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Valencia Deray KG, Danziger-Isakov LA, Downes KJ. Current and Emerging Antiviral Agents in the Prevention and Treatment of Cytomegalovirus in Pediatric Transplant Recipients. J Pediatric Infect Dis Soc 2024; 13:S14-S21. [PMID: 38417084 PMCID: PMC10901473 DOI: 10.1093/jpids/piad059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 08/16/2023] [Indexed: 03/01/2024]
Abstract
Despite current prophylaxis regimens, cytomegalovirus (CMV) is common in hematopoietic cell transplantation (HCT) and solid organ transplantation (SOT) and remains a significant cause of morbidity and mortality. Newer antiviral medications are reshaping the landscape for prevention and treatment of CMV DNAemia, infection, and disease. Letermovir is approved for CMV prevention in adult HCT patients and is attractive due to the absence of marrow suppression seen with ganciclovir/valganciclovir. Letermovir should not be routinely used for CMV treatment due to its low threshold for resistance. Maribavir is approved for the treatment of refractory or resistant CMV disease in HCT and SOT recipients ≥12 years of age, though it has no current role in CMV prevention. More research is needed to fully elucidate the roles, efficacy, and safety of these newer agents in prevention and treatment of CMV in pediatric transplant recipients.
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Affiliation(s)
- Kristen G Valencia Deray
- Department of Pediatrics, Division of Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
| | - Lara A Danziger-Isakov
- Division of Infectious Disease, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Kevin J Downes
- Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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2
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Szmit Z, Frączkiewicz J, Salamonowicz-Bodzioch M, Król A, Ussowicz M, Mielcarek-Siedziuk M, Liszka K, Marschollek P, Gorczyńska E, Kałwak K. The Impact of High CMV Viral Load and Refractory CMV Infection on Pediatric HSCT Recipients with Underlying Non-Malignant Disorder. J Clin Med 2022; 11:jcm11175187. [PMID: 36079123 PMCID: PMC9456677 DOI: 10.3390/jcm11175187] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 08/25/2022] [Accepted: 08/29/2022] [Indexed: 11/16/2022] Open
Abstract
Hematopoietic stem cell transplantation (HSCT) is a curative therapy for an increasing number of nonmalignant indications. Its use is restricted by severe transplant-related complications, including CMV infection; despite various prophylactic and therapeutic strategies, CMV reactivation has remarkable morbidity and mortality. The analysis included 94 children with nonmalignant disorder who underwent allogeneic HSCT in the Department of Pediatric Hematology, Oncology, and Bone Marrow Transplantation in Wrocław during years 2016–2020. Twenty-seven (29%) children presented with CMV infection, including ten (10/27; 37%) with high level CMV viremia (10,000 copies/mL). Six patients experienced subsequent CMV reactivation. The first-line ganciclovir-based (GCV) treatment was insufficient in 40% (11/27) of children. Overall survival (OS) was significantly lower in children with high CMV viremia compared to those with low levels/no CMV [1yrOS High CMV = 0.80 (95% CI 0.41–0.95) vs. 1yrOS others = 0.96 (95% CI 0.89–0.99)]. Similarly, patients with resistant and recurrent infections had greater risk of death. CMV reactivation at any level relevantly prolonged the hospital stay. CMV reactivation with high viremia load and resistant/recurrent CMV infections lead to a significant decrease in OS in children with nonmalignant disorders treated with HSCT. Our data proves there is an urgent need to introduce an effective anti-CMV prophylaxis in this cohort of patients.
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3
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Aristizabal AM, Perez P, Patiño Niño JA, Franco A, Tarapues EM, Beltran E, Medina D. Risk factors and incidence of cytomegalovirus viremia and disease in pediatric patients with allogeneic hematopoietic stem cell transplantation: An 8-year single-center experience in Latin America. Pediatr Transplant 2022; 26:e14324. [PMID: 35647735 DOI: 10.1111/petr.14324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 03/21/2022] [Accepted: 04/29/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Cytomegalovirus infection represents a significant cause of morbidity and mortality after hematopoietic stem cell transplantation. This study aimed to evaluate the incidence of viremia and disease due to cytomegalovirus and the risk factors in pediatric patients with hematopoietic stem cell transplantation in our institution. METHODS This was a retrospective cohort of patients under 19 years of age who underwent allogeneic hematopoietic stem cell transplantation due to any indication between 2012 and 2019. The analysis included the diagnosis of cytomegalovirus viremia or disease during post-transplant follow-up, evaluation of risk factors, and outcomes. The statistical analysis included univariate and multivariate analyses, and the cumulative incidence of cytomegalovirus viremia was determined by the Kaplan-Meier method using STATA 14 statistical software. RESULTS A total of 182 transplants were included. At 100 days, the cumulative incidence of cytomegalovirus viremia was 70.5%, and that of cytomegalovirus disease was 4.7%. Overall survival at 2 years was 74%, and event-free survival was 64%. The remaining demographic characteristics were not predictors of infection. There was no association between viremia and relapse or survival of the patients. Higher mortality was noted in cytomegalovirus disease. CONCLUSIONS During the study period, the incidence of cytomegalovirus disease was similar to that of other pediatric reports, but the incidence of viremia was higher. Pre-emptive therapy has diminished disease rates and death due to infection. Viral load cutoff points should be standardized to guide treatment and avoid myelotoxicity.
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Affiliation(s)
- Ana M Aristizabal
- Facultad de ciencias de la salud, Universidad Icesi, Cali, Colombia.,Departamento Materno-Infantil, Fundación Valle del Lili, Cali, Colombia.,Fundación Valle del Lili, Centro de Investigaciones Clínicas, Cali, Colombia
| | - Paola Perez
- Facultad de ciencias de la salud, Universidad Icesi, Cali, Colombia.,Fundación Valle del Lili, Centro de Investigaciones Clínicas, Cali, Colombia.,Departamento Materno-Infantil, Fundación Valle del Lili, Grupo de Infectología Pediátrica, Cali, Colombia
| | - Jaime A Patiño Niño
- Facultad de ciencias de la salud, Universidad Icesi, Cali, Colombia.,Fundación Valle del Lili, Centro de Investigaciones Clínicas, Cali, Colombia.,Departamento Materno-Infantil, Fundación Valle del Lili, Grupo de Infectología Pediátrica, Cali, Colombia
| | - Alexis Franco
- Facultad de ciencias de la salud, Universidad Icesi, Cali, Colombia.,Fundación Valle del Lili, Centro de Investigaciones Clínicas, Cali, Colombia.,Departamento Materno-Infantil, Fundación Valle del Lili, Unidad de trasplante de médula ósea, Cali, Colombia
| | - Eliana Manzi Tarapues
- Facultad de ciencias de la salud, Universidad Icesi, Cali, Colombia.,Fundación Valle del Lili, Centro de Investigaciones Clínicas, Cali, Colombia
| | - Estefania Beltran
- Fundación Valle del Lili, Centro de Investigaciones Clínicas, Cali, Colombia
| | - Diego Medina
- Facultad de ciencias de la salud, Universidad Icesi, Cali, Colombia.,Fundación Valle del Lili, Centro de Investigaciones Clínicas, Cali, Colombia.,Departamento Materno-Infantil, Fundación Valle del Lili, Unidad de trasplante de médula ósea, Cali, Colombia
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4
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P Daukshus N, Cirincione A, Siver M, Mathew S, Kunvarjee B, Chan A, Boelens JJ, Seo SK, Papanicolaou GA, Kernan NA. Letermovir for Cytomegalovirus Prevention in Adolescent Patients Following Hematopoietic Cell Transplantation. J Pediatric Infect Dis Soc 2022; 11:337-340. [PMID: 35472147 PMCID: PMC9989834 DOI: 10.1093/jpids/piac017] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 03/07/2022] [Indexed: 01/07/2023]
Abstract
There are limited data for letermovir as primary cytomegalovirus (CMV) prophylaxis in patients less than 18 years of age. We report 9 adolescent patients who received letermovir following hematopoietic cell transplantation. No patients developed clinically significant CMV while taking letermovir. Letermovir was well tolerated and efficacious in preventing CMV infections.
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Affiliation(s)
- Nicole P Daukshus
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | | | - Molly Siver
- Department of Pharmacy, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Sherry Mathew
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Binni Kunvarjee
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Amelia Chan
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jaap Jan Boelens
- Stem Cell Transplantation and Cellular Therapies, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Susan K Seo
- Infectious Disease Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | | | - Nancy A Kernan
- Stem Cell Transplantation and Cellular Therapies, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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5
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Şen S, Özdemir HH, Karadaş N, Bal ZŞ, Göktepe ŞÖ, Ece D, Balkan C, Aydinok Y, Karapinar DY. Is Monitoring of Cytomegalovirus Disease Required in Nontransplant Pediatric Acute Lymphoblastic Leukemia? J Pediatr Hematol Oncol 2021; 43:e935-e940. [PMID: 34387629 DOI: 10.1097/mph.0000000000002272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 05/16/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Cytomegalovirus (CMV) infections in developing countries are experienced at an early age. This study was performed to investigate the frequency of reactivation and risk factors of infection acquired at an early age of nontransplant acute lymphoblastic leukemia (ALL) patients receiving immunosuppressive therapy with weekly monitoring of CMV levels in Turkey. MATERIALS AND METHODS This was a retrospective, single-center study of 172 pediatric patients (102 boys and 70 girls) with ALL. All patients were monitored routinely for CMV-DNA at the initial presentation of leukemia and twice a week during chemotherapy. The CMV immunoglobulin (Ig)M/IgG titers were measured at admission. RESULTS CMV seropositivity at baseline was 90,11%. The overall prevalence of CMV infection (viremia) was 70.34%, 116 of whom were seropositive for CMV IgG and 5 of whom were negative for CMV at the time of ALL diagnosis. Reactivation was more common than de novo CMV infections (P=0.000). CMV seropositivity at the beginning of the leukemia diagnosis was found to be an independent predictor for developing CMV infection (P=0.001). A total of 60 CMV infection episodes were treated with antivirals. Four of these included organ involvement. The duration of CMV-DNA viremia episodes was longer in patients with CMV-DNA ≥1000 copies/mL (n=45) than in those with lower CMV-DNA levels (P=0.002). Infection was shown not to be associated with chemotherapy phase. CONCLUSION This study suggests the importance of monitoring for CMV infections in developing countries because of frequent reactivations in seropositive ALL patients. It should be kept in mind that low CMV-DNA levels may also lead to organ involvement.
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Affiliation(s)
- Semra Şen
- Department of Pediatric Infectious Disease, Ege University
- Department of Pediatric Infectious Disease, Celal Bayar University, Manisa, Turkey
| | | | | | - Zümrüt Ş Bal
- Pediatric Infectious Disease, Ege University Hospital, Izmir
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6
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Hakki M, Aitken SL, Danziger-Isakov L, Michaels MG, Carpenter PA, Chemaly RF, Papanicolaou GA, Boeckh M, Marty FM. American Society for Transplantation and Cellular Therapy Series: #3-Prevention of Cytomegalovirus Infection and Disease After Hematopoietic Cell Transplantation. Transplant Cell Ther 2021; 27:707-719. [PMID: 34452721 DOI: 10.1016/j.jtct.2021.05.001] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 05/02/2021] [Indexed: 11/20/2022]
Abstract
The Practice Guidelines Committee of the American Society for Transplantation and Cellular Therapy partnered with its Transplant Infectious Disease Special Interest Group to update its 2009 compendium-style infectious diseases guidelines for the care of hematopoietic cell transplant (HCT) recipients. A new approach was taken with the goal of better serving clinical providers by publishing each standalone topic in the infectious disease series as a concise format of frequently asked questions (FAQ), tables, and figures. Adult and pediatric infectious disease and HCT content experts developed and answered FAQs. Topics were finalized with harmonized recommendations that were made by assigning an A through E strength of recommendation paired with a level of supporting evidence graded I through III. The third topic in the series focuses on the prevention of cytomegalovirus infection and disease in HCT recipients by reviewing prophylaxis and preemptive therapy approaches; key definitions, relevant risk factors, and diagnostic monitoring considerations are also reviewed.
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Affiliation(s)
- Morgan Hakki
- Division of Infectious Diseases, Department of Medicine, Oregon Health and Science University, Portland, Oregon.
| | - Samuel L Aitken
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lara Danziger-Isakov
- Division of Infectious Disease, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Marian G Michaels
- Division of Pediatric Infectious Diseases, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh and the University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Paul A Carpenter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Roy F Chemaly
- Department of Infectious Diseases, Infection Control, & Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Michael Boeckh
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Vaccine and Infectious Disease Divisions, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Francisco M Marty
- Division of Infectious Diseases, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts
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7
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Yu U, Wang X, Zhang X, Wang C, Yang C, Zhou X, Li Y, Huang X, Wen J, Wen F, Liu S. Cytomegalovirus Infection and the Implications of Drug-Resistant Mutations in Pediatric Allogeneic Hematopoietic Stem Cell Transplant Recipients: A Retrospective Study from a Tertiary Hospital in China. Infect Dis Ther 2021; 10:1309-1322. [PMID: 33966176 PMCID: PMC8322184 DOI: 10.1007/s40121-021-00452-4] [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] [Accepted: 04/28/2021] [Indexed: 10/28/2022] Open
Abstract
INTRODUCTION Drug-resistant cytomegalovirus (CMV) infection remains a challenge in the management of pediatric recipients of hematopoietic stem cell transplantation (HSCT). In this study, we retrospectively reviewed the clinical data on pediatric recipients of HSCT and identified known and unknown drug-resistant CMV variants. METHODS A total of 221 children underwent allogeneic HSCT between October 2017 and November 2019 at Shenzhen Children's Hospital; of these, 35 patients were suspected of having drug-resistant CMV infections and were tested for drug-resistant mutations in the UL97 and UL54 genes by Sanger sequencing. RESULTS Mutations in UL97 or UL54, or in both, were detected in 11 patients. Most of these mutations have not been previously reported. The UL97 mutation (A582V) was detected in only one patient who also harbored two UL54 mutations (T760X and R876W). One patient with both the G604S and T691A mutations in the UL54 gene died of CMV pneumonia. We investigated the risk factors associated with the development of drug-resistant CMV infection. Patients in whom both the donor and recipient had positive CMV serostatuses were less likely to have drug-resistant mutations (Fisher's exact test, p < 0.05). CONCLUSION Newly and previously detected CMV mutations in UL97 and UL54 may be associated with the development of drug-resistant CMV infection. The detection of these mutations may provide guidance for the management of post-transplant CMV infections.
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Affiliation(s)
- Uet Yu
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Xiaodong Wang
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Xiaoling Zhang
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Chunjing Wang
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Chunlan Yang
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Xiaohui Zhou
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Yue Li
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Xiaochan Huang
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Jing Wen
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Feiqiu Wen
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Sixi Liu
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China.
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8
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Choi S, Kim YJ, Yoo KH, Sung KW, Koo HH, Kim SJ, Jang JH, Kim K, Jung CW, Huh HJ, Kang ES. Relationship of Circulating Cytomegalovirus Levels Obtained Through Antigenemia Testing and Quantitative PCR Differs Between Children and Adults. Ann Lab Med 2019; 40:88-91. [PMID: 31432647 PMCID: PMC6713664 DOI: 10.3343/alm.2020.40.1.88] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 05/05/2019] [Accepted: 07/11/2019] [Indexed: 12/19/2022] Open
Affiliation(s)
- Sooin Choi
- Department of Laboratory Medicine, Soonchunhyang University Hospital Cheonan, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Yae Jean Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Keon Hee Yoo
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ki Woong Sung
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hong Hoe Koo
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Suk Jin Kim
- Division of Hematology-Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jun Ho Jang
- Division of Hematology-Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kihyun Kim
- Division of Hematology-Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chul Won Jung
- Division of Hematology-Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee Jae Huh
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun Suk Kang
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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9
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Al Yazidi LS, Mitchell R, Palasanthiran P, O'Brien TA, McMullan B. Management and prevention of cytomegalovirus infection in paediatric hematopoietic stem cell transplant (HSCT) recipients: A binational survey. Pediatr Transplant 2019; 23:e13458. [PMID: 31081265 DOI: 10.1111/petr.13458] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 02/24/2019] [Accepted: 04/01/2019] [Indexed: 11/26/2022]
Abstract
CMV infection is an important cause of morbidity and mortality among HSCT recipients. Optimal strategies for prevention and management of CMV disease following haematopoietic stem cell transplantation remain uncertain. We conducted an online survey of Australasian paediatric allogeneic HSCT centres on management and prevention of CMV disease in this patient group. We asked for one response from a representative of the HSCT team and one from a representative of the ID team at each centre. All Australasian paediatric HSCT centres responded to our survey. Management of CMV in pre-transplant setting was consistent between centres. All centres used a pre-emptive strategy to prevent CMV disease, guided by quantitative CMV PCR. In the post-transplant post engraftment setting, all centres recommended using ganciclovir (5mg/kg/dose twice daily) as a first-line therapy for CMV reactivation or disease, with treatment duration of 14 days, provided declining CMV quantitative PCR. There was substantial variability of practice between centres in post-transplant management of CMV reactivation, especially during the pre-engraftment phase. Similarly, there was lack of uniformity in indication, dosing and duration of maintenance therapy. Divergence was noted between responses from HSCT and ID physicians within centres. This study identifies areas of uniformity and others of great variability in prevention and management strategies for CMV in paediatric HSCT. Data on CMV infection and management in HSCT patients should be routinely collected as part of prospective trials to inform guidelines and improve prevention and treatment of this important complication.
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Affiliation(s)
- Laila S Al Yazidi
- Immunology and Infectious Diseases Department, Sydney Children's Hospital, Sydney, New South Wales, Australia.,The School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia.,College of Medicine, Sultan Qaboos University, Muscat, Oman
| | - Richard Mitchell
- The School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia.,Kids Cancer Centre, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Pamela Palasanthiran
- Immunology and Infectious Diseases Department, Sydney Children's Hospital, Sydney, New South Wales, Australia.,The School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Tracey A O'Brien
- The School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia.,Kids Cancer Centre, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Brendan McMullan
- Immunology and Infectious Diseases Department, Sydney Children's Hospital, Sydney, New South Wales, Australia.,The School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia.,National Centre for Infections in Cancer, University of Melbourne, Melbourne, Victoria, Australia
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10
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Kilgore JT, Becken B, Varga MG, Parikh S, Prasad V, Lugo D, Chang YC. Use of Letermovir for Salvage Therapy for Resistant Cytomegalovirus in a Pediatric Hematopoietic Stem Cell Transplant Recipient. J Pediatric Infect Dis Soc 2019; 9:486-489. [PMID: 31362308 PMCID: PMC7495908 DOI: 10.1093/jpids/piz050] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 06/20/2019] [Indexed: 11/13/2022]
Abstract
We present here the first published use of letermovir for the treatment of resistant cytomegalovirus (CMV) in a pediatric patient. A 14-year-old girl underwent a double unrelated umbilical cord blood transplantation to treat her sickle cell disease (hemoglobin SS) and developed ganciclovir-resistant CMV DNAemia with end-organ involvement that was treated successfully with a combination of foscarnet and letermovir. After she was transitioned to letermovir monotherapy for secondary prophylaxis, she developed recurrent DNAemia with laboratory-confirmed ganciclovir, foscarnet, and letermovir resistance.
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Affiliation(s)
- Jacob T Kilgore
- Division of Pediatric Infectious Diseases, Duke University, Durham, North Carolina,Correspondence: J. T. Kilgore, MD, Duke University, Division of Pediatric Infectious Diseases, T915 Children’s Health Center, Box 3499 DUMC, Durham, NC 27710 ()
| | - Bradford Becken
- Division of Pediatric Infectious Diseases, Duke University, Durham, North Carolina
| | - Matthew G Varga
- Department of Epidemiology, Gillings School of Global Public Health and the Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Suhag Parikh
- Pediatric Bone Marrow Transplant Program, Duke University, Durham, North Carolina
| | - Vinod Prasad
- Pediatric Bone Marrow Transplant Program, Duke University, Durham, North Carolina
| | - Debra Lugo
- Division of Pediatric Infectious Diseases, Duke University, Durham, North Carolina,Pediatric Immunocompromised Host Program, Duke University, Durham, North Carolina
| | - Yeh-Chung Chang
- Division of Pediatric Infectious Diseases, Duke University, Durham, North Carolina,Pediatric Immunocompromised Host Program, Duke University, Durham, North Carolina
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11
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Phasuk N, Keatkla J, Rattanasiri S, Techasaensiri C, Anurathapan U, Apiwattanakul N. Monitoring of cytomegalovirus infection in non-transplant pediatric acute lymphoblastic leukemia patients during chemotherapy. Medicine (Baltimore) 2019; 98:e14256. [PMID: 30681620 PMCID: PMC6358396 DOI: 10.1097/md.0000000000014256] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Cytomegalovirus (CMV) infection is a significant cause of morbidity and mortality in the posttransplant setting; however, it is increasingly recognized in pediatric leukemia during chemotherapy. This study assessed the prevalence and associated factors of CMV infection in pediatric non-transplant leukemia patients.This was a cross-sectional study of 50 pediatric acute lymphoblastic leukemia (ALL) patients receiving chemotherapy at Ramathibodi Hospital from December 2015 to December 2016. CMV viral load quantified by DNA polymerase chain reaction (PCR) was monitored in different phases of chemotherapy: enrolment, post-induction, post-consolidation, post-intensification, and maintenance.One hundred forty one blood tests were evaluated from 50 patients. Overall prevalence of CMV DNAemia (≥20 copies/mL) and high-level CMV DNAemia (≥1000 copies/mL) was 52% (26 of 50) and 16.0% (8 of 50), respectively. All patients with high-level CMV DNAemia were in the maintenance phase of chemotherapy. One patient had CMV retinitis, while the rest had no end-organ CMV diseases. Increased lymphocyte count was significantly associated with protection from high-level CMV DNAemia (odds ratio 0.997, P = .02). Receiver operating characteristic curve identified a cut-off value of 798 cells/mm of absolute lymphocyte count (ALC) as a discriminator for the presence of high-level CMV DNAemia (area under the curve 0.756, 95% CI 0.645-0.867, P = .001) with 88.9% sensitivity and 50.4% specificity.CMV infection predominantly occurred during maintenance chemotherapy. Low ALC was significantly associated with high-level CMV DNAemia. CMV infection surveillance by quantitative CMV DNA PCR during maintenance chemotherapy in patients with ALC <800 cells/mm may be considered.
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Affiliation(s)
- Nonthapan Phasuk
- Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Bangkok, Thailand
- School of Medicine, Walailuk University, 222 Thasala District, Nakhon Si Thammarat, Thailand
| | - Jiraporn Keatkla
- Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Bangkok, Thailand
| | - Sasivimol Rattanasiri
- Section for Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Bangkok, Thailand
| | - Chonnamet Techasaensiri
- Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Bangkok, Thailand
| | - Usanarat Anurathapan
- Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Bangkok, Thailand
| | - Nopporn Apiwattanakul
- Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Bangkok, Thailand
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12
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Laberko A, Gennery AR. Clinical considerations in the hematopoietic stem cell transplant management of primary immunodeficiencies. Expert Rev Clin Immunol 2018; 14:297-306. [PMID: 29589971 DOI: 10.1080/1744666x.2018.1459189] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Primary immunodeficiencies (PID) are genetic immune disorders causing increased predisposition to infections and autoimmunity. The only curative procedure is hematopoietic stem cell transplantation (HSCT), results from which have improved dramatically since 2000. Complications remain a serious issue, especially in HLA non-identical transplantation. In PID patients, persistent infection and autoimmunity with end-organ damage cause particular problems with approach to transplantation. This article examines these, emphasising approach to management and consequences. Areas covered: It is challenging to know which patients should be offered HSCT. As new diseases are discovered, data are required to determine natural history, and HSCT outcomes. Treatment of adults can be challenging, although HSCT outcomes are encouraging. New methods of T-lymphocyte depletion show results comparable to those of matched sibling donor transplants. New cellular therapies to treat viral infections show promising results, and immunomodulatory methods are successful in treating acute graft-versus-host disease. Expert commentary: New T-lymphocyte depletion methods are a paradigm shift in approach to HSCT for PID. In combination with new cellular approaches to treating viral infection, immunomodulatory approaches to acute graft-versus-host disease and better understanding of endothelial activation syndromes, survival approaches 90%. Widespread introduction of newborn screening for severe combined immunodeficiencies will improve survival further.
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Affiliation(s)
- Alexandra Laberko
- a Immunology and Hematopoietic Stem Cell Transplantation Department , Dmitry Rogachev National Center for Pediatric Hematology, Oncology and Immunology , Moscow , Russia
| | - Andrew R Gennery
- b Primary Immunodeficiency Group, Institute of Cellular Medicine , Newcastle University , Newcastle upon Tyne , UK.,c Paediatric Immunology + HSCT , Great North Children's Hospital , Newcastle upon Tyne , UK
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13
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Slatter MA, Gennery AR. Hematopoietic cell transplantation in primary immunodeficiency - conventional and emerging indications. Expert Rev Clin Immunol 2018; 14:103-114. [PMID: 29300535 DOI: 10.1080/1744666x.2018.1424627] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Hematopoietic stem cell transplantation (HSCT) is an established curative treatment for many primary immunodeficiencies. Advances in donor selection, graft manipulation, conditioning and treatment of complications, mean that survival for many conditions is now around 90%. Next generation sequencing is identifying new immunodeficiencies, many of which are treatable with HSCT. Challenges remain however with short and long-term sequalae. This article reviews latest developments in HSCT for conventional primary immunodeficiencies and presents data on outcome for emerging diseases, Areas covered: This article reviews recently published literature detailing advances, particularly in conditioning regimens and new methods of T-lymphocyte depletion, as well as new information regarding approach and out come of transplanting patients with conventional primary immunodeficiencies. The article reviews data regarding transplant outcomes for newly described primary immunodeficiencies, particularly those associated with gain-of-function mutations. Expert commentary: New methods of graft manipulation have had significant impact on HSCT outcomes, with the range of PIDs treated using T-lymphocyte depletion significantly expanded. Outcomes for newly described diseases with variable phenotypes and clinical features, transplanted when the diagnosis was unknown are beginning to be described, and will improve as patients are identified earlier, and targeted therapies such as JAK inhibitors are used as a bridge to transplantation.
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Affiliation(s)
- Mary A Slatter
- a Institute of Cellular Medicine , Newcastle University , Newcastle Upon Tyne , UK.,b Paediatric Immunology and HSCT , Great North Children's Hospital , Newcastle Upon Tyne , UK
| | - Andrew R Gennery
- a Institute of Cellular Medicine , Newcastle University , Newcastle Upon Tyne , UK.,b Paediatric Immunology and HSCT , Great North Children's Hospital , Newcastle Upon Tyne , UK
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14
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Robin C, Hémery F, Dindorf C, Thillard J, Cabanne L, Redjoul R, Beckerich F, Rodriguez C, Pautas C, Toma A, Maury S, Durand-Zaleski I, Cordonnier C. Economic burden of preemptive treatment of CMV infection after allogeneic stem cell transplantation: a retrospective study of 208 consecutive patients. BMC Infect Dis 2017; 17:747. [PMID: 29207952 PMCID: PMC5717816 DOI: 10.1186/s12879-017-2854-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 11/24/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) infection and disease (CMV episodes) are global concerns after allogeneic hematopoietic stem cell transplantation (HSCT). They affect survival, both by direct and indirect effects. Due to safety issues of current anti-CMV antivirals, long-term CMV prophylaxis is poorly tolerated and the most common strategy to decrease the incidence of CMV disease is preemptive. New, less toxic, molecules are currently being assessed for CMV prophylaxis which should replace or considerably decrease the preemptive approach. The aim of this study was to assess the economic burden of CMV episodes after HSCT with a preemptive approach. METHODS We analyzed data from 208 consecutive adults transplanted in our institution, between 2008 and 2013. Hospital resource utilization was retrieved via the linked hospital admissions and Diagnostic Related Groups for the period of conditioning to 12 months after transplant. RESULTS CMV episodes occurred in 70 patients (34%) over the first 12 months following HSCT, after a mean of 75 days (median: 46 (7-334)). The mean total length of stay was significantly associated with the occurrence of a CMV episode (113.9 vs. 87.5 days, p = 0.0002) but was associated neither with the pre-transplant CMV serology of donors/recipients nor with survival. The mean cost of transplant was €104,016 (SD = €37,281) after 12 months. Bivariate and multivariate analyses indicated that the occurrence of >1 CMV episode increased the costs of allogeneic HSCT by 25-30% (p < 0.0001). CONCLUSION Our study, which is the largest, single-institution cost study of allogeneic HSCT in Europe, shows that two or more CMV episodes significantly increased the transplant cost. New prophylactic strategies to prevent CMV infection and disease should decrease transplant costs.
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Affiliation(s)
- Christine Robin
- Department of Hematology, Assistance Publique-Hopitaux de Paris (APHP), Henri Mondor Teaching Hospital, 94010 Créteil, France
- University Paris-Est Créteil (UPEC), 94000 Créteil, France
| | - François Hémery
- Department of Medical Information, APHP, Henri Mondor Teaching Hospital, Créteil, France
| | | | | | - Ludovic Cabanne
- Department of Hematology, Assistance Publique-Hopitaux de Paris (APHP), Henri Mondor Teaching Hospital, 94010 Créteil, France
| | - Rabah Redjoul
- Department of Hematology, Assistance Publique-Hopitaux de Paris (APHP), Henri Mondor Teaching Hospital, 94010 Créteil, France
| | - Florence Beckerich
- Department of Hematology, Assistance Publique-Hopitaux de Paris (APHP), Henri Mondor Teaching Hospital, 94010 Créteil, France
- University Paris-Est Créteil (UPEC), 94000 Créteil, France
| | - Christophe Rodriguez
- University Paris-Est Créteil (UPEC), 94000 Créteil, France
- Department of Virology, and INSERM U955 Team 18, APHP, Henri Mondor Teaching Hospital, 94000 Créteil, France
| | - Cécile Pautas
- Department of Hematology, Assistance Publique-Hopitaux de Paris (APHP), Henri Mondor Teaching Hospital, 94010 Créteil, France
| | - Andrea Toma
- Department of Hematology, Assistance Publique-Hopitaux de Paris (APHP), Henri Mondor Teaching Hospital, 94010 Créteil, France
| | - Sébastien Maury
- Department of Hematology, Assistance Publique-Hopitaux de Paris (APHP), Henri Mondor Teaching Hospital, 94010 Créteil, France
- University Paris-Est Créteil (UPEC), 94000 Créteil, France
| | - Isabelle Durand-Zaleski
- University Paris-Est Créteil (UPEC), 94000 Créteil, France
- Department of Public Health, APHP, Henri Mondor Teaching Hospital, 94000- Créteil, France
| | - Catherine Cordonnier
- Department of Hematology, Assistance Publique-Hopitaux de Paris (APHP), Henri Mondor Teaching Hospital, 94010 Créteil, France
- University Paris-Est Créteil (UPEC), 94000 Créteil, France
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15
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Abstract
Cytomegalovirus (CMV) is a frequent complication of hematopoietic stem cell transplant in pediatric patients, with significant morbidity and mortality. Antiviral drugs are used as prophylactic, preemptive or therapeutic medicines; however, no uniform guidelines exist for the best strategy to prevent CMV disease. Resistance to standard antiviral therapies can lead to further difficulty in managing CMV disease. Studies for investigational therapies are underway and could provide options for treatment of resistant CMV, while limiting toxicities associated with currently used antiviral therapies.
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16
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Ishii K, Onishi Y, Miyamura N, Fukuhara N, Ishizawa K, Nakanishi M, Ohnaka S, Miyasaka T, Kanno E, Kawakami K, Harigae H, Kaku M. Development and evaluation of a quantitative assay detecting cytomegalovirus transcripts for preemptive therapy in allogeneic hematopoietic stem cell transplant recipients. J Med Virol 2017; 89:1265-1273. [DOI: 10.1002/jmv.24775] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 12/28/2016] [Accepted: 01/06/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Keiko Ishii
- Department of Medical Microbiology, Mycology and Immunology; Tohoku University Graduate School of Medicine; Sendai Japan
| | - Yasushi Onishi
- Department of Hematology and Rheumatology; Tohoku University Hospital; Sendai Japan
| | - Namiko Miyamura
- Department of Medical Microbiology, Mycology and Immunology; Tohoku University Graduate School of Medicine; Sendai Japan
| | - Noriko Fukuhara
- Department of Hematology and Rheumatology; Tohoku University Hospital; Sendai Japan
| | - Kenichi Ishizawa
- Department of Hematology and Rheumatology; Tohoku University Hospital; Sendai Japan
| | | | | | - Tomomitsu Miyasaka
- Department of Medical Microbiology, Mycology and Immunology; Tohoku University Graduate School of Medicine; Sendai Japan
| | - Emi Kanno
- Department of Science of Nursing Practice; Tohoku University Graduate School of Medicine; Sendai Japan
| | - Kazuyoshi Kawakami
- Department of Medical Microbiology, Mycology and Immunology; Tohoku University Graduate School of Medicine; Sendai Japan
| | - Hideo Harigae
- Department of Hematology and Rheumatology; Tohoku University Hospital; Sendai Japan
| | - Mitsuo Kaku
- Department of Infection Control and Laboratory Diagnostics, Internal Medicine; Tohoku University Graduate School of Medicine; Sendai Japan
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17
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Tezer H, Kanık Yüksek S, Gülhan B, Özkaya Parlakay AN, Tuna Kırsaçlıoğlu C. Cytomegalovirus hepatitis in 49 pediatric patients with normal immunity. Turk J Med Sci 2016; 46:1629-1633. [PMID: 28081328 DOI: 10.3906/sag-1507-161] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 02/03/2016] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND/AIM Cytomegalovirus (CMV) hepatitis is generally asymptomatic or rarely can lead to severe complications in immunocompetent hosts. This study aims to evaluate CMV hepatitis in immunocompetent young children, which is discussed relatively rarely in the literature. MATERIALS AND METHODS A retrospective review of 49 pediatric patients with CMV hepatitis from January 2005 to December 2010 was performed. RESULTS The median age of the patients was 5.81 ± 6.49 months and 57.1% were female. Complaints were prolonged jaundice, vomiting, diarrhea, and abdominal distension. Seventeen patients (34.6%) had congenital or probable congenital CMV infection, while 32/49 (65.3%) had perinatal CMV infection. CMV hepatitis was accompanied by other system findings in 22 patients (44.9%), and only liver involvement was present in 27/49 (55.1%). Alanine aminotransferase and aspartate aminotransferase were elevated together in all patients. Cholestatic hepatitis was present in 13 patients (26.5%). Four patients (8.16%) were treated with ganciclovir. Complete improvement of hepatitis occurred in 48/49 (97.95%). The recovery time of liver function tests was 7-180 days (mean: 53.92 ± 40.8). CONCLUSION CMV hepatitis is usually mild and has a good outcome in immunocompetent individuals. However, cases should be carefully evaluated due to the important role of CMV in the etiology of infantile and neonatal hepatitis.
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Affiliation(s)
- Hasan Tezer
- Department of Pediatric Infectious Diseases, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Saliha Kanık Yüksek
- Department of Pediatric Infectious Diseases, Ankara Hematology Oncology Children's Training and Research Hospital, Ankara, Turkey
| | - Belgin Gülhan
- Department of Pediatric Infectious Diseases, Ankara Hematology Oncology Children's Training and Research Hospital, Ankara, Turkey
| | - Aslı Nur Özkaya Parlakay
- Department of Pediatric Infectious Diseases, Ankara Hematology Oncology Children's Training and Research Hospital, Ankara, Turkey
| | - Ceyda Tuna Kırsaçlıoğlu
- Department of Pediatric Gastroenterology, Ankara Hematology Oncology Children's Training and Research Hospital, Ankara, Turkey
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18
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Svenberg P, Remberger M, Uzunel M, Mattsson J, Gustafsson B, Fjaertoft G, Sundin M, Winiarski J, Ringdén O. Improved overall survival for pediatric patients undergoing allogeneic hematopoietic stem cell transplantation - A comparison of the last two decades. Pediatr Transplant 2016; 20:667-74. [PMID: 27251184 DOI: 10.1111/petr.12723] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2016] [Indexed: 01/06/2023]
Abstract
Pediatric protocols for allogeneic hematopoietic SCT have been altered during the last two decades. To compare the outcomes in children (<18 yr old), who underwent SCT at our center during 1992-2002 (P1) and 2003-2013 (P2). We retrospectively analyzed 188 patients in P1 and 201 patients in P2. The most significant protocol changes during P2 compared with P1 were a decrease in MAC protocols, particularly those containing TBI, an increase in RIC protocols, and altered GvHD prophylaxis. In addition, P2 had more patients with nonmalignant diagnoses (p = 0.002), more mismatched (MM) donors (p = 0.01), and more umbilical CB grafts (p = 0.03). Mesenchymal or DSCs were used for severe acute GvHD during P2. Three-yr OS in P1 was 58%, and in P2, it was 78% (p < 0.001). Improved OS was seen in both malignant disorders (51% vs. 68%; p = 0.05) and nonmalignant disorders (77% vs. 87%; p = 0.04). Multivariate analysis showed that SCT during P2 was associated with reduced mortality (HR = 0.57; p = 0.005), reduced TRM (HR = 0.57; p = 0.03), unchanged relapse rate, similar rate of GF, less chronic GvHD (HR = 0.49; p = 0.01), and more acute GvHD (HR = 1.77, p = 0.007). During recent years, OS has improved at our center, possibly reflecting the introduction of less toxic conditioning regimens and a number of other methodological developments in SCT.
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Affiliation(s)
- Petter Svenberg
- Oncology/Coagulation Section, Karolinska University Hospital, Stockholm, Sweden
| | - Mats Remberger
- Department of Oncology/Pathology, Karolinska Institute, Stockholm, Sweden.,Centre for Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden
| | - Mehmet Uzunel
- Division of Clinical Immunology and Transfusion Medicine, Department of Laboratory Medicine, Karolinska Institute, Stockholm, Sweden
| | - Jonas Mattsson
- Department of Oncology/Pathology, Karolinska Institute, Stockholm, Sweden.,Centre for Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden
| | - Britt Gustafsson
- Centre for Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden.,Division of Pediatrics, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden
| | - Gustav Fjaertoft
- Centre for Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Stockholm, Sweden
| | - Mikael Sundin
- Division of Pediatrics, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden.,Hematology/Immunology Section, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Jacek Winiarski
- Division of Pediatrics, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden.,Hematology/Immunology Section, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Olle Ringdén
- Division of Clinical Immunology and Transfusion Medicine, Department of Laboratory Medicine, Karolinska Institute, Stockholm, Sweden
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19
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Rowe RG, Guo D, Lee M, Margossian S, London WB, Lehmann L. Cytomegalovirus Infection in Pediatric Hematopoietic Stem Cell Transplantation: Risk Factors for Primary Infection and Cases of Recurrent and Late Infection at a Single Center. Biol Blood Marrow Transplant 2016; 22:1275-1283. [PMID: 27090959 DOI: 10.1016/j.bbmt.2016.04.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 04/08/2016] [Indexed: 12/28/2022]
Abstract
Cytomegalovirus (CMV) infection is a significant source of morbidity and mortality in allogeneic stem cell transplantation (SCT). We identified a cohort of 91 pediatric SCT patients at risk (defined as either donor and/or recipient seropositivity) for CMV infection at our institution. We retrospectively categorized at-risk SCT recipients as those who (1) were at risk of CMV infection in the post-SCT period, (2) had documented CMV infection before SCT, (3) experienced recurrence of post-SCT CMV viremia, or (4) experienced late post-SCT CMV viremia; categories were not mutually exclusive. We analyzed the impact of SCT-related factors on incidence of CMV infection and outcome, and we described the outcome of each of these cohorts. In univariate analysis, recipient CMV seropositivity, use of umbilical cord blood graft, and acute graft-versus-host disease (GVHD) predicted post-SCT CMV viremia, and the effects of acute GVHD (odds ratio, 4.018; 95% confidence interval, 1.032 to 15.643) and CMV seropositivity (odds ratio, 16.525; 95% confidence interval, 2.041 to 133.803) were confirmed in multivariate analysis. Patients with recurrence of post-SCT CMV viremia had a 50% all-cause mortality rate, compared with 12% in all 91 patients. Patients with pre-SCT CMV infection had a high incidence of post-SCT CMV infection but could successfully undergo SCT with antiviral prophylaxis and pre-emptive CMV treatment. All patients with late CMV infection had prior GVHD. Theses findings identify risk factors for post-SCT CMV infection and provide novel descriptions of childhood SCT recipients with pre-SCT, recurrent, and late CMV infection, which may contribute to risk stratification strategies for CMV at-risk patients in pediatric allogeneic SCT.
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Affiliation(s)
- R Grant Rowe
- Stem Cell Transplantation Program, Dana-Farber Boston Children's Cancer and Blood Disorders Center, Dana-Farber Cancer Institute, Boston, Massachusetts; Boston Children's Hospital, Boston, Massachusetts
| | - Dongjing Guo
- Boston Children's Hospital, Boston, Massachusetts
| | - Michelle Lee
- Stem Cell Transplantation Program, Dana-Farber Boston Children's Cancer and Blood Disorders Center, Dana-Farber Cancer Institute, Boston, Massachusetts; Boston Children's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Steven Margossian
- Stem Cell Transplantation Program, Dana-Farber Boston Children's Cancer and Blood Disorders Center, Dana-Farber Cancer Institute, Boston, Massachusetts; Boston Children's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Wendy B London
- Stem Cell Transplantation Program, Dana-Farber Boston Children's Cancer and Blood Disorders Center, Dana-Farber Cancer Institute, Boston, Massachusetts; Boston Children's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Leslie Lehmann
- Stem Cell Transplantation Program, Dana-Farber Boston Children's Cancer and Blood Disorders Center, Dana-Farber Cancer Institute, Boston, Massachusetts; Boston Children's Hospital, Boston, Massachusetts.
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20
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Abstract
PURPOSE OF REVIEW The purpose of this study is to explore the latest developments in the risk factors, prevention and treatment of cytomegalovirus (CMV) infection in immunocompromised children, including those with congenital immunodeficiency or iatrogenic immune suppression related to solid organ transplantation (SOT) or haematopoietic cell transplantation (HCT). RECENT FINDINGS CMV viral load measurements now have international standards, allowing for more reliable comparison across sites and within individuals. Preemptive and prophylactic therapy with routine CMV monitoring in transplant patients has yielded significant reduction in CMV morbidity and mortality in these patients. The majority of U.S. states have adopted routine newborn screening for severe combined immunodeficiency (SCID). Viral infections, including CMV, are a major obstacle preventing optimal curative transplantation in these patients. Several new antiviral agents are currently being investigated for CMV infection in immunocompromised patients. Knowledge on CMV drug resistance in children is emerging and requires further study. SUMMARY Conditions that diminish cell-mediated immunity impact the development of CMV infection and disease. These conditions include certain congenital immunodeficiencies and SOT and HCT. Infants identified as having SCID should be screened for CMV risk factors. A preemptive or prophylactic strategy should be chosen for CMV management in children who are high risk posttransplantation. In those who develop disease, viral loads should be monitored and resistance testing considered if response is not deemed adequate. Oral valganciclovir is being used as an alternative to ganciclovir in children, although pharmacokinetic data are limited. Other oral antiviral agents under development are promising future options for paediatric CMV therapy.
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21
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Houldcroft C. Sequencing drug-resistant cytomegalovirus in pediatric patients: toward personalized medicine. Future Virol 2015. [DOI: 10.2217/fvl.15.58] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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22
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Pfirrmann V, Oelsner S, Rettinger E, Huenecke S, Bonig H, Merker M, Wels WS, Cinatl J, Schubert R, Klingebiel T, Bader P. Cytomegalovirus-specific cytokine-induced killer cells: concurrent targeting of leukemia and cytomegalovirus. Cytotherapy 2015; 17:1139-51. [PMID: 26072027 DOI: 10.1016/j.jcyt.2015.04.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 04/22/2015] [Accepted: 04/23/2015] [Indexed: 01/10/2023]
Abstract
BACKGROUND AIMS Human cytomegalovirus (CMV) infection and reactivation is a leading complication of allogeneic hematopoietic stem cell transplantation (HSCT). In addition to drug treatment, the adoptive transfer of virus-specific T cells to restore cellular immunity has become a standard therapy after allogeneic HSCT. We recently demonstrated potent anti-leukemic activity of interleukin (IL)-15-activated cytokine-induced killer (CIK) cells. With the use of the same expansion protocol, we asked whether concurrent CMV antigen-pulsing might generate CIK cells with anti-leukemic and anti-CMV activity. METHODS CIK cells expanded in the presence of interferon-γ, IL-2, IL-15 and anti-CD3 antibody were pulsed once with CMV(pp65) peptide pool. CMV-specific CIK (CIK(pp65)) and conventional CIK cells were phenotypically and functionally characterized according to their cytokine secretion pattern, degranulation capacity and T-cell receptor (TCR)-mediated and NKG2D-mediated cytotoxicity. RESULTS We demonstrated that among CIK cells generated from CMV-seropositive donors, a single stimulation with CMV(pp65) protein co-expanded cytotoxic CMV-specific cells without sacrificing anti-tumor reactivity. Cells generated in this fashion lysed CMV(pp65)-loaded target cells and CMV-infected fibroblasts but also leukemic cells. Meanwhile, the alloreactive potential of CIK(pp65) cells remained low. Interestingly, CMV reactivity was TCR-mediated and CMV-specific cells could be found in CD3(+)CD8(+)CD56(+/-) cytotoxic T-cell subpopulations. CONCLUSIONS We provide an efficient method to generate CIK(pp65) cells that may represent a useful cell therapy approach for preemptive immunotherapy in patients who have both an apparent risk of CMV and impending leukemic relapse after allogeneic stem cell transplantation.
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Affiliation(s)
- Verena Pfirrmann
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescents, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.
| | - Sarah Oelsner
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescents, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany; Georg-Speyer-Haus, Institute for Tumor Biology and Experimental Therapy, Frankfurt/Main, Germany
| | - Eva Rettinger
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescents, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany
| | - Sabine Huenecke
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescents, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany
| | - Halvard Bonig
- Institute for Transfusion Medicine and Immunohematology and German Red Cross Blood Donor Service, University Hospital Frankfurt, Goethe University, Baden-Wuerttemberg-Hessen, Frankfurt/Main, Germany
| | - Michael Merker
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescents, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany
| | - Winfried S Wels
- Georg-Speyer-Haus, Institute for Tumor Biology and Experimental Therapy, Frankfurt/Main, Germany
| | - Jindrich Cinatl
- Institute for Experimental Cancer Research in Pediatrics, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany
| | - Ralf Schubert
- Division of Allergology, Pneumology and Cystic Fibrosis, Department of Children and Adolescents, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany
| | - Thomas Klingebiel
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescents, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany
| | - Peter Bader
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescents, University Hospital Frankfurt, Goethe University, Frankfurt/Main, Germany.
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23
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Abdel-Azim H, Balian C, Tewari P, Santizo R, Kapoor N, Mahadeo KM. A survey of infectious disease clinical practices among pediatric blood and marrow transplant programs in the United States. Pediatr Blood Cancer 2015; 62:731-5. [PMID: 25557155 DOI: 10.1002/pbc.25355] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 10/20/2014] [Indexed: 02/04/2023]
Abstract
We assessed clinical practice standards for infectious complications among pediatric blood and marrow transplant (PBMT) recipients. An anonymous online survey was sent to all 64 pediatric program directors (PD) of PBMT centers in the United States, which are accredited by the Foundation for the Accreditation of Cellular Therapy (FACT). The overall response rate was 56% (CI: 44-68%); variations in clinical practices were noted regarding (i) surveillance for late onset cytomegalovirus (CMV) infection and (ii) pharmacokinetic/therapeutic drug monitoring of antimicrobials. Prospective studies among PBMT recipients to address infectious complications among this population and variations in clinical practice may be required.
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Affiliation(s)
- Hisham Abdel-Azim
- Blood and Marrow Transplantation, Children's Hospital Los Angeles, Los Angeles, California
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24
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Infectious Prophylaxis in Paediatric Oncology and Stem Cell Transplantation. CURRENT PEDIATRICS REPORTS 2015. [DOI: 10.1007/s40124-015-0076-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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25
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Sousa H, Boutolleau D, Ribeiro J, Teixeira AL, Pinho Vaz C, Campilho F, Branca R, Campos A, Baldaque I, Medeiros R. Cytomegalovirus infection in patients who underwent allogeneic hematopoietic stem cell transplantation in Portugal: a five-year retrospective review. Biol Blood Marrow Transplant 2014; 20:1958-67. [PMID: 25139217 DOI: 10.1016/j.bbmt.2014.08.010] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Accepted: 08/12/2014] [Indexed: 02/03/2023]
Abstract
Cytomegalovirus (CMV) infection is 1 of the leading causes of morbidity and mortality after allogeneic hematopoietic stem cell transplantation (aHSCT), mainly within the first 100 days after transplantation. We aimed to characterize CMV infection in a cohort of 305 patients with different malignancies undergoing aHSCT at the Portuguese Institute of Oncology of Porto between January 2008 and December 2012. In total, 184 patients (60.3%) developed CMV infection, mainly viral reactivations rather than primary infections (96.2% versus 3.8%, respectively). The majority of patients (166 of 184) developed CMV infection ≤100 days after transplantation, with median time to infection of 29 days (range, 0 to 1285) and median duration of infection of 10 days (range, 2 to 372). Multivariate analysis revealed that CMV infection was increased in donor (D)-/recipient (R)+ and D+/R+ (odds ratio [OR], 10.5; 95% confidence interval [CI], 4.35 to 25.4; P < .001) and in patients with mismatched or unrelated donors (OR, 2.54; 95% CI, 1.34 to 4.80; P = .004). Cox regression model showed that the risk of death was significantly increased in patients >38 years old (OR, 1.89; 95% CI, 1.14 to 3.12; P = .0137), who underwent transplantation with peripheral blood (OR, 3.02; 95% CI, 1.33 to 6.86; P = .008), with mismatched or unrelated donor (OR, 2.16; 95% CI, 1.48 to 3.13; P < .001), and who developed CMV infection (OR, 1.76; 95% CI, 1.07 to 2.90; P = .025). Moreover, patients who developed CMV infection had a significantly reduced median post-transplantation survival (16 versus 36 months; P = .002).
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Affiliation(s)
- Hugo Sousa
- Virology Service, Portuguese Institute of Oncology of Porto, Porto, Portugal; Molecular Oncology Group, Portuguese Institute of Oncology of Porto, Porto, Portugal; Faculty of Medicine, University of Porto, Porto, Portugal.
| | - David Boutolleau
- Sorbonne Universités, UPMC Université Paris 06, CR7, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Paris, France; INSERM, U1135, CIMI-Paris, Paris, France; AP-HP, Hôpitaux Universitaires Pitié-Salpêtrière - Charles Foix, Service de Virologie, Paris, France
| | - Joana Ribeiro
- Virology Service, Portuguese Institute of Oncology of Porto, Porto, Portugal; Molecular Oncology Group, Portuguese Institute of Oncology of Porto, Porto, Portugal; Faculty of Medicine, University of Porto, Porto, Portugal
| | - Ana L Teixeira
- Virology Service, Portuguese Institute of Oncology of Porto, Porto, Portugal; Molecular Oncology Group, Portuguese Institute of Oncology of Porto, Porto, Portugal
| | - Carlos Pinho Vaz
- Bone Marrow Transplantation Unit, Portuguese Institute of Oncology of Porto, Porto, Portugal
| | - Fernando Campilho
- Bone Marrow Transplantation Unit, Portuguese Institute of Oncology of Porto, Porto, Portugal
| | - Rosa Branca
- Bone Marrow Transplantation Unit, Portuguese Institute of Oncology of Porto, Porto, Portugal
| | - António Campos
- Bone Marrow Transplantation Unit, Portuguese Institute of Oncology of Porto, Porto, Portugal
| | - Inês Baldaque
- Virology Service, Portuguese Institute of Oncology of Porto, Porto, Portugal
| | - Rui Medeiros
- Virology Service, Portuguese Institute of Oncology of Porto, Porto, Portugal; Molecular Oncology Group, Portuguese Institute of Oncology of Porto, Porto, Portugal; Research Department, Portuguese League Against Cancer (LPCC-NRNorte), Porto, Portugal
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