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Blackbourn L, Ahmad S, Yuan K, Uppu M, Kherallah B. Human Herpes Virus-6 (HHV-6) infectious encephalitis in an immunocompetent adult. IDCases 2024; 36:e01992. [PMID: 38846028 PMCID: PMC11154619 DOI: 10.1016/j.idcr.2024.e01992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 05/01/2024] [Accepted: 05/22/2024] [Indexed: 06/09/2024] Open
Abstract
Human herpesvirus 6 (HHV-6) is one of the most prevalent childhood viruses. HHV-6 reactivation in allogeneic hematopoietic cell transplant recipients and solid organ transplant recipients is well described in medical literature. We present a case of HHV-6 reactivation causing encephalitis, which is rare in immunocompetent adults.
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Affiliation(s)
- Lisle Blackbourn
- Department of Neurology, University of Illinois College of Medicine Peoria, Peoria, IL, United States
- OSF Illinois Neurological Institute, Peoria, IL, United States
| | - Sharjeel Ahmad
- Department of Infectious Disease, University of Illinois College of Medicine Peoria, Peoria, IL, United States
| | - K’la Yuan
- Department of Neurology, University of Illinois College of Medicine Peoria, Peoria, IL, United States
- OSF Illinois Neurological Institute, Peoria, IL, United States
| | - Manjari Uppu
- Department of Neurology, University of Illinois College of Medicine Peoria, Peoria, IL, United States
- OSF Illinois Neurological Institute, Peoria, IL, United States
| | - Bassil Kherallah
- Department of Neurology, University of Illinois College of Medicine Peoria, Peoria, IL, United States
- OSF Illinois Neurological Institute, Peoria, IL, United States
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2
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The preceding hyponatremia is a useful hallmark for the diagnosis of HHV-6 encephalitis after allogeneic hematopoietic stem cell transplantation. Bone Marrow Transplant 2023; 58:97-99. [PMID: 36243759 DOI: 10.1038/s41409-022-01843-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 09/28/2022] [Accepted: 09/29/2022] [Indexed: 01/10/2023]
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3
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Meng J, Ji H, Chen L, Liu A. Comparison of Droplet Digital PCR and Metagenomic Next-Generation Sequencing Methods for the Detection of Human Herpesvirus 6B Infection Using Cell-Free DNA from Patients Receiving CAR-T and Hematopoietic Stem Cell Transplantation. Infect Drug Resist 2022; 15:5353-5364. [PMID: 36110128 PMCID: PMC9469937 DOI: 10.2147/idr.s379439] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 09/01/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose The aim of this study was to examine and compare the differences between droplet digital PCR (ddPCR) and metagenomic next-generation sequencing (mNGS) in the detection of human herpesvirus 6B (HHV-6B). Long-term monitoring of HHV-6B viral load in patients receiving chimeric antigen receptor-modified T-cell (CAR-T) therapy and hematopoietic stem cell transplantation (HSCT) can be used to identify immune effector cell-associated neurotoxicity syndrome (ICANS) and guide drug therapy. Methods Twenty-seven patients with suspected HHV-6B infection who had both mNGS and ddPCR test results were analyzed retrospectively, including 19 patients who received CAR T-cell therapy and 8 who received HSCT. The HHV-6B probe and primers were designed, and the performance of the ddPCR assay was evaluated. Subsequently, ddPCR was performed utilizing blood and urine. Data on clinical information and mNGS investigations were collected. Results The ddPCR test results correlated significantly with the mNGS test results (P < 0.001, R2 = 0.672). Of the 27 time-paired samples, ddPCR showed positive HHV-6B detection in 20 samples, while mNGS alone showed positive HHV-6B detection in 12 samples. ddPCR detected additional HHV-6B infections in 8 samples that would have been missed if only mNGS were used. In addition, the first HHV-6B infection event was detected at a median of 14 days after CAR T-cell infusion (range, 8 to 19 days). Longitudinal monitoring of HHV-6B by ddPCR was performed to assess the effectiveness of antiviral therapy. The data showed that with antiviral treatment HHV-6B viral load gradually decreased. Conclusion Our results indicated that ddPCR improved the HHV-6B positive detection ratio and was an effective adjunct to mNGS methods. Furthermore, the longitudinal detection and quantification of HHV-6B viral load in patients undergoing CAR T-cell therapy and HSCT may serve as a guide for drug treatment.
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Affiliation(s)
- Jiao Meng
- Hematology Department, Harbin Medical University Cancer Hospital, Harbin Medical University, Harbin, People's Republic of China
| | - Hongyan Ji
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Liting Chen
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Aichun Liu
- Hematology Department, Harbin Medical University Cancer Hospital, Harbin Medical University, Harbin, People's Republic of China
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4
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Mekheal E, Tagliaferri AR, Vasquez KS, Pjetergjoka R, Lobue G, Townsend D, Leou K, Singhal M. A Rare Case of HHV-6 Encephalitis in an Immunocompetent Host: Case Report and Literature Review. Cureus 2022; 14:e23007. [PMID: 35415058 PMCID: PMC8993705 DOI: 10.7759/cureus.23007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2022] [Indexed: 11/19/2022] Open
Abstract
Human herpesvirus-6 (HHV-6) is a virus known for causing the highly contagious infection, roseola infantum, and has been associated with causing encephalitis in pediatric patients and less commonly in adult patients as well. Regardless of the patient's age, the primary HHV-6 infection could be complicated by neurological sequelae including encephalitis, acute encephalopathy with biphasic seizures syndrome, or demyelinating disease. HHV-6 encephalitis does occur in an adult as a primary infection or reactivation. However, immunocompromised, hematopoietic stem cell transplantation patients, and solid organ transplant recipients are the most affected population. Here we present a rare case of HHV-6 encephalitis in a 26-year-old healthy immunocompetent male. HHV-6 viral DNA was detected in the cerebrospinal fluid during the acute stage of the disease, and the diagnosis was confirmed by quantitative polymerase chain reaction (PCR). The patient was treated with ganciclovir and had a complete response to treatment without any further complication. The pathophysiology, clinical course, and treatment in otherwise immunocompetent adult patients are also discussed.
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5
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Zhu H, Ali A, Woan KV, Tam E, Yaghmour G, Flores A, Chaudhary P. Unique Challenges to Diagnosing Human Herpesvirus-6 (HHV-6) Encephalitis Following Post-Hematopoietic Stem Cell Transplant: A Case and Brief Review. Cell Transplant 2022; 31:9636897221119734. [PMID: 36927092 PMCID: PMC9478732 DOI: 10.1177/09636897221119734] [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] [Indexed: 11/15/2022] Open
Abstract
A patient with an ultimate diagnosis of human herpesvirus-6 (HHV-6) encephalitis developed central nervous system (CNS) symptoms 13 days after undergoing myeloablative haploidentical allogeneic hematopoietic stem cell transplant (HSCT). Due to the patient's body habitus, magnetic resonance (MR) imaging was not obtained until the onset of retrograde amnesia on day +24. MR imaging and other clinical findings eliminated all skepticism of HHV-6 encephalitis and HHV-6 antivirals were initiated on day +28, leading to gradual recovery. This case demonstrates some of the factors that may complicate the diagnosis of post-alloHSCT HHV-6 encephalitis. Because HHV-6 encephalitis and viremia can occur without warning, a single negative study should not exclude future development, especially if CNS symptoms are present. Acute graft-versus-host disease and cord blood transplantation are both significant risk factors for HHV-6 encephalitis. Human leukocyte antigen (HLA) mismatch, engraftment complications, or certain HLA alleles have also been associated with HHV-6 encephalitis. Chromosomally integrated HHV-6 must also be ruled out to prevent inappropriate and potentially harmful administration of antivirals. Due to the severe short- and long-term sequelae of HHV-6 encephalitis, appropriate treatment should be administered as soon as possible.
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Affiliation(s)
- Harrison Zhu
- School of Medicine, Baylor College of Medicine, Houston, TX, USA.,HHV-6 Foundation, Santa Barbara, CA, USA
| | - Amir Ali
- Jane Anne Nohl Division of Hematology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Karrune V Woan
- Jane Anne Nohl Division of Hematology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Eric Tam
- Jane Anne Nohl Division of Hematology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - George Yaghmour
- Jane Anne Nohl Division of Hematology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Alan Flores
- Jane Anne Nohl Division of Hematology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Preet Chaudhary
- Jane Anne Nohl Division of Hematology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Baleguli V, Cho YM, Horn J, Parris A. Human Herpesvirus 6 (HHV-6) Encephalitis in a Non-Transplant Patient With Polymyositis. Cureus 2021; 13:e19314. [PMID: 34900488 PMCID: PMC8648291 DOI: 10.7759/cureus.19314] [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] [Accepted: 11/06/2021] [Indexed: 11/13/2022] Open
Abstract
Human herpesvirus 6 (HHV-6) was initially labeled as a human B lymphotropic virus because it was isolated in patients diagnosed with lymphoproliferative disorders. There are two variants of HHV-6: HHV-6A and HHV-6B. A considerable majority of recorded primary infections and reactivation events are primarily due to HHV-6B. We report a case of HHV-6 encephalitis reactivation in a 75-year-old Caucasian diabetic female with a past medical history of polymyositis treated with prednisone for a long time who presented with generalized weakness and drowsiness. She developed her symptoms after contact with her grandchildren, who recently had viral-like symptoms treated with antibiotics. Magnetic resonance imaging (MRI) of the brain without contrast showed 14 mm high transverse relaxation time (T2)/fluid-attenuated inversion recovery (FLAIR) signal intensity focus on the left temporal lobe, suspicious for primary versus metastatic neoplasm. Cerebrospinal fluid analysis found that protein concentration was 75 mg/dl, glucose concentration 55 mg/dl, white blood cell count was 22/mm3, with a lymphocytic predominance. Meningitis/encephalitis polymerase chain reaction (PCR) panel detected HHV-6. She was discharged after treatment with ganciclovir for 14 days. It is crucial to recognize HHV-6 infections in immunocompromised patients who present with a T2/FLAIR signal intensity focus in the left temporal lobe. In a hospital setting, rapid HHV-6 encephalitis testing is important to make a correct diagnosis to avoid any delay to prevent further morbidity and mortality.
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Affiliation(s)
- Vidya Baleguli
- Internal Medicine, Northeast Georgia Medical Center, Gainesville, USA
| | - Young Min Cho
- Internal Medicine, Northeast Georgia Medical Center, Gainesville, USA
| | - Jon Horn
- Radiology, Northeast Georgia Medical Center, Gainesville, USA
| | - Addison Parris
- Internal Medicine, Northeast Georgia Medical Center, Gainesville, USA
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7
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Rebechi MT, Bork JT, Riedel DJ. HHV-6 Encephalitis After Chimeric Antigen Receptor T-cell Therapy (CAR-T): 2 Case Reports and a Brief Review of the Literature. Open Forum Infect Dis 2021; 8:ofab470. [PMID: 34738024 PMCID: PMC8562470 DOI: 10.1093/ofid/ofab470] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 09/22/2021] [Indexed: 01/04/2023] Open
Abstract
Human herpesvirus 6 (HHV-6) reactivation can occur in patients who are highly immunosuppressed, including those who have undergone hematopoietic stem cell transplantation (HSCT). HHV-6 encephalitis is a severe manifestation that is well described in the HSCT population. Chimeric antigen receptor T-cell (CAR-T) therapy is a novel cancer-directed immunotherapy that results in severe immunosuppression. Patients undergoing CAR-T therapy may be at risk for HHV-6 encephalitis, which can be difficult to distinguish from a common adverse effect of CAR-T therapy, neurotoxicity. Herein, we describe 2 patients diagnosed with HHV-6 encephalitis after CAR-T therapy and discuss the diagnostic approach and differential diagnosis for altered mental status after CAR-T therapy. Diagnosing HHV-6 encephalitis can be difficult in this patient population as altered mental status is common after CAR-T therapy and may be attributed to CAR-T-associated neurotoxicity.
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Affiliation(s)
| | - Jacqueline T Bork
- University of Maryland School of Medicine, Baltimore Maryland,USA.,Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland,USA
| | - David J Riedel
- University of Maryland School of Medicine, Baltimore Maryland,USA.,Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland,USA
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8
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Vinnakota JM, Zeiser R. Acute Graft- Versus-Host Disease, Infections, Vascular Events and Drug Toxicities Affecting the Central Nervous System. Front Immunol 2021; 12:748019. [PMID: 34691059 PMCID: PMC8527894 DOI: 10.3389/fimmu.2021.748019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 09/21/2021] [Indexed: 02/02/2023] Open
Abstract
Allogeneic hematopoietic cell transplantation (allo-HCT) is a curative therapy for patients with hematological malignancies. Acute Graft versus host diseases (GVHD) is a major immune mediated side effect of allo-HCT that can affect the central nervous system (CNS) in addition to post-allo-HCT vascular events, drug toxicity or infections. Here we summarize and discuss recent preclinical data on the CNS as a target of acute GVHD and the known mechanisms contributing to neurotoxicity with a focus on microglia and T cells. We also discuss open questions in the field and place the findings made in mouse models in a clinical context. While in mice the neurological deficits can be assessed in a controlled fashion, in patients the etiology of the CNS damage is difficult to attribute to acute GVHD versus infections, vascular events, and drug-induced toxicity. Ultimately, we discuss novel therapies for GVHD of the CNS. Our understanding of the biological mechanisms that lead to neurotoxicity after allo-HCT increased over the last decade. This review provides insights into CNS manifestations of GVHD versus other etiologies of CNS damage in mice and patients.
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Affiliation(s)
- Janaki Manoja Vinnakota
- Department of Medicine I - Medical Centre, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Faculty of Biology, Albert-Ludwigs-University, Freiburg, Germany
| | - Robert Zeiser
- Department of Medicine I - Medical Centre, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Signalling Research Centres BIOSS and CIBSS – Centre for Integrative Biological Signalling Studies, University of Freiburg, Freiburg, Germany
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9
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Lee YJ, Su Y, Cho C, Tamari R, Perales MA, Jakubowski AA, Papanicolaou G. Human herpes virus 6 DNAemia is associated with worse survival after ex vivo T-cell depleted hematopoietic cell transplant. J Infect Dis 2021; 225:453-464. [PMID: 34390240 DOI: 10.1093/infdis/jiab412] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 08/12/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND We examined the correlation between persistent HHV-6 DNAemia (p-HHV-6) and absolute lymphocyte counts (ALC), platelet counts (PLT) and all-cause mortality the 1-year after ex vivo T-cell depleted (TCD) hematopoietic cell transplant (HCT). METHODS We analyzed a cohort of adult TCD HCT recipients 2012-2016 prospectively monitored for plasma HHV-6 by qPCR from day +14 post-HCT (D+14) through D+100. P-HHV-6 was defined as ≥2 consecutive values of ≥500 copies/mL by D+100. PLT and ALC were compared between patients with and without p-HHV-6 using mixed model analysis of variance. Multivariable Cox proportional hazard models were used to identify the impact of p-HHV-6 on 1-year mortality. RESULTS Of 312 patients, 83 (27%) had p-HHV-6 by D+100. P-HHV-6 was associated with lower ALC and PLT in the first year post-HCT. In multivariable models, p-HHV-6 was associated with higher mortality by 1-year post-HCT (adjusted hazard ratio 2.97, 95% confidence intervals: 1.62-5.47, P=0.0005), after adjusting for age, antiviral treatment, and ALC at D+100. CONCLUSIONS P-HHV-6 was associated with lower ALC and PLT in the first year post-HCT. P-HHV-6 was an independent predictor of mortality in the first year after TCD HCT.
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Affiliation(s)
- Yeon Joo Lee
- Infectious Disease Service, Department of Medicine, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
| | - Yiqi Su
- Infectious Disease Service, Department of Medicine, New York, NY, USA
| | - Christina Cho
- Adult Bone Marrow Transplantation Service, Department of Medicine, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
| | - Roni Tamari
- Adult Bone Marrow Transplantation Service, Department of Medicine, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplantation Service, Department of Medicine, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
| | - Ann A Jakubowski
- Adult Bone Marrow Transplantation Service, Department of Medicine, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
| | - Genovefa Papanicolaou
- Infectious Disease Service, Department of Medicine, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
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10
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Wang X, Patel SA, Haddadin M, Cerny J. Post-allogeneic hematopoietic stem cell transplantation viral reactivations and viremias: a focused review on human herpesvirus-6, BK virus and adenovirus. Ther Adv Infect Dis 2021; 8:20499361211018027. [PMID: 34104434 PMCID: PMC8155777 DOI: 10.1177/20499361211018027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 04/27/2021] [Indexed: 12/30/2022] Open
Abstract
Human cytomegalovirus and Epstein-Barr virus have been recognized as potential drivers of morbidity and mortality of patients undergoing allogeneic stem cell transplantation for years. Specific protocols for monitoring, prophylaxis and pre-emptive therapy are in place in many transplant settings. In this review, we focus on the next three most frequent viruses, human herpesvirus-6, BK virus and adenovirus, causing reactivation and/or viremia after allogeneic transplant, which are increasingly detected in patients in the post-transplant period owing to emerging techniques of molecular biology, recipients' characteristics, treatment modalities used for conditioning and factors related donors or stem cell source. Given the less frequent detection of an illness related to these viruses, there are often no specific protocols in place for the management of affected patients. While some patients develop significant morbidity (generally older), others may not need therapy at all (generally younger or children). Furthermore, some of the antiviral therapies used are potentially toxic. With the addition of increased risk of secondary infections, risk of graft failure or increased risk of graft-versus-host disease as well as the relationship with other post-transplant complications, the outcomes of patients with these viremias remain unsatisfactory and even long-term survivors experience increased morbidity.
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Affiliation(s)
- Xin Wang
- Department of Medicine, UMass Memorial Medical Center, Worcester, MA, USA
| | - Shyam A Patel
- Division of Hematology-Oncology, Department of Medicine, UMass Memorial Medical Center, Worcester, MA, USA
| | - Michael Haddadin
- Division of Hematology-Oncology, Department of Medicine, UMass Memorial Medical Center, Worcester, MA, USA
| | - Jan Cerny
- Division of Hematology and Oncology, Department of Medicine, UMass Memorial Medical Center, 55 Lake Avenue North, Worcester, MA, 01655, USA
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11
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Handley G, Hasbun R, Okhuysen P. Human herpesvirus 6 and central nervous system disease in oncology patients: A retrospective case series and literature review. J Clin Virol 2021; 136:104740. [PMID: 33548682 DOI: 10.1016/j.jcv.2021.104740] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 01/18/2021] [Accepted: 01/24/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Human herpesvirus 6 (HHV-6) can reactivate with immunosuppression and cause central nervous system (CNS) dysfunction. Much of the literature describes cases after hematopoietic stem cell transplantation (HSCT), ranging from encephalitis to a post-transplant acute limbic encephalitis syndrome (PALE). Outside of HSCT, studies of HHV-6 encephalitis are limited to case reports. OBJECTIVES This study was designed to review HHV-6 CNS infection, and evaluate all patients admitted to MD Anderson Cancer Center between March 2016 and December 2018 with detectable HHV-6 DNA in the cerebrospinal fluid (CSF). STUDY DESIGN Patients with HHV-6 DNA detected in the CSF using the Viracor or Biofire® Meningitis Encephalitis Panel platforms and no other identified etiology were identified and demographic features, known risk factors, imaging findings, CSF analysis, treatments and patient outcomes were extracted from medical records. RESULTS 725 patients underwent HHV-6 testing during the study timeframe, with 19 cases (2.6 %) of HHV-6 mediated CNS disease identified. Most patients, 13/19 (68 %), had undergone HSCT with median time to presentation of 31 days after transplant. Survival at 240 days after transplant was 62 %. CSF had lymphocyte predominance and nearly all patients had peripheral lymphopenia. Other at risk populations identified included patients who received chimeric antigen receptor (CAR) T-cell therapy and biologic immunotherapy. Notable discordance among testing platforms was found in 5/9 (55 %) instances. CONCLUSIONS In addition to HSCT patients, HHV-6 reactivation leading to CNS disease also occurs in settings such as following adoptive T cell therapy or biologic immunotherapy. Significant diagnostic discordance exists between testing platforms.
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Affiliation(s)
- Guy Handley
- Department of Medicine, Division of Infectious Diseases, McGovern Medical School UT Health, 6431 Fannin, MSB 2.112, Houston, TX, 77030, USA.
| | - Rodrigo Hasbun
- Department of Medicine, Division of Infectious Diseases, McGovern Medical School UT Health, 6431 Fannin, MSB 2.112, Houston, TX, 77030, USA
| | - Pablo Okhuysen
- Department of Infectious Diseases, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1460, Houston, TX, 77030, USA
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12
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Voigt M, Sinn K, Malouhi A, Gecks T, Zinke J, Hilgendorf I, Scholl S, Hochhaus A, Schnetzke U. HHV-6 encephalitis in a non-transplanted adult acute myeloid leukemia patient. Ann Hematol 2021; 100:1895-1897. [PMID: 33443593 PMCID: PMC8195884 DOI: 10.1007/s00277-021-04409-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 01/03/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Margarete Voigt
- Klinik für Innere Medizin III, Fachbereich Endokrinologie, Universitätsklinikum Jena, Jena, Germany.,Klinik für Innere Medizin II, Abteilung für Hämatologie und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Konrad Sinn
- Klinik für Innere Medizin II, Abteilung für Hämatologie und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Amer Malouhi
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Jena, Jena, Germany
| | - Thomas Gecks
- Klinik für Innere Medizin I, Internistische Intensivmedizin, Universitätsklinikum Jena, Jena, Germany
| | - Jan Zinke
- Klinik für Neurologie, Klinikum St. Georg Leipzig, Leipzig, Germany
| | - Inken Hilgendorf
- Klinik für Innere Medizin II, Abteilung für Hämatologie und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Sebastian Scholl
- Klinik für Innere Medizin II, Abteilung für Hämatologie und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Andreas Hochhaus
- Klinik für Innere Medizin II, Abteilung für Hämatologie und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Ulf Schnetzke
- Klinik für Innere Medizin II, Abteilung für Hämatologie und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Germany.
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13
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Pathogen or Bystander: Clinical Significance of Detecting Human Herpesvirus 6 in Pediatric Cerebrospinal Fluid. J Clin Microbiol 2020; 58:JCM.00313-20. [PMID: 32102858 DOI: 10.1128/jcm.00313-20] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 02/22/2020] [Indexed: 02/08/2023] Open
Abstract
Human herpesvirus 6 (HHV-6) is an important cause of meningitis and meningoencephalitis. As testing for HHV-6 in cerebrospinal fluid (CSF) is more readily available using the FilmArray Meningitis/Encephalitis panel (FA-ME; BioFire Diagnostics, Salt Lake City, UT), we aimed to determine the clinical significance of detecting HHV-6 in order to identify true infections and to ensure appropriate antiviral initiation. Chart review on 25 patients positive for HHV-6 by FA-ME was performed to determine clinical presentation, comorbidity, treatment, and outcome. The presence of chromosomally integrated HHV-6 (ciHHV-6) DNA was also investigated. Of 1,005 children tested by FA-ME, HHV-6 was detected in 25 (2.5%). Five patients were diagnosed with either HHV-6 meningitis or meningoencephalitis based on HHV-6 detection in CSF, clinical presentation, and radiographic findings. Detection of HHV-6 by FA-ME led to discontinuation of acyclovir within 12.0 h in all 12 patients empirically treated with acyclovir. Six of the 12 patients were started on ganciclovir therapy within 6.8 h; 4 of these were treated specifically for HHV-6 infection, whereas therapy was discontinued in the remaining 2 patients. CSF parameters were not generally predictive of HHV-6 positivity. The presence of ciHHV-6 was confirmed in 3 of 18 patients who could be tested. Five of the 25 patients included in the study were diagnosed with HHV-6 meningitis/meningoencephalitis. FA-ME results led to discontinuation of empirical antiviral treatment in 12 patients and appropriate initiation of ganciclovir in 4 patients. In our institution, detection of HHV-6 using FA-ME led to faster establishment of disease etiology and optimization of antimicrobial therapy.
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14
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Santos CAQ, Rhee Y, Czapka MT, Kazi AS, Proia LA. Make Sure You Have a Safety Net: Updates in the Prevention and Management of Infectious Complications in Stem Cell Transplant Recipients. J Clin Med 2020; 9:jcm9030865. [PMID: 32245201 PMCID: PMC7141503 DOI: 10.3390/jcm9030865] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 03/11/2020] [Indexed: 12/11/2022] Open
Abstract
Hematopoietic stem cell transplant recipients are at increased risk of infection and immune dysregulation due to reception of cytotoxic chemotherapy; development of graft versus host disease, which necessitates treatment with immunosuppressive medications; and placement of invasive catheters. The prevention and management of infections in these vulnerable hosts is of utmost importance and a key “safety net” in stem cell transplantation. In this review, we provide updates on the prevention and management of CMV infection; invasive fungal infections; bacterial infections; Clostridium difficile infection; and EBV, HHV-6, adenovirus and BK infections. We discuss novel drugs, such as letermovir, isavuconazole, meropenem-vaborbactam and bezlotoxumab; weigh the pros and cons of using fluoroquinolone prophylaxis during neutropenia after stem cell transplantation; and provide updates on important viral infections after hematopoietic stem cell transplant (HSCT). Optimizing the prevention and management of infectious diseases by using the best available evidence will contribute to better outcomes for stem cell transplant recipients, and provide the best possible “safety net” for these immunocompromised hosts.
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Estimating the Risk of Human Herpesvirus 6 and Cytomegalovirus Transmission to Ugandan Infants from Viral Shedding in Saliva by Household Contacts. Viruses 2020; 12:v12020171. [PMID: 32028569 PMCID: PMC7077293 DOI: 10.3390/v12020171] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 01/27/2020] [Accepted: 01/29/2020] [Indexed: 02/07/2023] Open
Abstract
Human herpesvirus 6 (HHV-6) and cytomegalovirus (CMV) infections are common in early childhood. In a prospective Ugandan birth cohort study, most infants acquired HHV-6 (24/31; 77%) and CMV (20/30; 67%) during follow-up. To assess the transmission risk, we modeled a dose-response relationship between infant HHV-6 and CMV infections and weekly oral viral shedding by mothers and all other ("secondary") children in the home. Oral viral loads that were shed by mothers and secondary children were significantly associated with HHV-6 but not CMV transmission. While secondary children had higher and more frequent HHV-6 shedding than their mothers, they had a lower per-exposure transmission risk, suggesting that transmission to maternal contacts may be more efficient. HHV-6 transmission was relatively inefficient, occurring after <25% of all weekly exposures. Although HHV-6 transmission often occurs following repeated, low dose exposures, we found a non-linear dose-response relationship in which infection risk markedly increases when exposures reached a threshold of > 5 log10 DNA copies/mL. The lack of association between oral CMV shedding and transmission is consistent with breastfeeding being the dominant route of infant infection for that virus. These affirm saliva as the route of HHV-6 transmission and provide benchmarks for developing strategies to reduce the risk of infection and its related morbidity.
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Herpes Virus Infections Other than Cytomegalovirus in the Recipients of Hematopoietic Stem Cell Transplantation. Infect Dis Clin North Am 2019; 33:467-484. [PMID: 31005137 DOI: 10.1016/j.idc.2019.02.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
This review discusses the epidemiologic and clinical aspects of herpes viruses other than cytomegalovirus in patients who have undergone hematopoietic stem cell transplantation.
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Clinical practice recommendations for the diagnosis and management of human herpesvirus-6B encephalitis after allogeneic hematopoietic stem cell transplantation: the Japan Society for Hematopoietic Cell Transplantation. Bone Marrow Transplant 2019; 55:1004-1013. [PMID: 31745253 DOI: 10.1038/s41409-019-0752-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 11/06/2019] [Accepted: 11/06/2019] [Indexed: 01/04/2023]
Abstract
Reactivation of human herpesvirus (HHV)-6B is relatively common after allogeneic hematopoietic stem cell transplantation (HSCT) and HHV-6B diseases may consequently develop. Among them, HHV-6B encephalitis is a serious and often fatal complication. The aim of these clinical practice recommendations is to provide diagnostic and therapeutic guidance for HHV-6B encephalitis after allogeneic HSCT. In this evidence-based review, we critically evaluated data from the published literature. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assist in generating recommendations. We have summarized the findings that contribute to decision-making and we have provided our recommendations. In cases where rigorous clinical data are unavailable, recommendations have been developed in discussions with physicians who have relevant expertize.
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Green DA, Pereira M, Miko B, Radmard S, Whittier S, Thakur K. Clinical Significance of Human Herpesvirus 6 Positivity on the FilmArray Meningitis/Encephalitis Panel. Clin Infect Dis 2019; 67:1125-1128. [PMID: 29635334 PMCID: PMC7108106 DOI: 10.1093/cid/ciy288] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 04/07/2018] [Indexed: 11/13/2022] Open
Abstract
A review of 15 patients who tested positive for human herpesvirus 6 (HHV-6) on the FilmArray Meningitis/Encephalitis panel revealed that the majority were unlikely to have HHV-6 encephalitis. Criteria to assist interpretation of HHV-6 positive results are presented.
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Affiliation(s)
- Daniel A Green
- Department of Pathology & Cell Biology, New York, New York
| | | | | | - Sara Radmard
- Department of Neurology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Susan Whittier
- Department of Pathology & Cell Biology, New York, New York
| | - Kiran Thakur
- Department of Neurology, Columbia University College of Physicians and Surgeons, New York, New York
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19
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Takano K, Ogata M, Satou T, Miyazaki Y, Otsuka E, Saito N, Ueki T, Kako S, Fukuda T, Shirao K. Correlations of cytokine levels in cerebrospinal fluid and peripheral blood with outcome of HHV-6B encephalitis after hematopoietic stem cell transplantation. Transpl Infect Dis 2019; 21:e13172. [PMID: 31520510 DOI: 10.1111/tid.13172] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 07/07/2019] [Accepted: 08/23/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Human herpesvirus (HHV)-6B encephalitis has been recognized as a serious complication after allogeneic hematopoietic cell transplantation (allo-HCT). Little is known about the pathogenic mechanism for its progression. STUDY DESIGN We retrospectively evaluated the 16 kinds of cytokines and chemokines in cerebrospinal fluid (CSF) and plasma in patients who developed HHV-6B encephalitis. Among a total of 20 patients, 12 were categorized as the poor prognosis group (died of encephalitis; n = 8 and retained sequelae; n = 4), and other eight patients were categorized as the good prognosis group (complete recovery; n = 8). RESULTS Concentrations of CSF IL-6 and IL-8 at the onset of encephalitis were significantly higher in the poor prognosis group than in the good prognosis group (median CSF IL-6, 28.27 pg/mL vs 14.32 pg/mL, P = .004; median CSF IL-8, 128.70 pg/mL vs 59.43 pg/mL, P = .043). Regarding plasma, the concentration of each cytokine at the onset of encephalitis was not significantly different between the two groups, except IL-5. However, higher levels of IL-6, IL-7, and MCP-1 and lower levels of IL-12 were observed 1 week before the development of encephalitis in patients with poor prognosis (median IL-6; 464.17 pg/mL vs 47.82 pg/mL, P = .02; median IL-12; 1.63 pg/mL vs 6.57 pg/mL, P = .03). CONCLUSION We found that one week before onset of HHV-6B encephalitis, poor prognosis patients had high plasma concentrations of IL-6, IL-7, and MCP-1 and low concentrations of IL-12. At the onset of encephalitis, high concentrations of IL-6 and IL-8 in CSF were more common in the poor prognosis group, consistent with other evidence that IL-6 can have a role in CNS disturbances. Our findings show that specific cytokine status is associated with severe brain damage in patients with HHV-6B encephalitis, demonstrate prognostic value of plasma IL-6 concentrations, and suggest evaluation of anti-cytokine therapeutics in patients with HHV-6B encephalitis.
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Affiliation(s)
- Kuniko Takano
- Department of Medical Oncology and Hematology, Faculty of Medicine, Oita University, Oita, Japan
| | - Masao Ogata
- Department of Hematology, Oita University Hospital, Oita, Japan
| | - Takako Satou
- Department of Clinical Laboratory, Kouseiren Tsurumi Hospital, Oita, Japan
| | | | - Eiichi Otsuka
- Department of Hematology, Oita Prefectural Hospital, Oita, Japan
| | - Noriyuki Saito
- Department of Hematology, Hamanomachi Hospital, Fukuoka, Japan
| | - Toshimitsu Ueki
- Department of Hematology, Nagano Red Cross Hospital, Nagano, Japan
| | - Shinichi Kako
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Takahiro Fukuda
- Hematopoietic Stem Cell Transplantation Division, National Cancer Center Hospital, Tokyo, Japan
| | - Kuniaki Shirao
- Department of Medical Oncology and Hematology, Faculty of Medicine, Oita University, Oita, Japan
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Ward KN, Hill JA, Hubacek P, de la Camara R, Crocchiolo R, Einsele H, Navarro D, Robin C, Cordonnier C, Ljungman P. Guidelines from the 2017 European Conference on Infections in Leukaemia for management of HHV-6 infection in patients with hematologic malignancies and after hematopoietic stem cell transplantation. Haematologica 2019; 104:2155-2163. [PMID: 31467131 PMCID: PMC6821622 DOI: 10.3324/haematol.2019.223073] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 08/27/2019] [Indexed: 01/15/2023] Open
Abstract
Of the two human herpesvirus 6 (HHV-6) species, human herpesvirus 6B (HHV-6B) encephalitis is an important cause of morbidity and mortality after allogeneic hematopoietic stem cell transplant. Guidelines for the management of HHV-6 infections in patients with hematologic malignancies or post-transplant were prepared a decade ago but there have been no other guidelines since then despite significant advances in the understanding of HHV-6 encephalitis, its therapy, and other aspects of HHV-6 disease in this patient population. Revised guidelines prepared at the 2017 European Conference on Infections in Leukaemia covering diagnosis, preventative strategies and management of HHV-6 disease are now presented.
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Affiliation(s)
- Katherine N Ward
- Division of Infection and Immunity, University College London, London, UK
| | - Joshua A Hill
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Petr Hubacek
- Department of Medical Microbiology and Department of Paediatric Haematology and Oncology 2 Medical Faculty of Charles University and Motol University Hospital, Prague, Czech Republic
| | | | | | - Hermann Einsele
- Medizinische Klinik und Poliklinik II, Julius Maximilians Universität, Würzburg, Germany
| | - David Navarro
- Microbiology Service, Hospital Clínico Universitario, Instituto de Investigación INCLIVA and Department of Microbiology, School of Medicine, University of Valencia, Valencia, Spain
| | - Christine Robin
- Department of Haematology, Henri Mondor Hospital, Assistance Publique-Hopitaux de Paris, Université Paris-Est Créteil, Créteil, France
| | - Catherine Cordonnier
- Department of Haematology, Henri Mondor Hospital, Assistance Publique-Hopitaux de Paris, Université Paris-Est Créteil, Créteil, France
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Tamaki H, Ikegame K, Yoshihara S, Kaida K, Yoshihara K, Inoue T, Kato R, Nakata J, Fujioka T, Soma T, Okada M, Ogawa H. Low incidence of HHV‐6 reactivation in haploidentical hematopoietic stem cell transplantation with corticosteroid as graft‐vs‐host disease prophylaxis compared with cord blood transplantation. Transpl Infect Dis 2019; 21:e13073. [DOI: 10.1111/tid.13073] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 01/31/2019] [Accepted: 02/24/2019] [Indexed: 12/22/2022]
Affiliation(s)
- Hiroya Tamaki
- Division of Hematology, Department of Internal Medicine Hyogo College of Medicine Nishinomiya Japan
| | - Kazuhiro Ikegame
- Division of Hematology, Department of Internal Medicine Hyogo College of Medicine Nishinomiya Japan
| | - Satoshi Yoshihara
- Division of Hematology, Department of Internal Medicine Hyogo College of Medicine Nishinomiya Japan
| | - Katsuji Kaida
- Division of Hematology, Department of Internal Medicine Hyogo College of Medicine Nishinomiya Japan
| | - Kyoko Yoshihara
- Division of Hematology, Department of Internal Medicine Hyogo College of Medicine Nishinomiya Japan
| | - Takayuki Inoue
- Division of Hematology, Department of Internal Medicine Hyogo College of Medicine Nishinomiya Japan
| | - Ruri Kato
- Division of Hematology, Department of Internal Medicine Hyogo College of Medicine Nishinomiya Japan
| | - Jun Nakata
- Division of Hematology, Department of Internal Medicine Hyogo College of Medicine Nishinomiya Japan
| | - Tatsuya Fujioka
- Division of Hematology, Department of Internal Medicine Hyogo College of Medicine Nishinomiya Japan
| | - Toshihiro Soma
- Division of Hematology, Department of Internal Medicine Hyogo College of Medicine Nishinomiya Japan
- Laboratory of Cell Transplantation, Institute for Advanced Medical Sciences Hyogo College of Medicine Nishinomiya Japan
| | - Masaya Okada
- Division of Hematology, Department of Internal Medicine Hyogo College of Medicine Nishinomiya Japan
| | - Hiroyasu Ogawa
- Division of Hematology, Department of Internal Medicine Hyogo College of Medicine Nishinomiya Japan
- Laboratory of Cell Transplantation, Institute for Advanced Medical Sciences Hyogo College of Medicine Nishinomiya Japan
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22
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Slenker AK, Royer TL, Villalobos T. Human Herpesvirus 6 Positivity on the FilmArray Meningitis/Encephalitis Panel Needs Clinical Interpretation. Clin Infect Dis 2019; 69:192-194. [DOI: 10.1093/cid/ciz058] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 01/17/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
- Amy K Slenker
- Division of Infectious Diseases, Lehigh Valley Health Network
| | - Tricia L Royer
- Division of Infectious Diseases, Lehigh Valley Health Network
| | - Tibisay Villalobos
- Department of Pediatrics, Section of Infectious Diseases, Lehigh Valley Children’s Hospital, Allentown, Pennsylvania
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23
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Zerr DM. Human Herpesvirus 6B in the Transplant Recipient: When to Worry, When to Act. J Pediatric Infect Dis Soc 2018; 7:S75-S78. [PMID: 30590622 DOI: 10.1093/jpids/piy111] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Human herpesvirus 6B (HHV-6B) is a ubiquitous pathogen that infects most individuals before the age of three years. HHV-6B reactivates in approximately 40% of transplant recipients where it has been associated with a number of important outcomes, especially in allogeneic transplant recipients. This article will review the epidemiology, clinical manifestations, diagnosis, and treatment of HHV-6B infection.
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Affiliation(s)
- Danielle M Zerr
- Seattle Children's Research Institute and Department of Pediatrics, University of Washington, Seattle
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24
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Yoshimoto G, Mori Y, Kato K, Shima T, Miyawaki K, Kikushige Y, Kamezaki K, Numata A, Maeda T, Takenaka K, Iwasaki H, Teshima T, Akashi K, Miyamoto T. Human Herpes Virus-6–Associated Encephalitis/Myelitis Mimicking Calcineurin Inhibitor–Induced Pain Syndrome in Allogeneic Stem Cell Transplantation Recipients. Biol Blood Marrow Transplant 2018; 24:2540-2548. [DOI: 10.1016/j.bbmt.2018.07.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 07/11/2018] [Indexed: 10/28/2022]
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25
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Inui Y, Yakushijin K, Okamura A, Tanaka Y, Shinzato I, Nomura T, Ichikawa H, Mizutani Y, Kitao A, Kurata K, Kakiuchi S, Miyata Y, Sanada Y, Kitagawa K, Uryu K, Kawamoto S, Yamamoto K, Matsuoka H, Murayama T, Ito M, Minami H. Human herpesvirus 6 encephalitis in patients administered mycophenolate mofetil as prophylaxis for graft-versus-host disease after allogeneic hematopoietic stem cell transplantation. Transpl Infect Dis 2018; 21:e13024. [PMID: 30414316 DOI: 10.1111/tid.13024] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 10/11/2018] [Accepted: 10/28/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Human herpesvirus 6 (HHV-6) encephalitis is a known life-threatening complication following allogeneic hematopoietic stem cell transplantation (allo-HSCT). However, few studies have focused on the occurrence of HHV-6 encephalitis in patients receiving mycophenolate mofetil (MMF) combined with a calcineurin inhibitor as prophylaxis for graft-versus-host disease (GVHD). This study aimed to investigate the impact of MMF administered for GVHD prophylaxis in the occurrence of HHV-6 encephalitis after allo-HSCT and the characteristics of this condition. METHODS AND RESULTS We retrospectively analyzed 73 patients who underwent allo-HSCT (83 transplants) at our hospital between April 2010 and December 2015. MMF (2-3 g/d) was administered along with a calcineurin inhibitor. Seven patients (8.0%) developed encephalitis due to HHV-6. The median period from allo-HSCT to the onset of HHV-6 encephalitis was 23 days (range, 17-98 days). The cumulative incidence of HHV-6 encephalitis on day 100 after treatment was 12% and 6% in patients who underwent cord blood transplantation (CBT) and non-CBT (ie, bone marrow transplantation and peripheral blood stem cell transplantation), respectively (P = 0.344). Neurological symptoms of encephalitis were more severe in non-CBT cases than those in CBT cases. All patients diagnosed with HHV-6 encephalitis were treated with ganciclovir or foscarnet. None of the enrolled patients died from HHV-6 encephalitis. CONCLUSIONS Mycophenolate mofetil may have the potential to increase the frequency of severe HHV-6 encephalitis in patients undergoing CBT and non-CBT. Thus, MMF should be administered with caution, and patients should be monitored closely for HHV-6 encephalitis even those who did not undergo CBT.
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Affiliation(s)
- Yumiko Inui
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kimikazu Yakushijin
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Atsuo Okamura
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yasuhiro Tanaka
- Department of Hematology and Clinical Immunology, Kobe City Nishi-Kobe Medical Center, Kobe, Japan
| | - Isaku Shinzato
- Department of Hematology and Clinical Immunology, Kobe City Nishi-Kobe Medical Center, Kobe, Japan
| | - Tetsuhiko Nomura
- Department of Hematology, Hyogo Prefectural Awaji Medical Center, Hyogo, Japan
| | - Hiroya Ichikawa
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yu Mizutani
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Akihito Kitao
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Keiji Kurata
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Seiji Kakiuchi
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yoshiharu Miyata
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yukinari Sanada
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Koichi Kitagawa
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kiyoaki Uryu
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shinichiro Kawamoto
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Katsuya Yamamoto
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroshi Matsuoka
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tohru Murayama
- Department of Hematology, Hyogo Cancer Center, Hyogo, Japan
| | - Mitsuhiro Ito
- Laboratory of Hematology, Division of Medical Biophysics, Kobe University Graduate School of Health Sciences, Kobe, Japan
| | - Hironobu Minami
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
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Flamand L. Chromosomal Integration by Human Herpesviruses 6A and 6B. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1045:209-226. [PMID: 29896669 DOI: 10.1007/978-981-10-7230-7_10] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Upon infection and depending on the infected cell type, human herpesvirus 6A (HHV-6A) and 6B (HHV-6B) can replicate or enter a state of latency. HHV-6A and HHV-6B can integrate their genomes into host chromosomes as one way to establish latency. Viral integration takes place near the subtelomeric/telomeric junction of chromosomes. When HHV-6 infection and integration occur in gametes, the virus can be genetically transmitted. Inherited chromosomally integrated HHV-6 (iciHHV-6)-positive individuals carry one integrated HHV-6 copy per somatic cell. The prevalence of iciHHV-6+ individuals varies between 0.6% and 2%, depending on the geographical region sampled. In this chapter, the mechanisms leading to viral integration and reactivation from latency, as well as some of the biological and medical consequences associated with iciHHV-6, were discussed.
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Affiliation(s)
- Louis Flamand
- Division of Infectious and Immune Diseases, CHU de Québec Research Center, QC, Quebec, Canada. .,Department of Microbiology, Infectious Disease and Immunology, Faculty of Medicine, Université Laval, QC, Quebec, Canada.
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27
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Lin P, Tian X, Wang X. Seizures after transplantation. Seizure 2018; 61:177-185. [PMID: 30179843 DOI: 10.1016/j.seizure.2018.08.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 08/09/2018] [Accepted: 08/11/2018] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To summarize information on the history, incidence, clinical manifestation, best treatment, as well as prognosis of seizures in transplant recipients. METHODS In October 2017, we searched the literature on PubMed in English with the search terms: "transplantation" AND "seizure", "transplantation" AND "epilepsy", "transplantation"AND "status epilepticus", "immunosuppressant" AND "seizure", "immunosuppressant" AND "epilepsy". Publications not based on new data and original research were not included in this article. RESULTS Seizures including generalized seizures, focal seizures and status epilepticus are a common central nervous system complication after transplantation. The incidence of seizures varied between different kinds of transplantations. The reported incidence of seizures was 7%-27% in association with solid organ transplantations and 1.6%-15.4% with hematopoietic stem cell transplantation. Most of seizures appeared in the early post-transplantation period. Patients often had a favorable prognosis, however, in some conditions, recurrent or intractable seizures may occur. CONCLUSIONS The underlying pathogenesis of new-onset seizures or epilepsy in recipients of transplantation needs to be further elucidated. In addition, more information is required from prospective studies and research focusing on therapeutic strategies.
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Affiliation(s)
- Peijia Lin
- Department of Neurology, Chongqing Key Laboratory of Neurology, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Chongqing 400016, China.
| | - Xin Tian
- Department of Neurology, Chongqing Key Laboratory of Neurology, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Chongqing 400016, China.
| | - Xuefeng Wang
- Department of Neurology, Chongqing Key Laboratory of Neurology, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Chongqing 400016, China; Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing 100871, China.
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28
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Perruccio K, Sisinni L, Perez-Martinez A, Valentin J, Capolsini I, Massei MS, Caniglia M, Cesaro S. High Incidence of Early Human Herpesvirus-6 Infection in Children Undergoing Haploidentical Manipulated Stem Cell Transplantation for Hematologic Malignancies. Biol Blood Marrow Transplant 2018; 24:2549-2557. [PMID: 30067953 DOI: 10.1016/j.bbmt.2018.07.033] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 07/21/2018] [Indexed: 12/26/2022]
Abstract
Human herpesvirus-6 (HHV-6) infection is increasingly recognized among allogeneic hematopoietic stem cell transplantation (HSCT) recipients, with 30% at risk of reactivation in the haploidentical setting. It has been associated with encephalitis, acute graft-versus-host disease, and graft failure. Here we report 2 cohorts of pediatric haploidentical manipulated HSCT in which, despite many differences, HHV-6 reactivation and disease occurred with very high incidence compared with data reported in the literature and represented the main early post-transplant infectious complication compared with other viral, bacterial, or fungal infections. The 2 cohorts were recruited at the pediatric transplant centers of Perugia (n = 13), Barcelona (n = 10), and Madrid (n = 15). All patients received myeloablative conditioning regimens and 2 different types of ex vivo graft manipulation: CD34+ selection and regulatory T cell/conventional T cell infusion in 13 patients and CD45RA T cell depletion in 25 patients. Antiviral prophylaxis was acyclovir in 33 and foscarnet in 5 patients. HHV-6 DNAemia was checked by quantitative or qualitative PCR. In vitro experiments demonstrated that donor CD4+ T cells are the reservoir of HHV-6 and suggested a role of the graft composition in both transplant settings (rich in CD4+ T cells) in the high rate of HHV-6 infections. All patients presented very early HHV-6 DNAemia after transplantation, and although viremic, 9 patients (24%) developed symptomatic limbic encephalitis. All patients responded to antiviral treatment, and none died of infection, although 2 experienced long-term neurologic sequelae (22%). Moreover, 6 patients presented organ involvement in absence of other causes: 1 hepatitis, 1 pneumonia, 2 gastroenteritis, and 2 multiorgan involvement(1 encephalitis, pneumonia, and gastritis; 1 pneumonia and enteritis). Incidences of other viral, bacterial, and fungal diseases were lower in both cohorts. In vitro, HHV-6 was found to infect only CD4+ fraction of the graft. Co-culturing CD4+ T cells with CD56+ natural killer (NK) cells eliminated the virus, demonstrating the main role of NK cells in the antiviral immune response. All 38 pediatric patients undergoing these manipulated haploidentical HSCTs showed HHV-6 reactivation, and 14 of 38 developed HHV-6 disease with similar features in terms of timing, morbidity, response to treatment, and outcome. The graft composition in both transplant platforms, rich in CD4+ T cells and poor in NK cells, seems to play a key role. HHV-6 DNAemia surveillance was useful to diagnose and treat preemptively HHV-6 infection.
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Affiliation(s)
- Katia Perruccio
- Pediatric Oncology-Hematology, Santa Maria della Misericordia Hospital, Perugia, Italy.
| | - Luisa Sisinni
- Pediatric Hematology, Santa Creu Hospital, Sant Pau, Barcelona, Spain
| | | | | | - Ilaria Capolsini
- Pediatric Oncology-Hematology, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Maria Speranza Massei
- Pediatric Oncology-Hematology, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Maurizio Caniglia
- Pediatric Oncology-Hematology, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Simone Cesaro
- Pediatric Hematology-Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
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Genomic Integration of HHV-6 Mimicking Viral Reactivation after Autologous Stem Cell Transplantation. Mediterr J Hematol Infect Dis 2018. [PMID: 29531650 PMCID: PMC5841938 DOI: 10.4084/mjhid.2018.013] [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] [Indexed: 11/08/2022] Open
Abstract
The monitoring of Human Herpesvirus 6 (HHV-6) after allogeneic stem cell transplantation has proven to be useful in preventing life-threatening complications; however, the pathogenic role of HHV-6 after autologous transplantation is not well-characterized, although viral reactivation might be responsible for significant complications even after this type of transplant. Here we report, for the first time to our knowledge, the case of a patient with chromosomally integrated HHV-6 (ciHHV-6), presenting with high titers of HHV-6 DNA copies after autologous transplantation, mimicking HHV-6 reactivation. The presence of viral DNA in the follicle bulb confirmed the ciHHV-6 and allowed for the discontinuation of the antiviral treatment. Due to the increasing awareness of HHV-6 potential pathogenicity and the fact that ciHHV-6 is expected in 1–2% of the population, such a case might be helpful in recognizing ci HHV-6, thus avoiding unnecessary and potentially toxic antiviral therapy once the viral genomic integration is confirmed.
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30
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Ueki T, Hoshi K, Hiroshima Y, Sumi M, Ichikawa N, Ogata M, Satou T, Fukuda T, Kobayashi H. Analysis of five cases of human herpesvirus-6 myelitis among 121 cord blood transplantations. Int J Hematol 2017; 107:363-372. [PMID: 29022282 DOI: 10.1007/s12185-017-2347-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Revised: 10/03/2017] [Accepted: 10/06/2017] [Indexed: 11/29/2022]
Abstract
Reports of myelitis associated with human herpesvirus-6 (HHV-6) following allogeneic transplantation are rare. Of 121 cases of cord blood transplantation (CBT) performed at Nagano Red Cross Hospital, five cases (4.1%) of HHV-6 myelitis developed at around the time of engraftment. The major symptom identified in all five patients was superficial pain or pruritus linked to segmental levels of the spinal cord. Other identified symptoms were fever or low-grade fever in all five patients, autonomic nerve disorder in four patients, bladder and rectal disturbance in two patients, and extrapyramidal disorder in two patients. These symptoms were experienced primarily 16-39 days after CBT. HHV-6 PCR tests were all positive for cerebrospinal fluid and for plasma. Of the four cases tested by magnetic resonance imaging (MRI), three showed spinal cord abnormality. Antiviral therapy using foscarnet or ganciclovir was effective in every case. Although one case treated from 12 days after onset experienced long-term pain resembling postherpetic neuralgia, symptoms in the four cases were completely relieved after antiviral therapy. In summary, the major symptoms of HHV-6 myelitis were superficial pain linked to segmental levels of the spinal cord. Prognosis may be improved by early initiation of antiviral therapy.
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Affiliation(s)
- Toshimitsu Ueki
- Department of Hematology, Nagano Red Cross Hospital, Nagano, Japan.
| | - Kenichi Hoshi
- Department of Neurology, Nagano Red Cross Hospital, Nagano, Japan
| | - Yuki Hiroshima
- Department of Hematology, Nagano Red Cross Hospital, Nagano, Japan
| | - Masahiko Sumi
- Department of Hematology, Nagano Red Cross Hospital, Nagano, Japan
| | - Naoaki Ichikawa
- Department of Hematology, Nagano Red Cross Hospital, Nagano, Japan
| | - Masao Ogata
- Department of Hematology, Faculty of Medicine, Oita University, Oita, Japan
| | - Takako Satou
- Department of Hematology, Faculty of Medicine, Oita University, Oita, Japan
| | - Takahiro Fukuda
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Hikaru Kobayashi
- Department of Hematology, Nagano Red Cross Hospital, Nagano, Japan
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Frey JW, Cherabie JN, Assi MA. Human herpesvirus-6 encephalitis following chemotherapy induction for acute myelogenous leukemia. Transpl Infect Dis 2017; 19. [DOI: 10.1111/tid.12756] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 04/28/2017] [Accepted: 05/18/2017] [Indexed: 11/26/2022]
Affiliation(s)
- John W. Frey
- Kansas City University of Medicine and Biosciences; Kansas City MO USA
| | - Joseph N. Cherabie
- Department of Internal Medicine; University of Kansas School of Medicine - Wichita; Wichita KS USA
| | - Maha A. Assi
- Department of Infectious Disease; University of Kansas School of Medicine - Wichita; Wichita KS USA
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Righi E, Carnelutti A, Muser D, Zaja F, Lucchini E, Pea F, Di Gregorio F, Alavi A, Bassetti M. Successful treatment and FDG-PET/CT monitoring of HHV-6 encephalitis in a non-neutropenic patient: case report and literature review. J Neurovirol 2017; 23:908-912. [PMID: 28822107 DOI: 10.1007/s13365-017-0566-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 07/23/2017] [Accepted: 08/02/2017] [Indexed: 11/27/2022]
Abstract
Human herpesvirus (HHV)-6 reactivation is associated with severe forms of encephalitis among patients undergoing hematopoietic stem cell transplantation. Cases in non-neutropenic patients are uncommon. The efficacy of ganciclovir and other compounds that are used for the treatment of HHV-6 encephalitis remains suboptimal and linked to toxicity. Valganciclovir, the oral prodrug of ganciclovir, could be practical to treat outpatients, but it is not commonly used for severe cases. We report a case of HHV-6 encephalitis in a non-neutropenic patient successfully treated with valganciclovir and undergoing therapeutic drug monitoring in plasma and in the cerebrospinal fluid. Resolution of infectious foci was documented by cerebral MRI and F18-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT). A review of the literature on HHV-6 encephalitis is also reported.
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Affiliation(s)
- Elda Righi
- Infectious Diseases Division, Santa Maria della Misericordia University Hospital, 50, Colugna Street, 33100, Udine, Italy.
| | - Alessia Carnelutti
- Infectious Diseases Division, Santa Maria della Misericordia University Hospital, 50, Colugna Street, 33100, Udine, Italy
| | - Daniele Muser
- Department of Cardiology, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Francesco Zaja
- Department of Hematology, DISM, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Elisa Lucchini
- Department of Hematology, DISM, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Federico Pea
- Institute of Clinical Pharmacology, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Fernando Di Gregorio
- Division of Nuclear Medicine, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Abass Alavi
- Division of Nuclear Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Matteo Bassetti
- Infectious Diseases Division, Santa Maria della Misericordia University Hospital, 50, Colugna Street, 33100, Udine, Italy
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Ogata M, Oshima K, Ikebe T, Takano K, Kanamori H, Kondo T, Ueda Y, Mori T, Hashimoto H, Ogawa H, Eto T, Ueki T, Miyamoto T, Ichinohe T, Atsuta Y, Fukuda T. Clinical characteristics and outcome of human herpesvirus-6 encephalitis after allogeneic hematopoietic stem cell transplantation. Bone Marrow Transplant 2017; 52:1563-1570. [PMID: 28783148 DOI: 10.1038/bmt.2017.175] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 06/09/2017] [Accepted: 06/29/2017] [Indexed: 11/09/2022]
Abstract
In this retrospective analysis using the Transplant Registry Unified Management Program, we identified 145 patients with human herpesvirus (HHV)-6 encephalitis among 6593 recipients. The cumulative incidences of HHV-6 encephalitis at 100 days after transplantation in all patients, recipients of bone marrow or PBSCs and recipients of cord blood were 2.3%, 1.6% and 5.0%, respectively. Risk factors identified in multivariate analysis were male sex, type of transplanted cells (relative risk in cord blood transplantation, 11.09, P<0.001; relative risk in transplantation from HLA-mismatched unrelated donor, 9.48, P<0.001; vs transplantation from HLA-matched related donor) and GvHD prophylaxis by calcineurin inhibitor alone. At 100 days after transplantation, the overall survival rate was 58.3% and 80.5% among patients with and without HHV-6 encephalitis, respectively (P<0.001). Neuropsychological sequelae remained in 57% of 121 evaluated patients. With both foscarnet and ganciclovir, full-dose therapy (foscarnet ⩾180 mg/kg, ganciclovir ⩾10 mg/kg) was associated with better response rate (foscarnet, 93% vs 74%, P=0.044; ganciclovir, 84% vs 58%, P=0.047). HHV-6 encephalitis is not rare not only in cord blood transplant recipients but also in recipients of HLA-mismatched unrelated donors. In this study, development of HHV-6 encephalitis was associated with a poor survival rate, and neurological sequelae remained in many patients.
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Affiliation(s)
- M Ogata
- Department of Medical Oncology and Hematology, Oita University Faculty of Medicine, Oita, Japan
| | - K Oshima
- Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - T Ikebe
- Department of Medical Oncology and Hematology, Oita University Faculty of Medicine, Oita, Japan
| | - K Takano
- Department of Medical Oncology and Hematology, Oita University Faculty of Medicine, Oita, Japan
| | - H Kanamori
- Department of Hematology, Kanagawa Cancer Center, Kanagawa, Japan
| | - T Kondo
- Department of Hematology/Oncology, Kyoto University Hospital, Kyoto, Japan
| | - Y Ueda
- Department of Hematology/Oncology, Kurashiki Central Hospital, Okayama, Japan
| | - T Mori
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - H Hashimoto
- Department of Hematology, Kobe General Hospital/Institute of Biomedical Research and Innovation, Hyogo, Japan
| | - H Ogawa
- Division of Hematology, Hyogo College of Medicine, Hyogo, Japan
| | - T Eto
- Department of Hematology, Hamanomachi Hospital, Fukuoka, Japan
| | - T Ueki
- Department of Hematology, Nagano Red Cross Hospital, Nagano, Japan
| | - T Miyamoto
- Medicine and Biosystemic Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - T Ichinohe
- Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Y Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation, Aichi, Japan.,Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - T Fukuda
- Division of Hematopoietic Stem Cell Transplantation Division, National Cancer Center Hospital, Tokyo, Japan
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Huang YT, Kim SJ, Lee YJ, Burack D, Nichols P, Maloy M, Perales MA, Giralt SA, Jakubowski AA, Papanicolaou GA. Co-Infections by Double-Stranded DNA Viruses after Ex Vivo T Cell-Depleted, CD34 + Selected Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2017; 23:1759-1766. [PMID: 28668490 DOI: 10.1016/j.bbmt.2017.06.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 06/14/2017] [Indexed: 12/16/2022]
Abstract
Recipients of ex vivo T cell-depleted (TCD) hematopoietic cell transplantation (HCT) are at risk of infection by double-stranded (ds) DNA viruses. We report rates of dsDNA viremia, end-organ disease (EOD), infection-related mortality, and overall survival (OS) in a contemporary cohort of adult TCD HCT recipients routinely monitored for cytomegalovirus (CMV), adenovirus (ADV), human herpesvirus 6 (HHV6), and Epstein-Barr virus (EBV). Healthcare utilization in the first 6 months post-HCT was compared between patients with dsDNA viremia versus no viremia. This was an observational study of adult patients with acute leukemia and myelodysplastic syndrome who received CD34+ selected, peripheral blood HCT at Memorial Sloan Kettering Cancer Center from March 2012 through December 2014. Patients were prospectively monitored by quantitative PCR assays for CMV, ADV, HHV6, and EBV in whole blood or plasma. The cumulative incidence of viremia(s) at day +180, EOD at 1 year, and OS at 1 year were estimated by the Kaplan-Meier method and compared by the log-rank test among patient with and without viremia/EOD. Standardized incidence ratios were used to compare overall length of hospital stay (LOS), number of readmissions after HCT, and length of readmissions through day +180. Of 156 patients, 96 (62%) were CMV recipient seropositive. Forty-two patients received grafts from matched related (27%), 86 from matched unrelated (55%), and 28 from mismatched (18%) donors. Overall, 132 patients (85%) had ≥1 viremia and 52 (33%) ≥2 viremias by day +180. The cumulative incidences for CMV, HHV6, ADV, and EBV viremia were 44%, 61%, 7%, and 16%, respectively, with median times of onset 28 days (interquartile range [IQR], 25 to 33), 33 days (IQR, 25 to 47), 60 days (IQR, 19 to 84), and 79 days (IQR, 54 to 106) post-HCT, respectively. Twenty-eight patients (18%) developed EOD by dsDNA viruses at 1 year post-HCT. Treatment for CMV accounted for 91% total antiviral treatment-days. Compared with patients with no viremia, patients with CMV viremia, HHV6 viremia, or ≥2 viremias experienced longer LOS (P <.001) and a higher number of readmissions (P <.001) by day +180. OS rate at 1 year was 79% and was similar between patients with or without dsDNA viremias. EOD was associated with lower 1-year OS rates (63.4%) versus without EOD (81.1%) (P = .02). Of 33 patients who died, 10 died due to infection, and 7 of these infection-related deaths were due to dsDNA viruses. Viremia by dsDNA viruses occurred in 85% of TCD HCT recipients by day +100 and 33% of patients experienced ≥2 viremias by day +180. CMV accounted for most antiviral use. CMV, HHV6, or ≥2 viremias were associated with more readmissions and longer LOS. One year OS rate was 78%. EOD by dsDNA viruses was associated with decreased 1-year OS. Infections by dsDNA viruses pose a substantial burden after TCD HCT.
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Affiliation(s)
- Yao-Ting Huang
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Seong Jin Kim
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yeon Joo Lee
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Daniel Burack
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Paige Nichols
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Molly Maloy
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Miguel-Angel Perales
- Department of Medicine, Weill Cornell Medical College, New York, New York; Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sergio A Giralt
- Department of Medicine, Weill Cornell Medical College, New York, New York; Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ann A Jakubowski
- Department of Medicine, Weill Cornell Medical College, New York, New York; Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Genovefa A Papanicolaou
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York.
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35
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Human Herpesvirus 6B Induces Hypomethylation on Chromosome 17p13.3, Correlating with Increased Gene Expression and Virus Integration. J Virol 2017; 91:JVI.02105-16. [PMID: 28298607 DOI: 10.1128/jvi.02105-16] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 03/03/2017] [Indexed: 12/21/2022] Open
Abstract
Human herpesvirus 6B (HHV-6B) is a neurotropic betaherpesvirus that achieves latency by integrating its genome into host cell chromosomes. Several viruses can induce epigenetic modifications in their host cells, but no study has investigated the epigenetic modifications induced by HHV-6B. This study analyzed methylation with an Illumina 450K array, comparing HHV-6B-infected and uninfected Molt-3 T cells 3 days postinfection. Bisulfite pyrosequencing was used to validate the Illumina results and to investigate methylation over time in vitro Expression of genes was investigated using quantitative PCR (qPCR), and virus integration was investigated with PCR. A total of 406 CpG sites showed a significant HHV-6B-induced change in methylation in vitro Remarkably, 86% (351/406) of these CpGs were located <1 Mb from chromosomal ends and were all hypomethylated in virus-infected cells. This was most evident at chromosome 17p13.3, where HHV-6B had induced CpG hypomethylation after 2 days of infection, possibly through TET2, which was found to be upregulated by the virus. In addition, virus-induced cytosine hydroxymethylation was observed. Genes located in the hypomethylated region at 17p13.3 showed significantly upregulated expression in HHV-6B-infected cells. A temporal experiment revealed HHV-6B integration in Molt-3 cell DNA 3 days after infection. The telomere at 17p has repeatedly been described as an integration site for HHV-6B, and we show for the first time that HHV-6B induces hypomethylation in this region during acute infection, which may play a role in the integration process, possibly by making the DNA more accessible.IMPORTANCE The ability to establish latency in the host is a hallmark of herpesviruses, but the mechanisms differ. Human herpesvirus 6B (HHV-6B) is known to establish latency through integration of its genome into the telomeric regions of host cells, with the ability to reactivate. Our study is the first to show that HHV-6B specifically induces hypomethylated regions close to the telomeres and that integrating viruses may use the host methylation machinery to facilitate their integration process. The results from this study contribute to knowledge of HHV-6B biology and virus-host interaction. This in turn will lead to further progress in our understanding of the underlying mechanisms by which HHV-6B contributes to pathological processes and may have important implications in both disease prevention and treatment.
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36
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Miyashita N, Endo T, Onozawa M, Hashimoto D, Kondo T, Fujimoto K, Kahata K, Sugita J, Goto H, Matsukawa T, Hashino S, Teshima T. Risk factors of human herpesvirus 6 encephalitis/myelitis after allogeneic hematopoietic stem cell transplantation. Transpl Infect Dis 2017; 19. [DOI: 10.1111/tid.12682] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 06/25/2016] [Accepted: 11/19/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Naohiro Miyashita
- Department of Hematology; Hokkaido University Graduate School of Medicine; Hokkaido Japan
| | - Tomoyuki Endo
- Department of Hematology; Hokkaido University Graduate School of Medicine; Hokkaido Japan
| | - Masahiro Onozawa
- Department of Hematology; Hokkaido University Graduate School of Medicine; Hokkaido Japan
| | - Daigo Hashimoto
- Department of Hematology; Hokkaido University Graduate School of Medicine; Hokkaido Japan
| | - Takeshi Kondo
- Department of Hematology; Hokkaido University Graduate School of Medicine; Hokkaido Japan
| | - Katsuya Fujimoto
- Department of Hematology; Hokkaido University Graduate School of Medicine; Hokkaido Japan
| | - Kaoru Kahata
- Department of Hematology; Hokkaido University Graduate School of Medicine; Hokkaido Japan
| | - Junichi Sugita
- Department of Hematology; Hokkaido University Graduate School of Medicine; Hokkaido Japan
| | - Hideki Goto
- Department of Hematology; Hokkaido University Graduate School of Medicine; Hokkaido Japan
| | - Toshihiro Matsukawa
- Department of Hematology; Hokkaido University Graduate School of Medicine; Hokkaido Japan
| | | | - Takanori Teshima
- Department of Hematology; Hokkaido University Graduate School of Medicine; Hokkaido Japan
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Ongrádi J, Ablashi DV, Yoshikawa T, Stercz B, Ogata M. Roseolovirus-associated encephalitis in immunocompetent and immunocompromised individuals. J Neurovirol 2017; 23:1-19. [PMID: 27538995 PMCID: PMC5329081 DOI: 10.1007/s13365-016-0473-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 06/15/2016] [Accepted: 07/17/2016] [Indexed: 01/26/2023]
Abstract
The roseoloviruses, human herpesvirus (HHV)-6A, HHV-6B, and HHV-7, can cause severe encephalitis or encephalopathy. In immunocompetent children, primary HHV-6B infection is occasionally accompanied by diverse clinical forms of encephalitis. Roseolovirus coinfections with heterologous viruses and delayed primary HHV-7 infection in immunocompetent adults result in very severe neurological and generalized symptoms. Recovery from neurological sequelae is slow and sometimes incomplete. In immunocompromised patients with underlying hematological malignancies and transplantation, frequent single or simultaneous reactivation of roseoloviruses elicit severe, lethal organ dysfunctions, including damages in the limbic system, brain stem, and hippocampus. Most cases have been due to HHV-6B with HHV-6A accounting for 2-3%. The most severe manifestation of HHV-6B reactivation is post-transplantation limbic encephalitis. Seizures, cognitive problems, and abnormal EEG are common. Major risk factors for HHV-6B-associated encephalitis include unrelated cord blood cell transplantation and repeated hematopoietic stem cell transplantation. Rare genetic disorders, male gender, certain HLA constellation, and immune tolerance to replicating HHV-6 in persons carrying chromosomally integrated HHV-6 might also predispose an individual to roseolovirus-associated brain damage. At this time, little is known about the risk factors for HHV-7-associated encephalitis. Intrathecal glial cell destruction due to virus replication, overexpression of proinflammatory cytokines, and viral mimicry of chemokines all contribute to brain dysfunction. High virus load in the cerebrospinal fluid, hippocampal astrogliosis, and viral protein expression in HHV-6B-associated cases and multiple microscopic neuronal degeneration in HHV-7-associated cases are typical laboratory findings. Early empirical therapy with ganciclovir or foscarnet might save the life of a patient with roseolovirus-associated encephalitis.
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Affiliation(s)
- Joseph Ongrádi
- Institute of Medical Microbiology, Semmelweis University, Nagyvárad tér 4, Budapest, 1089, Hungary.
| | - Dharam V Ablashi
- HHV-6 Foundation, 1482 East Valley Road, Santa Barbara, CA, 93101, USA
| | - Tetsushi Yoshikawa
- Department of Pediatrics, Fujita Health University School of Medicine, 1-98, Kotsukake-cho, Dengakugakolo, Toyoake, Aichi, 470-1192, Japan
| | - Balázs Stercz
- Institute of Medical Microbiology, Semmelweis University, Nagyvárad tér 4, Budapest, 1089, Hungary
| | - Masao Ogata
- Department of Medical Oncology and Hematology, Oita University Hospital, Hasama-machi, Yufu City, 879-5593, Japan
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38
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Schmidt-Hieber M, Silling G, Schalk E, Heinz W, Panse J, Penack O, Christopeit M, Buchheidt D, Meyding-Lamadé U, Hähnel S, Wolf HH, Ruhnke M, Schwartz S, Maschmeyer G. CNS infections in patients with hematological disorders (including allogeneic stem-cell transplantation)-Guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO). Ann Oncol 2016; 27:1207-25. [PMID: 27052648 PMCID: PMC4922317 DOI: 10.1093/annonc/mdw155] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 03/24/2016] [Indexed: 12/22/2022] Open
Abstract
Diagnosis of CNS infections remains a great challenge in patients with hematological disorders since symptoms might both be masked and be mimicked by other conditions such as metabolic disturbances or consequences from antineoplastic treatment. Thus, awareness of this complication is crucial and any suspicion of a CNS infection should lead to timely and adequate diagnostics and treatment to improve the outcome in this population. Infections of the central nervous system (CNS) are infrequently diagnosed in immunocompetent patients, but they do occur in a significant proportion of patients with hematological disorders. In particular, patients undergoing allogeneic hematopoietic stem-cell transplantation carry a high risk for CNS infections of up to 15%. Fungi and Toxoplasma gondii are the predominant causative agents. The diagnosis of CNS infections is based on neuroimaging, cerebrospinal fluid examination and biopsy of suspicious lesions in selected patients. However, identification of CNS infections in immunocompromised patients could represent a major challenge since metabolic disturbances, side-effects of antineoplastic or immunosuppressive drugs and CNS involvement of the underlying hematological disorder may mimic symptoms of a CNS infection. The prognosis of CNS infections is generally poor in these patients, albeit the introduction of novel substances (e.g. voriconazole) has improved the outcome in distinct patient subgroups. This guideline has been developed by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO) with the contribution of a panel of 14 experts certified in internal medicine, hematology/oncology, infectious diseases, intensive care, neurology and neuroradiology. Grades of recommendation and levels of evidence were categorized by using novel criteria, as recently published by the European Society of Clinical Microbiology and Infectious Diseases.
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Affiliation(s)
- M Schmidt-Hieber
- Department of Hematology, Oncology and Tumor Immunology, HELIOS Clinic Berlin-Buch, Berlin
| | - G Silling
- Department of Hematology, Oncology and Stem Cell Transplantation, University Hospital, Aachen, Medical Faculty, RWTH Aachen, Aachen
| | - E Schalk
- Department of Hematology and Oncology, Otto-von-Guericke University Hospital Magdeburg, Magdeburg
| | - W Heinz
- Department of Internal Medicine II, University Hospital Würzburg, Center of Internal Medicine, Würzburg
| | - J Panse
- Department of Hematology, Oncology and Stem Cell Transplantation, University Hospital, Aachen, Medical Faculty, RWTH Aachen, Aachen
| | - O Penack
- Department of Hematology, Oncology and Tumor Immunology, Charité University Medicine, Campus Virchow Clinic, Berlin
| | - M Christopeit
- Department of Stem Cell Transplantation, University Medical Center Hamburg Eppendorf, Hamburg
| | - D Buchheidt
- Department of Hematology and Oncology, Mannheim University Hospital, University of Heidelberg, Mannheim
| | - U Meyding-Lamadé
- Department of Neurology, Hospital Nordwest Frankfurt, Frankfurt/M., Germany Brunei Neuroscience Stroke and Rehabilitation Centre, Jerudong, Brunei Darussalam Department of Neuroinfectiology, Otto-Meyerhof-Centre, University of Heidelberg, Heidelberg
| | - S Hähnel
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg
| | - H H Wolf
- Department of Hematology and Oncology, University Hospital Halle, Halle
| | - M Ruhnke
- Paracelsus Clinic Osnabrück, Osnabrück
| | - S Schwartz
- Department of Hematology and Oncology, Charité University Medicine, Campus Benjamin Franklin, Berlin
| | - G Maschmeyer
- Department of Hematology, Oncology and Palliative Care, Ernst von Bergmann Clinic, Potsdam, Germany
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Reactivation of Human Herpes Virus-6 After Pediatric Stem Cell Transplantation: Risk Factors, Onset, Clinical Symptoms and Association With Severity of Acute Graft-Versus-Host Disease. Pediatr Infect Dis J 2015; 34:1118-27. [PMID: 26132825 DOI: 10.1097/inf.0000000000000824] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND METHODS To study clinical symptoms, timing and consequences of human herpesvirus-6 (HHV-6) reactivation after pediatric allogeneic stem cell transplantation (SCT), HHV-6 was investigated by plasma polymerase chain reaction in a cohort of 106 pediatric SCT recipients. RESULTS HHV-6 viremia was detected post-SCT in 48% of the patients with a median time of onset at 20 days after SCT. In week 3 and 4 post-SCT, HHV-6 is the most common infectious agent detected. In up to 30% of the patients with fever of unknown origin, HHV-6 was the only detected infectious agent to explain fever. Patients transplanted with an unrelated donor or receiving serotherapy were at increased risk of HHV-6 reactivation. The onset of HHV-6 reactivation coincided with the appearance of lymphocytes and monocytes in peripheral blood. Treatment with alemtuzumab (MabCampath) delayed both lymphocyte and monocyte engraftment and, concomitantly, onset of HHV-6 reactivation was delayed in those cases. HHV-6 reactivation was not associated with an increased incidence of acute graft-versus-host disease (GvHD). However, progression to grade II-IV GvHD was in 9 of 10 patients associated with HHV-6 reactivation before GvHD (P = 0.006) and HHV-6 was the only infection with such an association. CONCLUSIONS HHV-6 frequently reactivates after pediatric SCT around the time of mononuclear cell engraftment and is associated with an increased severity of GvHD. HHV-6 may explain fever of unknown origin in 30% of the patients early after SCT. Assessment of HHV-6 reactivation in patients early after SCT can be instrumental for clinical decision making.
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Coreactivation of Human Herpesvirus 6 and Cytomegalovirus Is Associated With Worse Clinical Outcome in Critically Ill Adults. Crit Care Med 2015; 43:1415-22. [PMID: 25821919 DOI: 10.1097/ccm.0000000000000969] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Imataki O, Uemura M. Ganciclovir-resistant HHV-6 encephalitis that progressed rapidly after bone marrow transplantation. J Clin Virol 2015. [DOI: 10.1016/j.jcv.2015.06.097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Ogata M, Fukuda T, Teshima T. Human herpesvirus-6 encephalitis after allogeneic hematopoietic cell transplantation: What we do and do not know. Bone Marrow Transplant 2015; 50:1030-6. [DOI: 10.1038/bmt.2015.76] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 02/04/2015] [Accepted: 02/28/2015] [Indexed: 01/13/2023]
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Child and adult forms of human herpesvirus 6 encephalitis: looking back, looking forward. Curr Opin Neurol 2014; 27:349-55. [PMID: 24792343 DOI: 10.1097/wco.0000000000000085] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW This review evaluates publications on human herpesvirus 6 (HHV-6) encephalitis recognizing firstly that HHV-6A and HHV-6B are separate species with differing properties, and secondly the phenomenon of chromosomal integration; this occurs in a minority of persons and the complete viral genome of either HHV-6A or HHV-6B is present in every nucleated cell in the body. Although chromosomal integration has not been associated with disease, the resulting very high level of viral DNA in human tissues and blood has sometimes been wrongly misinterpreted as active infection. RECENT FINDINGS No disease has been linked to HHV-6A, whereas HHV-6B may cause encephalitis. Encephalitis due to primary HHV-6B infection in young children is commonly reported from Japan, but very rarely elsewhere in the world, suggesting a genetic predisposition. Reports of HHV-6A or HHV-6B encephalitis in immunocompetent older children/adults are most likely due to chromosomal integration and not active infection. HHV-6B reactivation is well established as causing limbic encephalitis after haematopoietic stem cell transplantation, particularly after receipt of cord blood; the outcome is poor and preventive strategies are ineffective. SUMMARY Understanding the pathophysiology of HHV-6B encephalitis remains incomplete, especially regarding young children. Clinical trials of antiviral therapy are warranted for treatment and prevention of HHV-6B encephalitis after transplantation.
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Tweedy J, Spyrou MA, Hubacek P, Kuhl U, Lassner D, Gompels UA. Analyses of germline, chromosomally integrated human herpesvirus 6A and B genomes indicate emergent infection and new inflammatory mediators. J Gen Virol 2014; 96:370-389. [PMID: 25355130 DOI: 10.1099/vir.0.068536-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Human herpesvirus-6A (HHV-6A) is rarer than HHV-6B in many infant populations. However, they are similarly prevalent as germline, chromosomally integrated genomes (ciHHV-6A/B). This integrated form affects 0.1-1 % of the human population, where potentially virus gene expression could be in every cell, although virus relationships and health effects are not clear. In a Czech/German patient cohort ciHHV-6A was more common and diverse than ciHHV-6B. Quantitative PCR, nucleotide sequencing and telomeric integration site amplification characterized ciHHV-6 in 44 German myocarditis/cardiomyopathy and Czech malignancy/inflammatory disease (MI) patients plus donors. Comparisons were made to sequences from global virus reference strains, and blood DNA from childhood-infections from Zambia (HHV-6A mainly) and Japan (HHV-6B). The MI cohort were 86 % (18/21) ciHHV-6A, the cardiac cohort 65 % (13/20) ciHHV-6B, suggesting different disease links. Reactivation was supported by findings of 1) recombination between ciHHV-6A and HHV-6B genes in 20 % (4/21) of the MI cohort; 2) expression in a patient subset, of early/late transcripts from the inflammatory mediator genes chemokine receptor U51 and chemokine U83, both identical to ciHHV-6A DNA sequences; and 3) superinfection shown by deep sequencing identifying minor virus-variants only in ciHHV-6A, which expressed transcripts, indicating virus infection reactivates latent ciHHV-6A. Half the MI cohort had more than two copies per cell, median 5.2, indicative of reactivation. Remarkably, the integrated genomes encoded the secreted-active form of virus chemokines, rare in virus from childhood-infections. This shows integrated virus genomes can contribute new human genes with links to inflammatory pathology and supports ciHHV-6A reactivation as a source for emergent infection.
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Affiliation(s)
- J Tweedy
- Pathogen Molecular Biology Department, London School of Hygiene and Tropical Medicine, University of London, London, UK
| | - M A Spyrou
- Pathogen Molecular Biology Department, London School of Hygiene and Tropical Medicine, University of London, London, UK
| | - P Hubacek
- Department of Medical Microbiology and Department of Paediatric Haematology and Oncology, 2nd Medical Faculty of Charles University and Motol University Hospital, Prague, Czech Republic
| | - U Kuhl
- Department of Cardiology and Pneumology, Charité-University Medicine Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - D Lassner
- Institute of Cardiac Diagnostics and Therapy (IKDT), Berlin, Germany
| | - U A Gompels
- Pathogen Molecular Biology Department, London School of Hygiene and Tropical Medicine, University of London, London, UK
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Yamamoto T, Watarai Y, Goto N, Horikoshi Y, Yamada S, Yasui K, Tsujita M, Hiramitsu T, Narumi S, Katayama A, Uchida K, Kobayashi T. Encephalitis caused by human herpesvirus-6B in pancreas-after-kidney transplantation. Transpl Infect Dis 2014; 16:853-8. [PMID: 25040797 DOI: 10.1111/tid.12270] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 04/12/2014] [Accepted: 05/05/2014] [Indexed: 11/30/2022]
Abstract
Human herpesvirus-6 (HHV-6) is a common pathogen among children, classically presenting with fever and rash that resolves without specific therapy. HHV-6 can be reactivated in the immunosuppressed patient. After bone marrow and solid organ transplantation, HHV-6 has been linked to various clinical syndromes, including undifferentiated febrile illness, encephalitis, myelitis, hepatitis, pneumonitis, and bone marrow suppression. However, HHV-6 encephalitis after pancreatic transplant has rarely been reported. Early diagnosis and treatment of HHV-6 encephalitis may be important for affected patients. We report the case of a 53-year-old pancreas-after-kidney transplant recipient who initially presented with high fever and confusion 3 weeks after operation. We managed to save the patient's life and preserve the pancreas graft function. We also review previously reported cases of HHV-6B encephalitis in solid organ transplant recipients.
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Affiliation(s)
- T Yamamoto
- Department of Transplant Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan; Department of Transplant Immunology, Nagoya University School of Medicine, Nagoya, Japan
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Human herpesvirus 6A infection in CD46 transgenic mice: viral persistence in the brain and increased production of proinflammatory chemokines via Toll-like receptor 9. J Virol 2014; 88:5421-36. [PMID: 24574405 DOI: 10.1128/jvi.03763-13] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
UNLABELLED Human herpesvirus 6 (HHV-6) is widely spread in the human population and has been associated with several neuroinflammatory diseases, including multiple sclerosis. To develop a small-animal model of HHV-6 infection, we analyzed the susceptibility of several lines of transgenic mice expressing human CD46, identified as a receptor for HHV-6. We showed that HHV-6A (GS) infection results in the expression of viral transcripts in primary brain glial cultures from CD46-expressing mice, while HHV-6B (Z29) infection was inefficient. HHV-6A DNA persisted for up to 9 months in the brain of CD46-expressing mice but not in the nontransgenic littermates, whereas HHV-6B DNA levels decreased rapidly after infection in all mice. Persistence in the brain was observed with infectious but not heat-inactivated HHV-6A. Immunohistological studies revealed the presence of infiltrating lymphocytes in periventricular areas of the brain of HHV-6A-infected mice. Furthermore, HHV-6A stimulated the production of a panel of proinflammatory chemokines in primary brain glial cultures, including CCL2, CCL5, and CXCL10, and induced the expression of CCL5 in the brains of HHV-6A-infected mice. HHV-6A-induced production of chemokines in the primary glial cultures was dependent on the stimulation of toll-like receptor 9 (TLR9). Finally, HHV-6A induced signaling through human TLR9 as well, extending observations from the murine model to human infection. Altogether, this study presents a first murine model for HHV-6A-induced brain infection and suggests a role for TLR9 in the HHV-6A-initiated production of proinflammatory chemokines in the brain, opening novel perspectives for the study of virus-associated neuropathology. IMPORTANCE HHV-6 infection has been related to neuroinflammatory diseases; however, the lack of a suitable small-animal infection model has considerably hampered further studies of HHV-6-induced neuropathogenesis. In this study, we have characterized a new model for HHV-6 infection in mice expressing the human CD46 protein. Infection of CD46 transgenic mice with HHV-6A resulted in long-term persistence of viral DNA in the brains of infected animals and was followed by lymphocyte infiltration and upregulation of the CCL5 chemokine in the absence of clinical signs of disease. The secretion of a panel of chemokines was increased after infection in primary murine brain glial cultures, and the HHV-6-induced chemokine expression was inhibited when TLR9 signaling was blocked. These results describe the first murine model for HHV-6A-induced brain infection and suggest the importance of the TLR9 pathway in HHV-6A-initiated neuroinflammation.
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Frequent human herpesvirus-6 viremia but low incidence of encephalitis in double-unit cord blood recipients transplanted without antithymocyte globulin. Biol Blood Marrow Transplant 2014; 20:787-93. [PMID: 24548875 DOI: 10.1016/j.bbmt.2014.02.010] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Accepted: 02/13/2014] [Indexed: 02/06/2023]
Abstract
Cord blood transplantation (CBT) is a known risk factor for human herpesvirus-6 (HHV-6) infection. We analyzed the nature of HHV-6 infections in 125 double-unit CBT recipients (median age, 42 years) transplanted for hematologic malignancies with calcineurin inhibitor/mycophenolate mofetil prophylaxis and no antithymocyte globulin. One hundred seventeen patients (94%) reactivated HHV-6 by quantitative plasma PCR (median peak, 7600 copies/mL; range, 100 to 160,000) at a median of 20 days (range, 10 to 59) after transplantation. HHV-6 encephalitis occurred in 2 patients (1.6%), of whom 1 died and 1 recovered with therapy. No association was found between high-level HHV-6 viremia (≥10,000 or ≥25,000 copies/mL) and age, diagnosis, conditioning intensity, or dominant unit characteristics or between high-level viremia and transplant outcomes (engraftment, cytomegalovirus reactivation, day 100 grades II to IV acute graft-versus-host disease, day 100 transplant-related mortality, or 1-year disease-free survival). HHV-6 therapy delayed the onset of cytomegalovirus reactivation. Interestingly, HHV-6 resolution was observed in untreated patients, and resolution of viremia correlated with absolute lymphocyte count recovery. We observed a low incidence of encephalitis and no association with CBT outcomes. Our data suggest therapy in uncomplicated viremia may not be warranted. However, further investigation of the risk-to-benefit of HHV-6 viremia treatment and standardization of PCR testing is required.
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Hoffman MJ, Stosor V. Central nervous system infections in cancer patients and hematopoietic stem cell transplant recipients. Cancer Treat Res 2014; 161:253-298. [PMID: 24706228 DOI: 10.1007/978-3-319-04220-6_9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Central nervous system (CNS) infections in cancer patients present a diagnostic and therapeutic challenge for clinicians. While CNS infections are not frequent complications of cancer, its therapies, or hematopoietic stem cell transplantation, the importance of CNS infections lies in their propensity to result in profound morbidity and substantial mortality in this vulnerable patient population. With an expanding population of patients with malignant disease undergoing more potent and aggressive therapies and with the advent of newer immunomodulatory agents, the incidence of CNS infectious complications is likely to rise. This chapter will summarize the clinical and diagnostic evaluation of potential infections of the CNS in these patients and will discuss particular pathogens of interest with regard to this at-risk patient population.
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Affiliation(s)
- Michael J Hoffman
- Department of Medicine, Northwestern University Feinberg School of Medicine, 251 E. Huron St. Feinberg 16-738, Chicago, IL, 60605, USA,
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Affiliation(s)
- Joshua A Hill
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA.
| | - Nagagopal Venna
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
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