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Case R, Stoner P, Myrick S, Zimmermann E. Solitary ascending colon ulcer diagnosed as gastrointestinal CMV disease. BMJ Case Rep 2019; 12:12/2/bcr-2018-226355. [PMID: 30739086 DOI: 10.1136/bcr-2018-226355] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 42-year-old woman with a history of cholangiocarcinoma on adjuvant chemotherapy with capecitabine presented with painless haematochezia. She was found to have an isolated twenty-five mm ulcer in the ascending colon. Biopsies of the ulceration demonstrated typical cytomegalovirus (CMV) inclusions and her peripheral blood CMV PCR was significantly elevated. This is an unusual case of a solitary proximal colon ulcer. Non-steroidal anti-inflammatory drugs, inflammatory bowel disease and malignancy, are the most frequent causes of isolated ulcers in the proximal colon. Gastrointestinal (GI) CMV disease most commonly causes CMV colitis and is considered rare outside of the transplant population and other severely immunosuppressed patient groups. Patients who have received chemotherapy may also be at risk for GI CMV disease. The diagnosis should be suspected in patients who present with haematochezia or watery diarrhoea within a broad window of time after receiving chemotherapy.
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Affiliation(s)
- Robert Case
- Department of Internal Medicine, University of Florida, Gainesville, Florida, USA
| | - Patrick Stoner
- Department of Internal Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Samuel Myrick
- Florida Cancer Affiliates Ocala, Ocala, Florida, USA
| | - Ellen Zimmermann
- Gastroenterology, University of Florida College of Medicine, Gainesville, Florida, USA
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2
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Noble J, Gatault P, Sautenet B, Gaudy-Graffin C, Beby-Defaux A, Thierry A, Essig M, Halimi JM, Munteanu E, Alain S, Buchler M. Predictive factors of spontaneous CMV DNAemia clearance in kidney transplantation. J Clin Virol 2018; 99-100:38-43. [DOI: 10.1016/j.jcv.2017.12.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 11/18/2017] [Accepted: 12/20/2017] [Indexed: 12/26/2022]
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3
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Madi N, Al-Qaser M, Edan R, Al-Nakib W. Clinical Utility of Viral Load in the Management of Cytomegalovirus Infection in Solid Organ Transplant Patients in Kuwait. Transplant Proc 2015; 47:1802-7. [DOI: 10.1016/j.transproceed.2015.05.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 04/28/2015] [Accepted: 05/14/2015] [Indexed: 02/07/2023]
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4
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Clinical utility of viral load in management of cytomegalovirus infection after solid organ transplantation. Clin Microbiol Rev 2014; 26:703-27. [PMID: 24092851 DOI: 10.1128/cmr.00015-13] [Citation(s) in RCA: 151] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The negative impact of cytomegalovirus (CMV) infection on transplant outcomes warrants efforts toward improving its prevention, diagnosis, and treatment. During the last 2 decades, significant breakthroughs in diagnostic virology have facilitated remarkable improvements in CMV disease management. During this period, CMV nucleic acid amplification testing (NAT) evolved to become one of the most commonly performed tests in clinical virology laboratories. NAT provides a means for rapid and sensitive diagnosis of CMV infection in transplant recipients. Viral quantification also introduced several principles of CMV disease management. Specifically, viral load has been utilized (i) for prognostication of CMV disease, (ii) to guide preemptive therapy, (iii) to assess the efficacy of antiviral treatment, (iv) to guide the duration of treatment, and (v) to indicate the risk of clinical relapse or antiviral drug resistance. However, there remain important limitations that require further optimization, including the interassay variability in viral load reporting, which has limited the generation of standardized viral load thresholds for various clinical indications. The recent introduction of an international reference standard should advance the major goal of uniform viral load reporting and interpretation. However, it has also become apparent that other aspects of NAT should be standardized, including sample selection, nucleic acid extraction, amplification, detection, and calibration, among others. This review article synthesizes the vast amount of information on CMV NAT and provides a timely review of the clinical utility of viral load testing in the management of CMV in solid organ transplant recipients. Current limitations are highlighted, and avenues for further research are suggested to optimize the clinical application of NAT in the management of CMV after transplantation.
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Abstract
Since the early 1990s, great efforts have been made in the field of human cytomegalovirus (HCMV) diagnosis. Besides HCMV diagnosis in immunosuppressed patients (solid organ transplant recipients, hematopoietic stem cell transplant patients and AIDS patients), diagnosis in connection with congenital HCMV infection is of great interest. This review focuses on the development and clinical utility of serological assays, as well as on virological tests (molecular and nonmolecular assays). Interpretation of these tests is strongly dependent on the patient group (solid organ transplant recipients and hematopoietic stem cell transplant patients) and whether the tests are used for screening, risk stratification or diagnosis. Furthermore, a better understanding of HCMV infection has led to new approaches in HCMV diagnosis and monitoring. Thus, assays for viral resistance testing and assays for monitoring the HCMV-specific cellular immune response are increasingly important for the guidance of antiviral therapy.
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Metzgar D, Lovari R, Ray K, Baynes D, Drapp D, Frinder M, Vijesurier R, Stemler M, Ofsaiof R, Carolan H, Welk J, Toleno D, Ranken R, Hall TA, Massire C, Sampath R, Blyn LB, Goveia J, Schneider G. Analytical characterization of an assay designed to detect and identify diverse agents of disseminated viral infection. J Clin Virol 2013; 59:177-83. [PMID: 24440177 DOI: 10.1016/j.jcv.2013.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Revised: 12/14/2013] [Accepted: 12/18/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Diverse viruses often reactivate in or infect cancer patients, patients with immunocompromising infections or genetic conditions, and transplant recipients undergoing immunosuppressive therapy. These infections can disseminate, leading to death, transplant rejection, and other severe outcomes. OBJECTIVES To develop and characterize an assay capable of inclusive and accurate identification of diverse potentially disseminating viruses directly from plasma specimens. STUDY DESIGN We developed a PCR/electrospray ionization mass spectrometry (PCR/ESI-MS) assay designed to simultaneously detect and identify adenovirus, enterovirus, polyomaviruses JC and BK, parvovirus B19, HSV-1, HSV-2, VZV, EBV, CMV, and herpesviruses 6-8 in plasma specimens. The assay performance was characterized analytically, and the results from clinical plasma samples were compared to the results obtained from single-analyte real time PCR tests currently used in clinical practice. RESULTS The assay demonstrated sensitivity and specificity to diverse strains of the targeted viral families and robustness to interfering substances and potentially cross reacting organisms. The assay yielded 94% sensitivity when testing clinical plasma samples previously identified as positive using standard-of-care real-time PCR tests for a single target virus (available samples included positive samples for 11 viruses targeted by the assay). CONCLUSIONS The assay functioned as designed, providing simultaneous broad-spectrum detection and identification of diverse agents of disseminated viral infection. Among 156 clinical samples tested, 37 detections were made in addition to the detections matching the initial clinical positive results.
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Affiliation(s)
- David Metzgar
- Ibis Biosciences, a Division of Abbott, 2251 Faraday Ave, Ste 150, Carlsbad, CA 92008, United States.
| | - Robert Lovari
- Ibis Biosciences, a Division of Abbott, 2251 Faraday Ave, Ste 150, Carlsbad, CA 92008, United States
| | - Keith Ray
- Ibis Biosciences, a Division of Abbott, 2251 Faraday Ave, Ste 150, Carlsbad, CA 92008, United States
| | - Darcie Baynes
- Ibis Biosciences, a Division of Abbott, 2251 Faraday Ave, Ste 150, Carlsbad, CA 92008, United States
| | - Darren Drapp
- Ibis Biosciences, a Division of Abbott, 2251 Faraday Ave, Ste 150, Carlsbad, CA 92008, United States
| | - Mark Frinder
- Ibis Biosciences, a Division of Abbott, 2251 Faraday Ave, Ste 150, Carlsbad, CA 92008, United States
| | - Roy Vijesurier
- Ibis Biosciences, a Division of Abbott, 2251 Faraday Ave, Ste 150, Carlsbad, CA 92008, United States
| | - Michelle Stemler
- Ibis Biosciences, a Division of Abbott, 2251 Faraday Ave, Ste 150, Carlsbad, CA 92008, United States
| | - Reuben Ofsaiof
- Ibis Biosciences, a Division of Abbott, 2251 Faraday Ave, Ste 150, Carlsbad, CA 92008, United States
| | - Heather Carolan
- Ibis Biosciences, a Division of Abbott, 2251 Faraday Ave, Ste 150, Carlsbad, CA 92008, United States
| | - Joseph Welk
- Ibis Biosciences, a Division of Abbott, 2251 Faraday Ave, Ste 150, Carlsbad, CA 92008, United States
| | - Donna Toleno
- Ibis Biosciences, a Division of Abbott, 2251 Faraday Ave, Ste 150, Carlsbad, CA 92008, United States
| | - Raymond Ranken
- Ibis Biosciences, a Division of Abbott, 2251 Faraday Ave, Ste 150, Carlsbad, CA 92008, United States
| | - Thomas A Hall
- Ibis Biosciences, a Division of Abbott, 2251 Faraday Ave, Ste 150, Carlsbad, CA 92008, United States
| | - Christian Massire
- Ibis Biosciences, a Division of Abbott, 2251 Faraday Ave, Ste 150, Carlsbad, CA 92008, United States
| | - Rangarajan Sampath
- Ibis Biosciences, a Division of Abbott, 2251 Faraday Ave, Ste 150, Carlsbad, CA 92008, United States
| | - Lawrence B Blyn
- Ibis Biosciences, a Division of Abbott, 2251 Faraday Ave, Ste 150, Carlsbad, CA 92008, United States
| | - Jon Goveia
- Ibis Biosciences, a Division of Abbott, 2251 Faraday Ave, Ste 150, Carlsbad, CA 92008, United States
| | - George Schneider
- Ibis Biosciences, a Division of Abbott, 2251 Faraday Ave, Ste 150, Carlsbad, CA 92008, United States
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Jongsma H, Bouts AH, Cornelissen EAM, Beersma MFC, Cransberg K. Cytomegalovirus prophylaxis in pediatric kidney transplantation: the Dutch experience. Pediatr Transplant 2013; 17:510-7. [PMID: 23890076 DOI: 10.1111/petr.12115] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/21/2013] [Indexed: 11/30/2022]
Abstract
Many children receiving a kidney transplant are seronegative for CMV and therefore, highly susceptible to a primary CMV infection. This study aims at evaluating incidence, time of occurrence, and severity of CMV infection in the first year post-transplantation in relation to different types of CMV prophylaxis. Transplantations in three centers in the Netherlands between 1999 and 2010 were included. Retrospective, observational, multicenter study. Clinical data and PCR measurements of CMV were collected. Prophylaxis in high-risk patients (CMV serostatus D+R-) consisted of (val)ganciclovir during three months, or acyclovir plus CMV immunoglobulin at a former stage. Intermediate-risk patients (R+) received (val)acyclovir, or acyclovir plus CMV immunoglobulin at a former stage. Low-risk patients (D-R-) did not receive prophylaxis. Infection was defined as CMV PCR above 50 geq/mL plasma or whole blood, a clinically relevant infection above 1000 geq/mL. One hundred and fifty-nine transplantations were included. CMV infection was documented for 41% of high-risk, 24% of intermediate-risk, and 13% of low-risk patients, in the latter two groups typically during the first three months. The infection rate was highest in the high-risk group after cessation of valganciclovir prophylaxis. Valganciclovir provided better protection than did acyclovir + CMV immunoglobulin. Adding an IL2-receptor blocker to the immunosuppressive regimen did not affect the infection rate. Acute graft rejection was not related with CMV infection. Valganciclovir prophylaxis effectively prevents CMV infection in high-risk pediatric kidney recipients, but only during prophylaxis. Valacyclovir prophylaxis in intermediate-risk patients is less effective.
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Affiliation(s)
- Hidde Jongsma
- Department of Pediatric Nephrology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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8
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Max D, Brandsch C, Schumann S, Kühne H, Frommhagen M, Schutkowski A, Hirche F, Staege MS, Stangl GI. Maternal vitamin D deficiency causes smaller muscle fibers and altered transcript levels of genes involved in protein degradation, myogenesis, and cytoskeleton organization in the newborn rat. Mol Nutr Food Res 2013; 58:343-52. [PMID: 23963738 DOI: 10.1002/mnfr.201300360] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Revised: 06/24/2013] [Accepted: 06/26/2013] [Indexed: 12/17/2022]
Abstract
SCOPE Epidemiologic data reveal associations between low serum concentrations of 25-hydroxyvitamin D (25(OH)D) and higher risk of falls and muscle weakness. Fetal stage is critical for the development of skeletal muscle, but little information is available on the impact of maternal vitamin D deficiency on muscles of offspring. METHODS AND RESULTS To investigate the morphology and transcriptome of gastrocnemius muscle in newborns in response to maternal vitamin D deficiency, 14 female rats were fed either a vitamin D₃ deficient (0 IU/kg) or a vitamin D₃ adequate diet (1000 IU/kg) 8 weeks prior to conception, during pregnancy, and lactation. Analysis of cholecalciferol, 25(OH)D₃ and 1,25-dihydroxyvitamin D₃ show that dams fed the vitamin D deficient diet and their newborns suffered from a relevant vitamin D deficiency. Muscle cells of vitamin D deficient newborns were smaller than those of vitamin D adequate newborns (p < 0.05). Muscle transcriptome of the newborns revealed 426 probe sets as differentially expressed (259 upregulated, 167 downregulated) in response to vitamin D deficiency (fold change ≥1.5, p < 0.05). The effected genes are involved in protein catabolism, cell differentiation and proliferation, muscle cell development, and cytoskeleton organization. CONCLUSION Maternal vitamin D deficiency has a major impact on morphology and gene expression profile of skeletal muscle in newborns.
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Affiliation(s)
- Daniela Max
- Institute of Agricultural and Nutritional Sciences, Martin-Luther-University Halle-Wittenberg, Halle/Saale, Germany
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9
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Quantification of cytomegalovirus DNA by a fully automated real-time PCR for early diagnosis and monitoring of active viral infection in solid organ transplant recipients. J Clin Virol 2012. [PMID: 23182772 DOI: 10.1016/j.jcv.2012.10.015] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Quantification of cytomegalovirus (CMV) DNA by real-time PCR is currently considered an alternative diagnostic approach for the evaluation of active infection in transplant patients. The pp65 antigenemia assay has been used as reference test for monitoring active CMV infection and guiding preemptive therapy in transplant recipients. However, this assay suffers from some limitations: need for immediate processing of the samples, labour-intensive process, lack of standardization and subjective result interpretation. OBJECTIVES The aim of this study was to evaluate the performance of a new commercially available real-time PCR assay coupled with a fully automated DNA extraction system (COBAS Ampliprep/COBAS Taqman CMV Test, Roche Diagnostics) for the detection of CMV-DNA in plasma comparing it with pp65 antigenemia assay for monitoring active CMV infection in solid organ transplant recipients (SOTRs). STUDY DESIGN A total of 266 consecutive samples from 45 SOTRs were monitored with pp65 antigenemia and in parallel with CMV-DNA quantitation by real-time PCR assay. RESULTS Fifty-eight samples resulted PCR-positive, 163 negative and for 45 samples the CMV-DNA values obtained were below the lower limit of quantification (<150 copies/ml); pp65 antigen was detected in 47 samples and resulted negative in 219 specimens. Concordance between the two evaluations was 76.7%; also a good correlation was observed (r=0.718). Considering the existing treatment criteria based on pp65 antigenemia evaluation corresponding to pp65 levels≥20 positive cells/200,000, preemptive therapy was administered to four asymptomatically infected patients. The corresponding cut-off value of CMV-DNA load calculated for discrimination between self-clearing infections and those requiring therapy was 2500 copies/ml (or 2275 IU/ml). CONCLUSION The fully automated real-time PCR from Roche provided specific and sensitive results and represented a rapid and simple assay for the evaluation and monitoring of CMV infection in SOTRs. Further studies are required to validate the threshold level for the initiation of preemptive therapy.
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Abstract
Cytomegalovirus (CMV) infection is common worldwide, but the majority are asymptomatic. However, during initial infection or reactivation, CMV can cause tissue-invasive end-organ damage including in the gastrointestinal tract, especially in immunocompromised individuals. Gastrointestinal CMV disease can present with myriad of symptoms and be highly variable endoscopically. In this article we review the manifestations of CMV infection within the luminal gastrointestinal tract and discuss the options for diagnosis and management.
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Affiliation(s)
- David M You
- Department of Gastroenterology, Naval Medical Center, San Diego, CA 92134, USA.
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11
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Rha B, Redden D, Benfield M, Lakeman F, Whitley RJ, Shimamura M. Correlation and clinical utility of pp65 antigenemia and quantitative polymerase chain reaction assays for detection of cytomegalovirus in pediatric renal transplant patients. Pediatr Transplant 2012; 16:627-37. [PMID: 22694244 PMCID: PMC3461327 DOI: 10.1111/j.1399-3046.2012.01741.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
qPCR and pp65 antigenemia assays are used to monitor CMV infection in renal transplant recipients, but correlation of assays in a pediatric population has not been evaluated. Paired CMV real-time qPCR and pp65 antigenemia tests from 882 blood samples collected from 115 pediatric renal transplant recipients were analyzed in this retrospective cohort study for the strength of association and clinical correlates. The assays correlated well in detecting infection (κ = 0.61). Higher qPCR values were demonstrated with increasing levels of antigenemia (p < 0.01). Discordant test results were associated with antiviral treatment (OR 4.33, p < 0.01) and low-level viremia, with odds of concordance increasing at higher qPCR values (OR 3.67, p < 0.01), and no discordance occurring above 8500 genomic equivalents/mL. Among discordant samples, neither test preceded the other in detecting initial infection or in returning to negative while on treatment. Only two cases of disease occurred during the two-yr study period. With strong agreement in the detection of CMV infection, either qPCR or pp65 antigenemia assays can be used effectively for monitoring pediatric renal transplant patients for both detection and resolution of infection.
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Affiliation(s)
- Brian Rha
- Department of Pediatrics Biostatistics, The University of Alabama, Birmingham, AL, USA.
| | - David Redden
- Department of Biostatistics, School of Public Health, The University of Alabama at Birmingham, AL, USA
| | - Mark Benfield
- Pediatric Nephrology of Alabama, Birmingham, AL, USA
| | - Fred Lakeman
- Department of Pediatrics, Division of Infectious Diseases, School of Public Health, The University of Alabama at Birmingham, AL, USA
| | - Richard J. Whitley
- Department of Pediatrics, Division of Infectious Diseases, School of Public Health, The University of Alabama at Birmingham, AL, USA
| | - Masako Shimamura
- Department of Pediatrics, Division of Infectious Diseases, School of Public Health, The University of Alabama at Birmingham, AL, USA
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12
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Fariñas MC, Torre-Cisneros J, Pahissa A. [Lights and shadows of cytomegalovirus infection in solid organ transplantation]. Enferm Infecc Microbiol Clin 2012; 29 Suppl 6:1-3. [PMID: 22541913 DOI: 10.1016/s0213-005x(11)70048-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Cytomegalovirus (CMV) develops in 30-80% of patients undergoing solid organ transplantation (SOT). The incidence and presence of symptomatic disease varies depending on the type of transplant, the presence of associated risk factors, the intensity of immunosuppression, and the prevention strategies used. The impact of CMV on SOT is due not only to the effects of CMV disease per se, but also to its multiple indirect effects resulting from its immunomodulatory role and immunoactivation caused by viral latency. The two prophylactic strategies used (universal prophylaxis and preemptive therapy) are equally useful. Both strategies have advantages and disadvantages, and uncertainties remain on the populations that should receive prophylaxis and for how long. Viral monitoring to detect CMV infection is important for diagnosis, prognosis and evaluation of treatment response. The new real-time polymerase chain reaction techniques have provided numerous advantages but standardization remains an issue and common reference values are required. Specific anti-CMV drugs are available but issues such as the role of valganciclovir versus ganciclovir, the development of resistances and optimal treatment length are still being debated. Complementary therapy with mTOR inhibitors and vaccine strategies against CMV are alternatives for which conclusive data are lacking.
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Affiliation(s)
- M Carmen Fariñas
- Unidad de Enfermedades Infecciosas, Hospital Universitario Marqués de Valdecilla, IFIMAV, Universidad de Cantabria, Santander, España.
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Khansarinejad B, Soleimanjahi H, Mirab Samiee S, Hamidieh AA, Paryan M, Sanahmadi Y. Quantitation of human cytomegalovirus DNA in plasma using an affordable in-house qPCR assay. J Virol Methods 2012; 183:170-5. [DOI: 10.1016/j.jviromet.2012.04.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2012] [Revised: 04/05/2012] [Accepted: 04/23/2012] [Indexed: 12/17/2022]
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Cimsit B, Tichy EM, Patel SB, Rosencrantz R, Emre S. Treatment of adenovirus hepatitis with cidofovir in a pediatric liver transplant recipient. Pediatr Transplant 2012; 16:E90-3. [PMID: 21226811 DOI: 10.1111/j.1399-3046.2010.01443.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AdV hepatitis is a rarely reported complication after pediatric liver transplantation that is associated with high rates of morbidity, mortality and graft failure. Successful treatment of AdV relies on early diagnosis of disease by quantitative PCR measurement of adenoviral DNA in blood and histological evidence in tissue biopsy. Pharmacologic treatment largely consists of antiviral therapy with CDV, an acyclic nucleoside phosphonate analog and reduction in immunosuppression. This report describes a case of AdV hepatitis in a pediatric liver transplant recipient successfully treated with a modified, renal sparing dosing of CDV.
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Affiliation(s)
- Bayindir Cimsit
- Surgery, Yale University School of Medicine, New Haven, CT 06520, USA
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15
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Rhee JY, Peck KR, Lee NY, Song JH. Clinical usefulness of plasma quantitative polymerase chain reaction assay: diagnosis of cytomegalovirus infection in kidney transplant recipients. Transplant Proc 2012; 43:2624-9. [PMID: 21911135 DOI: 10.1016/j.transproceed.2011.05.054] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Accepted: 05/11/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND Preemptive therapy is used to prevent cytomegalovirus (CMV) disease in transplant recipients. The CMV antigenemia assay, which has been commonly used as a predictive marker for preemptive therapy, requires intensive labor and immediate processing. We compared the cutoff value of plasma CMV polymerase chain reaction (PCR) with CMV antigenemia in kidney transplant recipients. METHODS We compared two diagnostic methods for CMV infection in kidney transplant recipients: quantitative PCR (qPCR) versus antigenemia. We evaluated the optimal cutoff value of plasma CMV qPCR by using receiver-operating characteristic curves for specific antigenemia values. All kidney transplant recipients from January 2004 to January 2005 were enrolled and followed with CMV antigenemia and plasma CMV qPCR. RESULTS The analyses were performed on 899 samples collected from 111 patients in the early posttransplant period, matching 84.1% of patients for the results of CMV antigenemia and plasma CMV qPCR. For patients with symptomatic CMV infection and disease, who showed ≥25 positive cells in the antigenemia assay, the cutoff value for qPCR was 17.8 copies/μL with a sensitivity of 97.1%, a specificity of 89.1%, and a positive predictive value of 26.6%. CONCLUSIONS Diagnostic assays for CMV such as CMV antigenemia and quantitative plasma PCR, showed similar diagnostic values. They are the methods of choice for the diagnosis and monitoring of active CMV infection after kidney transplantation. However, because of the relatively low positive predictive value of qPCR, this test may lead to unnecessary preemptive treatment in kidney transplant recipients.
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Affiliation(s)
- J-Y Rhee
- Division of Infectious diseases, Department of Medicine, Dankook University College of Medicine, Dankook University Hospital, Cheonan, South Korea
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16
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Técnicas de monitorización de la infección por citomegalovirus en los trasplantados de órgano sólido. Enferm Infecc Microbiol Clin 2011; 29 Suppl 6:18-23. [DOI: 10.1016/s0213-005x(11)70052-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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17
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18
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Kerschner H, Bauer C, Schlag P, Lee S, Goedel S, Popow-Kraupp T. Clinical evaluation of a fully automated CMV PCR assay. J Clin Virol 2011; 50:281-6. [DOI: 10.1016/j.jcv.2010.12.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2010] [Revised: 12/01/2010] [Accepted: 12/21/2010] [Indexed: 11/29/2022]
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Peres RMB, Costa CRC, Andrade PD, Bonon SHA, Albuquerque DM, de Oliveira C, Vigorito AC, Aranha FJP, de Souza CA, Costa SCB. Surveillance of active human cytomegalovirus infection in hematopoietic stem cell transplantation (HLA sibling identical donor): search for optimal cutoff value by real-time PCR. BMC Infect Dis 2010; 10:147. [PMID: 20515464 PMCID: PMC2890007 DOI: 10.1186/1471-2334-10-147] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2009] [Accepted: 06/01/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Human cytomegalovirus (CMV) infection still causes significant morbidity and mortality after allogeneic hematopoietic stem cell transplantation (HSCT). Therefore, it is extremely important to diagnosis and monitor active CMV infection in HSCT patients, defining the CMV DNA levels of virus replication that warrant intervention with antiviral agents in order to accurately prevent CMV disease and further related complications. METHODS During the first 150 days after allogeneic HSTC, thirty patients were monitored weekly for active CMV infection by pp65 antigenemia, nested-PCR and real-time PCR assays. Receiver operating characteristic (ROC) plot analysis was performed to determine a threshold value of the CMV DNA load by real-time PCR. RESULTS Using ROC curves, the optimal cutoff value by real-time PCR was 418.4 copies/104 PBL (sensitivity, 71.4%; specificity, 89.7%). Twenty seven (90%) of the 30 analyzed patients had active CMV infection and two (6.7%) developed CMV disease. Eleven (40.7%) of these 27 patients had acute GVHD, 18 (66.7%) had opportunistic infection, 5 (18.5%) had chronic rejection and 11 (40.7%) died - one died of CMV disease associated with GVHD and bacterial infection. CONCLUSIONS The low incidence of CMV disease in HSCT recipients in our study attests to the efficacy of CMV surveillance based on clinical routine assay. The quantification of CMV DNA load using real-time PCR appears to be applicable to the clinical practice and an optimal cutoff value for guiding timely preemptive therapy should be clinically validated in future studies.
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Affiliation(s)
- Renata M B Peres
- Department of Clinical Medicine, Faculty of Medical Sciences, University of Campinas, P.O. Box 6111, Zipe Code 13083-970, Campinas, SP, Brazil
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Kasper DC, Mechtler TP, Reischer GH, Witt A, Langgartner M, Pollak A, Herkner KR, Berger A. The bacterial load of Ureaplasma parvum in amniotic fluid is correlated with an increased intrauterine inflammatory response. Diagn Microbiol Infect Dis 2010; 67:117-21. [PMID: 20207094 DOI: 10.1016/j.diagmicrobio.2009.12.023] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2009] [Revised: 12/22/2009] [Accepted: 12/30/2009] [Indexed: 01/08/2023]
Abstract
Ureaplasma spp. are the most frequently isolated microorganisms inside the amniotic cavity and have been associated with spontaneous abortion, chorioamnionitis, premature rupture of the membranes (PROM), and preterm labor (PL). We analyzed 118 samples from amniotic fluid of preterm infants before 34 weeks of gestation by quantitative polymerase chain reaction (qPCR). Bacterial load, Ureaplasma biovar discrimination (Ureaplasma urealyticum and Ureaplasma parvum), and the level of inflammation were correlated with short-term clinical outcome. U. parvum was the predominant biovar, and increased bacterial load was significantly linked to histologic chorioamnionitis, PROM + PL, early-onset sepsis, and bronchopulmonary dysplasia. Furthermore, there was a positive correlation between the amount of U. parvum and the magnitude of inflammatory response inside the amniotic cavity observed by elevated interleukin 8 levels. We postulate that the bacterial load of Ureaplasma spp. measured by qPCR should be determined in studies investigating the potential clinical impact of intrauterine Ureaplasma spp. on the outcome of preterm infants.
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Affiliation(s)
- David C Kasper
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, A-1090 Vienna, Austria.
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Fan J, Zhang X, Chen X, Gao H, Yang M, Zhao H, Hu J, Ma W. Monitoring of human cytomegalovirus glycoprotein B genotypes using real-time quantitative PCR in immunocompromised Chinese patients. J Virol Methods 2009; 160:74-7. [DOI: 10.1016/j.jviromet.2009.04.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2009] [Revised: 04/02/2009] [Accepted: 04/21/2009] [Indexed: 11/24/2022]
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Lautenschlager I. CMV infection, diagnosis and antiviral strategies after liver transplantation. Transpl Int 2009; 22:1031-40. [PMID: 19619175 DOI: 10.1111/j.1432-2277.2009.00907.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Cytomegalovirus (CMV) is a significant pathogen complicating the post-transplant course of organ recipients. In liver transplant patients, the febrile clinical illness caused by CMV may be associated with end-organ disease, such as hepatitis or infection of the gastrointestinal tract. In addition to direct effects, CMV may have indirect effects including the risk of other infections or graft rejection. Recently, major advances in the management of CMV infection have been achieved through the development of new diagnostic techniques and antiviral strategies to prevent CMV disease. Quantitative nucleic acid testing to monitor viral load is now commonly used to diagnose and guide the treatment of CMV infections. The standardization of the testing, however, needs to be improved. There are two main strategies to prevent CMV disease after liver transplantation: prophylaxis and pre-emptive therapy. Both strategies are effective, but also have disadvantages. The disadvantages of prophylaxis include prolonged drug exposure, the development of resistance and, most of all, the development of delayed and late-onset CMV disease. On the other hand, the pre-emptive strategy is based on frequent laboratory monitoring of viral loads, and some patients may develop symptomatic infection before the diagnosis of CMV. This overview summarizes the current status of CMV in liver transplantation.
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Affiliation(s)
- Irmeli Lautenschlager
- Transplant Unit Research Laboratory, Transplantation and Liver Surgery Clinic, and Department of Virology, Helsinki University Hospital, and University of Helsinki, Helsinki, Finland.
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Pang XL, Fox JD, Fenton JM, Miller GG, Caliendo AM, Preiksaitis JK. Interlaboratory comparison of cytomegalovirus viral load assays. Am J Transplant 2009; 9:258-68. [PMID: 19178413 DOI: 10.1111/j.1600-6143.2008.02513.x] [Citation(s) in RCA: 189] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
To assess interlaboratory variability in qualitative and quantitative cytomegalovirus (CMV) viral load (VL) testing, we distributed a panel of samples to 33 laboratories in the USA, Canada and Europe who performed testing using commercial reagents (n = 17) or laboratory-developed assays (n = 18). The panel included two negatives, seven samples constructed from purified CMV nucleocapsids in plasma (2.0-6.0 log(10) copies/mL) and three clinical plasma samples. Interlaboratory variation was observed in both actual (range, 2.0-4.0 log(10) copies/mL) and self-reported lower limits of detection (range, 1.0-4.0 log(10) copies/mL). Variation observed in reported results for individual samples ranged from 2.0 log(10) (minimum) to 4.3 log(10) (maximum)(.) Variation was greatest at low VLs. Assuming +/- 0.5 log(10) relative to the expected result represents an acceptable result, 57.6% of results fell within this range. Use of commercially available reagents and procedures was associated with less variability compared with laboratory-developed assays. Interlaboratory variability on replicate samples was significantly greater than intralaboratory variability (p < 0.0001). The significant interlaboratory variability in CMV VL observed may be impacting patient care and limiting interinstitutional comparisons. The creation of an international reference standard for CMV VL assay calibration would be an important step in quality improvement of this laboratory tool.
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Affiliation(s)
- X L Pang
- Provincial Laboratory for Public Health (Microbiology), Alberta, Canada
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Cellular normalization of viral DNA loads on whole blood improves the clinical management of cytomegalovirus or Epstein Barr virus infections in the setting of pre-emptive therapy. J Med Virol 2008; 81:90-8. [PMID: 19031462 DOI: 10.1002/jmv.21334] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Two quantitative duplex real-time PCR assays were developed for co-amplification of human albumin and cytomegalovirus (CMV) or Epstein Barr virus (EBV) genes after automated extraction on whole blood, and compared two units for expressing viral DNA loads (copies per ml of blood or per 10(6) peripheral blood leukocytes (PBLs)) on 1,138 positive samples. Both PCRs were characterized by high sensitivity, reproducibility, and linear range. Automated extraction by a MagNA Pure LC Instrument was shown to be more efficient when peripheral blood cell count was inferior to 5 x 10(9) PBLs/L. Albumin co-amplification allows the detection of PCR inhibitors and normalization of viral load according to the number of cells calculated in the sample. The two ways of expressing viral load results were highly correlated, but quantitative differences varied in relation to variations of blood cell count. As these two viruses are highly cell associated, viral loads can be underestimated in patients with leucopenia. In the setting of pre-emptive strategies during CMV infection, the units in which results are expressed can influence clinical management, as illustrated in this article.
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Heo WB, Won DI, Kim YL, Kim MH, Oh HB, Suh JS. [Evaluation of Biosewoom Real-Q Cytomegalovirus Quantification kit for Cytomegalovirus viral load measure]. Korean J Lab Med 2008; 27:298-304. [PMID: 18094592 DOI: 10.3343/kjlm.2007.27.4.298] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Rapid and accurate laboratory tests are essential to detect cytomegalovirus (CMV) infections in solid organs and haematopoietic stem cell transplant recipients. We assessed the realtime quantitative PCR (RQ-PCR) technology for its usefulness in detecting CMV DNA. METHODS We evaluated the analytical performance of CMV RQ-PCR using Real-Q Cytomegalovirus Quantification kit (BioSewoom Inc., Korea). To evaluate its clinical utility, we also compared it to pp65 antigenemia test, an immunostaining method, on 343 samples of total 84 patients, including 63 transplant recipients. RESULTS The detection limit of RQ-PCR was 63 copies/mL and none of hepatitis B virus, hepatitis C virus, or human immunodeficiency virus showed a cross-reactivity with CMV. Total coefficient of variation (CV) was 10.4-19.5%. It detected CMV DNA in a linear range from 1 x 10(2) to 5 x 10(11) copies/mL (P<10(-13), R(2)=0.9994). The qualitative positive rates of pp65 antigenemia test and RQ-PCR were 4.7%, 16.3%, respectively and concordance rate between the two tests was 84.8% (Kappa=0.221, P<10(-6)). In comparison of quantitative results, the correlation between two tests was significant (r=0.45, P<10(-17)). In comparison among three groups by pp65 antigen level, CMV DNA level obtained with RQ-PCR increased significantly (P<10(-3) and P<10(-7), respectively). CONCLUSIONS The RQ-PCR is easier to perform than the immunostaining method, has good analytical performance and reflects the blood level of viral DNA well. It may be a new method substituting the pp65 antigenemia test. Further studies determining RQ-PCR value starting pre-emptive therapy will be required.
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Affiliation(s)
- Woon Bo Heo
- Department of Laboratory Medicine, Kyung Pook National University Hospital, Daegu, Korea
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Cytomegalovirus DNA Measurement in Blood and Plasma Using Roche LightCycler CMV Quantification Reagents. ACTA ACUST UNITED AC 2008; 17:166-73. [DOI: 10.1097/pdm.0b013e3181599242] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Britt W. Manifestations of human cytomegalovirus infection: proposed mechanisms of acute and chronic disease. Curr Top Microbiol Immunol 2008; 325:417-70. [PMID: 18637519 DOI: 10.1007/978-3-540-77349-8_23] [Citation(s) in RCA: 232] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Infections with human cytomegalovirus (HCMV) are a major cause of morbidity and mortality in humans with acquired or developmental deficits in innate and adaptive immunity. In the normal immunocompetent host, symptoms rarely accompany acute infections, although prolonged virus shedding is frequent. Virus persistence is established in all infected individuals and appears to be maintained by both a chronic productive infections as well as latency with restricted viral gene expression. The contributions of the each of these mechanisms to the persistence of this virus in the individual is unknown but frequent virus shedding into the saliva and genitourinary tract likely accounts for the near universal incidence of infection in most populations in the world. The pathogenesis of disease associated with acute HCMV infection is most readily attributable to lytic virus replication and end organ damage either secondary to virus replication and cell death or from host immunological responses that target virus-infected cells. Antiviral agents limit the severity of disease associated with acute HCMV infections, suggesting a requirement for virus replication in clinical syndromes associated with acute infection. End organ disease secondary to unchecked virus replication can be observed in infants infected in utero, allograft recipients receiving potent immunosuppressive agents, and patients with HIV infections that exhibit a loss of adaptive immune function. In contrast, diseases associated with chronic or persistent infections appear in normal individuals and in the allografts of the transplant recipient. The manifestations of these infections appear related to chronic inflammation, but it is unclear if poorly controlled virus replication is necessary for the different phenotypic expressions of disease that are reported in these patients. Although the relationship between HCMV infection and chronic allograft rejection is well known, the mechanisms that account for the role of this virus in graft loss are not well understood. However, the capacity of this virus to persist in the midst of intense inflammation suggests that its persistence could serve as a trigger for the induction of host-vs-graft responses or alternatively host responses to HCMV could contribute to the inflammatory milieu characteristic of chronic allograft rejection.
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Affiliation(s)
- W Britt
- Department of Pediatrics, University of Alabama School of Medicine, Childrens Hospital, Harbor Bldg. 104, 1600 7th Ave. South Birmingham, AL 35233, USA.
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Evaluation of an automated extraction system in combination with Affigene® CMV Trender for CMV DNA quantitative determination: Comparison with nested PCR and pp65 antigen test. J Virol Methods 2008; 151:61-5. [DOI: 10.1016/j.jviromet.2008.03.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2007] [Revised: 03/13/2008] [Accepted: 03/18/2008] [Indexed: 12/18/2022]
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BenMarzouk-Hidalgo OJ, Cordero E, Martín-Peña A, García-Prado E, Gentil MA, Gomez-Bravo MA, Barrera-Pulido L, Cisneros JM, Perez-Romero P. Prevention of cytomegalovirus disease using preemptive treatment after solid organ transplant in patients at high risk for cytomegalovirus infection. Antivir Ther 2008. [DOI: 10.1177/135965350901400509] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background The use of pre-emptive or prophylactic treatment to control cytomegalovirus (CMV) replication after solid organ transplant (SOT) remains controversial. The aim of this study was to evaluate whether administration of pre-emptive treatment to control viral replication guided by a highly sensitive diagnostic tool is an effective approach for preventing CMV disease, even in high-risk transplant recipients. Methods Plasma samples from eight SOT patients were tested using antigenaemia and real-time PCR (RT-PCR) assays. Pre-emptive treatment was administered guided by RT-PCR when viral load values were >1,000 copies/ml. Results All patients developed episodes of CMV infection, but none of them developed CMV disease or indirect effects. No patient in this study died or experienced graft rejection. Treatment was needed in 10 replication episodes. At the end of treatment, four had undetectable levels and the other six were cleared 3 weeks later. In 42.6% of tested samples RT-PCR was more sensitive for detecting viral infection. Conclusions Pre-emptive monitoring of SOT patients at high risk for CMV infection protected patients from developing CMV disease during the first 6 months after transplant. The use of this sensitive method for guiding pre-emptive treatment diminished viral load early enough that it did not have consequences for patient health.
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Affiliation(s)
- Omar Jesus BenMarzouk-Hidalgo
- Service of Infectious Diseases, Hospitales Universitarios Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBiS), Seville, Spain
| | - Elisa Cordero
- Service of Infectious Diseases, Hospitales Universitarios Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBiS), Seville, Spain
| | - Almudena Martín-Peña
- Service of Infectious Diseases, Hospitales Universitarios Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBiS), Seville, Spain
| | - Elena García-Prado
- Service of Infectious Diseases, Hospitales Universitarios Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBiS), Seville, Spain
| | - Miguel Angel Gentil
- Service of Nephrology, Hospitales Universitarios Virgen del Rocío, Seville, Spain
| | - Miguel Angel Gomez-Bravo
- Hepatho-bilio-pancreatic Surgery and Hepatic Transplant Unit, Hospitales Universitarios Virgen del Rocío, Seville, Spain
| | - Lydia Barrera-Pulido
- Hepatho-bilio-pancreatic Surgery and Hepatic Transplant Unit, Hospitales Universitarios Virgen del Rocío, Seville, Spain
| | - Jose Miguel Cisneros
- Service of Infectious Diseases, Hospitales Universitarios Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBiS), Seville, Spain
| | - Pilar Perez-Romero
- Service of Infectious Diseases, Hospitales Universitarios Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBiS), Seville, Spain
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Monitoring of Cytomegalovirus Reactivation in Bone Marrow Transplant Recipients by Real-time PCR. Pathol Oncol Res 2008; 14:399-409. [DOI: 10.1007/s12253-008-9030-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2008] [Accepted: 03/05/2008] [Indexed: 10/21/2022]
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Egli A, Bergamin O, Müllhaupt B, Seebach J, Mueller N, Hirsch H. Cytomegalovirus-associated chorioretinitis after liver transplantation: case report and review of the literature. Transpl Infect Dis 2008; 10:27-43. [DOI: 10.1111/j.1399-3062.2007.00285.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Drew WL. Laboratory diagnosis of cytomegalovirus infection and disease in immunocompromised patients. Curr Opin Infect Dis 2007; 20:408-11. [PMID: 17609601 DOI: 10.1097/qco.0b013e32821f6010] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW To review new developments in PCR technology as they apply to detecting cytomegalovirus viremia and pneumonia, recent advances in detecting CMV resistance to antivirals and assays of specific CMV lymphocyte function. RECENT FINDINGS This review summarizes the attempts to use real time PCR for cytomegalovirus deoxyribonucleic acidemia and to compare it to conventional PCR and antigenemia, it also reviews the use of quantitative PCR on bronchoalveolar lavage to assist in the diagnosis of CMV pneumonia. Phenotypic assays of susceptibility in tissue culture are much too slow to assist clinical decisions, taking weeks for completion. Genotypic assays may be performed directly on clinical samples such as blood, and cerebrospinal fluid and can be done by sequencing in a very few days.Finally, assays of lymphocytic functional responsiveness to cytomegalovirus can be used to identify transplant recipients at continuing risk for cytomegalovirus disease. SUMMARY Assays for CMV DNA or antigen in blood are superior to culture for documenting viremia and pneumonia. Genotypic assays have largely replaced phenotypic assays for CMV resistance to antivirals. Lymphocyte responses to CMV antigen(s) may identify patients at risk for CMV disease.
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Affiliation(s)
- W Lawrence Drew
- University of California, San Francisco, UCSF Medical Center at Mount Zion, San Francisco, California 94115, USA.
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Hunt CM, Papay JI, Edwards RI, Theodore D, Alpers DH, Dollery C, Debruin TW, Adkison KK, Stirnadel HA, Gibbs TG. Monitoring liver safety in drug development: the GSK experience. Regul Toxicol Pharmacol 2007; 49:90-100. [PMID: 17655994 DOI: 10.1016/j.yrtph.2007.06.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2007] [Revised: 06/09/2007] [Accepted: 06/12/2007] [Indexed: 12/17/2022]
Abstract
To promptly identify and evaluate liver safety events, an evidence-based liver safety system was created for global Phase I-III clinical trials. The goals of this system included improving clinical trial subject safety, expanding information on liver safety events, and improving data quality across studies by establishing and communicating: Two different algorithms for liver stopping criteria were developed. The most stringent criteria were selected for healthy volunteers in Phase I studies, where no treatment benefit is anticipated and clinical safety data are limited. With an interest in assessing potential liver "tolerance" or adaptation with accruing safety information, slightly higher liver chemistry thresholds were set for Phase II-III studies. This paper will describe the importance of liver safety in drug development, laboratory tests used to monitor liver safety, the rationale for selected liver chemistry subject stopping criteria, and implementation of this safety system.
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Affiliation(s)
- Christine M Hunt
- GlaxoSmithKline Research and Development, RTP, Durham, NC 27709, USA.
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Gerna G, Baldanti F, Torsellini M, Minoli L, Viganò M, Oggionni T, Rampino T, Castiglioni B, Goglio A, Colledan M, Mammana C, Nozza F, Lilleri D. Evaluation of Cytomegalovirus DNAaemia versus pp65-Antigenaemia Cutoff for Guiding Preemptive therapy in Transplant Recipients: A Randomized Study. Antivir Ther 2007. [DOI: 10.1177/135965350701200108] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Methods A bicentre, randomized, prospective open-label study aimed at defining a DNAaemia versus antigenaemia cutoff for guiding preemptive therapy of human cytomegalovirus (HCMV) infections in solid organ transplant recipients (SOTR) was completed. Overall, 99 patients were enrolled in the DNAaemia arm and 101 patients in the antigenaemia arm. Patients were randomized to be monitored for HCMV infection in the blood by either assay. Antiviral treatment was started in both seropositive and seronegative patients when levels greater than 300,000 DNA copies/ml blood or 100 pp65-positive leukocytes in the relevant arm were reached. Results HCMV infection was detected in 81/99 (81.8%) patients in the DNAaemia arm and in 87/101 (86.1%) patients in the antigenaemia arm ( P=ns). Antiviral treatment was given to 23/99 (23.0%) patients in the DNAaemia arm and 42/101 (41.0%) patients in the antigenaemia arm ( P=0.01). In the DNAaemia arm, antiviral therapy was significantly delayed and duration of the first course of treatment was significantly greater than in the antigenaemia arm. However, total duration of treatment was comparable in the two arms. No case of HCMV disease occurred in patients treated after reaching the relevant cutoff. However, four patients (three in the antigenaemia arm, and one in the DNAaemia arm) suffered from HCMV disease prior to reaching the relevant cutoff. Conclusions Compared with antigenaemia, a single DNAaemia cutoff: (i) significantly reduces the number of patients requiring treatment; (ii) may be safely adopted to guide preemptive therapy of both primary and reactivated HCMV infections in SOTR; and (iii) does not significantly modify the overall duration of treatment.
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Affiliation(s)
- Giuseppe Gerna
- Servizio di Virologia, Fondazione, IRCCS Policlinico San Matteo, Pavia, Italy
| | - Fausto Baldanti
- Servizio di Virologia, Fondazione, IRCCS Policlinico San Matteo, Pavia, Italy
- Laboratori Sperimentali di Ricerca, Fondazione, IRCCS Policlinico San Matteo, Pavia, Italy
| | - Maria Torsellini
- Servizio di Virologia, Fondazione, IRCCS Policlinico San Matteo, Pavia, Italy
- Istituto di Clinica delle Malattie Infettive, Università di Pavia, Pavia, Italy
| | - Lorenzo Minoli
- Istituto di Clinica delle Malattie Infettive, Università di Pavia, Pavia, Italy
| | - Mario Viganò
- Divisione di Cardiochirurgia, Università di Pavia, Pavia, Italy
| | - Tiberio Oggionni
- Clinica di Malattie dell'Apparato Respiratorio, Università di Pavia, Pavia, Italy
| | - Teresa Rampino
- Dipartimento di Medicina Interna, Sezione di Nefrologia, Università di Pavia, Pavia, Italy
| | - Barbara Castiglioni
- Istituto di Clinica delle Malattie Infettive, Università di Pavia, Pavia, Italy
- Divisione di Cardiochirurgia, Università di Pavia, Pavia, Italy
| | - Antonio Goglio
- Servizio di Microbiologia e Virologia, Ospedali Riuniti di Bergamo, Bergamo, Italy
| | - Michele Colledan
- Divisione di Chirurgia III, Dipartimento Cardiovascolare, Ospedali Riuniti di Bergamo, Bergamo, Italy
| | - Carmelo Mammana
- Dipartimento Cardiovascolare, Ospedali Riuniti di Bergamo, Bergamo, Italy
| | - Francesca Nozza
- Servizio di Microbiologia e Virologia, Ospedali Riuniti di Bergamo, Bergamo, Italy
| | - Daniele Lilleri
- Servizio di Virologia, Fondazione, IRCCS Policlinico San Matteo, Pavia, Italy
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Madi N, Al-Nakib W, Mustafa AS, Saeed T, Pacsa A, Nampoory MRN. Detection and monitoring of cytomegalovirus infection in renal transplant patients by quantitative real-time PCR. Med Princ Pract 2007; 16:268-73. [PMID: 17541291 DOI: 10.1159/000102148] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2006] [Accepted: 09/10/2006] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES To establish a sensitive and specific real-time PCR for quantitation of cytomegalovirus (CMV) DNA in clinical specimens. SUBJECTS AND METHODS In a prospective study, CMV DNA was quantified in blood samples of 255 kidney recipients with and without CMV-related symptoms between the years 2000 and 2005 in Kuwait. In a selected group of patients, the effect of anti-CMV chemotherapy was monitored by quantitative real-time PCR (qRT-PCR). RESULTS The established qRT-PCR assay had a sensitivity to detect 30 CMV DNA copies. CMV DNA was detected in 54/255 (24%) patients; of these, 17 (31.5%) were asymptomatic, and 37 patients (68.5%) had symptomatic CMV infection. Sequential blood specimens were collected from all CMV-positive patients and tested by CMV pp65 antigenemia and qRT-PCR assays. There was a moderate positive correlation between the two assays (Pearson's correlation = 0.52). The median CMV viral load measured by qRT-PCR was higher in symptomatic (6.5 x 10(4) copies/ml) than in asymptomatic (185copies/ml) patients (p = 0.001). The estimated cut-off value of CMV DNA for CMV symptoms/disease was > or =800 copies/ml of blood. Testing of sequential samples from patients treated with symptomatic CMV infection showed that the viral load was significantly reduced after 3 weeks of anti-CMV chemotherapy (p = 0.001). CONCLUSION The reported qRT-PCR is a sensitive method for quantitation of CMV DNA in the blood of kidney recipients and can be useful in monitoring the efficacy of anti-CMV therapy.
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Affiliation(s)
- Nada Madi
- WHO Collaborative Centre for Virus Reference and Research and for Immunodeficiency Syndrome for EMR, Virology Unit, Department of Microbiology, Faculty of Medicine, Kuwait University, Kuwait.
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Abstract
When patients with inflammatory bowel disease (IBD) are admitted to the hospital with a flare of acute severe colitis, the possibility of a concurrent cytomegalovirus (CMV) infection causing or worsening the colitis is often considered. IBD patients are usually immunosuppressed, and therefore presumably at increased risk for active CMV infection and disease. Multiple techniques are used to diagnose CMV infection, including endoscopy, histology, serology, viral culture, CMV antigen testing, and CMV DNA testing. Immunohistochemistry (IHC) performed on colon biopsy specimens with monoclonal antibodies directed against CMV immediate early antigen is considered by most to be the current gold standard for diagnosis. The prevalence of CMV infection in acute severe colitis appears to be 21-34%, and the prevalence of CMV infection in the steroid refractory subgroup of these patients is 33-36%. After antiviral therapy, colitis remission rates in IBD patients with CMV infection range from 67% to 100%, though CMV histological infection or the presence of circulating virus alone is not always associated with steroid resistance, and may not require antiviral therapy.
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Affiliation(s)
- Ahmed Kandiel
- Center for Inflammatory Bowel Disease, Department of Gastroenterology/Hepatology, Cleveland Clinic, Cleveland, Ohio 44195, USA
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Real-time fluorescent quantitative PCR assay for measuring cytomegalovirus DNA load in patients after haematopoietic stem cell transplantation. Chin Med J (Engl) 2006. [DOI: 10.1097/00029330-200605020-00014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Conraths FJ, Schares G. Validation of molecular-diagnostic techniques in the parasitological laboratory. Vet Parasitol 2006; 136:91-8. [PMID: 16414191 DOI: 10.1016/j.vetpar.2005.12.004] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Diagnostic laboratories today often operate according to standard quality management procedures such as ISO/IEC 17025. This requires that only validated methods are used. Validation procedures help to document that a particular protocol used by the accredited laboratory has a guaranteed performance in that particular laboratory. Several study designs exist for validation procedures. Computer programmes are available to help with the statistical analysis of validation results. The agreement beyond chance of results obtained in the protocol that is to be validated can be compared to those achieved in an already established test (agreement). For a method that is used under routine conditions or for epidemiological studies, it is necessary to assess the diagnostic sensitivity and diagnostic specificity of the technique. These parameters can be estimated by comparing the method that needs to be validated with an existing reliable method ('gold standard'). This is done by testing a standard set of well-documented samples using both techniques in parallel. Approaches using Bayes' theorem are used to perform gold standard-free validations. Many PCR-based methods are characterised by an excellent analytical sensitivity and are thus good candidates for diagnostic tools of the required diagnostic sensitivity. However, the high level of analytical sensitivity can also make molecular techniques susceptible to cross-contamination and carry-over problems leading to false-positive results. Moreover, the presence of inhibitors can cause false-negative results. After an initial validation, test performance needs to be continuously monitored, e.g. by using combined Shewhart-CUSUM control routines, and test results compared to those obtained by other laboratories (proficiency testing).
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Affiliation(s)
- Franz J Conraths
- Friedrich-Loeffler-Institut, Federal Research Institute for Animal Health, Institute of Epidemiology, Seestr. 55, D-16868 Wusterhausen, Germany.
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Pradeau K, Couty L, Szelag JC, Turlure P, Rolle F, Ferrat P, Bordessoule D, Le Meur Y, Denis F, Ranger-Rogez S. Multiplex real-time PCR assay for simultaneous quantitation of human cytomegalovirus and herpesvirus-6 in polymorphonuclear and mononuclear cells of transplant recipients. J Virol Methods 2006; 132:77-84. [PMID: 16300835 DOI: 10.1016/j.jviromet.2005.09.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2005] [Revised: 08/31/2005] [Accepted: 09/06/2005] [Indexed: 01/01/2023]
Abstract
Human cytomegalovirus (HCMV) and human herpesvirus-6 (HHV-6) are two closely related viruses, which belong to the Herpesviridae family. Following primary infection, they are thought to persist for life as latent forms in mononuclear cells. HCMV and HHV-6 can cause considerable morbidity in immunocompromised individuals, such as transplant patients. A sensitive and specific LightCycler multiplex real-time PCR assay based on fluorescence energy transfer (known as FRET) was developed. This assay, by using two sets of hybridization probes specific for HHV-6 (A and B) and HCMV, can differentiate reliably and quantify simultaneously both viruses in order to diagnose reactivation processes. The assay was optimized and the lower limit of detection for both viruses was determined to be 10 viral genome copies per reaction. Both viruses were quantified in 83 peripheral blood mononuclear cells (PBMCs) and 87 polymorphonuclear leukocytes (PMNLs) collected from 32 transplant recipients. This multiplex real-time quantitative PCR was finally compared with two other quantitation and detection assays used daily in laboratory (PCR DIG detection and antigenemia for HCMV, TaqMan Assay for HHV-6). This technique can be useful for the differentiation and quantitation of HCMV and HHV-6 for monitoring transplant patients.
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Affiliation(s)
- Karine Pradeau
- Laboratoire de Virologie, CHU Dupuytren, Limoges, France
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Torre-Cisneros J, Fortún J, Aguado JM, de la Cámara R, Cisneros JM, Gavaldá J, Gurguí M, Lumbreras C, Martín C, Martín-Dávila P, Montejo M, Moreno A, Muñoz P, Pahissa A, Pérez JL, Rovira M, Bernardos A, Gil-Vernet S, Quijano Y, Rábago G, Román A, Varó E. Recomendaciones GESITRA-SEIMC y RESITRA sobre prevención y tratamiento de la infección por citomegalovirus en pacientes trasplantados. Enferm Infecc Microbiol Clin 2005; 23:424-37. [PMID: 16159543 DOI: 10.1157/13078802] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Cytomegalovirus (CMV) infection remains an important complication of transplantation. The last decade has been characterized by improvements to management that has reduced its morbidity and mortality. The advance has been particularly important in the diagnosis and prevention. Several techniques have been developed that allow the increasingly rapid and sensitive diagnosis. The different preventive strategies include use of appropriate blood products, immune globulin, and antiviral agents either as prophylaxis or pre-emptive therapy. The development of effective oral drugs as valganciclovir also represents a new advance. It is necessary to summarize these advances to facilitate the development of local policies reflecting recent changes. The Group of Study of Infections in Transplantation (GESITRA) of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) has therefore produced actual recommendations in the management of CMV infection after transplantation.
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