Simultaneous infection with multiple herpesviruses

Coexisting infectious diseases on admission as a risk factor for mechanical ventilation in patients with Guillain-Barré syndrome

Background

The aim of this study was to investigate patient characteristics on admission to hospital that increase the risk of subsequent mechanical ventilation (MV) use for patients with Guillain–Barré syndrome (GBS).

Methods

We extracted data from the Japanese Diagnosis Procedure Combination (DPC) database for 4132 GBS patients admitted to hospital. Clinical characteristics of GBS patients with and without MV were compared. Multivariate logistic regression analyses were performed to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) for the associations of requirement for MV with coexisting infectious diseases, after adjustment for potential confounding variables, age, sex, hospital type, and ambulance transportation.

Results

In total, 281 patients required MV, and 493 patients had coexisting respiratory diseases on admission. After adjustment for covariates and stratification by coexisting respiratory diseases, multivariate logistic regression analysis revealed that coexisting cytomegaloviral (CMV) disease (OR 8.81; 95% CI, 2.34–33.1) and herpes simplex viral (HSV) infections (OR 4.83; 95% CI, 1.16–20.1) were significantly associated with the requirement for MV in the group without coexisting respiratory diseases.

Conclusion

Our findings suggest that coexisting CMV and HSV infections on admission might be significantly associated with increased risk of respiratory failure in GBS patients.

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Subjects of this study were 4132 inpatients with Guillain–Barré syndrome.

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Data were derived from the Japanese Diagnosis Procedure Combination (DPC) database.

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Association between comorbidities and mechanical ventilation use was evaluated.

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Cytomegaloviral and herpes simplex viral infections were associated with ventilation.

Coreactivation of Human Herpesvirus 6 and Cytomegalovirus Is Associated With Worse Clinical Outcome in Critically Ill Adults

OBJECTIVES

Human herpesvirus 6 is associated with a variety of complications in immunocompromised patients, but no studies have systematically and comprehensively assessed the impact of human herpesvirus 6 reactivation, and its interaction with cytomegalovirus, in ICU patients.

DESIGN

We prospectively assessed human herpesvirus 6 and cytomegalovirus viremia by twice-weekly plasma polymerase chain reaction in a longitudinal cohort study of 115 adult, immunocompetent ICU patients. The association of human herpesvirus 6 and cytomegalovirus reactivation with death or continued hospitalization by day 30 (primary endpoint) was assessed by multivariable logistic regression analyses.

SETTING

This study was performed in trauma, medical, surgical, and cardiac ICUs at two separate hospitals of a large tertiary care academic medical center.

PATIENTS

A total of 115 cytomegalovirus seropositive, immunocompetent adults with critical illness were enrolled in this study.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Human herpesvirus 6 viremia occurred in 23% of patients at a median of 10 days. Human herpesvirus 6B was the species detected in eight samples available for testing. Most patients with human herpesvirus 6 reactivation also reactivated cytomegalovirus (70%). Severity of illness was not associated with viral reactivation. Mechanical ventilation, burn ICU, major infection, human herpesvirus 6 reactivation, and cytomegalovirus reactivation were associated with the primary endpoint in unadjusted analyses. In a multivariable model adjusting for mechanical ventilation and ICU type, only coreactivation of human herpesvirus 6 and cytomegalovirus was significantly associated with the primary endpoint (adjusted odds ratio, 7.5; 95% CI, 1.9-29.9; p = 0.005) compared to patients with only human herpesvirus 6, only cytomegalovirus, or no viral reactivation.

CONCLUSIONS

Coreactivation of both human herpesvirus 6 and cytomegalovirus in ICU patients is associated with worse outcome than reactivation of either virus alone. Future studies should define the underlying mechanism(s) and determine whether prevention or treatment of viral reactivation improves clinical outcome.

Detection of intraocular antibody production to herpesviruses in acute retinal necrosis syndrome

In order to improve the determination of the causative agent in acute retinal necrosis syndrome, we evaluated the detection of intraocular antibody production to herpesviruses in 28 patients with this disease. Intraocular antibody production was determined by calculation of the Goldmann-Witmer coefficient whereby specific antibody titers in the inflamed eye and circulation are related to the total IgG content in ocular fluid and serum. Specific antibody titers to herpesviruses and Toxoplasma were determined by the indirect immunofluorescence technique. Thirty-five patients with ocular toxoplasmosis, cataract, or proliferative vitreoretinal disorders were tested as controls. By this technique, intraocular antibody production to varicella zoster virus or herpes simplex virus could be established in 16 (57%) of the patients with the typical clinical features of acute retinal necrosis, compared to none of the controls. Of the 33 affected eyes, 21 (64%) had a visual outcome of less than 20/200. We concluded that detection of intraocular antibody production to herpesviruses may be a useful diagnostic tool in establishing the causative agents in acute retinal necrosis.

Treatment of childhood combined Epstein-Barr virus/cytomegalovirus infection with oral bovine transfer factor

An illness lasting for two years, with recurrent fever, rash, abdominal pain, and arthralgia, developed in a four year old boy. He was found to have a combined Epstein-Barr virus and cytomegalovirus (CMV) infection. His symptoms, CMV in his urine, and an absent in vitro lymphocyte response to CMV antigen persisted for two years. After treatment with orally administered bovine transfer factor clinical symptoms and viruria disappeared and specific immunity to CMV developed. Evaluation of this treatment in chronic virus infections is warranted.

Epstein-Barr virus-related serology in marrow transplant recipients

Serial sera from 50 marrow transplant recipients were examined for their spectra and titers of antibodies to EBV-specific antigens. Immediately before or after transplant, blood products passively transferred antibodies to EB viral capsid antigen (VCA) and EBV nuclear antigen (EBNA). In most recipients, passively-transferred antibodies were replaced by endogenous antibodies regardless of whether donor or recipient had EBV antibodies before transplantation. Commencement or resumption of endogenous EBV antibody production was not associated with signs of infectious mononucleosis or heterophil antibody responses. Antibodies to VCA rose to abnormally high titers, followed successively by antibody to early antigens (EA), and disproportionately low levels of anti-EBNA. Unusually high anti-VCA and anti-EA levels persisted when tests of immune function returned to normal. Antibodies to other herpes group viruses showed no consistent changes. We conclude that (1) EBV does not cause significant clinical problems in marrow transplant recipients; (2) persistent EBV infection can become established or reestablished in the presence of antibodies to EBV; (3) marrow transplant recipients show the same exaggerated immune response to EBV as other immunodeficient patients; and (4) the pattern of EBV-specific antibodies may be a more sensitive measure of defective cell-mediated immunity than most conventional tests of immune function.