsch HH. Antivirals for the treatment of polyomavirus BK replication. Expert Rev Anti Infect Ther 2014; 5:105-15. [PMID: 17266458 DOI: 10.1586/14787210.5.1.105] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Antiviral drugs with specific activity against polyomavirus replication have not been developed in the past. This deficiency has become fully apparent with the emergence of polyomavirus-associated nephropathy in kidney-transplant recipients, with a prevalence rate of up to 10%. In most cases, high BK virus replication in tubular epithelial cells causes significant cytopathology, leading to permanently impaired renal allograft function and return to hemodialysis within 6-60 months. In 5-10% of allogenic bone marrow/hematopoietic stem cell transplant recipients, high-level BK virus replication in the ureter/bladder mucosa has been associated with postengraftment hemorrhagic cystitis, which appears to involve significant immunopathology. Thus, in view of the increasing clinical need, a number of drugs have been studied in small case series. We review the antiviral strategies explored to date and specifically discuss available in vivo and in vitro data on cidofovir, leflunomide, fluoroquinolones and intravenous immunoglobulins, regarding mechanism, administration, dosing and outcome and provide a perspective on future therapy options.
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Affiliation(s)
- Christine Hanssen Rinaldo
- University Hospital of North Norway, Department of Microbiology and Infection Control, PO Box 56, N-9038 Tromsø, Norway. christine.rinaldo@unn
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Dahlhaus S, Hoepner R, Chan A, Kleiter I, Adams O, Lukas C, Hellwig K, Gold R. Disease course and outcome of 15 monocentrically treated natalizumab-associated progressive multifocal leukoencephalopathy patients. J Neurol Neurosurg Psychiatry 2013; 84:1068-74. [PMID: 23606731 PMCID: PMC3786662 DOI: 10.1136/jnnp-2013-304897] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
OBJECTIVE Although the prognosis of natalizumab-associated progressive multifocal leukoencephalopathy (PML) seems to be better than HIV-associated PML, little is known about the long-term functional outcome in multiple sclerosis (MS) patients and the subsequent return of MS disease activity. We evaluated retrospectively 15 patients with natalizumab-associated PML treated at our centre. PATIENTS AND METHODS Fifteen MS-PML patients (nine women, six men) were referred to us from adjacent local centres. The patients had a median natalizumab exposure of 34 months at PML diagnosis. They received standardised treatment as described in previous work. Expanded Disability Status Scale (EDSS) and Karnofsky score in the year pre-PML, at PML-diagnosis (pre-immune reconstitution inflammatory syndrome (IRIS)) and post-PML were determined in 3-6 monthly intervals. RESULTS The median follow-up of these 15 patients was 21.5 months. None of the 15 patients died. Three patients had a Karnofsky score of 80 or higher, nine patients between 50-70 and three patients of 40 or lower at latest examination. Eight of the 15 patients developed seizures during acute PML phase. Fifty percent of those patients were not seizure-free one year post PML, despite continuation of antiepileptic treatment. The median EDSS in the year pre-PML was 2.5, 4.5 at PML diagnosis, 6.5 post-IRIS and 5.5 at latest examination. CSF became virus-free in eight of the 15 patients after a median time of 4.5 months. In nine patients, disease reappeared after a median time of seven months from PML diagnosis. CONCLUSIONS Although the clinical outcome of natalizumab-treated PML patients is much better than in patients with HIV-associated PML, this may be further improved by treatment at reference centres using standardised therapy regimens and transient intensive care if needed. Systematic studies of appropriate MS immunotherapies after PML are critically needed.
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Affiliation(s)
- Stefanie Dahlhaus
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
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Progressive multifocal leukoencephalopathy developed 26 years after renal transplantation. Clin Neurol Neurosurg 2013; 115:1482-4. [DOI: 10.1016/j.clineuro.2012.11.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2012] [Revised: 10/16/2012] [Accepted: 11/18/2012] [Indexed: 11/20/2022]
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Burke MT, Trnka P, Walsh M, Poole L, McTaggart SJ, Burke JR. Progressive multifocal leukoencephalopathy with gastrointestinal disease in a pediatric kidney transplant recipient. Pediatr Transplant 2013; 17:E119-24. [PMID: 23902604 DOI: 10.1111/petr.12107] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/30/2013] [Indexed: 12/12/2022]
Abstract
PML is a demyelinating disease of the central nervous system caused by infection with JCV. Several cases of PML in bone marrow and solid organ transplant recipients have been reported in recent years. JCV has been isolated from the gastrointestinal mucosa of immunocompromised patients, but there are no published reports of PML associated with symptomatic gastrointestinal involvement in kidney transplant recipients. We report a case of a nine-yr-old girl with a kidney transplant who developed a severe gastrointestinal illness causing pseudo-obstruction in association with PML. JCV was suspected as the causative agent in this patient by the detection of high JCV titer through PCR analysis of the cerebrospinal fluid and blood and positive staining for simian virus 40 in the colon. JCV intestinal infection should be considered in kidney transplant recipients presenting with intestinal pseudo-obstruction.
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Affiliation(s)
- M T Burke
- Department of Renal Medicine, Nambour General Hospital, Nambour, Qld, Australia.
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Cohen BA, Stosor V. Opportunistic Infections of the Central Nervous System in the Transplant Patient. Curr Neurol Neurosci Rep 2013; 13:376. [DOI: 10.1007/s11910-013-0376-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Perspectives of public health laboratories in emerging infectious diseases. Emerg Microbes Infect 2013; 2:e37. [PMID: 26038473 PMCID: PMC3697305 DOI: 10.1038/emi.2013.34] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Revised: 04/30/2013] [Accepted: 05/09/2013] [Indexed: 12/21/2022]
Abstract
The world has experienced an increased incidence and transboundary spread of emerging infectious diseases over the last four decades. We divided emerging infectious diseases into four categories, with subcategories in categories 1 and 4. The categorization was based on the nature and characteristics of pathogens or infectious agents causing the emerging infections, which are directly related to the mechanisms and patterns of infectious disease emergence. The factors or combinations of factors contributing to the emergence of these pathogens vary within each category. We also classified public health laboratories into three types based on function, namely, research, reference and analytical diagnostic laboratories, with the last category being subclassified into primary (community-based) public health and clinical (medical) analytical diagnostic laboratories. The frontline/leading and/or supportive roles to be adopted by each type of public health laboratory for optimal performance to establish the correct etiological agents causing the diseases or outbreaks vary with respect to each category of emerging infectious diseases. We emphasize the need, especially for an outbreak investigation, to establish a harmonized and coordinated national public health laboratory system that integrates different categories of public health laboratories within a country and that is closely linked to the national public health delivery system and regional and international high-end laboratories.
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JC polyomavirus (JCV) and monoclonal antibodies: friends or potential foes? Clin Dev Immunol 2013; 2013:967581. [PMID: 23878587 PMCID: PMC3708391 DOI: 10.1155/2013/967581] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Accepted: 06/13/2013] [Indexed: 12/13/2022]
Abstract
Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease of the central nervous system (CNS), observed in immunodeficient patients and caused by JC virus ((JCV), also called JC polyomavirus (JCPyV)). After the HIV pandemic and the introduction of immunomodulatory therapy, the PML incidence significantly increased. The correlation between the use of natalizumab, a drug used in multiple sclerosis (MS), and the PML development of particular relevance. The high incidence of PML in natalizumab-treated patients has highlighted the importance of two factors: the need of PML risk stratification among natalizumab-treated patients and the need of effective therapeutic options. In this review, we discuss these two needs under the light of the major viral models of PML etiopathogenesis.
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Moua T, Rizza SA, Kennedy CC. Leg weakness in a lung transplant patient. Transpl Infect Dis 2013; 15:E102-6. [PMID: 23582024 DOI: 10.1111/tid.12080] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Revised: 11/15/2012] [Accepted: 12/23/2012] [Indexed: 11/29/2022]
Abstract
Progressive multifocal leukoencephalopathy (PML) is associated with JC polyomavirus (JCV) infection of central nervous system oligodendrocytes resulting in demyelinization and progressive focal neurologic deficits. Reactivation of dormant JCV occurs in the setting of immunosuppression, most commonly in patients with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) or hematological malignancies. PML has also been reported in solid organ transplant recipients. We report the case of a 61-year-old man after bilateral lung transplantation for chronic hypersensitivity pneumonitis who presented with leg weakness, cognitive decline, and expressive aphasia at 5 months post transplantation. Magnetic resonance imaging and brain biopsy were consistent with PML. Treatment attempt with cytarabine was unsuccessful, and immunomodulation resulted in recurrent grade A3 rejection. The difficulty of managing PML in lung transplant patients is highlighted by the lack of directed therapy and risk of graft rejection or failure with attempts at decreasing immunosuppression.
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Affiliation(s)
- T Moua
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, USA.
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40
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Gunst JD, Jensen-Fangel S, Jespersen B, Ostergaard L, Søgaard OS. Central nervous system infections among individuals with and without end-stage renal disease. J Infect 2013; 67:19-26. [PMID: 23549040 DOI: 10.1016/j.jinf.2013.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Revised: 02/27/2013] [Accepted: 03/15/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Individuals with immunodeficiencies are at increased risk of central nervous system (CNS) infections. Data are limited on the risk of CNS infections in patients with end-stage renal disease (ESRD). METHODS We conducted a population-based, nationwide cohort study among ESRD patients from 1990 to 2009. Data on ESRD patients was obtained from the Danish Nephrology Registry database. Each ESRD patient was matched with up to 19 population controls. Using the National Hospital Registry we identified hospital admissions with CNS infection as primary discharge diagnosis. RESULTS The study included 13,374 ESRD patients and 245,397 population controls, providing 67,012 person-years and 2,237,237 person-years of observation, respectively. The overall incidence rate (IR) of first-time hospitalisation for CNS infection was 149 per 100,000 person-years (95%-confidence interval [CI], 123-181) among ESRD patients. The IR of CNS infection was comparable among dialysis and transplant patients. Compared to population controls, the incidence rate-ratio of first CNS infection was 5.58 (95%-CI, 4.47-6.91) for ESRD patients in general. The 30-day mortality following hospitalisation for CNS infections was 21% (95%-CI, 14-30) among ESRD patients and 13% (95%-CI, 10-16) among population controls. CONCLUSIONS ESRD patients have considerable excess risk and mortality from CNS infections, which is of great clinical and public health concern.
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Affiliation(s)
- Jesper D Gunst
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus N, Denmark.
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Tang YW. Laboratory diagnosis of CNS infections by molecular amplification techniques. ACTA ACUST UNITED AC 2013; 1:489-509. [PMID: 23496356 DOI: 10.1517/17530059.1.4.489] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The initial presentation of symptoms and clinical manifestations of CNS infectious diseases often makes a specific diagnosis difficult and uncertain, and the emergence of polymerase chain reaction-led molecular techniques have been used in improving organism-specific diagnosis. These techniques have not only provided rapid, non-invasive detection of microorganisms causing CNS infections, but also demonstrated several neurologic disorders linked to infectious pathogens. Molecular methods performed on cerebrospinal fluid are recognized as the new 'gold standard' for some of these infections caused by microorganisms that are difficult to detect and identify. Although molecular techniques are predicted to be widely used in diagnosing and monitoring CNS infections, the limitations as well as strengths of these techniques must be clearly understood by both clinicians and laboratory personnel.
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Affiliation(s)
- Yi-Wei Tang
- Vanderbilt University Medical Center, 4605 TVC, Nashville, TN 37232-5310, USA +1 615 322 2035 ; +1 615 343 8420 ;
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Kusne S, Vilchez RA, Zanwar P, Quiroz J, Mazur MJ, Heilman RL, Mulligan D, Butel JS. Polyomavirus JC urinary shedding in kidney and liver transplant recipients associated with reduced creatinine clearance. J Infect Dis 2012; 206:875-80. [PMID: 22802433 PMCID: PMC3501156 DOI: 10.1093/infdis/jis469] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2012] [Accepted: 04/16/2012] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Polyomavirus reactivation can cause significant morbidity in solid organ transplant recipients, particularly BK virus (BKV) in kidney transplant patients. Less is known about dynamics of John Cunningham virus (JCV) in nonkidney organ transplant patients. METHODS We examined the frequency of urinary shedding of polyomaviruses BKV and JCV and their relationship to creatinine clearance (CrCl) in a longitudinal study of 41 kidney and 33 liver transplant recipients. RESULTS Any polyomavirus urinary shedding was more frequent in liver than kidney recipients (64% vs 39%; P= .03). JCV was excreted more frequently by liver than kidney recipients (71% vs 38%), whereas BKV was shed more often by kidney than liver patients (69% vs 52%). Mean JCV loads were significantly higher than those of BKV in both patient groups (P< .0001). Lower mean CrCl values were significantly associated with JCV shedding in both kidney and liver recipients (P< .001). CONCLUSIONS These findings suggest that BKV and JCV display different patterns of reactivation and shedding in kidney and liver transplant patients and that JCV may have a role in renal dysfunction in some solid organ transplant recipients.
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Affiliation(s)
- Shimon Kusne
- Department of Medicine, Mayo Clinic Arizona, Scottsdale, Arizona, USA.
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Razonable RR. Management of viral infections in solid organ transplant recipients. Expert Rev Anti Infect Ther 2011; 9:685-700. [PMID: 21692673 DOI: 10.1586/eri.11.43] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Management of viral infections after transplantation involves antiviral drug therapy (if available) and reduction in immunosuppression, which allows for development of pathogen-specific immunity to the offending virus. Prevention of viral infections is of the utmost importance, and this may be accomplished through vaccination, antiviral strategies and infection control measures. This article discusses the current management of selected viral pathogens that cause clinical illness in solid organ transplant recipients. The benefits and toxicities of antiviral therapies are discussed in the context of prevention and treatment of various viral diseases. The emerging issue of antiviral resistance is emphasized for cytomegalovirus, recurrent hepatitis B and influenza, while the importance of immunominimization is discussed in the management of BK nephropathy and virus-associated malignancies.
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Affiliation(s)
- Raymund R Razonable
- Division of Infectious Diseases, Department of Medicine, and the William J von Leibig Transplant Center, College of Medicine, Mayo Clinic, Rochester, MN 55905, USA.
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44
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Rare, unusual, and less common virus infections after organ transplantation. Curr Opin Organ Transplant 2011; 16:580-7. [DOI: 10.1097/mot.0b013e32834cdaf2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Abstract
The simian virus 40 and murine polyomaviruses were shown to be DNA tumor viruses in their natural hosts and/or heterologous experimental hosts in the mid-20th Century. The first two human polyomaviruses, the BK polyomavirus and JC polyomavirus, were discovered in 1971 and were shown to induce severe disease in immunocompromised patients, but their involvement in human cancers is still a matter for debate. The discovery of a polyomavirus associated with Merkel cell carcinoma (Merkel cell polyomavirus) in 2008 resulted in a renewed interest in the Polyomaviridae family, leading to the discovery of new human polyomaviruses. This review addresses the involvement of the nine human polyomaviruses and simian virus 40 in human diseases, with a particular focus on their prevalence and the humoral response directed against structural antigens in the general population and in subjects presenting specific diseases.
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Affiliation(s)
- Jérôme TJ Nicol
- Université François Rabelais, INSERM U618 Equipe Vecteurs, Virus, Vaccins. Faculté des Sciences Pharmaceutiques Philippe Maupas, 31 avenue Monge, 37200 TOURS, France
| | - Antoine Touzé
- Université François Rabelais, INSERM U618 Equipe Vecteurs, Virus, Vaccins. Faculté des Sciences Pharmaceutiques Philippe Maupas, 31 avenue Monge, 37200 TOURS, France
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Pustavoitau A, Bhardwaj A, Stevens R. Analytic Review: Neurological Complications of Transplantation. J Intensive Care Med 2011; 26:209-22. [DOI: 10.1177/0885066610389549] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Recipients of solid organ or hematopoietic cell transplants are at risk of life-threatening neurological disorders including encephalopathy, seizures, infections and tumors of the central nervous system, stroke, central pontine myelinolysis, and neuromuscular disorders—often requiring admission to, or occurring in, the intensive care unit (ICU). Many of these complications are linked directly or indirectly to immunosuppressive therapy. However, neurological disorders may also result from graft versus host disease, or be an expression of the underlying disease which prompted transplantation, as well as injury induced during radiation, chemotherapy, surgery, and ICU stay. In rare cases, neuroinfectious pathogens may be transmitted with the transplanted tissue or organ. Diagnosis may be a challenge because clinical symptoms and findings on neuroimaging lack specificity, and a biological specimen or tissue diagnosis is often needed for definitive diagnosis. Management is centered on preventing further neurological injury, etiology-targeted therapy, and balancing the benefits and toxicities of specific immunosuppressive agents.
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Affiliation(s)
- Aliaksei Pustavoitau
- Departments of Anesthesiology Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Anish Bhardwaj
- Departments of Neurology and Neurological Surgery, Tufts University School of Medicine, Boston, MA, USA,
| | - Robert Stevens
- Departments of Anesthesiology Critical Care Medicine, Neurology, Neurosurgery, and Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Abstract
Natalizumab is an α4-integrin antagonist approved as monotherapy for patients with relapsing multiple sclerosis (MS), based on demonstrated efficacy in the pivotal AFFIRM study (N = 942). Natalizumab monotherapy reduced risk of disability progression by 42%–54% and annualized relapse rate by 68% during a period of 2 years. Natalizumab was also associated with significant reductions in number of T2-hyperintense, gadolinium-enhancing, and T1-hypointense lesions and in volume of T2-hyperintense lesions (all p < 0.001) on magnetic resonance imaging. Furthermore, natalizumab-treated patients in AFFIRM experienced significant improvements from baseline in the physical and mental components of the Short Form-36 (p ≤ 0.01) and a 35% reduction in risk of clinically significant vision loss (p = 0.008 vs placebo). Natalizumab was well tolerated in phase 3 studies. Common adverse events were generally mild and included headache, fatigue, urinary tract infections, and arthralgia. Serious adverse events were similar between treatment groups. The incidence of serious hypersensitivity reactions associated with natalizumab was <1%. Progressive multifocal leukoencephalopathy was a rare complication of treatment, observed in 2 patients with MS who received natalizumab plus interferon β-1a. The robust clinical benefits of natalizumab, including benefits on patient-reported quality of life, make it an important addition to disease-modifying therapies available to patients with relapsing MS.
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Wu J, Langford LA, Schellingerhout D, Guha-Thakurta N, Tummala S, Weinberg JS, Puduvalli VK. Progressive multifocal leukoencephalopathy in a patient with glioblastoma. J Neurooncol 2011; 103:791-6. [PMID: 21120583 PMCID: PMC5546753 DOI: 10.1007/s11060-010-0453-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2010] [Accepted: 10/25/2010] [Indexed: 02/03/2023]
Abstract
Malignant gliomas are aggressive malignancies which inevitably recur despite multimodality treatment. In a subset of patients who are longer term survivors of this disease, progressive radiologic worsening can also occur from late effects of radiation rather than recurrent tumor, a differential diagnosis that is commonly considered in this setting. However, other causes for radiologic progression are not as well recognized and could potentially confound management leading to incorrect treatment decisions. Progressive multifocal leukoencephalopathy (PML) is a rare infectious demyelinating disease of the central nervous system seen primarily in immunocompromised patients, the early diagnosis and treatment of which remains a challenge. Here, we report a case of a long term survivor with glioblastoma whose diagnostic and therapeutic management was confounded by the development of PML. We review the radiological features and clinical course of this patient to highlight the dramatic neurological course in the setting of a highly malignant tumor, and emphasize the unusual changes in diffusion weighted images, and the need for clinical suspicion for early diagnosis of PML.
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Affiliation(s)
- Jing Wu
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Lauren A. Langford
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Dawid Schellingerhout
- Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Nandita Guha-Thakurta
- Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Sudhakar Tummala
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Jeffrey S. Weinberg
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Vinay K. Puduvalli
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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Fernández-Ruiz M, de la Serna J, Ruiz J, López-Medrano F. [Progressive multifocal leukoencephalopathy in a patient with acute myeloid leukaemia after allogeneic hematopoietic-cell transplantation]. Enferm Infecc Microbiol Clin 2011; 29:636-7. [PMID: 21696864 DOI: 10.1016/j.eimc.2011.03.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2011] [Revised: 03/13/2011] [Accepted: 03/31/2011] [Indexed: 11/17/2022]
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Affiliation(s)
- Christina Nguyen
- Division of Pediatric Nephrology, Children’s
Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Ron Shapiro
- Department of Surgery, Thomas E. Starzl Transplantation
Institute, University of Pittsburgh, Pittsburgh, PA, USA
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