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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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2
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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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3
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Anand P. Neurologic Infections in Patients on Immunomodulatory and Immunosuppressive Therapies. ACTA ACUST UNITED AC 2021; 27:1066-1104. [PMID: 34623105 DOI: 10.1212/con.0000000000000985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Both broadly immunosuppressive medications and selective immunomodulatory agents that act on particular components of the immune system are increasingly used in the treatment of neurologic and non-neurologic diseases. These therapies predispose patients to particular infections, some of which may affect the nervous system. Therefore, familiarity with the clinical and radiologic features of neurologic infections associated with specific immunomodulatory therapies is of importance for the practicing neurologist. This article reviews these neuroinfectious conditions, as well as other neurologic complications unique to transplant recipients and other patients who are immunocompromised. RECENT FINDINGS Diagnosis of infectious pathogens in patients who are immunocompromised may be particularly challenging because a decreased immune response can lead to atypical imaging or laboratory findings. Next-generation sequencing and other novel diagnostic modalities may improve the rate of early identification of neurologic infections in patients who are immunocompromised and ultimately ameliorate outcomes in this vulnerable population. SUMMARY A broad range of bacterial, viral, fungal, and parasitic infections of the nervous system can complicate solid organ and hematopoietic cell transplantation as well as other forms of immunocompromise. In addition to neurologic infections, such patients are at risk of neurotoxic and neuroinflammatory complications related to immunomodulatory and immunosuppressive therapies. Early recognition of infectious and noninfectious complications of immunocompromise is essential to guide appropriate treatment, which can include antimicrobial therapy and, in some cases, withdrawal of the predisposing medication with a transition to an alternative regimen.
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4
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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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Basher F, Camargo JF, Diaz-Paez M, Lekakis LJ, Pereira DL. Aseptic Meningitis after Recovery from SARS-CoV-2 in an Allogeneic Stem Cell Transplant Recipient. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2021; 14:11795476211009811. [PMID: 33953633 PMCID: PMC8058782 DOI: 10.1177/11795476211009811] [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: 10/11/2020] [Accepted: 03/19/2021] [Indexed: 01/10/2023]
Abstract
SARS-CoV-2 emerged as a worldwide pandemic in late 2019 and initially was described as a primary respiratory illness. The clinical manifestations of COVID-19 are now known to encompass nearly all organ systems, including the central nervous system. We present a case of an allogeneic hematopoietic stem cell transplant recipient who recovered from documented SARS-CoV-2 infection and later presented with symptoms of meningitis. While cerebrospinal fluid analysis did not reveal any bacterial or viral etiologies, evidence of an inflammatory state, including ophthalmologic findings of episcleritis, indicate what is likely the first reported case of aseptic meningitis associated with SARS-CoV-2 infection after initial clinical recovery.
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Affiliation(s)
- Fahmin Basher
- Division of General Internal Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jose F Camargo
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Meilin Diaz-Paez
- Division of Transplantation and Cellular Therapy, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Lazaros J Lekakis
- Division of Transplantation and Cellular Therapy, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Denise L Pereira
- Division of Transplantation and Cellular Therapy, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
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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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Abu Sitta E, Khazan A, Luttmann K, Hanrahan J. HHV-6: an unusual cause of cerebellar ataxia. BMJ Case Rep 2020; 13:13/3/e234303. [PMID: 32188617 DOI: 10.1136/bcr-2020-234303] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Human herpesvirus 6 (HHV-6) infection is the cause of roseola infantum in children. The reactivation of HHV-6 is associated with multiple clinical syndromes including encephalitis and myelitis, especially in haematopoietic stem cell transplant recipients. However, the virus can cause encephalitis in other immunosuppressed as well as immunocompetent individuals. We report a case of a 70-year-old woman who was immunocompromised secondary to treatment of rheumatoid arthritis with leflunomide and methotrexate. The patient presented with acute ataxia, diplopia and dysarthria. MRI brain showed an enhancing lesion in the midbrain. The diagnosis of HHV-6 encephalitis was made after HHV-6 A DNA was detected in both serum and cerebrospinal fluid. Treatment consisted of a 3-week course of intravenous ganciclovir along with physiotherapy. At a 3-month follow-up, repeat MRI brain showed a decrease in size and oedema of the lesion and the patient's neurological function was improved.
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Affiliation(s)
- Emad Abu Sitta
- Department of Infectious Disease, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Ana Khazan
- College of Medicine and Life Sciences, Medical School, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Kelly Luttmann
- Department of Infectious Disease, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Jennifer Hanrahan
- Department of Infectious Disease, University of Toledo Medical Center, Toledo, Ohio, USA
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8
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Clinical characteristics of human herpesvirus-6 myelitis after allogeneic hematopoietic stem cell transplantation and its favorable outcome by early intervention. Bone Marrow Transplant 2019; 55:939-945. [PMID: 31754252 DOI: 10.1038/s41409-019-0755-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 10/30/2019] [Accepted: 11/07/2019] [Indexed: 12/16/2022]
Abstract
After allogeneic hematopoietic stem cell transplantation (HSCT), human herpesvirus-6 (HHV-6) can cause serious central nervous system (CNS) disorder and typically presents as encephalitis. Another manifestation of HHV-6 is myelitis, which has not been fully evaluated. In this study, we retrospectively analyzed 19 patients who developed HHV-6 myelitis after allogeneic HSCT. Median onset was 20 days after transplantation (range, 13-31), with a cumulative incidence of 4.1% at day 40 after transplantation. Median age at transplant was 50 years (range, 17-61). Median copy number of HHV-6 DNA was 3000 copies/ml in cerebrospinal fluid (CSF; range, 200-100,000). The most common symptoms were pruritus, pain of the extremities/back, and numbness. Three patients subsequently developed encephalitis in the clinical course of myelitis; their HHV-6 copy numbers in CSF had been higher than 10,000 copies/ml at the onset of myelitis. Antiviral agents were initiated shortly after onset in all patients, resulting in recovery. These results suggest that myelitis would be an important subtype of HHV-6-associated CNS disorders after allogeneic HSCT, whose prognosis could be favorable by an early intervention. Transplant physicians should recognize early posttransplant neurological symptoms such as pruritus, pain, or numbness as possible signs of HHV-6 myelitis, which could also progress to encephalitis.
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9
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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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10
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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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11
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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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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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13
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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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14
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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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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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16
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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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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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18
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Boucher A, Herrmann JL, Morand P, Buzelé R, Crabol Y, Stahl JP, Mailles A. Epidemiology of infectious encephalitis causes in 2016. Med Mal Infect 2017; 47:221-235. [PMID: 28341533 DOI: 10.1016/j.medmal.2017.02.003] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 02/17/2017] [Indexed: 10/19/2022]
Abstract
We performed a literature search in the Medline database, using the PubMed website. The incidence of presumably infectious encephalitis is estimated at 1.5-7 cases/100,000 inhabitants/year, excluding epidemics. Infectious encephalitis and immune-mediated encephalitis share similar clinical signs and symptoms. The latter accounts for a significant proportion of presumably infectious encephalitis cases without any established etiological diagnosis; as shown from a prospective cohort study where 21% of cases were due to an immune cause. Several infectious agents are frequently reported in all studies: Herpes simplex virus (HSV) is the most frequent pathogen in 65% of studies, followed by Varicella-zoster virus (VZV) in several studies. Enteroviruses are also reported; being the most frequent viruses in two studies, and the 2nd or 3rd viruses in five other studies. There are important regional differences, especially in case of vector-borne transmission: Asia and the Japanese encephalitis virus, Eastern and Northern Europe/Eastern Russia and the tick-borne encephalitis virus, Northern America and Flavivirus or Alphavirus. Bacteria can also be incriminated: Mycobacterium tuberculosis and Listeria monocytogenes are the most frequent, after HSV and VZV, in a French prospective study. The epidemiology of encephalitis is constantly evolving. Epidemiological data may indicate the emergence and/or dissemination of new causative agents. The dissemination and emergence of causative agents are fostered by environmental, social, and economical changes, but prevention programs (vaccination, vector controls) help reduce the incidence of other infectious diseases and associated encephalitis (e.g., measles).
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Affiliation(s)
- A Boucher
- Maladies infectieuses, CHU de Lille, 59000 Lille, France
| | - J L Herrmann
- Microbiologie, CHU de Garches, 92380 Garches, France
| | - P Morand
- Virologie, CHU Grenoble Alpes, 38700 La Tronche, France
| | - R Buzelé
- Médecine interne, centre hospitalier de Saint-Brieuc, 22027 Saint-Brieuc, France
| | - Y Crabol
- Médecine interne, centre hospitalier Vannes-Aufray, 56000 Vannes, France
| | - J P Stahl
- Maladies infectieuses, CHU Grenoble Alpes, Grenoble - "European Study Group for the Infections of the Brain (ESGIB)", 38700 La Tronche, France.
| | - A Mailles
- Direction des maladies infectieuses, santé publique France - "European Study Group for the Infections of the Brain (ESGIB)", 94410 Saint-Maurice, France
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19
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Zhang XH, Zhang JM, Han W, Chen H, Chen YH, Wang FR, Wang JZ, Zhang YY, Mo XD, Chen Y, Wang Y, Chang YJ, Xu LP, Liu KY, Huang XJ. Viral encephalitis after haplo-identical hematopoietic stem cell transplantation: Causative viral spectrum, characteristics, and risk factors. Eur J Haematol 2017; 98:450-458. [PMID: 28129450 DOI: 10.1111/ejh.12855] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2017] [Indexed: 12/25/2022]
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20
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Imaging spectrum of central nervous system complications of hematopoietic stem cell and solid organ transplantation. Neuroradiology 2017; 59:105-126. [PMID: 28255902 DOI: 10.1007/s00234-017-1804-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 02/06/2017] [Indexed: 02/06/2023]
Abstract
Neurologic complications are common after hematopoietic stem cell transplantation (HSCT) and solid organ transplantation (SOT) and affect 30-60% of transplant recipients. The aim of this article is to provide a practical imaging approach based on the timeline and etiology of CNS abnormalities, and neurologic complications related to transplantation of specific organs. The lesions will be classified based upon the interval from HSCT procedure: pre-engraftment period <30 days, early post-engraftment period 30-100 days, late post-engraftment period >100 days, and the interval from SOT procedure: postoperative phase 1-4 weeks, early posttransplant syndromes 1-6 months, late posttransplant syndromes >6 months. Further differentiation will be based on etiology: infections, drug toxicity, metabolic derangements, cerebrovascular complications, and posttransplantation malignancies. In addition, differentiation will be based on complications specific to the type of transplantation: allogeneic and autologous hematopoietic stem cells (HSC), heart, lung, kidney, pancreas, and liver. Thus, in this article we emphasize the strategic role of neuroradiology in the diagnosis and response to treatment by utilizing a methodical approach in the work up of patients with neurologic complications after transplantation.
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21
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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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22
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Coinfection of human herpesviruses 6A (HHV-6A) and HHV-6B as demonstrated by novel digital droplet PCR assay. PLoS One 2014; 9:e92328. [PMID: 24663487 PMCID: PMC3963908 DOI: 10.1371/journal.pone.0092328] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Accepted: 02/20/2014] [Indexed: 01/23/2023] Open
Abstract
The human herpesviruses HHV-6A and HHV-6B have been associated with various neurologic disorders partly due to the detection of elevated viral DNA levels in patients compared to controls. However the reported frequency of these viruses varies widely, likely reflecting differences in PCR methodologies used for detection. Digital droplet PCR (ddPCR) is a third generation PCR technology that enables the absolute quantification of target DNA molecules. Mounting evidence of the biological differences between HHV-6A and HHV-6B has led to their recent reclassification as separate species. As it is now especially relevant to investigate each virus, our objectives were to first design a multiplex HHV-6A and HHV-6B ddPCR assay and then to investigate the incidence of HHV-6A and HHV-6B coinfection in samples from healthy donors and patients with MS, a disease in which HHV-6 is thought to play a role. In our assessment of healthy donors, we observed a heretofore-underappreciated high frequency of coinfection in PBMC and serum, and found that our assay precisely detects both HHV-6A and HHV-6B chromosomally integrated virus, which has important implications in clinical settings. Interestingly, upon comparing the saliva from MS patients and healthy donors, we detected a significantly elevated frequency of coinfection in MS saliva; increased detection of HHV-6A in MS patients is consistent with other studies suggesting that this viral species (thought to be more neurotropic than HHV-6B) is more prevalent among MS patients compared to healthy donors. As the biology and disease associations between these two viral species differ, identifying and quantifying both species of HHV-6 may provide clinically relevant information, as well as enhance our understanding of the roles of each in health and disease.
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23
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Status Epilepticus due to Severe HHV-6 Encephalitis in an Allogeneic Stem Cell Transplant Recipient. Mediterr J Hematol Infect Dis 2014; 6:e2014008. [PMID: 24455117 PMCID: PMC3894844 DOI: 10.4084/mjhid.2014.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 11/28/2013] [Indexed: 11/08/2022] Open
Abstract
Reactivation of human herpes virus-6 (HHV-6) after stem cell transplantation occurs frequently. It is associated with clinical manifestations varying from nonspecific symptoms such as fevers or rash, to severe life threatening complications including post-transplantation limbic encephalitis. We report a case of severe HHV-6 encephalitis with viremia in an allogeneic peripheral stem cell transplant recipient who presented with status epilepticus unresponsive to antiepileptic therapy. With intravenous ganciclovir and supportive care, the patient’s condition improved. Awareness of HHV-6 infection in stem cell transplant recipients may help with early diagnosis and improved outcome.
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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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25
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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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Ogata M, Satou T, Kadota JI, Saito N, Yoshida T, Okumura H, Ueki T, Nagafuji K, Kako S, Uoshima N, Tsudo M, Itamura H, Fukuda T. Human herpesvirus 6 (HHV-6) reactivation and HHV-6 encephalitis after allogeneic hematopoietic cell transplantation: a multicenter, prospective study. Clin Infect Dis 2013; 57:671-81. [PMID: 23723198 DOI: 10.1093/cid/cit358] [Citation(s) in RCA: 132] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The epidemiology of human herpesvirus 6 (HHV-6) encephalitis after allogeneic hematopoietic cell transplantation (HCT) and its relationship with HHV-6 reactivation have not been sufficiently characterized. METHODS This prospective, multicenter study of 230 allogeneic HCT recipients investigated the epidemiology of HHV-6 reactivation and HHV-6 encephalitis. Plasma HHV-6 DNA load was prospectively evaluated twice weekly until 70 days after HCT. RESULTS Cumulative incidence of positive HHV-6 DNA and high-level HHV-6 reactivation (plasma HHV-6 DNA ≥10(4) copies/mL) at day 70 after HCT was 72.2% and 37.0%, respectively. Multivariate analysis identified myeloablative conditioning (hazard ratio [HR], 1.9; P = .004), umbilical cord blood transplantation (UCBT) (HR, 2.0; P = .003), and male sex (HR, 1.6; P = .04) as risk factors for displaying high-level HHV-6 reactivation. HHV-6 encephalitis occurred in 7 patients, and cumulative incidence at day 70 was 3.0%. None of the144 patients without high-level HHV-6 reactivation and 7 of 86 patients (8.1%) with high-level HHV-6 reactivation developed HHV-6 encephalitis (P = .0009). Prevalence of HHV-6 encephalitis was significantly higher among patients receiving UCBT than in patients with other sources (cumulative incidence at day 70, 7.9% vs 1.2%, P = .008). In each of 7 patients with HHV-6 encephalitis, central nervous system (CNS) symptoms developed concomitant with peak plasma HHV-6 DNA (range, 21 656-433 639 copies/mL). CONCLUSIONS High levels of plasma HHV-6 DNA are associated with higher risk of HHV-6 encephalitis. UCBT is a significant risk factor for HHV-6 encephalitis. HHV-6 encephalitis should be considered if CNS dysfunction develops concomitant to high-level plasma HHV-6 DNA after allogeneic HCT.
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Affiliation(s)
- Masao Ogata
- Department of Hematology, Oita University Hospital, Hasama-machi, Yufu-city 879-5593, Japan.
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Bhanushali MJ, Kranick SM, Freeman AF, Cuellar-Rodriguez JM, Battiwalla M, Gea-Banacloche JC, Hickstein DD, Pavletic S, Fahle G, Nath A. Human herpes 6 virus encephalitis complicating allogeneic hematopoietic stem cell transplantation. Neurology 2013; 80:1494-500. [PMID: 23516318 DOI: 10.1212/wnl.0b013e31828cf8a2] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To describe the presentation and management of encephalitis due to human herpes 6 virus (HHV-6) in patients who underwent allogeneic hematopoietic stem cell transplant (alloHSCT), via retrospective chart review. METHODS Of the 243 patients who underwent alloHSCT at the NIH Clinical Center during 2009 to 2011, we retrospectively analyzed 9 diagnosed with HHV-6 encephalitis post-alloHSCT. RESULTS Eight men and 1 woman (aged 19-60 years) met diagnostic criteria for study inclusion. The median time from HSCT to initial symptoms was 21 days. All patients presented with altered mental status and headaches. Seven patients had amnesia and 2 presented with fever of unknown etiology. Four patients had clinical seizures during the disease course. Brain MRI within 7 days was normal in all patients. Repeat MRI after 7 days showed hyperintensity in the limbic area in 3 patients. On initial testing, CSF analysis indicated acellularity and normal or minimally elevated protein; presence of HHV-6 was detected by PCR. After 7 days, mildly elevated protein and minimal pleocytosis were noted. Ganciclovir, foscarnet, or valganciclovir alone or in combination was initiated with subsequent improvement. Four patients remained alive at 1 year posttransplant; 2 had persistent memory deficits. Presence of encephalitis was associated with higher mortality post-alloHSCT. CONCLUSION High clinical suspicion and CSF PCR testing are important for early diagnosis of HHV-6 encephalitis post-HSCT. Abnormalities on brain MRI or CSF testing may be minimal and delayed. Diagnosis and management of HHV-6 encephalitis is challenging, and a larger prospective study is needed for further research.
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Affiliation(s)
- Minal J Bhanushali
- National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health, Bethesda, MD, USA
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Abstract
PURPOSE OF REVIEW Human herpesvirus 6 (HHV-6) frequently reactivates after solid-organ and hematopoietic cell transplantation (HCT), and it has been associated with important outcomes in these settings. In 1-2% of recipients or donors, HHV-6 was inherited through chromosomal integration. Although HHV-6 chromosomal integration has not been associated with disease, the resulting very high levels of HHV-6 DNA in human tissue and blood samples can be challenging to interpret in the transplant setting. This review addresses the recent findings regarding the clinical outcomes associated with HHV-6 as well as diagnostic and therapeutic concerns. RECENT FINDINGS The evidence supports a causal association between HHV-6 and central nervous system disease. New studies have further characterized the impact of HHV-6 on the central nervous system. In addition, new studies have explored the associations between HHV-6 and other important outcomes. The implications of integrated HHV-6 in transplant recipients remain undefined, though the possibility of an association with organ rejection has been suggested. New exploratory data exist regarding the safety of antiviral prophylactic and preemptive strategies. SUMMARY Our understanding of the full clinical impact of HHV-6 in the transplant population remains incomplete. A large antiviral trial would not only help to further define causality between HHV-6 associated clinical outcomes but also start to define preventive strategies.
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Foscarnet against human herpesvirus (HHV)-6 reactivation after allo-SCT: breakthrough HHV-6 encephalitis following antiviral prophylaxis. Bone Marrow Transplant 2012; 48:257-64. [PMID: 22750998 DOI: 10.1038/bmt.2012.121] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
High incidences of human herpesvirus (HHV)-6 encephalitis have recently been reported from several Japanese SCT centers. To evaluate the effect of low-dose foscarnet (PFA) in preventing HHV-6 infection among recipients of unrelated BM or cord blood (CB), we examined consecutive cohorts without prophylaxis against HHV-6 (cohort 1, n=51) and with PFA prophylaxis (cohort 2, PFA 50 mg/kg/day for 10 days after engraftment, n=67). Plasma real-time PCR assay was performed weekly. High-level reactivation defined as HHV-6 DNA > or =10(4) copies/mL by day 70 was the primary endpoint. No significant reduction of high-level reactivation was seen in cohort 2 (19.4%) compared with cohort 1 (33.8%, P=0.095). A trend was identified toward fewer high-level HHV-6 reactivations in cohort 2 among recipients of unrelated BM (P=0.067), but no difference in incidence was observed among CB recipients (P=0.75). Breakthrough HHV-6 encephalitis occurred following PFA prophylaxis in three patients, and incidence of HHV-6 encephalitis did not differ between cohort 1 (9.9%) and cohort 2 (4.5%, P=0.24). In conclusion, 50 mg/kg/day of PFA does not effectively suppress HHV-6 reactivation and cannot prevent all cases of HHV-6 encephalitis. To effectively prevent HHV-6 encephalitis, alternative approaches based on the pathogenesis of HHV-6 encephalitis will probably be required.
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Cord-blood hematopoietic stem cell transplant confers an increased risk for human herpesvirus-6-associated acute limbic encephalitis: a cohort analysis. Biol Blood Marrow Transplant 2012; 18:1638-48. [PMID: 22564265 DOI: 10.1016/j.bbmt.2012.04.016] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Accepted: 04/30/2012] [Indexed: 01/18/2023]
Abstract
Human herpesvirus-6 (HHV-6) frequently reactivates after allogeneic hematopoietic stem cell transplantation (HSCT); its most severe manifestation is the syndrome of posttransplantation acute limbic encephalitis (HHV-6-PALE). The epidemiology, risk factors, and characteristics of HHV-6-PALE after unrelated cord-blood transplantation (UCBT) are not well characterized. We analyzed 1344 patients undergoing allogeneic HSCT between March 2003 and March 2010 to identify risk factors and characteristics of HHV-6-PALE. The cohort included 1243 adult-donor HSCT and 101 UCBT recipients. All patients diagnosed with HHV-6-PALE had HHV-6 DNA in cerebrospinal fluid (CSF) specimens in addition to symptoms and studies indicating limbic encephalitis. Nineteen cases (1.4%) of HHV-6-PALE were identified during this study: 10 after UCBT (9.9%) and 9 after adult-donor HSCT (0.7%), for an incidence rate of 1.2 cases/1000 patient-days compared to 0.08 cases/1000 patient-days (P < .001), respectively. Risk factors for HHV-6-PALE on multivariable Cox modeling were UCBT (adjusted hazard ratio [aHR], 20.0; 95% confidence interval [CI], 7.3-55.0; P < .001), time-dependent acute graft-versus-host disease (aGVHD) grades II to IV (aHR, 7.5; 95% CI, 2.8-19.8; P < .001), and adult-mismatched donor (aHR, 4.3; 95% CI, 1.1-17.3; P = .04). Death from HHV-6-PALE occurred in 50% of affected patients undergoing UCBT and no recipients of adult-donor cells. Patients receiving UCBT have increased risk for HHV-6-PALE and greater morbidity from this disease.
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Agut H. Infections aiguës à herpèsvirus humain 6 (HHV-6) : quand et comment traiter ? ACTA ACUST UNITED AC 2011; 59:108-12. [DOI: 10.1016/j.patbio.2010.07.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2010] [Accepted: 07/30/2010] [Indexed: 11/29/2022]
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Sumi M, Shimizu I, Sato K, Ueki T, Akahane D, Ueno M, Ichikawa N, Nakao S, Kobayashi H. Graft failure in cord blood transplantation successfully treated with short-term reduced-intensity conditioning regimen and second allogeneic transplantation. Int J Hematol 2010; 92:744-50. [PMID: 21052879 DOI: 10.1007/s12185-010-0714-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2010] [Revised: 10/05/2010] [Accepted: 10/20/2010] [Indexed: 11/29/2022]
Abstract
Graft failure (GF) remains a major problem in cord blood transplantation (CBT). In 36 adult patients undergoing CBT at our hospital between July 2003 and December 2009, six patients developed GF (primary, n = 5; secondary, n = 1). All six patients underwent second stem cell transplantation (SCT). Three patients had acute myeloid leukemia, one had acute lymphoblastic leukemia, one had chronic myeloid leukemia, and one had aplastic anemia. Five patients were complicated with sepsis before the second SCT. The median elapsed time from first CBT to the diagnosis of primary GF was 27 days. Secondary GF was diagnosed on day 567. The median elapsed time from primary GF to second SCT was 9 days. In the patient with secondary GF, the elapsed time was 35 days. Cord blood grafts were used in 5 patients and a matched sibling donor in one patient. All 6 patients underwent second transplantation following a modified '1-day'-based preparative regimen consisting of fludarabine (30 mg/m(2), 1 day, n = 2; 2 days, n = 1; 3 days, n = 3), cyclophosphamide (2 g/m(2)), and total body irradiation (2 Gy). All patients achieved neutrophil engraftment, and the median elapsed time from second SCT to engraftment was 35 days. Four patients remain alive between 5 and 38 months after second SCT. '1-day'-based short-term conditioning may be a promising salvage regimen.
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Affiliation(s)
- Masahiko Sumi
- Department of Hematology, Nagano Red Cross Hospital, 5-22-1 Wakasato, Nagano, Nagano 380-8582, Japan.
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High Incidence of Human Herpes Virus 6-Associated Encephalitis/Myelitis following a Second Unrelated Cord Blood Transplantation. Biol Blood Marrow Transplant 2010; 16:1596-602. [DOI: 10.1016/j.bbmt.2010.05.009] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2010] [Accepted: 05/15/2010] [Indexed: 11/22/2022]
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Schmidt-Hieber M, Schwender J, Heinz WJ, Zabelina T, Kühl JS, Mousset S, Schüttrumpf S, Junghanss C, Silling G, Basara N, Neuburger S, Thiel E, Blau IW. Viral encephalitis after allogeneic stem cell transplantation: a rare complication with distinct characteristics of different causative agents. Haematologica 2010; 96:142-9. [PMID: 20851868 DOI: 10.3324/haematol.2010.029876] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Limited data are available on characteristics of viral encephalitis in patients after allogeneic stem cell transplantation. DESIGN AND METHODS We analyzed 2,628 patients after allogeneic stem cell transplantation to identify risk factors and characteristics of viral encephalitis. RESULTS Viral encephalitis occurred in 32 patients (1.2%, 95% confidence interval 0.8%-1.6%) and was associated with the use of OKT-3 or alemtuzumab for T-cell depletion (P < 0.001) and an increased mortality (P = 0.011) in comparison to patients without viral encephalitis. Detected viruses included human herpesvirus-6 (28%), Epstein-Barr virus (19%), herpes simplex virus (13%), JC virus (9%), varicella zoster virus (6%), cytomegalovirus (6%) and adenovirus (3%). More than one virus was identified in 16% of the patients. The median onset time was 106 days after allogeneic stem cell transplantation for the total group of 32 patients, but onset times were shortest in those with human herpesvirus-6 encephalitis and longest in those with JC virus-associated progressive multifocal leukoencephalopathy. The probability of a sustained response to treatment was 63% (95% confidence interval 44%-82%) with a median survival of 94 (95% confidence interval 36-152) days after onset, but significant variation was found when considering different causative viruses. Patients with herpes simplex virus encephalitis had the most favorable outcome with no encephalitis-related deaths. CONCLUSIONS The use of OKT-3 or alemtuzumab for in vivo T-cell depletion is associated with an increased risk of viral encephalitis after allogeneic stem cell transplantation. Different viruses are frequently associated with distinct characteristics such as onset time, response to treatment and outcome.
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Affiliation(s)
- Martin Schmidt-Hieber
- Medizinische Klinik III (Hämatologie, Onkologie and Transfusionsmedizin), Charité Campus Benjamin Franklin, Berlin, Germany.
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Abstract
Pathogenetic roles of human herpesvirus (HHV)-6 in lymphoproliferative diseases have been of continued interest. Many molecular studies have tried to establish a pathogenic role for HHV-6 in lymphoid malignancies. However, whether HHV-6 plays a role in these pathologies remains unclear, as positive polymerase chain reaction results for HHV-6 in those studies may reflect latent infection or reactivation rather than presence of HHV-6 in neoplastic cells. A small number of studies have investigated HHV-6 antigen expression in pathologic specimens. As a result, the lack of HHV-6 antigen expression on neoplastic cells argues against any major pathogenic role of HHV-6. The role of HHV-6 in childhood acute lymphoblastic leukemia (ALL) has also been of interest but remains controversial, with 2 studies documenting higher levels of HHV-6 antibody in ALL patients, and another 2 large-scale studies finding no significant differences in HHV-6 seroprevalences between ALL patients and controls. Alternatively, HHV-6 is increasingly recognized as an important opportunistic pathogen. HHV-6 reactivation is common among recipients of allogeneic stem cell transplantation (SCT), and is linked to various clinical manifestations. In particular, HHV-6 encephalitis appears to be significant, life-threatening complication. Most HHV-6 encephalitis develops in patients receiving transplant from an unrelated donor, particularly cord blood, typically around the time of engraftment. Symptoms are characterized by short-term memory loss and seizures. Magnetic resonance imaging typically shows limbic encephalitis. Prognosis for HHV-6 encephalitis is poor, but appropriate prophylactic measures have not been established. Establishment of preventive strategies against HHV-6 encephalitis represents an important challenge for physicians involved with SCT.
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Affiliation(s)
- Masao Ogata
- Department of Hematology, Oita University Faculty of Medicine, Yufu-city, Oita, Japan.
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Ogata M, Satou T, Kawano R, Takakura S, Goto K, Ikewaki J, Kohno K, Ikebe T, Ando T, Miyazaki Y, Ohtsuka E, Saburi Y, Saikawa T, Kadota J. Correlations of HHV-6 viral load and plasma IL-6 concentration with HHV-6 encephalitis in allogeneic stem cell transplant recipients. Bone Marrow Transplant 2009; 45:129-36. [DOI: 10.1038/bmt.2009.116] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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