1
|
Vassallo F, Nuzzi R, Cattani I, Dellacasa C, Giaccone L, De Rosa FG, Cavallo R, Iovino G, Brunello L, Bruno B, Busca A. CMV retinitis in a stem cell transplant recipient treated with foscarnet intravitreal injection and CMV specific immunoglobulins. Ther Adv Hematol 2020; 11:2040620720975651. [PMID: 33354311 PMCID: PMC7734499 DOI: 10.1177/2040620720975651] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 10/23/2020] [Indexed: 01/03/2023] Open
Abstract
Cytomegalovirus (CMV) retinitis (CMVR) has been reported rarely in patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT). In addition, little is known about strategies for ophthalmic surveillance and adequate antiviral treatment of CMVR. A case of CMVR in an allogeneic HSCT recipient is described, including clinical signs and therapy. An adult patient received HSCT from a matched unrelated donor for treatment of a Burkitt lymphoma. Donor and recipients were both CMV positive. Starting on day +40, the patient presented multiple CMV reactivation, treated with valganciclovir, foscarnet and a combination of both. On day +160, the patient started complaining of conjunctival hyperaemia and a decrease in visual acuity. Fundoscopy revealed retinal lesions consistent with CMVR, although whole blood CMV DNAemia was negative. Aqueous humor biopsy showed the presence of CMV infection (CMV DNA 230400 UI/ml). CMVR was treated with foscarnet (180 mg i.v. and 1.2 mg intravitreal injection) combined with anti CMV immunoglobulin at 0.5 ml/kg every 2 weeks. After 4 weeks of systemic therapy, 20 weekly doses of intravitreal foscarnet and six cycles of immunoglobulins, a significant improvement of visual acuity was observed. The treatment was well tolerated with no side effect. In conclusion, our case suggests that systemic and local antiviral treatment combined with CMV-specific-IVIG, may reduce CMV load in the eye of patients with CMVR, leading to a consistent improvement of visual acuity. Systematic ophthalmologic examination should be recommended in HSCT recipients with multiple CMV reactivations and high peak CMV DNA levels.
Collapse
Affiliation(s)
- Francesco Vassallo
- Department of Oncology and Hematology, AOU Citta' della Salute e della Scienza, Turin, Italy
| | - Raffaele Nuzzi
- Eye Clinic Section, Department of Surgical Sciences, University of Turin, Italy
| | - Ilaria Cattani
- Eye Clinic Section, Department of Surgical Sciences, University of Turin, Italy
| | - Chiara Dellacasa
- Stem Cell Transplant Center, AOU Citta' della Salute e della Scienza, Turin, Italy
| | - Luisa Giaccone
- Stem Cell Transplant Center, AOU Citta' della Salute e della Scienza, Turin, Italy
| | | | - Rossana Cavallo
- SC Microbiology and Virology, A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy
| | - Giorgia Iovino
- Department of Oncology and Hematology, AOU Citta' della Salute e della Scienza, Turin, Italy
| | - Lucia Brunello
- Stem Cell Transplant Center, AOU Citta' della Salute e della Scienza, Turin, Italy
| | - Benedetto Bruno
- Stem Cell Transplant Center, AOU Citta' della Salute e della Scienza, Turin, Italy
| | - Alessandro Busca
- Stem Cell Transplant Center, AOU Citta' della Salute e della Scienza, Corso Bramante 88, Turin, 10126, Italy
| |
Collapse
|
2
|
Shi HY, Cheng YF, Huang XJ, Wang Y, Suo P, Xu LP, Liu KY, Zhang XH, Yan CH, Wang FR, Sun YQ, Zhang S, Kong J, Gao YQ, Xie YX. [Clinical analysis of cytomegalovirus infection after haplotype hematopoietic stem cell transplantation in children]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2019; 40:426-428. [PMID: 31207710 PMCID: PMC7342226 DOI: 10.3760/cma.j.issn.0253-2727.2019.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Indexed: 11/13/2022]
Affiliation(s)
- H Y Shi
- Department of Hematology, Shanxi Children's Hospital, Taiyuan 030013, China
| | - Y F Cheng
- Peking University Institute of Hematology and Peking University People's Hospital, Beijing 100044, China
| | - X J Huang
- Peking University Institute of Hematology and Peking University People's Hospital, Beijing 100044, China
| | - Y Wang
- Peking University Institute of Hematology and Peking University People's Hospital, Beijing 100044, China
| | - P Suo
- Peking University Institute of Hematology and Peking University People's Hospital, Beijing 100044, China
| | - L P Xu
- Peking University Institute of Hematology and Peking University People's Hospital, Beijing 100044, China
| | - K Y Liu
- Peking University Institute of Hematology and Peking University People's Hospital, Beijing 100044, China
| | - X H Zhang
- Peking University Institute of Hematology and Peking University People's Hospital, Beijing 100044, China
| | - C H Yan
- Peking University Institute of Hematology and Peking University People's Hospital, Beijing 100044, China
| | - F R Wang
- Peking University Institute of Hematology and Peking University People's Hospital, Beijing 100044, China
| | - Y Q Sun
- Peking University Institute of Hematology and Peking University People's Hospital, Beijing 100044, China
| | - S Zhang
- Peking University Institute of Hematology and Peking University People's Hospital, Beijing 100044, China
| | - J Kong
- Peking University Institute of Hematology and Peking University People's Hospital, Beijing 100044, China
| | - Y Q Gao
- Peking University Institute of Hematology and Peking University People's Hospital, Beijing 100044, China
| | - Y X Xie
- Department of Hematology, Shanxi Dayi Hospital, Taiyuan 030032, China
| |
Collapse
|
3
|
Bauters T, Bordon V, Florin L, Padalko E, Andrei G, Gillemot S, Fiten P, Opdenakker G, Snoeck R, Laureys G. Multidrug-resistant cytomegalovirus infection in a pediatric stem cell transplantation patient. Antiviral Res 2016; 132:149-53. [DOI: 10.1016/j.antiviral.2016.05.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 05/12/2016] [Accepted: 05/26/2016] [Indexed: 11/16/2022]
|
4
|
Azevedo* LS, Pierrotti LC, Abdala E, Costa SF, Strabelli TMV, Campos SV, Ramos JF, Latif AZA, Litvinov N, Maluf NZ, Filho HHC, Pannuti CS, Lopes MH, dos Santos VA, da Cruz Gouveia Linardi C, Yasuda MAS, de Sousa Marques HH. Cytomegalovirus infection in transplant recipients. Clinics (Sao Paulo) 2015; 70:515-23. [PMID: 26222822 PMCID: PMC4496754 DOI: 10.6061/clinics/2015(07)09] [Citation(s) in RCA: 175] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Revised: 03/31/2015] [Accepted: 03/31/2015] [Indexed: 12/12/2022] Open
Abstract
Cytomegalovirus infection is a frequent complication after transplantation. This infection occurs due to transmission from the transplanted organ, due to reactivation of latent infection, or after a primary infection in seronegative patients and can be defined as follows: latent infection, active infection, viral syndrome or invasive disease. This condition occurs mainly between 30 and 90 days after transplantation. In hematopoietic stem cell transplantation in particular, infection usually occurs within the first 30 days after transplantation and in the presence of graft-versus-host disease. The major risk factors are when the recipient is cytomegalovirus seronegative and the donor is seropositive as well as when lymphocyte-depleting antibodies are used. There are two methods for the diagnosis of cytomegalovirus infection: the pp65 antigenemia assay and polymerase chain reaction. Serology has no value for the diagnosis of active disease, whereas histology of the affected tissue and bronchoalveolar lavage analysis are useful in the diagnosis of invasive disease. Cytomegalovirus disease can be prevented by prophylaxis (the administration of antiviral drugs to all or to a subgroup of patients who are at higher risk of viral replication) or by preemptive therapy (the early diagnosis of viral replication before development of the disease and prescription of antiviral treatment to prevent the appearance of clinical disease). The drug used is intravenous or oral ganciclovir; oral valganciclovir; or, less frequently, valacyclovir. Prophylaxis should continue for 90 to 180 days. Treatment is always indicated in cytomegalovirus disease, and the gold-standard drug is intravenous ganciclovir. Treatment should be given for 2 to 3 weeks and should be continued for an additional 7 days after the first negative result for viremia.
Collapse
Affiliation(s)
- Luiz Sergio Azevedo*
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Committee for Infection in Immunosuppressed Patients, São Paulo/SP, Brazil
| | - Lígia Camera Pierrotti
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Committee for Infection in Immunosuppressed Patients, São Paulo/SP, Brazil
| | - Edson Abdala
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Committee for Infection in Immunosuppressed Patients, São Paulo/SP, Brazil
| | - Silvia Figueiredo Costa
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Committee for Infection in Immunosuppressed Patients, São Paulo/SP, Brazil
| | - Tânia Mara Varejão Strabelli
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Committee for Infection in Immunosuppressed Patients, São Paulo/SP, Brazil
| | - Silvia Vidal Campos
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Committee for Infection in Immunosuppressed Patients, São Paulo/SP, Brazil
| | - Jéssica Fernandes Ramos
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Committee for Infection in Immunosuppressed Patients, São Paulo/SP, Brazil
| | - Acram Zahredine Abdul Latif
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Committee for Infection in Immunosuppressed Patients, São Paulo/SP, Brazil
| | - Nadia Litvinov
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Committee for Infection in Immunosuppressed Patients, São Paulo/SP, Brazil
| | - Natalya Zaidan Maluf
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Committee for Infection in Immunosuppressed Patients, São Paulo/SP, Brazil
| | - Helio Hehl Caiaffa Filho
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Committee for Infection in Immunosuppressed Patients, São Paulo/SP, Brazil
| | - Claudio Sergio Pannuti
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Committee for Infection in Immunosuppressed Patients, São Paulo/SP, Brazil
| | - Marta Heloisa Lopes
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Committee for Infection in Immunosuppressed Patients, São Paulo/SP, Brazil
| | - Vera Aparecida dos Santos
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Committee for Infection in Immunosuppressed Patients, São Paulo/SP, Brazil
| | - Camila da Cruz Gouveia Linardi
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Committee for Infection in Immunosuppressed Patients, São Paulo/SP, Brazil
| | - Maria Aparecida Shikanai Yasuda
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Committee for Infection in Immunosuppressed Patients, São Paulo/SP, Brazil
| | - Heloisa Helena de Sousa Marques
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Committee for Infection in Immunosuppressed Patients, São Paulo/SP, Brazil
| |
Collapse
|
5
|
Bacigalupo A, Boyd A, Slipper J, Curtis J, Clissold S. Foscarnet in the management of cytomegalovirus infections in hematopoietic stem cell transplant patients. Expert Rev Anti Infect Ther 2012; 10:1249-64. [PMID: 23167560 DOI: 10.1586/eri.12.115] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Despite significant advances in the day-to-day management of patients receiving hematopoietic stem cell transplantations, including the introduction of new antiviral drugs, cytomegalovirus (CMV) infection continues to be a major cause of morbidity and mortality. The aim of this article is to undertake a literature-based review of foscarnet in this therapeutic setting and to align current best-published evidence with recent recommendations presented at the European Conference on Infections in Leukaemia. Ganciclovir remains the mainstay of CMV infection/disease antiviral management protocols. However, approximately a third of patients develop severe neutropenia and others become resistant to ganciclovir, and thus, a reasonably large proportion of patients are not able to receive and/or continue with this medication. Foscarnet is a suitable option as both pre-emptive therapy or for the treatment of active disease in these patients. Randomized trials have demonstrated that foscarnet is equally effective when compared with ganciclovir for pre-emptive treatment of CMV infections: the outcome was comparable with ganciclovir in terms of control of antigenemia and survival rates. There is a paucity of information for its use in the prophylaxis of CMV, although preliminary data show that it was effective in some patients at high risk of CMV reactivation. The main adverse events associated with foscarnet are renal impairment, serum electrolyte and hemoglobin disturbances, seizures and local genital irritation/ulceration. Foscarnet is a well-established antiviral option in immunocompromised patients, and it is usually administered as a second-line option to ganciclovir. In patients receiving hematopoietic stem cell transplantation, it has proven efficacy when used pre-emptively to treat CMV reactivation, as an alternative to and also in combination with ganciclovir.
Collapse
|
6
|
Mota A, Breda J, Silva R, Magalhães A, Falcão-Reis F. Cytomegalovirus retinitis in an immunocompromised infant: a case report and review of the literature. Case Rep Ophthalmol 2011; 2:238-42. [PMID: 21941498 PMCID: PMC3177802 DOI: 10.1159/000330550] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose To describe a case of bilateral cytomegalovirus retinitis (CMVR) in an immunocompromised infant. Methods A 4-month-old male infant with severe combined immunodeficiency syndrome was examined for the presence of CMVR. Ocular involvement was recorded and monitored by digital imaging. Results The child had bilateral CMVR, with a fine granular pattern, present both in the peripheral retina and posterior pole. There was no vitritis. The active areas of retinitis progressively resolved with intravenous ganciclovir treatment. At the 3-month follow-up examination, no recurrence was observed. Conclusion Ganciclovir treatment was effective in this case. The prognosis depends on rapid institution of effective antiviral therapy and on a patient's systemic immunocompetence.
Collapse
Affiliation(s)
- A Mota
- Department of Ophthalmology, Hospital S. João, Porto, Portugal
| | | | | | | | | |
Collapse
|
7
|
Nigro G, Sali E, Anceschi MM, Mazzocco M, Maranghi L, Clerico A, Castello MA. Foscarnet therapy for congenital cytomegalovirus liver fibrosis following prenatal ascites. J Matern Fetal Neonatal Med 2010; 15:325-9. [PMID: 15280124 DOI: 10.1080/14767050410001701349] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
We report on an infant with multi-system disease including liver fibrosis, right microphthalmia with cataract, interstitial pneumonitis, and hyperechoic lesions in the basal ganglia and in the periventricular and thalamic regions. Prenatal ascites with hepatomegaly concomitantly with detection of cytomegalovirus (CMV) DNA in the amniotic fluid, following recurrent maternal CMV infection, had been shown. Although CMV culture and DNA detection were negative in the urine, the infant was given foscarnet because CMV infection was demonstrated in the liver by DNA detection and immunohistochemical staining. Favorable clinical outcome and absence of CMV in the liver were subsequently shown. Our case suggests that congenital CMV disease following maternal recurrence may not be associated with disseminated infection but only with intracellular infection. The diagnosis should therefore be based on CMV detection in the involved organs. Moreover, this is the first report on the possible efficacy and safety of foscarnet for therapy of immunocompetent infants with congenital CMV disease.
Collapse
Affiliation(s)
- G Nigro
- Pediatric Institute and Department of Gynecological Sciences, Perinatalogy and Child Health, La Sapienza University, Rome, Italy
| | | | | | | | | | | | | |
Collapse
|
8
|
Cesaro S, Boaro MP, Pillon M, Calore E, Cermakova I, Perruccio K, Mengoli C, Messina C. Immune reconstitution complicated by CMV retinitis in a pediatric patient who underwent haploidentical CD34+-selected hematopoietic stem cell transplant for acute lymphoblastic leukemia. Int J Hematol 2008; 88:145-148. [PMID: 18604650 DOI: 10.1007/s12185-008-0126-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2008] [Revised: 05/22/2008] [Accepted: 06/04/2008] [Indexed: 12/28/2022]
Abstract
We describe two episodes of CMV retinitis in a pediatric patient who underwent a CD34+ selected graft from his haploidentical father. Both recipient and donor were cytomegalovirus (CMV) seropositive. Both episodes occurred late post-grafting during a phase of complete immunological recovery with sufficient numbers of circulating CMV-specific clones. Antiviral treatment with foscarnet and ganciclovir was successful but prolonged treatment was required to prevent relapses. We hypothesize that this complication was more related to an immune reconstitution process than to an immune-deficient state post-grafting. We conclude that CMV retinitis is a late complication of HSCT that can occur despite satisfactory immune reconstitution. Usually, it is responsive to antiviral therapy. Dilated fundoscopic examination is essential both for examining patients with reduced visual acuity and for screening asymptomatic patients.
Collapse
Affiliation(s)
- Simone Cesaro
- Pediatric Hematology Oncology, Department of Pediatrics, University of Padova, Via Giustiniani 3, 35128, Padova, Italy.
| | - Maria Paola Boaro
- Pediatric Hematology Oncology, Department of Pediatrics, University of Padova, Via Giustiniani 3, 35128, Padova, Italy
| | - Marta Pillon
- Pediatric Hematology Oncology, Department of Pediatrics, University of Padova, Via Giustiniani 3, 35128, Padova, Italy
| | - Elisabetta Calore
- Pediatric Hematology Oncology, Department of Pediatrics, University of Padova, Via Giustiniani 3, 35128, Padova, Italy
| | - Ivete Cermakova
- Service of Pediatric Ophthalmology, Department of Pediatrics, University of Padova, Padova, Italy
| | - Katia Perruccio
- Division of Hematology and Clinical Immunology, Department of Clinical and Experimental Medicine, IRCCS Foundation on Transplantation Biotechnologies, University of Perugia, Perugia, Italy
| | - Carlo Mengoli
- Department of Histology, Microbiology and Medical Biotechnology, University of Padova, Padova, Italy
| | - Chiara Messina
- Pediatric Hematology Oncology, Department of Pediatrics, University of Padova, Via Giustiniani 3, 35128, Padova, Italy
| |
Collapse
|
9
|
Affiliation(s)
- Torsten W Wiegand
- Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, USA
| | | |
Collapse
|