Treatment of cytomegalovirus pneumonitis with hyperimmune plasma

Evaluation of immunoglobulin G preparations for anti-cytomegalovirus antibodies with reference to neutralizing antibody in the presence of complement

Eighteen commercially available immunoglobulin G (IgG) preparations were evaluated by various methods for anti-cytomegalovirus (CMV) antibodies. The modifications of immunoglobulin G molecules, such as sulfonation, alkylation, and enzyme treatments, resulted in profound reductions in anti-CMV antibody titers. However, after reversion in vitro, sulfonated IgG preparations which have been shown to be reverted in vivo (Y. Masuho, K. Tomibe, K. Matsuzawa, T. Watanabe, S. Ishimoto, S. Tsunoda, and T. Noguchi, J. Biochem. 79:1377-1379, 1976) restored the anti-CMV antibody titers to levels comparable with those of nonsulfonated IgG preparations. There is no good correlation among the titers tested by different methods. As a method which reflects the biological activities in vivo, the neutralization test in the presence of complement is suitable for the evaluation of IgG preparations.

Comparison of the neutralizing and ELISA antibody titres to human cytomegalovirus (HCMV) in human sera and in gamma globulin preparations

Administration of anti-cytomegalovirus gamma globulin has been reported to prevent acute human cytomegalovirus (HCMV) infection in immunocompromised patients. Most likely the gamma globulin acts by its neutralizing activity. However, the antibody titer to HCMV in hyperimmune gamma globulin is usually detected by an enzyme immunoassay (ELISA). We, therefore, compared the ELISA titres with the neutralizing antibody titres in the sera of blood donors and in hyperimmune gamma globulins. A poor correlation between both titres was found. Gamma globulin preparations with identical ELISA titres clearly differed in the neutralizing titre. If neutralization is the important mechanism by which the hyperimmune gamma globulins work, our results would favour a routine testing of the neutralizing antibody titre in HCMV hyperimmune gamma globulins.

Prevention of cytomegalovirus infection by prophylaxis with an intravenous, hyperimmune, native, unmodified cytomegalovirus globulin. Randomized trial in bone marrow transplant recipients

We have completed a randomized trial to evaluate the safety and effectiveness of hyperimmune cytomegalovirus intravenous human globulin in prevention of cytomegalovirus infection and related problems in bone marrow transplant recipients. Prophylactic intravenous administration of this native, intact, hyperimmune, cytomegalovirus IgG, at a dose of 200 mg/kg 25, 50, and 75 days following transplant resulted in complete protection against cytomegalovirus infection during the 120 days covered by the treatment (p = 0.009). There was no interstitial pneumonia or mortality in the group receiving the hyperimmune IgG. This is significant at the p = 0.014 when compared with the supporting treatment control group. In bone marrow transplant recipients, prophylaxis with a total dosage of 0.6 g/kg of an intravenous hyperimmune cytomegalovirus globulin was safe and afforded effective protection against cytomegalovirus infection and interstitial pneumonia in this high-risk population.

Persistent cytomegalovirus infection: association with profound immunodeficiency and treatment with interferon

Cytomegalovirus (CMV) was repeatedly isolated from urine and saliva of a 20-month-old male child with recurrent episodes of pneumonia, high fever, rash, lymphadenopathy, oral ulceration, and neutropenia. Immunologic evaluation revealed decreased serum IgG and IgA, increased IgM, depressed T- and B-lymphocyte functions, and decreased natural killer (NK) activity for herpes simplex-type I virus-infected targets. NK activity was augmented following exposure of the patient's lymphocytes to interferon (IF) in vitro. The child was treated with interferon (four courses, dosage varying from 2 million U/day to 1 million U three times/week for periods of 10, 28, 80, and 67 days, respectively, interspersed over 9 months) and hyperimmune plasma infusions every 3 weeks. Toward the end of interferon therapy oral Levamisole was started and a feeding gastrostomy was inserted to provide nutritional support. Clinical recovery was associated with reversal of immunologic abnormalities except for the hypogammaglobulinemia. Aggressive antiviral therapy (e.g., with IF) followed by immunostimulation (e.g., with Levamisole) may prove effective in controlling certain viral infections in immunodeficiency disorders.

Transpleural lung biopsy by the thoracoscopic route in patients with diffuse interstitial pulmonary disease

Thoracoscopy was carried out in 81 cases of diffuse pulmonary disease in order to obtain lung tissue for biopsy. After we established artificial pneumothorax, the thoracoscope was introduced under local anesthesia, multiple biopsy specimens (theta 3 mm) were obtained under visual control, and an underwater sealed drain was left in place. The method was used to determine the cause of x-ray shadowing and respiratory distress in 26 immunocompromised patients. Within 2-48 hours, all biopsy specimens provided sufficient microbiologic and morphologic information to guide management, eg, specific antimicrobial drugs, decreasing or intensifying immunosuppression, or cytostatic therapy. Thoracoscopy was tolerated better than fiberoptic bronchoscopy, especially in hypoxic patients. Persisting or recurring pneumothoraces were seen in four patients and was not a major complication. In one very ill patient, the spleen was punctured accidentally before biopsy specimens were taken. Of 63 nonimmunocompromised patients, a histologic diagnosis was obtained in 57 (90 percent). In most of these patients, previous biopsy procedures had produced inconclusive results. Also in this group persisting or recurring pneumothoraces were seen in four patients, but closed eventually in a conservative way.

Successful treatment with acyclovir of an immunodeficient patient infected simultaneously with multiple herpesviruses

A patient with recurrent simultaneous chronic infections, including cytomegalovirus pneumonia, disseminated zoster and perineal herpes simplex infection, whose immune responses were deficient (immunodeficient), is presented. Following treatment with acyclovir (19-(2-hydroxyethoxymethyl)guanine), this patient had a rapid remission of these viral infections. The patient's clinical improvement is remarkable considering the duration of the viral infections and the continued immune deficiency. Acyclovir appears to act by a highly selective activation by and inhibition of viral enzymes. Prospective trials of this agent in immunosuppressed patients with herpes virus infections seem warranted.