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Cytomegalovirus and other herpesviruses after hematopoietic cell and solid organ transplantation: From antiviral drugs to virus-specific T cells. Transpl Immunol 2022; 71:101539. [PMID: 35051589 DOI: 10.1016/j.trim.2022.101539] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 01/11/2022] [Accepted: 01/11/2022] [Indexed: 12/13/2022]
Abstract
Herpesviruses can either cause primary infection or may get reactivated after both hematopoietic cell and solid organ transplantations. In general, viral infections increase post-transplant morbidity and mortality. Prophylactic, preemptive, or therapeutically administered antiviral drugs may be associated with serious side effects and may induce viral resistance. Virus-specific T cells represent a valuable addition to antiviral treatment, with high rates of response and minimal side effects. Even low numbers of virus-specific T cells manufactured by direct selection methods can reconstitute virus-specific immunity after transplantation and control viral replication. Virus-specific T cells belong to the advanced therapy medicinal products, and their production is regulated by appropriate legislation; also, strict safety regulations are required to minimize their side effects.
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Scheuenpflug J, Kropeit D, Erb-Zohar K, Theis JGW, Stobernack HP, McCormick D, Zimmermann H, Rübsamen-Schaeff H. The Effect of Oral Letermovir Administration on the Pharmacokinetics of a Single Oral Dose of P-Glycoprotein Substrate Digoxin in Healthy Volunteers. Clin Pharmacol Drug Dev 2021; 11:6-15. [PMID: 34812580 DOI: 10.1002/cpdd.1043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 09/27/2021] [Indexed: 11/12/2022]
Abstract
Letermovir is a human cytomegalovirus (CMV) terminase inhibitor approved in the United States, Canada, Japan, and the European Union for prophylaxis of CMV infection and disease in CMV-seropositive, allogeneic, hematopoietic stem-cell transplant recipients. In vitro, letermovir is a substrate and potential modulator of P-glycoprotein. The potential of letermovir to alter the pharmacokinetics of digoxin (a P-glycoprotein substrate) upon coadministration in healthy subjects was therefore investigated in a phase 1 trial (EudraCT: 2011-004516-39). Oral letermovir 240 mg was administered twice daily for 12 days with a single oral digoxin 0.5-mg dose on day 7; after a washout period, oral digoxin 0.5 mg was administered on day 35 (sequence 1). The period order was reversed after a 28-day washout for sequence 2. Pharmacokinetics and safety were evaluated. The presence of steady-state letermovir reduced digoxin area under the plasma concentration-time curve from administration until last quantifiable measurement by 12% and maximum plasma concentration by 22% compared with digoxin alone; digoxin half-life and elimination rate remained similar in both conditions. The between-subject variability of digoxin maximum plasma concentration was higher with letermovir than without (42% vs 31%) and similar for digoxin area under the plasma concentration-time curve in both periods. No specific safety or tolerability concerns were identified. Overall, letermovir had no clinically relevant effect on concomitant administration with digoxin.
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Affiliation(s)
- Jürgen Scheuenpflug
- AiCuris Anti-infective Cures AG, Wuppertal, Germany.,Merck KGaA, Darmstadt, Germany
| | - Dirk Kropeit
- AiCuris Anti-infective Cures AG, Wuppertal, Germany
| | | | | | | | - David McCormick
- AiCuris Anti-infective Cures AG, Wuppertal, Germany.,DMPK Solutions Ltd, Nottinghamshire, UK
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Fitch T, Myers KC, Dewan M, Towe C, Dandoy C. Pulmonary Complications After Pediatric Stem Cell Transplant. Front Oncol 2021; 11:755878. [PMID: 34722309 PMCID: PMC8550452 DOI: 10.3389/fonc.2021.755878] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 09/14/2021] [Indexed: 12/02/2022] Open
Abstract
The number of disorders that benefit from hematopoietic stem cell transplantation (HSCT) has increased, causing the overall number of HSCT to increase accordingly. Disorders treated by HSCT include malignancy, benign hematologic disorders, bone marrow failure syndromes, and certain genetic diagnoses. Thus, understanding the complications, diagnostic workup of complications, and subsequent treatments has become increasingly important. One such category of complications includes the pulmonary system. While the overall incidence of pulmonary complications has decreased, the morbidity and mortality of these complications remain high. Therefore, having a clear differential diagnosis and diagnostic workup is imperative. Pulmonary complications can be subdivided by time of onset and whether the complication is infectious or non-infectious. While most infectious complications have clear diagnostic criteria and treatment courses, the non-infectious complications are more varied and not always well understood. This review article discusses pulmonary complications of HSCT recipients and outlines current knowledge, gaps in knowledge, and current treatment of each complication. This article includes some adult studies, as there is a significant paucity of pediatric data.
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Affiliation(s)
- Taylor Fitch
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center (CCHMC), University of Cincinnati School of Medicine, Cincinnati, OH, United States
| | - Kasiani C Myers
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center (CCHMC), University of Cincinnati School of Medicine, Cincinnati, OH, United States
| | - Maya Dewan
- Division of Critical Care, Cincinnati Children's Hospital Medical Center (CCHMC), University of Cincinnati School of Medicine, Cincinnati, OH, United States
| | - Christopher Towe
- Division of Pulmonology, Cincinnati Children's Hospital Medical Center (CCHMC), University of Cincinnati School of Medicine, Cincinnati, OH, United States
| | - Christopher Dandoy
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center (CCHMC), University of Cincinnati School of Medicine, Cincinnati, OH, United States
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Astashchanka A, Ryan J, Lin E, Nokes B, Jamieson C, Kligerman S, Malhotra A, Mandel J, Joshua J. Pulmonary Complications in Hematopoietic Stem Cell Transplant Recipients-A Clinician Primer. J Clin Med 2021; 10:3227. [PMID: 34362012 PMCID: PMC8348211 DOI: 10.3390/jcm10153227] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 07/11/2021] [Accepted: 07/16/2021] [Indexed: 12/15/2022] Open
Abstract
Hematopoietic stem cell transplants (HSCT) are becoming more widespread as a result of optimization of conditioning regimens and prevention of short-term complications with prophylactic antibiotics and antifungals. However, pulmonary complications post-HSCT remain a leading cause of morbidity and mortality and are a challenge to clinicians in both diagnosis and treatment. This comprehensive review provides a primer for non-pulmonary healthcare providers, synthesizing the current evidence behind common infectious and non-infectious post-transplant pulmonary complications based on time (peri-engraftment, early post-transplantation, and late post-transplantation). Utilizing the combination of timing of presentation, clinical symptoms, histopathology, and radiographic findings should increase rates of early diagnosis, treatment, and prognostication of these severe illness states.
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Affiliation(s)
- Anna Astashchanka
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California San Diego, La Jolla, CA 92121, USA; (A.A.); (E.L.); (B.N.); (A.M.); (J.M.)
| | - Joseph Ryan
- Division of Hematology & Oncology, Scripps Clinic, La Jolla, CA 92037, USA;
| | - Erica Lin
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California San Diego, La Jolla, CA 92121, USA; (A.A.); (E.L.); (B.N.); (A.M.); (J.M.)
| | - Brandon Nokes
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California San Diego, La Jolla, CA 92121, USA; (A.A.); (E.L.); (B.N.); (A.M.); (J.M.)
| | - Catriona Jamieson
- Sanford Stem Cell Clinical Center, Moores Cancer Center, Department of Medicine, Division of Regenerative Medicine, University of California San Diego, La Jolla, CA 92093, USA;
| | - Seth Kligerman
- Division of Cardiothoracic Radiology, University of California San Diego, La Jolla, CA 92121, USA;
| | - Atul Malhotra
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California San Diego, La Jolla, CA 92121, USA; (A.A.); (E.L.); (B.N.); (A.M.); (J.M.)
| | - Jess Mandel
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California San Diego, La Jolla, CA 92121, USA; (A.A.); (E.L.); (B.N.); (A.M.); (J.M.)
| | - Jisha Joshua
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California San Diego, La Jolla, CA 92121, USA; (A.A.); (E.L.); (B.N.); (A.M.); (J.M.)
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Lim SY, Lee YW, Jung J, Kim MJ, Chong YP, Lee SO, Choi SH, Kim YS, Choi EJ, Park HS, Lee JH, Lee JH, Lee KH, Kim SH. Diagnostic yield of a bronchoalveolar lavage fluid galactomannan assay in patients with negative serum galactomannan results suspected to have invasive pulmonary aspergillosis. Mycoses 2021; 64:1124-1131. [PMID: 33740824 DOI: 10.1111/myc.13269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/09/2021] [Accepted: 03/12/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVES There are limited data in real clinical practice on the diagnostic value of a bronchoalveolar lavage (BAL) fluid galactomannan (GM) assay in patients with suspected invasive pulmonary aspergillosis (IPA) who had negative serum GM results. Thus, we investigated the diagnostic performance of a BAL GM assay in patients with negative serum GM assay results who were suspected to have IPA. METHODS This retrospective study was performed between May 2008 and April 2019 at a tertiary-care hospital in Seoul, South Korea. All patients with suspected IPA whose serum GM assays revealed negative results who sequentially underwent BAL were enrolled in this study. RESULTS A total of 341 patients with suspected IPA including four cases of proven IPA, 38 cases of probable IPA, 107 cases of possible IPA and 192 patients without IPA were enrolled. Of these 341 patients, 107 (31%) with possible IPA were excluded from the final analysis. Of 42 patients with proven and probable IPA who had initial negative serum GM results, 24 (57%) had positive BAL GM results (n = 24) or BAL fungal culture results (n = 8). In addition, BAL revealed evidence of other opportunistic infections including Pneumocystis jirovecii pneumonia (14% [26/190]), cytomegalovirus (CMV) pneumonia (5% [9/188]) and respiratory viral pneumonia (6% [12/193]). CONCLUSION Sequential BAL in patients with suspected IPA who had initial negative serum GM results provided additional diagnostic yield in approximately half of patients with evidence of another co-infection.
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Affiliation(s)
- So Yun Lim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yun Woo Lee
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jiwon Jung
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Min Jae Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong Pil Chong
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Oh Lee
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Ho Choi
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yang Soo Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun-Ji Choi
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Han-Seung Park
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung-Hee Lee
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Je-Hwan Lee
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyoo-Hyung Lee
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Han Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Badran O, Ouryvaev A, Baturov V, Shai A. Cytomegalovirus pneumonia complicating immune checkpoint inhibitors-induced pneumonitis: A case report. Mol Clin Oncol 2021; 14:120. [PMID: 33903826 DOI: 10.3892/mco.2021.2282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 02/11/2021] [Indexed: 12/20/2022] Open
Abstract
A 63-year-old man was hospitalized for immune check-point inhibitors (ICIs) medicated pneumonitis, secondary to treatment with pembrolizumab for non-small cell lung cancer. He was treated with high dose steroids, mycophenolate mofetil, empiric broad spectrum antibiotics and empiric trimethoprim-sulfamethoxazole and intravenous immunoglobulin. Despite the aforementioned treatment, his condition continued to deteriorate. The patient was admitted to the intensive care unit. While intubated, he underwent bronchoscopy and lavage, which was analyzed for potential infectious agents. Cytomegalovirus (CMV) pneumonia was diagnosed and treated. He passed away despite antiviral treatment and maximal supportive care. CMV infection should be suspected in patients failing to recover from toxicities of ICIs with appropriate immunosuppression.
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Affiliation(s)
- Omar Badran
- Department of Oncology, Galilee Medical Centre, Nahariya 22100, Israel
| | - Anton Ouryvaev
- Department of Oncology, Galilee Medical Centre, Nahariya 22100, Israel
| | - Veronika Baturov
- Department of Radiology, Galilee Medical Centre, Nahariya 22100, Israel
| | - Ayelet Shai
- Department of Oncology, Galilee Medical Centre, Nahariya 22100, Israel.,Azriely Faculty of Medicine, Bar Ilan University, Zafed 1211502, Israel
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Rapoport BL, Cooksley T, Johnson DB, Anderson R, Shannon VR. Treatment of infections in cancer patients: an update from the neutropenia, infection and myelosuppression study group of the Multinational Association for Supportive Care in Cancer (MASCC). Expert Rev Clin Pharmacol 2021; 14:295-313. [PMID: 33517803 DOI: 10.1080/17512433.2021.1884067] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Patients with hematological and advanced solid malignancies have acquired immune dysfunction, often exacerbated by treatment, posing a significant risk for the development of infections. This review evaluates the utility of current clinical and treatment guidelines, in the setting of management of infections in cancer patients. AREAS COVERED These include causes of infection in cancer patients, management of patients with high-risk and low-risk febrile neutropenia, management of low-risk patients in an outpatient setting, the role of granulocyte colony-stimulating factor (G-CSF) in the prevention and treatment of neutropenia-related infections, management of lung infections in various clinical settings, and emerging challenges surrounding the risk of infection in cancer patients treated with novel treatments. The literature search was performed by accessing PubMed and other databases, focusing on published clinical trials of relevant anti-cancer agents and diseases, primarily covering the recent past, but also including several key studies published during the last decade and, somewhat earlier in a few cases. EXPERT REVIEW Notwithstanding the promise of gene therapy/gene editing in hematological malignancies and some types of solid cancers, innovations introduced in clinical practice include more discerning clinical management such as the generalized use of biosimilar formulations of G-CSF and the implementation of novel, innovative immunotherapies.
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Affiliation(s)
- Bernardo L Rapoport
- Department of Immunology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.,The Medical Oncology Centre of Rosebank, Saxonwold, Johannesburg, South Africa.,The Multinational Association for Supportive Care in Cancer (MASCC), Chair of the Neutropenia, Infection and Myelosuppression Study Group
| | - Tim Cooksley
- Manchester University Foundation Trust, Manchester, United Kingdom. The Christie, University of Manchester, Manchester, UK.,The Multinational Association for Supportive Care in Cancer (MASCC), Infection and Myelosuppression Study Group
| | - Douglas B Johnson
- Douglas B. Johnson, Department of Medicine, Vanderbilt University Medical Center and Vanderbilt Ingram Cancer Center, Nashville, Tennessee, USA
| | - Ronald Anderson
- Department of Immunology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Vickie R Shannon
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, USA
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Payandeh M, Zamanian MH, Nomanpour B, Farhadi MS, Janbakhsh A, Rostamian M, Elahi A, Jafari S, Dehghannejad M. Survey of HCMV in allogenic and autologous stem cell transplantation by real-time PCR in Kermanshah, west of Iran. Infect Agent Cancer 2021; 16:8. [PMID: 33531035 PMCID: PMC7856721 DOI: 10.1186/s13027-021-00349-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 01/27/2021] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Human Cytomegalovirus (HCMV) is the most important viral pathogen in people undergoing bone marrow transplantation (BMT). HCMV detection in the early stages makes is possible to save the patients' lives through immediate and timely treatment. The aim of this study was to investigate the status of HCMV using the real-time PCR method in BMT patients in Kermanshah, west of Iran. METHODS HCMV monitoring was done in 120 patients who underwent BMT, 38 allogeneic cases and 82 autologous cases, using the ELISA serology test before transplantation. The participants were followed up 100 days after transplantation for HCMV detection in blood samples using real-time PCR. Preemptive therapy started with Ganciclovir and Foscarnet when the viral load was > 200 HCMV DNA copies/ml. RESULTS Despite preemptive therapy, infection recurred in less than 1 month. HCMV recurred more frequently in patients undergoing allogenic transplation versus those receiving autologous transplantation. Recurrence was seen in 5 patients receiving allogenic transplantation. HCMV recurrence occurred in five patients with allogeneic transplantation. Twelve patients undergoing allogeneic or autologous transplantation (83%) and a virus load of > 1000 copies/ml showed HCMV-related symptoms. Three patients died, two due to HCMV-related pneumonia and the other one due to a fungal infection. CONCLUSION Real-time PCR may be a useful method for quantification and monitoring of HCMV recurrence and may be helpful in choosing more efficient HCMV preemptive treatment in BMT recipients.
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Affiliation(s)
- Mehrdad Payandeh
- Hematology and Medical Oncology Dept., Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mohammad Hossein Zamanian
- Infectious Diseases Dept., School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Bizhan Nomanpour
- Microbiology Dept., Medical school of Kermanshah, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | | | - Alireza Janbakhsh
- Infectious Diseases Dept., School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mosayeb Rostamian
- Infectious Diseases Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Azam Elahi
- Clinical Research Development Center, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Somayeh Jafari
- Clinical Research Development Center, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mohammad Dehghannejad
- Medical School of Kermanshah, Kermanshah University of Medical Sciences, Kermanshah, Iran.
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Zhao C, Huang XJ, Sun YQ, Xu LP, Zhang XH, Liu KY, Yan CH, Wang Y. [Impact of poor graft function on cytomegalovirus pneumonia in patients who have undergone haploidentical stem cell transplantation]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 41:552-556. [PMID: 32810961 PMCID: PMC7449765 DOI: 10.3760/cma.j.issn.0253-2727.2020.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Indexed: 11/05/2022]
Abstract
Objective: To retrospectively analyze the impact of primary PGF on CMV pneumonia in patients who have undergone haplo-HSCT. Methods: The clinical data of 122 patients who underwent haplo-HSCT at the Peking University Institute of Hematology from 2011-2012 were retrospectively reviewed. The incidence rate of CMV pneumonia between PGF and good graft function (GGF) was compared, and the factors were analyzed. In addition, outcomes in PGF patients with CMV pneumonia have been described. Results: Total 122 patients were retrospectively reviewed, and of these, 26 (21.3% ) had PGF, while 96 (78.7% ) had GGF. In addition, 15 patients had CMV pneumonia, and the median time to the development of CMV pneumonia was 103 (31-262) days; the 1-year cumulative incidence of CMV pneumonia was 12.3% (95% CI 6.2% -18.4% ) . In patients with primary PGF and GGF after Haplo-HSCT, the incidence of CMV pneumonia was 30.8% (8/26) and 7.3% (7/96) , respectively (P=0.002) . Moreover, 24 patients had CMV viremia (92.3% ) , while of the 96 GGF patients, 79 (82.3% ) had CMV viremia (P=0.212) . In multivariate analysis, the results showed that primary PGF had a significant influence on CMV pneumonia (P=0.005) . Compared with those without CMV pneumonia, patients with CMV pneumonia had poorer overall survival 37.3% (95% CI 11.2% -63.4% ) vs. 78.9% (95% CI 72.0% -87.6% ) (χ(2)=16.361, P<0.001) . The 1-year overall survival (OS) was 25.0% (95% CI 0% -55.0% ) and 50.0% (95% CI 26.9% -73.1% ) (χ(2)=4.656, P=0.031) in PGF patients with (8/26) and without (18/26) CMV pneumonia. Conclusion: The incidence of cytomegalovirus pneumonia in patients with primary poor graft function increases and the survival rate decreases.
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Affiliation(s)
- C Zhao
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - X J Huang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China; Hematology Collaborative Innovation Center, Peking University, Beijing 100871, China
| | - Y Q Sun
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - L P Xu
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - X H Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - K Y Liu
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - C H Yan
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Y Wang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China; Hematology Collaborative Innovation Center, Peking University, Beijing 100871, China
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10
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CMV-Reactive NK Cells in Pediatric Post-Hematopoietic Stem Cell Transplant. Transplant Proc 2020; 52:353-359. [DOI: 10.1016/j.transproceed.2019.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 10/21/2019] [Accepted: 11/10/2019] [Indexed: 12/19/2022]
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Lu W, Chen HP, Chan YJ, Wang FD. Clinical significance of post-treatment viral load of cytomegalovirus in patients with hematologic malignancies. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2019; 54:245-252. [PMID: 31444112 DOI: 10.1016/j.jmii.2019.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 06/28/2019] [Accepted: 07/16/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Patients with hematologic diseases were at high risk for cytomegalovirus (CMV) diseases. In the present study, we compare various prognostic factors during CMV viremia, with specific emphasis on the relationship between viremia eradication and the long-term prognosis of patients after each episode. METHODS Adult patients with hematologic diseases who had a detectable CMV viral load (VL) (equal to or above 150 copies/mL) were included in the study. Medical records were reviewed for demographic data including age, sex, hematologic and other underlying diseases, status of stem cell transplantation, antiviral medication, serum CMV viral load before and after antiviral treatment. RESULTS A total of 101 episodes of CMV viremia occurred in patients with hematologic diseases. Comparison of various prognostic factors revealed non-survivors more frequently suffered from pneumonia and concomitant bacterial or fungal infections, had less frequently undergone hematopoietic stem cell transplantation (HSCT), and had higher peak VLs during viremic episodes. After antiviral therapy, eradication of viremia was much less frequently achieved in non-survivors. The Kaplan-Meier curves revealed that patients with detectable end-treatment VL had lower survival rates even if the antivirals were administered for more than 21 days. In a multivariate Cox proportional-hazard model, a detectable VL at the end of antiviral therapy independently predicted mortality within 180 days. CONCLUSIONS In patients with hematologic diseases suffering CMV viremia, failure to eradicate viremia after antiviral therapy indicates a higher chance of mortality and can be regarded as a useful indicator in evaluating the patient's long-term prognosis.
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Affiliation(s)
- Wei Lu
- Division of Internal Medicine, Department of Medicine, Cardinal Tien Hospital, Xindian Dist., New Taipei City, Taiwan; Division of Infectious Diseases, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hsin-Pai Chen
- Division of Infectious Diseases, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan.
| | - Yu-Jiun Chan
- Division of Infectious Diseases, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Public Health, School of Medicine, National Yang-Ming University, Taipei, Taiwan; Division Microbiology, Department of Pathology and Laboratory Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Fu-Der Wang
- Division of Infectious Diseases, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan; Institute of Public Health, School of Medicine, National Yang-Ming University, Taipei, Taiwan
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12
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Respiratory Infections. INFECTIONS IN NEUTROPENIC CANCER PATIENTS 2019. [PMCID: PMC7120562 DOI: 10.1007/978-3-030-21859-1_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Pneumonia is defined as the presence of a new pulmonary infiltrate on radiologic imaging in the patient with appropriate clinical symptoms such as fever, cough, production of purulent sputum, shortness of breath and/or hypoxia, in the absence of pulmonary edema [1, 2].
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Wieruszewski PM, Herasevich S, Gajic O, Yadav H. Respiratory failure in the hematopoietic stem cell transplant recipient. World J Crit Care Med 2018; 7:62-72. [PMID: 30370228 PMCID: PMC6201323 DOI: 10.5492/wjccm.v7.i5.62] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 09/04/2018] [Accepted: 10/10/2018] [Indexed: 02/06/2023] Open
Abstract
The number of patients receiving hematopoietic stem cell transplantation (HSCT) is rapidly rising worldwide. Despite substantial improvements in peri-transplant care, pulmonary complications resulting in respiratory failure remain a major contributor to morbidity and mortality in the post-transplant period, and represent a major barrier to the overall success of HSCT. Infectious complications include pneumonia due to bacteria, viruses, and fungi, and most commonly occur during neutropenia in the early post-transplant period. Non-infectious complications include idiopathic pneumonia syndrome, peri-engraftment respiratory distress syndrome, diffuse alveolar hemorrhage, pulmonary veno-occlusive disease, delayed pulmonary toxicity syndrome, cryptogenic organizing pneumonia, bronchiolitis obliterans syndrome, and post-transplant lymphoproliferative disorder. These complications have distinct clinical features and risk factors, occur at differing times following transplant, and contribute to morbidity and mortality.
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Affiliation(s)
- Patrick M Wieruszewski
- Department of Pharmacy, Mayo Clinic, Rochester, MN 55905, United States
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Group, Mayo Clinic, Rochester, MN 55905, United States
| | - Svetlana Herasevich
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Group, Mayo Clinic, Rochester, MN 55905, United States
- Department of Anesthesiology, Mayo Clinic, Rochester, MN 55905, United States
| | - Ognjen Gajic
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Group, Mayo Clinic, Rochester, MN 55905, United States
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | - Hemang Yadav
- Multidisciplinary Epidemiology and Translational Research in Intensive Care Group, Mayo Clinic, Rochester, MN 55905, United States
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States
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14
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Bronchoscopy and Bronchoalveolar Lavage in the Diagnosis and Management of Pulmonary Infections in Immunocompromised Children. J Pediatr Hematol Oncol 2018; 40:532-535. [PMID: 30102649 DOI: 10.1097/mph.0000000000001283] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Immunocompromised children are at high risk of rapid deterioration and of developing life-threatening pulmonary infections. Etiologies in this setting are diverse, including those that are infectious and noninfectious, and many etiologies may coexist. Accurate diagnosis is required for the rational use of medications. Fiberoptic bronchoscopy (FOB) with bronchoalveolar lavage (BAL) can identify infectious causes in this population. OBJECTIVES The aims of this study were to evaluate diagnostic rate, safety, and changes in treatment following FOB with BAL, when applied with advanced laboratory diagnostic techniques. PATIENTS AND METHODS We reviewed the records of children who underwent FOB with BAL during the period spanning from 2006 to 2014 in the Hematology-Oncology Department. BAL samples were processed in microbiology, virology, cytology, and molecular laboratories. RESULTS Antimicrobials were initiated in 91 of 117 children. BAL yielded an infectious etiology in 55 episodes. Management was altered in 74 patients following a positive (40/55) or a negative (30/54) result (4 patients had missing data). No severe complications associated with the procedures occurred. CONCLUSIONS Most immunocompromised patients with pulmonary manifestations are treated empirically with multiple medications. Evaluation FOB/BAL is a useful diagnostic tool, and seems to have changed the course of therapy in more than half of patients, by initiation or cessation of treatment. FOB/BAL is a safe diagnostic tool for the evaluation of pulmonary manifestations in this setting.
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Marshall WL, McCrea JB, Macha S, Menzel K, Liu F, van Schanke A, de Haes JIU, Hussaini A, Jordan HR, Drexel M, Kantesaria BS, Tsai C, Cho CR, Hulskotte EGJ, Butterton JR, Iwamoto M. Pharmacokinetics and Tolerability of Letermovir Coadministered With Azole Antifungals (Posaconazole or Voriconazole) in Healthy Subjects. J Clin Pharmacol 2018; 58:897-904. [DOI: 10.1002/jcph.1094] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 01/15/2018] [Indexed: 11/10/2022]
Affiliation(s)
| | | | | | | | - Fang Liu
- Merck & Co, Inc; Kenilworth NJ USA
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16
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Yoshikawa T. Betaherpesvirus Complications and Management During Hematopoietic Stem Cell Transplantation. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1045:251-270. [PMID: 29896671 DOI: 10.1007/978-981-10-7230-7_12] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Two of the four betaherpesviruses, Cytomegalovirus (CMV) and human herpesvirus 6B (HHV-6B), play an important role in opportunistic infections in hematopoietic stem cell transplant (HSCT) recipients. These viruses are ubiquitous in humans and can latently infect mononuclear lymphocytes, complicating the diagnosis of the diseases they cause. Although the detection of viral DNA in a patient's peripheral blood by real-time PCR is widely used for monitoring viral infection, it is insufficient for the diagnosis of virus-associated disease. Theoretically, end-organ disease should be confirmed by detecting either viral antigen or significant amounts of viral DNA in a tissue sample obtained from the involved organ; however, this is often difficult to perform in clinical practice. The frequency of CMV-associated diseases has decreased gradually as a result of the introduction of preemptive or prophylactic treatments; however, CMV and HHV-6B infections remain a major problem in HSCT recipients. Measurement of viral DNA load in peripheral blood or plasma using real-time PCR is commonly used for monitoring these infections. Additionally, recent data suggest that an assessment of host immune response, particularly cytotoxic T-cell response, may be a reliable tool for predicting these viral infections. The antiviral drugs ganciclovir and foscarnet are used as first-line treatments; however, it is well known that these drugs have side effects, such as bone marrow suppression and nephrotoxicity. Further research is required to develop less-toxic antiviral drugs.
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Affiliation(s)
- Tetsushi Yoshikawa
- Department of Pediatrics, Fujita Health University School of Medicine, Toyoake, Japan.
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17
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Affiliation(s)
- Margaret L Green
- University of Washington, 1959 NE Pacific Street, Box 359930, Seattle, WA 98195, USA; Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, Seattle, WA 98109, USA.
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18
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Solyanik O, Gaass T, Hellbach K, Dinkel J. [Pneumonia in immunosuppressed patients]. Radiologe 2017; 57:22-28. [PMID: 28058476 DOI: 10.1007/s00117-016-0197-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
CLINICAL/METHODICAL ISSUE Pulmonary infections are a common complication in immunosuppressed patients with a frequently fatal prognosis despite modern prophylactic therapy. An early and correct diagnosis is important for initiation of the appropriate therapy. STANDARD RADIOLOGICAL METHODS Chest radiography is the preferred initial imaging examination but is not accurate enough for the detection of pulmonary infections in immunosuppressed patients. METHODICAL INNOVATIONS Pneumonia is caused by a broad spectrum of pathogens in immunocompromised patients. In addition to imaging, the clinical history and epidemiology also play an important role in the diagnostics. PERFORMANCE Using epidemiological and anamnestic information, computed tomography (CT) shows a significantly better sensitivity and specificity particularly for the diagnosis of atypical forms of pneumonia. Due to the exact imaging of the different infiltration patterns CT provides an increased sensitivity with respect to the etiological classification of pulmonary infections. PRACTICAL RECOMMENDATIONS This article reviews in particular the radiological findings of commonly occurring pulmonary infections in immunosuppressed patients.
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Affiliation(s)
- O Solyanik
- Institut für klinische Radiologie, Klinikum der Ludwig-Maximilians-Universität München, Campus Großhadern, Marchioninistraße 15, 81377, München, Deutschland
| | - T Gaass
- Institut für klinische Radiologie, Klinikum der Ludwig-Maximilians-Universität München, Campus Großhadern, Marchioninistraße 15, 81377, München, Deutschland
| | - K Hellbach
- Institut für klinische Radiologie, Klinikum der Ludwig-Maximilians-Universität München, Campus Großhadern, Marchioninistraße 15, 81377, München, Deutschland
| | - J Dinkel
- Institut für klinische Radiologie, Klinikum der Ludwig-Maximilians-Universität München, Campus Großhadern, Marchioninistraße 15, 81377, München, Deutschland. .,Comprehensive Pneumology Center Munich (CPC‑M), Max-Lebsche-Platz 31, 81377, München, Deutschland.
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Kropeit D, von Richter O, Stobernack HP, Rübsamen-Schaeff H, Zimmermann H. Pharmacokinetics and Safety of Letermovir Coadministered With Cyclosporine A or Tacrolimus in Healthy Subjects. Clin Pharmacol Drug Dev 2017; 7:9-21. [PMID: 28967706 DOI: 10.1002/cpdd.388] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 07/27/2017] [Indexed: 11/10/2022]
Abstract
Letermovir is being developed for human cytomegalovirus infection treatment and prophylaxis. In patients receiving transplants, antivirals are coadministered with cyclosporine A (CsA) or tacrolimus (TAC) immunosuppressants. Therefore, we investigated the potential for letermovir-immunosuppressant interactions. In 2 phase 1 clinical trials either CsA 50 mg or TAC 5 mg was administered to healthy males. Following washout, letermovir 80 mg was dosed twice daily for 7 and 11 days in the CsA and TAC trials, respectively, with a second dose of immunosuppressant coadministered with letermovir at steady state. In addition, letermovir 40 mg twice daily was administered for 14 days, and either CsA 50 or 200 mg administered on days 7 and 14. Pharmacokinetics and tolerability were assessed. Letermovir increased CsA and TAC Cmax by 37% and 70%, respectively, and exposure by 70% and 78%, respectively, compared with immunosuppressant alone; t½ was also increased from 10.7 to 17.9 hours for CsA. CsA (50/200 mg) increased letermovir Cmax,ss (109%/167%) and AUCss,τ (126%/237%) and decreased t½ (4.33 to 3.68/3.04 hours) versus letermovir alone. TAC did not significantly affect letermovir pharmacokinetics. All treatments were well tolerated. Concomitant letermovir increased TAC and CsA exposure. CsA altered letermovir pharmacokinetics, whereas TAC did not.
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Affiliation(s)
- Dirk Kropeit
- AiCuris Anti-infective Cures GmbH, Wuppertal, Germany
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20
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21
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Massoud R, Assi R, Fares E, Haffar B, Charafeddine M, Kreidieh N, Mahfouz R, Kanj SS, El Zakhem A, Kharfan-Dabaja M, Bazarbachi A, El Cheikh J. Cytomegalovirus reactivation in lymphoma and myeloma patients undergoing autologous peripheral blood stem cell transplantation. J Clin Virol 2017; 95:36-41. [PMID: 28843110 DOI: 10.1016/j.jcv.2017.08.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 06/05/2017] [Accepted: 08/10/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Cytomegalovirus reactivation is often diagnosed in allogeneic hematopoietic cell transplant recipients and therefore could lead to CMV-related disease, involving many organs in these immunocompromised patients. In contrast, few studies investigated CMV reactivation and end-organ disease in patients undergoing Autologous Peripheral Blood Stem Cell Transplant (ASCT) since they are considered at low risk for both reactivation and disease. OBJECTIVES The primary outcome of the analysis was to understand the difference in incidence of CMV reactivation between MM and Lymphoma patients. Secondary outcomes included the difference between MM and Lymphoma patients when considering the effect of CMV reactivation on transplant related mortality (TRM) overall survival (OS) progression free survival (PFS), risk factors for reactivation, and median time to reactivation. STUDY DESIGN In this report, we retrospectively compared the incidence, risk factors, and outcome of CMV reactivation in adult patients with Myeloma (MM) and Lymphoma undergoing ASCT at the American university of Beirut Medical Center in Lebanon (AUBMC). A total of 324 consecutive ASCT were performed between January 2005 and March 2016. Serial weekly monitoring for CMV quantification was done using a quantitative PCR, starting from transplantation until the hospital discharge and afterwards based on the clinical symptoms in cases of clinical suspicion of reactivation after discharge from the hospital. RESULTS The cumulative incidence of CMV reactivation was 16% (n=53) with a median time of 16 (range, 4-242) days after ASCT. The incidence of reactivation was significantly higher in the MM (22%) and NHL (20%) groups, when compared to the HL (4%) (P=0.001). There was a higher incidence of CMV reactivation according to age (≥50 vs ≤50 years) with higher incidence in the older population 24% vs 10% respectively (p=0.0043). The mean time to CMV reactivation was significantly higher in the NHL group with a mean of 53.7days when compared to the HL and MM groups with mean 19.75days and 12.66 (range, 4-34) days respectively (P=0.003). Twenty-two patients (76%) and three patients (75%) patients required specific antiviral therapy in the MM group and HL groups respectively; which was significantly higher (P<0.001) then the NHL group with 13 (65%) patients requiring specific antiviral therapy. Five patients (1.5%) developed CMV disease at a median of 60days (range, 7-107) post ASCT: there was significant difference in the mean-time to reactivation based on disease type MM versus lymphoma 10 versus 33days (P=0.007). In multivariate analysis, a higher age was associated with an increased risk of CMV reactivation; MM and NHL had higher risk of CMV reactivation when compared to HL, and progressive disease at transplant was associated with increased risk of CMV reactivation. After a median follow-up of 21.5 months (range: 1-125), there was no significant impact on PFS, however there was significant decrease in OS of lymphoma patients who had CMV reactivation when compared to those without CMV reactivation (204 and 112days respectively P=0.045). TRM increased from 1.1% in patients with no CMV reactivation to 13% in patients with CMV reactivation (P=0.003). CONCLUSION Our data suggests that CMV reactivation is not uncommon in ASCT recipients and may contribute to increase TRM. MM patients may have a higher incidence, of CMV reactivation with more anti-viral treatment requirements when compared to lymphoma patients, especially in older population.
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Affiliation(s)
- Radwan Massoud
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rita Assi
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Elie Fares
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Basel Haffar
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Maya Charafeddine
- Division of Hematology and Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nabila Kreidieh
- Department of Pathology and Laboratory Medicine, American University of Beirut, Beirut, Lebanon
| | - Rami Mahfouz
- Department of Pathology and Laboratory Medicine, American University of Beirut, Beirut, Lebanon
| | - Souha S Kanj
- Division of Infectious Diseases, Department of Internal Medicine American University of Beirut, Beirut, Lebanon
| | - Aline El Zakhem
- Division of Infectious Diseases, Department of Internal Medicine American University of Beirut, Beirut, Lebanon
| | - Mohamed Kharfan-Dabaja
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Ali Bazarbachi
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Jean El Cheikh
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
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Marchesi F, Pimpinelli F, Ensoli F, Mengarelli A. Cytomegalovirus infection in hematologic malignancy settings other than the allogeneic transplant. Hematol Oncol 2017; 36:381-391. [DOI: 10.1002/hon.2453] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 05/28/2017] [Accepted: 06/05/2017] [Indexed: 12/13/2022]
Affiliation(s)
- F. Marchesi
- Hematology and Stem Cell Transplant Unit; Regina Elena National Cancer Institute; Rome Italy
| | - F. Pimpinelli
- Molecular Virology, Pathology and Microbiology Laboratory; San Gallicano Dermatological Institute; Rome Italy
| | - F. Ensoli
- Molecular Virology, Pathology and Microbiology Laboratory; San Gallicano Dermatological Institute; Rome Italy
| | - A. Mengarelli
- Hematology and Stem Cell Transplant Unit; Regina Elena National Cancer Institute; Rome Italy
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23
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Kropeit D, Scheuenpflug J, Erb-Zohar K, Halabi A, Stobernack HP, Hulskotte EGJ, van Schanke A, Zimmermann H, Rübsamen-Schaeff H. Pharmacokinetics and safety of letermovir, a novel anti-human cytomegalovirus drug, in patients with renal impairment. Br J Clin Pharmacol 2017; 83:1944-1953. [PMID: 28345163 DOI: 10.1111/bcp.13292] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 03/08/2017] [Accepted: 03/14/2017] [Indexed: 12/18/2022] Open
Abstract
AIMS Human cytomegalovirus remains a significant issue for immunocompromised patients and existing viral polymerase targeting therapies are associated with significant toxicity. Accordingly, the viral terminase complex inhibitor, letermovir, is in development. We assessed letermovir pharmacokinetics in renal impairment. METHODS This was a Phase 1, open-label, nonrandomised trial. Estimated glomerular filtration rate based on the Modification of Diet Renal Disease equation was used to create three groups of eight subjects: healthy function (estimated glomerular filtration rate ≥ 90 ml min-1 1.73m-2 ), moderate (30-59 ml min-1 1.73m-2 ) and severe (<30 ml min-1 1.73m-2 ) impairment. Oral letermovir 120 mg was dosed once-daily for 8 days and blood collected for pharmacokinetic analyses. RESULTS All 24 subjects enrolled completed the trial. Moderate and severe renal impairment increased mean unbound letermovir fractions by 11% and 26%, respectively, vs. healthy subjects. Exposure (AUCτ,ss and Css,max ) was increased with renal impairment [least square mean ratios (90% confidence intervals) total letermovir vs. healthy subjects, AUCτ,ss 192% (143-258%) and 142% (83-243%) for moderate and severe impairment, respectively; Css,max 125% (87-182%) and 106% (75-151%), respectively]. Clearance was decreased vs. healthy subjects. Correlation analyses indicated a correlation between decreasing renal function and increased unbound letermovir concentration (R2 = 0.5076, P < 0.0001). Correlations were identified between decreased clearance with both decreased renal function (R2 = 0.0662, P = 0.2249 and R2 = 0.1861, P = 0.0353 total and unbound clearance, respectively) and increased age (R2 = 0.3548, P = 0.0021 and R2 = 0.3166, P = 0.0042 total and unbound clearance, respectively). Multiple-dose letermovir 120 mg was well tolerated across groups. CONCLUSIONS Renal impairment increased exposure to letermovir, although age was a confounding factor.
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Affiliation(s)
- Dirk Kropeit
- AiCuris Anti-infective Cures GmbH, Wuppertal, Germany
| | | | | | - Atef Halabi
- CRS Clinical Research Services Kiel GmbH, Kiel, Germany
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24
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Chan ST, Logan AC. The clinical impact of cytomegalovirus infection following allogeneic hematopoietic cell transplantation: Why the quest for meaningful prophylaxis still matters. Blood Rev 2017; 31:173-183. [DOI: 10.1016/j.blre.2017.01.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 12/16/2016] [Accepted: 01/31/2017] [Indexed: 11/28/2022]
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25
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Burgener EB, Waggoner J, Pinsky BA, Chen SF. Clinical characteristics and outcomes of pediatric patients with CMV DNA detection in bronchoalveolar lavage fluid. Pediatr Pulmonol 2017; 52:112-118. [PMID: 27280337 DOI: 10.1002/ppul.23494] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 04/01/2016] [Accepted: 05/06/2016] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Cytomegalovirus (CMV) infection can cause severe pulmonary disease in immunocompromised patients. There are no standard diagnostic criteria for CMV pulmonary disease beyond histopathology findings on lung tissue, which is challenging to obtain in pediatric patients. Bronchoalveolar lavage (BAL) fluid is easier to obtain. Since CMV remains latent after primary infection and can potentially reactivate due to any inflammatory response, CMV detection in BAL specimen may not indicate acute CMV pulmonary disease. Thus, we describe the clinical manifestations and outcomes of pediatric patients with CMV detection in BAL fluid. METHODS We reviewed the clinical, radiologic, and laboratory data of patients <19 years old with a BAL specimen positive for CMV during a 5-year period. RESULTS Thirty-four encounters in 29 patients were found with CMV detected in their BAL specimen. Half (17/34) of the encounters were in immunocompromised patients. CMV, polymerase chain reaction (PCR) was the most common positive test. Forty-seven percent of the patients had other infections detected in BAL specimens. The majority of patients were never treated for CMV and resolved their acute respiratory illness. Only one patient had probable CMV pulmonary disease. DISCUSSION CMV is frequently recovered from BAL specimens but does not usually indicate acute CMV pulmonary disease. We would suggest that other diagnoses be considered first, even if CMV is recovered. Pediatr Pulmonol. 2017;52:112-118. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Elizabeth B Burgener
- Department of Pediatrics, Pulmonary Medicine, Stanford University School of Medicine, Palo Alto, 94304, California
| | - Jesse Waggoner
- Department of Medicine, Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Benjamin A Pinsky
- Department of Medicine, Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Palo Alto, California.,Department of Pathology, Stanford University School of Medicine, Palo Alto, California
| | - Sharon F Chen
- Department of Pediatrics, Infectious Disease, Stanford University School of Medicine, Palo Alto, California
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Cytomegalovirus infection in patients with haematological diseases and after autologous stem cell transplantation as consolidation: a single-centre study. Ann Hematol 2016; 96:125-131. [PMID: 27730340 DOI: 10.1007/s00277-016-2831-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 09/19/2016] [Indexed: 10/20/2022]
Abstract
Because of the widespread use of immunosuppressive drugs, CMV infection is one of the most important causes of morbidity and mortality in patients with haematological malignancies worldwide. The aim of the study was to retrospectively analyse the epidemiology of CMV infection in haematological patients. Between 2008 and 2014, 1238 quantitative CMV DNA detections from plasma specimens were performed. These specimens were collected from 271 patients with haematological malignancy. Patients were grouped on the basis of underlying diseases (lymphoid and myeloid malignancies and other haematological diseases). In the lymphoid and myeloid groups, we distinguished ASCT and non-ASCT groups. During the studied period, the majority of examined patients (82.6 %) were treated with lymphoproliferative disease. A total of 126 (46.5 %) patients underwent ASCT, while 145 (53.5 %) did not have stem cell transplantation. A total of 118 (9.5 %) of 1238 plasma specimens proved to be positive for CMV DNA; these specimens were collected from 66 (24.4 %) patients. Twenty-four (16.6 %) of 145 non-ASCT patients had CMV PCR positive specimens. Among non-ASCT patients with positive CMV PCR results, 10 patients were asymptomatic, 14 had symptomatic reactivation, while 2 had CMV disease. In the ASCT group, 42 (33.3 %) patients had CMV PCR positive samples. CMV reactivation was asymptomatic in 34 (81 %) cases, and 8 (19 %) patients had symptomatic reactivation. In the non-ASCT group, the rate of CMV infection is low. In the ASCT group, the prevalence of CMV infection was higher than in the non-ASCT group, but the majority of CMV infection was asymptomatic and only small number of patients had symptomatic reactivation. Thus, our results also showed that the use of routine CMV DNA monitoring is not necessary in patients with haematological malignancies not receiving fludarabine-containing regimen or alemtuzumab, in spite of this to decrease the mortality we have to consider the use of molecular tests in case of suspected infectious conditions.
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Blyth E, Withers B, Clancy L, Gottlieb D. CMV-specific immune reconstitution following allogeneic stem cell transplantation. Virulence 2016; 7:967-980. [PMID: 27580355 DOI: 10.1080/21505594.2016.1221022] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Cytomegalovirus (CMV) remains a major contributor to morbidity and mortality following allogeneic haemopoietic stem cell transplant (HSCT) despite widespread use of viraemia monitoring and pre-emptive antiviral therapy. Uncontrolled viral replication occurs primarily in the first 100 d post transplant but this high risk period can extend to many months if immune recovery is delayed. The re-establishment of a functional population of cellular effectors is essential for control of virus replication and depends on recipient and donor serostatus, the stem cell source, degree of HLA matching and post-transplant factors such as CMV antigen exposure, presence of GVHD and ongoing use of immune suppression. A number of immune monitoring assays exist but have not yet become widely accessible for routine clinical use. Vaccination, adoptive transfer of CMV specific T cells and a number of graft engineering processes are being evaluated to enhance of CMV specific immune recovery post HSCT.
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Affiliation(s)
- Emily Blyth
- a Westmead Institute for Medical Research at the University of Sydney , Westmead , Sydney , Australia.,b Blood and Marrow Transplant Unit, Westmead Hospital , Sydney , Australia.,c Department of Haematology , Westmead , Sydney , Australia
| | - Barbara Withers
- a Westmead Institute for Medical Research at the University of Sydney , Westmead , Sydney , Australia
| | - Leighton Clancy
- a Westmead Institute for Medical Research at the University of Sydney , Westmead , Sydney , Australia.,d Sydney Cellular Therapies Laboratory , Westmead , Sydney , Australia
| | - David Gottlieb
- a Westmead Institute for Medical Research at the University of Sydney , Westmead , Sydney , Australia.,b Blood and Marrow Transplant Unit, Westmead Hospital , Sydney , Australia.,c Department of Haematology , Westmead , Sydney , Australia.,d Sydney Cellular Therapies Laboratory , Westmead , Sydney , Australia
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28
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Cytomegalovirus infection in autologous stem cell transplant recipients in the era of rituximab. Ann Hematol 2016; 95:1323-7. [PMID: 27225264 DOI: 10.1007/s00277-016-2700-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 05/18/2016] [Indexed: 10/21/2022]
Abstract
The incidence of cytomegalovirus (CMV) reactivation/disease after autologous stem cell transplant (ASCT) is much lower than that after allogeneic stem cell transplantation. With the recent use of rituximab during cancer chemotherapy or conditioning regimens prior to transplantation, there has been an increasing concern of opportunistic infections including CMV. In the present study, we reviewed the patients undergoing ASCT from December 2007 to December 2013 to identify those developing CMV reactivation/disease. Out of the 978 patients who underwent ASCT at the Karmanos Cancer Institute, 239 patients were tested for symptomatic CMV reactivation based on clinical suspicion. Of the tested patients, 7/239 (2.9 %) were documented to have CMV reactivation within 90 days of ASCT. The median time to develop CMV viremia was 32 days from transplantation. Of the 239 patients tested, CMV viremia was detected in 3 out of 72 patients who received rituximab as compared to 4 out of 167 patients who did not. Three of these seven viremic patients were treated with anti-viral drugs; viremia resolved in all patients at a median of 24 days. Three patients were found to develop other bacterial and/or fungal infections following CMV viremia. Two of the seven patients died during 1-year follow-up, due to primary disease progression or Candida sepsis. None of the patients developed proven tissue-invasive CMV disease. The study did not evaluate the incidence of asymptomatic CMV infection/reactivation. Despite prior publications based on limited data, rituximab does not appear to contribute to an increased frequency of symptomatic CMV reactivation following ASCT.
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Maschmeyer G, Donnelly JP. How to manage lung infiltrates in adults suffering from haematological malignancies outside allogeneic haematopoietic stem cell transplantation. Br J Haematol 2016; 173:179-89. [PMID: 26729577 PMCID: PMC7161791 DOI: 10.1111/bjh.13934] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 12/13/2015] [Indexed: 12/20/2022]
Abstract
Pulmonary complications affect up to 40% of patients with severe neutropenia lasting for more than 10 d. As they are frequently associated with fever and elevation of C‐reactive protein or other signs of inflammation, they are mostly handled as pneumonia. However, the differential diagnosis is broad, and a causative microbial agent remains undetected in the majority of cases. Pulmonary side effects from cytotoxic treatment or pulmonary involvement by the underlying malignancy must always be taken into account and may provide grounds for invasive diagnostic procedures in selected patients. Pneumocystis jirovecii (in patients not receiving co‐trimoxazole as prophylaxis), multi‐resistant gram‐negative bacilli, mycobacteria or respiratory viruses may be involved. High‐risk patients may be infected by filamentous fungi, such as Aspergillus spp., but these infections are seldom proven when treatment is initiated. Microorganisms isolated from cultures of blood, bronchoalveolar lavage or respiratory secretions need careful interpretation as they may be irrelevant for determining the aetiology of pulmonary infiltrates, particularly when cultures yield coagulase‐negative staphylococci, enterococci or Candida species. Non‐culture based diagnostics for detecting Aspergillus galactomannan, beta‐D‐glucan or DNA from blood, bronchoalveolar lavage or tissue samples can facilitate the diagnosis, but must always be interpreted in the context of clinical and imaging findings. Systemic antifungal treatment with mould‐active agents, given in combination with broad‐spectrum antibiotics, improves clinical outcome when given pre‐emptively. Co‐trimoxazole remains the first‐line treatment for Pneumocystis pneumonia, while cytomegalovirus pneumonia will respond to ganciclovir or foscarnet in most cases. The clinical outcome of acute respiratory failure can also be successful with proper intensive care, when indicated.
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Affiliation(s)
- Georg Maschmeyer
- Department of Haematology, Oncology and Palliative Care, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - J Peter Donnelly
- Department of Haematology, Radboud University Medical Centre, Nijmegen, The Netherlands
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Alam MM, Bayoumy M, Ali A, Alali M, Al-enezi B, Abosoudah I. Cytomegalovirus infection in children after bone marrow transplantation: Risk factors, clinical aspects and outcomes. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.pid.2016.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Hilal T, Gul Z. Exploring the possibilities: airspace disease in the postallogeneic haematopoietic stem cell transplant period. BMJ Case Rep 2015; 2015:bcr-2015-211922. [PMID: 26516247 DOI: 10.1136/bcr-2015-211922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 50-year-old man with a history of myelodysplastic syndrome status postallogeneic haematopoietic stem cell transplantation (HSCT) in July 2013 presented in January 2014 with a 6-week history of worsening shortness of breath and dry cough. Chest imaging revealed scattered groundglass opacities in the upper lobes bilaterally and two areas of focal consolidation on the left side. Bronchoscopy with bronchoalveolar lavage grew methicillin-resistant Staphylococcus aureus and the patient was treated with a prolonged course of vancomycin without improvement in symptoms or oxygenation. Image-guided core biopsy of an area of consolidation revealed histological findings of acute fibrinous and organising pneumonia. The patient was diagnosed with what appeared to be a manifestation of chronic graft-versus-host disease of the lung and started on high-dose corticosteroids with resultant improvement in symptoms. The response was short-lived and the patient expired 2 months later.
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Affiliation(s)
- Talal Hilal
- Department of Internal Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Zartash Gul
- Division of Hematology, University of Kentucky, Lexington, Kentucky, USA
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Role of bronchoalveolar lavage in the diagnosis of pulmonary infiltrates in immunocompromised patients. Curr Opin Infect Dis 2015; 27:322-8. [PMID: 24977681 DOI: 10.1097/qco.0000000000000072] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To describe the role of bronchoalveolar lavage (BAL) in the evaluation of pulmonary disease in immunocompromised patients. RECENT FINDINGS Recent discoveries in this field are largely in two areas: the array of diagnostic testing performed on BAL fluid and technical details that can enhance the yield from this procedure. Regarding diagnostic testing, the addition of new assays, including Aspergillus galactomannan antigen assay, respiratory viral panels, and Pneumocystis jirovecii PCR, has improved the diagnostic yield of BAL over conventional cultures and stains. To improve the diagnostic yield of the procedure itself, it should be done early in the clinical course, with the BAL in the anatomic area most affected, and with a preprocedural computed tomography of the chest to properly plan the procedure. SUMMARY Bronchoscopic evaluation with BAL can provide important diagnostic information in immunocompromised patients with pulmonary diseases and should be routinely performed when clinically indicated and able to be completed safely.
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Davis ZB, Cooley SA, Cichocki F, Felices M, Wangen R, Luo X, DeFor TE, Bryceson YT, Diamond DJ, Brunstein C, Blazar BR, Wagner JE, Weisdorf DJ, Horowitz A, Guethlein LA, Parham P, Verneris MR, Miller JS. Adaptive Natural Killer Cell and Killer Cell Immunoglobulin-Like Receptor-Expressing T Cell Responses are Induced by Cytomegalovirus and Are Associated with Protection against Cytomegalovirus Reactivation after Allogeneic Donor Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2015; 21:1653-62. [PMID: 26055301 PMCID: PMC4557961 DOI: 10.1016/j.bbmt.2015.05.025] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Accepted: 05/27/2015] [Indexed: 11/26/2022]
Abstract
Cytomegalovirus (CMV) reactivates in >30% of CMV-seropositive patients after allogeneic hematopoietic cell transplantation (HCT). Previously, we reported an increase of natural killer (NK) cells expressing NKG2C, CD57, and inhibitory killer cell immunoglobulin-like receptors (KIRs) in response to CMV reactivation after HCT. These NK cells persist after the resolution of infection and display "adaptive" or memory properties. Despite these findings, the differential impact of persistent/inactive versus reactivated CMV on NK versus T cell maturation after HCT from different graft sources has not been defined. We compared the phenotype of NK and T cells from 292 recipients of allogeneic sibling (n = 118) or umbilical cord blood (UCB; n = 174) grafts based on recipient pretransplantation CMV serostatus and post-HCT CMV reactivation. This cohort was utilized to evaluate CMV-dependent increases in KIR-expressing NK cells exhibiting an adaptive phenotype (NKG2C(+)CD57(+)). Compared with CMV-seronegative recipients, those who reactivated CMV had the highest adaptive cell frequencies, whereas intermediate frequencies were observed in CMV-seropositive recipients harboring persistent/nonreplicating CMV. The same effect was observed in T cells and CD56(+) T cells. These adaptive lymphocyte subsets were increased in CMV-seropositive recipients of sibling but not UCB grafts and were correlated with lower rates of CMV reactivation (sibling 33% versus UCB 51%; P < .01). These data suggest that persistent/nonreplicating recipient CMV induces rapid production of adaptive NK and T cells from mature cells from sibling but not UCB grafts. These adaptive lymphocytes are associated with protection from CMV reactivation.
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Affiliation(s)
- Zachary B Davis
- Blood and Marrow Transplant Program, Departments of Pediatrics and Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Sarah A Cooley
- Blood and Marrow Transplant Program, Departments of Pediatrics and Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Frank Cichocki
- Blood and Marrow Transplant Program, Departments of Pediatrics and Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Martin Felices
- Blood and Marrow Transplant Program, Departments of Pediatrics and Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Rose Wangen
- Blood and Marrow Transplant Program, Departments of Pediatrics and Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Xianghua Luo
- Division of Biostatistics, School of Public Health and Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Todd E DeFor
- Blood and Marrow Transplant Program, Departments of Pediatrics and Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Yenan T Bryceson
- Centre for Infectious Medicine, Department of Medicine, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Don J Diamond
- Division of Translational Vaccine Research, Beckman Research Institute of the City of Hope, Duarte, California
| | - Claudio Brunstein
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Bruce R Blazar
- Blood and Marrow Transplant Program, Department of Pediatric, University of Minnesota, Minneapolis, Minnesota
| | - John E Wagner
- Blood and Marrow Transplant Program, Department of Pediatric, University of Minnesota, Minneapolis, Minnesota
| | - Daniel J Weisdorf
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Amir Horowitz
- Structural Biology and Microbiology and Immunology, Stanford University, Stanford, California
| | - Lisbeth A Guethlein
- Structural Biology and Microbiology and Immunology, Stanford University, Stanford, California
| | - Peter Parham
- Structural Biology and Microbiology and Immunology, Stanford University, Stanford, California
| | - Michael R Verneris
- Blood and Marrow Transplant Program, Department of Pediatric, University of Minnesota, Minneapolis, Minnesota
| | - Jeffrey S Miller
- Centre for Infectious Medicine, Department of Medicine, Karolinska University Hospital Huddinge, Stockholm, Sweden.
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Wu JL, Ma HY, Lu CY, Chen JM, Lee PI, Jou ST, Yang YL, Chang HH, Lu MY, Chang LY, Huang LM. Risk factors and outcomes of cytomegalovirus viremia in pediatric hematopoietic stem cell transplantation patients. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2015; 50:307-313. [PMID: 26346369 DOI: 10.1016/j.jmii.2015.07.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 06/30/2015] [Accepted: 07/23/2015] [Indexed: 12/26/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) is a major pathogen causing significant mortality and morbidity in immunocompromised hosts. It is important to find risk factors associated with CMV viremia and its outcome. METHODS We investigated the incidence, time of onset, risk factors for CMV viremia, and characteristics of CMV diseases in 57 pediatric patients receiving hematopoietic stem cell transplantation (HSCT). Between August 2011 and March 2014, cases of pediatric HSCT patients at the National Taiwan University Children's Hospital were reviewed. Viremia was identified by plasma CMV real-time polymerase chain reaction (RT-PCR) assay. RESULTS Eighteen (32%) of the 57 patients developed CMV viremia at a median of 23 days post-HSCT (range -3 to +721 days). Eighty-nine percent (16/18) of CMV viremia occurred within 100 days posttransplantation. Four patients finally had CMV diseases (1 with CMV colitis and 3 with CMV pneumonitis) and one patient died of CMV pneumonitis complicated with pulmonary hemorrhage and sepsis. Significant risk factors associated with CMV viremia via univariate analysis include older age (p = 0.03), leukemic patients [odds ratio (OR): 5.2, 95% confidence interval (CI): 1.52∼17.7, p = 0.008), allogeneic HSCT (OR: 14.57, 95% CI: 1.76∼120.5, p = 0.002), antithymoglobulin (ATG) use before transplantation (OR: 5.09, 95% CI: 1.52∼16.9, p = 0.007), graft-versus-host disease (GvHD) (OR: 10.1, 95% CI: 2.7∼38.7, p < 0.001), and gastrointestinal GvHD (OR: 10.9, 95% CI: 2.72∼43.9, p = 0.001). CONCLUSION In pediatric posttransplantation patients, CMV viremia mostly occurred within 100 days after transplantation. Risk factors associated with CMV viremia include older diagnostic age, leukemic patients, unrelated donor HSCT, pretransplant ATG use, GvHD, and gastrointestinal GvHD.
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Affiliation(s)
- Jhong-Lin Wu
- Division of Infectious Disease, Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taiwan, ROC
| | - Hsuan-Yin Ma
- Division of Infectious Disease, Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taiwan, ROC
| | - Chun-Yi Lu
- Division of Infectious Disease, Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taiwan, ROC
| | - Jong-Min Chen
- Division of Infectious Disease, Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taiwan, ROC
| | - Ping-Ing Lee
- Division of Infectious Disease, Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taiwan, ROC
| | - Shiann-Tarng Jou
- Division of Hematology-Oncology, Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taiwan, ROC
| | - Yung-Lin Yang
- Division of Hematology-Oncology, Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taiwan, ROC
| | - Hsiu-Hao Chang
- Division of Hematology-Oncology, Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taiwan, ROC
| | - Meng-Yao Lu
- Division of Hematology-Oncology, Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taiwan, ROC
| | - Luan-Ying Chang
- Division of Infectious Disease, Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taiwan, ROC.
| | - Li-Min Huang
- Division of Infectious Disease, Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taiwan, ROC
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Abstract
PURPOSE OF REVIEW Pneumonia is the leading cause of death among neutropenic cancer patients, particularly those with acute leukaemia. Even with empiric therapy, case fatality rates of neutropenic pneumonias remain unacceptably high. However, recent advances in the management of neutropenic pneumonia offer hope for improved outcomes in the cancer setting. This review summarizes recent literature regarding the clinical presentation, microbiologic trends, diagnostic advances and therapeutic recommendations for cancer-related neutropenic pneumonia. RECENT FINDINGS Although neutropenic patients acquire pathogens both in community and nosocomial settings, patients' obligate healthcare exposures result in the frequent identification of multidrug-resistant bacterial organisms on conventional culture-based assessment of respiratory secretions. Modern molecular techniques, including expanded use of galactomannan testing, have further facilitated identification of fungal pathogens, allowing for aggressive interventions that appear to improve patient outcomes. Multiple interested societies have issued updated guidelines for antibiotic therapy of suspected neutropenic pneumonia. The benefit of antibiotic medications may be further enhanced by agents that promote host responses to infection. SUMMARY Neutropenic cancer patients have numerous potential causes for pulmonary infiltrates and clinical deterioration, with lower respiratory tract infections among the most deadly. Early clinical suspicion, diagnosis and intervention for neutropenic pneumonia provide cancer patients' best hope for survival.
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Arnaout K, Patel N, Jain M, El-Amm J, Amro F, Tabbara IA. Complications of allogeneic hematopoietic stem cell transplantation. Cancer Invest 2014; 32:349-62. [PMID: 24902046 DOI: 10.3109/07357907.2014.919301] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Infection, graft-versus-host disease (GVHD), and to a lesser extent sinusoidal obstructive syndrome (SOS) represent the major causes of morbidity and mortality in patients undergoing allogeneic hematopoietic stem cell transplantation (AHSCT). During the last decade, progress in prevention and treatment of these complications led to improvement in the outcome of these patients. Despite the fact that nonmyeloablative regimens have been increasingly used in elderly patients and in patients with co-morbidities, the nonrelapse related mortality remains a challenge and long-term follow-up is required. The objective of this manuscript is to provide an updated concise review of the complications of AHSCT and of the available treatment interventions.
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Affiliation(s)
- Karim Arnaout
- Department of Medicine, Division of Hematology and Oncology, George Washington University Medical Center, Washington, USA
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Chi AK, Soubani AO, White AC, Miller KB. An update on pulmonary complications of hematopoietic stem cell transplantation. Chest 2014; 144:1913-1922. [PMID: 24297123 DOI: 10.1378/chest.12-1708] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The indications for hematopoietic stem cell transplantation (HSCT) continue to expand. However, the risk for pulmonary complications post-HSCT continues to be high. Early recognition and treatment of pulmonary complications may improve outcomes. This is an overview of diagnosis, manifestations, and treatment of the most common infectious and noninfectious pulmonary complications post-HSCT. Knowing the patient's timeframe post-HSCT (preengraftment, postengraftment, late), type of HSCT (allogeneic vs autologous), radiographic findings, and clinical presentation can help to differentiate between the many pulmonary complications. This article will also address pretransplantation evaluation and infectious and noninfectious complications in the patient post-HSCT. While mortality post-HSCT continues to improve, respiratory failure continues to be the leading cause of ICU admissions for patients who have undergone HSCT. Mechanical ventilation is a predictor of poor outcomes in these patients, and further research is needed regarding their critical care management, treatment options for noninfectious pulmonary complications, and mortality prediction models posttransplantation.
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Affiliation(s)
| | | | - Alexander C White
- Tufts Medical Center, Boston, MA; New England Sinai Hospital, Steward Health Care, Stoughton, MA
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Michelis FV, Branch DR, Scovell I, Bloch E, Pendergrast J, Lipton JH, Cserti-Gazdewich CM. Acute hemolysis after intravenous immunoglobulin amid host factors of ABO-mismatched bone marrow transplantation, inflammation, and activated mononuclear phagocytes. Transfusion 2013; 54:681-90. [DOI: 10.1111/trf.12329] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Revised: 05/03/2013] [Accepted: 05/22/2013] [Indexed: 01/25/2023]
Affiliation(s)
- Fotios V. Michelis
- Blood and Marrow Transplant Program; Princess Margaret Hospital; University Health Network; Toronto Ontario Canada
- Research & Development; Canadian Blood Services; Toronto Ontario Canada
- Transfusion Medicine Laboratory; University Health Network; University of Toronto; Toronto Ontario Canada
| | - Donald R. Branch
- Blood and Marrow Transplant Program; Princess Margaret Hospital; University Health Network; Toronto Ontario Canada
- Research & Development; Canadian Blood Services; Toronto Ontario Canada
- Transfusion Medicine Laboratory; University Health Network; University of Toronto; Toronto Ontario Canada
| | - Iain Scovell
- Blood and Marrow Transplant Program; Princess Margaret Hospital; University Health Network; Toronto Ontario Canada
- Research & Development; Canadian Blood Services; Toronto Ontario Canada
- Transfusion Medicine Laboratory; University Health Network; University of Toronto; Toronto Ontario Canada
| | - Evgenia Bloch
- Blood and Marrow Transplant Program; Princess Margaret Hospital; University Health Network; Toronto Ontario Canada
- Research & Development; Canadian Blood Services; Toronto Ontario Canada
- Transfusion Medicine Laboratory; University Health Network; University of Toronto; Toronto Ontario Canada
| | - Jacob Pendergrast
- Blood and Marrow Transplant Program; Princess Margaret Hospital; University Health Network; Toronto Ontario Canada
- Research & Development; Canadian Blood Services; Toronto Ontario Canada
- Transfusion Medicine Laboratory; University Health Network; University of Toronto; Toronto Ontario Canada
| | - Jeffrey H. Lipton
- Blood and Marrow Transplant Program; Princess Margaret Hospital; University Health Network; Toronto Ontario Canada
- Research & Development; Canadian Blood Services; Toronto Ontario Canada
- Transfusion Medicine Laboratory; University Health Network; University of Toronto; Toronto Ontario Canada
| | - Christine M. Cserti-Gazdewich
- Blood and Marrow Transplant Program; Princess Margaret Hospital; University Health Network; Toronto Ontario Canada
- Research & Development; Canadian Blood Services; Toronto Ontario Canada
- Transfusion Medicine Laboratory; University Health Network; University of Toronto; Toronto Ontario Canada
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Travi G, Pergam SA. Cytomegalovirus pneumonia in hematopoietic stem cell recipients. J Intensive Care Med 2013; 29:200-12. [PMID: 23753231 DOI: 10.1177/0885066613476454] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Accepted: 10/23/2012] [Indexed: 01/29/2023]
Abstract
Cytomegalovirus (CMV) is a frequently encountered infection following hematopoietic cell transplantation, and tissue invasive pneumonia is a dreaded complication of the virus in this population. In this review of CMV pneumonia, we address epidemiology, pathogenesis, diagnostics, current therapy, and strategies to prevent the development of CMV. We also review emerging treatment and prevention options for this challenging disease.
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Affiliation(s)
- Giovanna Travi
- Department of Infectious Diseases, AO Ospedale Niguarda Cà Granda, Milan, Italy
| | - Steven A Pergam
- Vaccine and Infectious Diseases and Clinical Research Divisions, Fred Hutchinson Cancer Research Center, Seattle, WA, USA Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, USA
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Fares S, Irfan FB. Thoracic Emergencies in Immunocompromised Patients. Emerg Med Clin North Am 2012; 30:565-89, x. [DOI: 10.1016/j.emc.2011.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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CMV infection after transplant from cord blood compared to other alternative donors: the importance of donor-negative CMV serostatus. Biol Blood Marrow Transplant 2011; 18:92-9. [PMID: 21689774 DOI: 10.1016/j.bbmt.2011.05.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Accepted: 05/23/2011] [Indexed: 01/03/2023]
Abstract
Cytomegalovirus (CMV) infection and disease are important complications after hematopoietic stem cell transplant, particularly after transplant from alternative donors. Allogeneic cord blood transplantation (CBT) is being increasingly used, but immune recovery may be delayed. The aim of this study was to compare CMV infection in CBT with transplants from unrelated or mismatched related donors, from now on defined as alternative donors. A total of 165 consecutive transplants were divided in 2 groups: (1) alternative donors transplants (n = 85) and (2) CBT recipients (n = 80). Donor and recipient (D/R) CMV serostatus were recorded. The incidence of CMV infection, its severity, timing, and outcome were compared. Median follow-up was 257 days (1-1328). CMV infection was monitored by CMV antigenemia and expressed as CMV Ag positive cell/2 × 10(5) polymorphonuclear blood cells. There was a trend toward a higher cumulative incidence of CMV infection among CBT than alternative donor transplant recipients (64% vs 51%, P = .12). The median time to CMV reactivation was 35 days, and was comparable in the 2 groups (P = .8). The maximum number of CMV-positive cells was similar in the 2 groups (11 versus 16, P = .2). The time interval between the first and the last positive CMV antigenemia was almost 4 times longer in CBT compared with alternative donor transplants (109 vs 29 days, respectively, P = .008). The incidence of late CMV infection was also higher in CBT (62% vs 24%, P < .001). The incidence of early and late CMV infection in CBT was similar to D-/R+ alternative transplants, and higher than in D+/R+ alternative transplants: early infection, 72% in CBT versus 69% in D-/R+ alternative versus 55% in D+/R+ alternative (P = .21); and late infection, 67% in CBT versus 60% in D-/R+ alternative versus 7% in D+/R+ alternative (P < .001). Transplant-related mortality and overall survival were similar between the groups: 34% versus 36% (P = .6) and 54% versus 46% (P = .3) for alternative transplant and CBT, respectively. Longer duration and higher incidence of late CMV infection was seen in CBT patients, when compared with alternative donor transplants, whereas no difference in mortality was observed. The duration and incidence of late CMV infection were similar when D-/R+ CBT were compared with D-/R+ alternative donor transplants.
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Abstract
Infectious complications are a serious cause of morbidity and mortality following hematopoietic stem cell transplantation (HSCT), and the lung is a particular target organ post-transplant. Our laboratory has used a murine bone marrow transplant model to study alterations in immunity that occur as a result of transplantation. Our studies focus on immune responses that occur following immune cell reconstitution in the absence of immunosuppressive drug therapy or graft-versus-host disease. We have found that impaired clearance of both bacterial and viral pulmonary infections is related to specific alterations in immune cell function and cytokine production. Our data offer insight into mechanisms that contribute to opportunistic infections in HSCT recipients.
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Affiliation(s)
- Stephanie M. Coomes
- Graduate Program in Immunology, University of Michigan, Ann Arbor, MI 48109-2200, USA
| | - Leah L. N. Hubbard
- Graduate Program in Immunology, University of Michigan, Ann Arbor, MI 48109-2200, USA
| | - Bethany B. Moore
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan, 4053 BSRB, 109 Zina Pitcher Pl., Ann Arbor, MI 48109-2200, USA
- Department of Microbiology and Immunology, University of Michigan, Ann Arbor, MI 48109-2200, USA
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45
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Ljungman P, Hakki M, Boeckh M. Cytomegalovirus in hematopoietic stem cell transplant recipients. Hematol Oncol Clin North Am 2011; 25:151-69. [PMID: 21236396 DOI: 10.1016/j.hoc.2010.11.011] [Citation(s) in RCA: 256] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
This article examines the clinical manifestations of and risk factors for cytomegalovirus (CMV). Prevention of CMV infection and disease are also explored. Antiviral resistance and management of CMV are examined.
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Affiliation(s)
- Per Ljungman
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
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46
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Abstract
This article examines the clinical manifestations of and risk factors for cytomegalovirus (CMV). Prevention of CMV infection and disease are also explored. Antiviral resistance and management of CMV are examined.
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Abstract
Human cytomegalovirus (HCMV) is a beta herpes virus with a double stranded DNA genome of 240kbp. The virus is prevalent and establishes a latent infection in most adults. HCMV is an opportunistic pathogen for patients with impaired cellular immunity. HCMV pneumonia is a common presentation of HCMV disease in immunocompromised patients. The incidence of HCMV pneumonitis can be as high as 90% in lung transplant recipients. This paper takes a fresh look at the challenging perspectives of molecular, immunologic, cellular, diagnostic, clinical, and therapeutic characteristics of HCMV infection as future targets for development of antiviral strategies.
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Affiliation(s)
- Erik Langhoff
- James J. Peters VA Medical Center, 130 West Kingsbridge Road, Bronx, NY 10468, USA.
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Coomes SM, Wilke CA, Moore TA, Moore BB. Induction of TGF-beta 1, not regulatory T cells, impairs antiviral immunity in the lung following bone marrow transplant. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2010; 184:5130-40. [PMID: 20348421 PMCID: PMC3314499 DOI: 10.4049/jimmunol.0901871] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Patients receiving hematopoietic stem cell transplantation or bone marrow transplantation (BMT) as therapy for various malignancies or autoimmune diseases have an increased risk for infectious complications posttransplant, especially in the lung. We have used BMT in mice and murine gammaherpesvirus, gammaHV-68, to study the efficacy of adaptive immune responses post-BMT. Five weeks posttransplant, mice have fully reconstituted their hematopoietic lineages in both the lung and periphery. When challenged with virus, however, BMT mice have a reduced ability to clear lytic virus from the lung. Defective viral control in BMT mice is not related to impaired leukocyte recruitment or defective APC function. Rather, BMT mice are characterized by defective CD4 cell proliferation, skewing of effector CD4 T cells from a Th1 to a Th17 phenotype, and an immunosuppressive lung environment at the time of infection that includes overexpression of TGF-beta1 and PGE(2) and increased numbers of regulatory T cells. Neither indomethacin treatment to block PG synthesis nor anti-CD25 depletion of regulatory T cells improved antiviral host defense post-BMT. Transplanting mice with transgenic bone marrow expressing a dominant-negative TGF-betaRII under the permissive CD4 promoter created mice in which effector CD4 and CD8 cells were unresponsive to TGF-beta1. Mice with TGF-beta1-nonresponsive effector T cells had restored antiviral immunity and improved Th1 responses post-BMT. Thus, our results indicate that overexpression of TGF-beta1 following myeloablative conditioning post-BMT results in impaired effector T cell responses to viral infection.
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MESH Headings
- Animals
- Bone Marrow Transplantation/adverse effects
- Bone Marrow Transplantation/immunology
- Cell Differentiation/immunology
- Cell Proliferation
- Growth Inhibitors/adverse effects
- Growth Inhibitors/biosynthesis
- Growth Inhibitors/genetics
- Herpesviridae Infections/immunology
- Herpesviridae Infections/therapy
- Herpesviridae Infections/virology
- Interleukin-17/biosynthesis
- Mice
- Mice, Inbred BALB C
- Mice, Inbred C3H
- Mice, Inbred C57BL
- Mice, Transgenic
- Pneumonia, Viral/immunology
- Pneumonia, Viral/therapy
- Pneumonia, Viral/virology
- Protein Serine-Threonine Kinases/administration & dosage
- Protein Serine-Threonine Kinases/therapeutic use
- Receptor, Transforming Growth Factor-beta Type II
- Receptors, Transforming Growth Factor beta/administration & dosage
- Receptors, Transforming Growth Factor beta/therapeutic use
- Rhadinovirus/immunology
- T-Lymphocytes, Regulatory/immunology
- T-Lymphocytes, Regulatory/pathology
- T-Lymphocytes, Regulatory/virology
- Th1 Cells/immunology
- Th1 Cells/pathology
- Th1 Cells/virology
- Transforming Growth Factor beta1/adverse effects
- Transforming Growth Factor beta1/biosynthesis
- Transforming Growth Factor beta1/genetics
- Transplantation Conditioning/methods
- Tumor Virus Infections/immunology
- Tumor Virus Infections/therapy
- Tumor Virus Infections/virology
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Affiliation(s)
| | - Carol A. Wilke
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Thomas A. Moore
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Bethany B. Moore
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109
- Department of Microbiology and Immunology, University of Michigan, Ann Arbor, MI 48109
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Colmenero JDD, Castón JJ, Torre-Cisneros J. Fiebre, disnea e infiltrados pulmonares en una mujer de 50 años en tratamiento inmunodepresor. Med Clin (Barc) 2009; 132:638-44. [DOI: 10.1016/j.medcli.2008.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2008] [Accepted: 10/08/2008] [Indexed: 11/30/2022]
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Torres H, Aguilera E, Safdar A, Rohatgi N, Raad I, Sepulveda C, Luna M, Kontoyiannis D, Chemaly R. Fatal cytomegalovirus pneumonia in patients with haematological malignancies: an autopsy-based case–control study. Clin Microbiol Infect 2008; 14:1160-6. [DOI: 10.1111/j.1469-0691.2008.02106.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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