A prospective study of the role of cytomegalovirus in post-transfusion mononucleosis

Prevention of Transfusion-Transmitted Cytomegalovirus Infections: Which is the Optimal Strategy?

Traditionally, leukoreduction and selection of blood products from seronegative donors have been used as alternative strategies to reduce the risk of transfusion-transmitted cytomegalovirus infections (TT-CMV) in atrisk patients. After the introduction of universal leukoreduction for red blood cell and platelet concentrates in Germany, a controversy evolved as to whether the additional selection of blood products from seronegative donors would reduce or even increase the risk of TT-CMV. This review summarizes the current knowledge about CMV infections in blood donors and the implications of this information on the effect of potential transfusion strategies. Even though there are conflicting data about the incidence of TT-CMV remaining after the introduction of leukodepletion, it has been clearly shown that both prevalence and concentration of CMV DNA in peripheral blood are highest in newly seropositive donors. Therefore, avoidance of blood products from these donors is the most important goal of any transfusion strategy. This goal can be reached by: i) selection of blood products from seronegative donors, ii) provision of CMV DNA-negative blood products, or iii) provision of blood from long-term seropositive donors. In cases of suspected TT-CMV, all implicated donors should be investigated carefully to gather further knowledge on which donors confer the lowest risk for TT-CMV.

[Cytomegalovirus ileitis in a non-immunocompromised old patient: a case report]

INTRODUCTION

Cytomegalovirus ileitis occurs rarely in immunocompetent subjects.

CASE REPORT

An 88-year-old woman presented with severe pain located in right iliac fossa. Biological tests showed an increase in C-reactive protein and neutrophils. Colonoscopy revealed a severely ulcerated and inflamed terminal ileal mucosa. Histopathological analysis of biopsies showed a typical cytopathic effect with ballooned cells and intranuclear inclusions, confirmed by positive immunological marking with anti-cytomegalovirus antibodies. Cytomegalovirus polymerase chain reaction in the plasma showed positive activity. The patient was successfully treated with valganciclovir.

CONCLUSION

The predominant or isolated ileal location of cytomegalovirus infection should be known, especially in the elderly because aging could be a risk factor.

Incidence of cytomegaloviremia in blood-bank donors and in infants with congenital cytomegalic inclusion disease

During a 15-month period, cytomegalovirus (CMV) isolations were attempted from leukocytes derived from 290 healthy blood-bank donors. The major proportion of the specimens were tested 2 to 5 hr after donation. However, CMV was not recovered from any of the specimens examined. At the time of donation, 75% of donors had CMV complement-fixing antibodies demonstrable in titers of 10 to >/=320. The age of the study group ranged from 17 to 57 years. During the same time period and with the use of identical isolation techniques, postnatal cytomegaloviremia was demonstrated in four infants with cytomegalic inclusion disease. Failure to detect cytomegaloviremia in 290 normal blood donors questions its occurrence outside pathological conditions. These results do not support the concept that CMV infection, concurrent with post-transfusion mononucleosis syndrome, is transmitted through the blood donor's leukocytes.

Primary cytomegalovirus infection following open heart surgery

Among 674 patients undergoing open heart surgery in 1981-82, 86 (13%) were cytomegalovirus (CMV) antibody-negative when tested by an enzyme-linked immunosorbent assay prior to operation. At follow-up, 54 (67%) of 80 patients restudied had seroconverted after the operation, and 35 of the 54 seroconvertants had been ill with fever and elevated liver enzymes. Among the latter 35 patients, 26 demonstrated a significant rise in CMV antibody titre, most often detected in the third week following the onset of illness. The older patients were more susceptible to illness and seroconversion, and there was a positive correlation between age and the number of blood units given. Thus, at least one third of the seronegative patients developed symptomatic CMV illness after open heart surgery. This is a much higher incidence than earlier reported.

Human cytomegalovirus infection of human hematopoietic progenitor cells

For a number of years it has been well established that human cytomegalovirus (HCMV) can be transmitted by the cellular components of blood. HCMV is also associated with a number of hematologic disorders. Although HCMV was thought to be present in blood cells in a latent or persistent form, it was not known how the virus was maintained and which cells were the carriers of HCMV. In addition to peripheral blood cells, there has been clinical evidence that HCMV may be associated with specific disorders of the hematopoietic system. Recently, a number of advances in cell and molecular biology have helped to develop a better understanding of the relationship between HCMV and the hematopoietic system. The application of the polymerase chain reaction (PCR) to the study of HCMV infection has revealed that the virus was present in mononuclear cells with only limited transcription of its genome. Studies conducted in our laboratory have demonstrated that both CD34+ progenitor cells and monocytes could be infected with HCMV and virus recovered when the cells were allowed to terminally differentiate. Subsequently, these results have been confirmed in vivo: HCMV DNA and limited RNA transcripts could be detected in in vivo infected hematopoietic progenitor cells and HCMV has been rescued from macrophages derived through in vitro differentiation of monocytes from normal seropositive blood donors. Although our understanding of the relationship between HCMV and the hematopoietic system has been advanced, the mechanisms by which the virus can be maintained in a latent state and how it is reactivated is still unclear. Furthermore, it remains to be determined what HCMV-mediated effect is responsible for the inhibition of hematopoiesis following an in vitro infection and its significance in vivo.

Spread of Human Cytomegalovirus (HCMV) After Infection of Human Hematopoietic Progenitor Cells: Model of HCMV Latency

Clinical experience and laboratory data suggest that human cytomegalovirus (HCMV) is present in peripheral blood of seropositive individuals in a latent or persistent state and can be transmitted via blood products and be reactivated in seropositive imunocompromised patients. The pathophysiology of HCMV latency and the nature of HCMV interaction with hematopoietic cells remains unknown. In this study, we investigated the infection of bone marrow (BM) progenitor cells and their progeny as a model of HCMV latency. A clinical isolate and the recombinant laboratory strain Towne/lox containing the Escherichia coli β galactosidase (β-gal) gene regulated by immediately early (IE) HCMV promoter were used to infect highly purified CD34+ cells. Although the infection of these cells with a clinical isolate was associated with an inhibition of proliferation by 59%, an expansion of progeny derived from these cells was possible. Polymerase chain reaction analysis and staining for β-gal have shown that HCMV persisted in infected BM CD34+ cells and their progeny for up to 4 weeks. However, IE and late gene products (mRNA and protein) were detected only late in the course of infection and their expression correlated with terminal macrophage differentiation of the CD34+-derived progeny. Although early infection of CD34+ progenitor cells was not productive (as shown by the plaque assay), infectious virus could be recovered from the terminally differentiated cultures. BM progenitor cells may serve as a reservoir of the latent virus with limited transcription. Proliferation and monocytic maturation of infected progenitors may lead to the numerical expansion of HCMV-infected cells, which serve as a source of HCMV dissemination and reactivation.

Spread of Human Cytomegalovirus (HCMV) After Infection of Human Hematopoietic Progenitor Cells: Model of HCMV Latency

Clinical experience and laboratory data suggest that human cytomegalovirus (HCMV) is present in peripheral blood of seropositive individuals in a latent or persistent state and can be transmitted via blood products and be reactivated in seropositive imunocompromised patients. The pathophysiology of HCMV latency and the nature of HCMV interaction with hematopoietic cells remains unknown. In this study, we investigated the infection of bone marrow (BM) progenitor cells and their progeny as a model of HCMV latency. A clinical isolate and the recombinant laboratory strain Towne/lox containing the Escherichia coli β galactosidase (β-gal) gene regulated by immediately early (IE) HCMV promoter were used to infect highly purified CD34+ cells. Although the infection of these cells with a clinical isolate was associated with an inhibition of proliferation by 59%, an expansion of progeny derived from these cells was possible. Polymerase chain reaction analysis and staining for β-gal have shown that HCMV persisted in infected BM CD34+ cells and their progeny for up to 4 weeks. However, IE and late gene products (mRNA and protein) were detected only late in the course of infection and their expression correlated with terminal macrophage differentiation of the CD34+-derived progeny. Although early infection of CD34+ progenitor cells was not productive (as shown by the plaque assay), infectious virus could be recovered from the terminally differentiated cultures. BM progenitor cells may serve as a reservoir of the latent virus with limited transcription. Proliferation and monocytic maturation of infected progenitors may lead to the numerical expansion of HCMV-infected cells, which serve as a source of HCMV dissemination and reactivation.

Effect of hepatitis C antibody screening in blood donors on post-transfusion hepatitis in Taiwan

A national screening programme for antibody to hepatitis C virus (HCV) in blood donors in Taiwan began in July 1992 using a second-generation immunoassay. To study the impact of this screening on post-transfusion hepatitis in Taiwan, a prospective study on post-transfusion hepatitis, that was started in 1987, was continued. As of June 1994, 245 patients who received a blood transfusion after July 1992 had completed a follow-up period for more than 6 months post-transfusion. Of them, seven (2.8%) recipients developed acute post-transfusion hepatitis. The hepatitis in six cases could not be attributed to infection by hepatitis A, B, C, D, E viruses or cytomegalovirus (CMV) or Epstein-Barr virus (EBV). The remaining patient seroconverted to both IgG and IgM anti-CMV. All seven patients recovered in 6 months without development of chronicity, and the mean peak alanine aminotransferase level was lower compared with that of the cases before anti-HCV screening (i.e. pre-July 1992). These results indicate that the current anti-HCV screening has effectively interrupted HCV transmission through blood transfusion in Taiwan.

Human cytomegalovirus DNA is not detectable with nested double polymerase chain reaction in healthy blood donors

The PCR method was introduced to detect cytomegalovirus (CMV) DNA from 189 peripheral blood samples of volunteer donors. We adopted the nested double PCR method with primers specific for immediate early gene 1 followed by electrophoresis and ethidium bromide staining. This nested double PCR method was sensitive enough to detect approximately a single copy of CMV DNA. However, we failed to obtain positive amplification of CMV DNA from any of these donor samples. In contrast, CMV DNA could be detected in all 3 tested immunocompromised patients who had undergone bone marrow transplantation. These results support our previous report that the frequency of CMV DNA is of an order lower than 1 copy/10(5) leucocytes in the peripheral blood of healthy seropositive individuals.

Progressive encephalopathy associated with cytomegalovirus infection without immune deficiency

Slowly progressive encephalopathy caused by cytomegalovirus is an unusual disorder, and its pathogenesis remains unknown except for cases associated with the acquired immune deficiency syndrome and organ transplantation. We report a case who showed clinical features of progressive encephalopathy. Cytomegalovirus was repeatedly isolated from urine, and cytomegalovirus-infected cells were detected in bone marrow. Serial computed tomographic head scan revealed periventricular calcification and its progression to the thalamus, cerebellum, and brain stem. On autopsy, there were multiple calcifications and diffuse glial proliferation in the gray and white matter. Perivascular inflammation was only minimal. There was no evidence of immune deficiency. This case suggests that progressive encephalopathy can be caused by cytomegalovirus infection without immune deficiency. This type of cytomegalovirus infection may be unusual, but its serious outcome should remind us to detect it accurately.

Cytomegalovirus studies on blood donors in north-east Scotland and a review of UK data

The epidemiology of cytomegalovirus (CMV) infection as assessed by CMV antibody testing varies significantly in different parts of the world and also in different regions of a country. A study was therefore carried out to assess the prevalence of CMV antibody in our blood donors, looking in particular at different subgroups of donors as divided by age, sex and social class, to see how we could maximise the yield of CMV-negative blood from our testing. It was shown that patterns of CMV infection in the North East of Scotland followed well-established norms. Data from other Regional Transfusion Centres within the UK were also collected for comparison.

Transfusion-acquired cytomegalovirus infection in children in a hyperendemic area

Thirty-nine children without previous cytomegalovirus (CMV) infection received blood transfusion in the National Taiwan University Hospital. The overall transfusion-acquired CMV infection rate was 36% (14/39). Donor CMV seropositive rate was 70%. None of the nine children who had received seronegative blood became infected, in contrast to 14 of the 21 children (67%) who had received seropositive blood (P = 0.002). Another significant risk factor associated with CMV infection was the use of fresh blood: 13 of 15 (87%) with fresh seropositive blood were infected, in contrast to one of six (17%) with "old" seropositive blood (P = 0.01). Most of the fresh blood was used within 24 hours. This blood processing method was shown to account for the extremely high rate of CMV infection in those who had received fresh seropositive blood. The results indicated that the incidence of CMV infection can be reduced by avoiding the use of fresh blood, especially blood less than 24 hours old. For such a population in Taiwan with high prevalence of positive CMV antibody, this approach was more applicable than screening donor blood for CMV antibody.

Limiting the usage of blood products in cardiovascular surgery

We studied the effect of the initiation of a five part program of blood component conservation on blood product utilization in patients undergoing major cardiovascular surgery. We encouraged physicians and nurses to adhere to a set of guidelines that would limit the exposure of these patients to complications associated with blood product administration. Through this effort the amounts of packed red cells, fresh frozen plasma, platelets, and cryoprecipitate used were markedly reduced. After the start of the conservation program, overall blood product usage was reduced 29% despite a 46% increase in the surgical caseload, and there was a 53% decrease in the amount of donor exposure (units of individual blood products administered) per patient.

Transfusion-associated viral infections

Viral infections are a frequent occurrence following transfusion of blood products. While generally benign, these infections are capable of causing significant morbidity and mortality. Therefore, it is prudent to follow several general approaches diligently to reduce the risks of these infections in patients undergoing transfusions of blood products. These suggested measures include the following: 1. Prescribe and administer blood and blood products only when absolutely needed. 2. Use volunteer blood donors only. 3. Avoid use of pooled blood products when possible. 4. Use only blood and blood products that have been appropriately tested for HBsAg and HIV. 5. Use ALT determinations to screen blood products and eliminate those with high level. 6. Avoid the use of clotting-factor concentrates but, if necessary, use only those which have been heat-treated. 7. Limit use of leukocyte transfusion. 8. Use only CMV seronegative blood and blood products or frozen deglycerolized red cells in patients at high risk for posttransfusion CMV infection.

Transfusion-transmitted cytomegalovirus infections: significance and control

Cytomegalovirus (CMV) is a herpes virus which can give rise to primary infections, reactivated infections, or reinfections in humans. Seroepidemiologic studies have shown CMV infection to be worldwide with the highest antibody prevalences detected in Third World countries; however, significant regional variations can be seen within a given country. Antibody prevalence varies directly with age and inversely according to socioeconomic status. Numerous prospective studies of blood transfusion recipients carried out since 1966 have shown marked differences in infection rates but relatively little associated disease. Infection rates were highest in seronegative recipients given large amounts of fresh blood. Recently published reports have shown substantially lower infection rates than earlier studies, a change likely to be due to the current practice of transfusing fewer units of older blood. CMV has not been found to play a significant role in the etiology of posttransfusion hepatitis. CMV infections have been found to be an important source of morbidity and mortality in immunocompromised patients. Several studies of transfused, premature infants have shown significant differences in infection rates and disease expression. Seronegative low-birth-weight infants receiving blood from seropositive donors are at greatest risk. Blood from CMV-seronegative donors substantially lowers the risk of infection. Receiving a kidney or heart from a CMV-seropositive donor appears to be a more salient risk factor than blood transfusion in renal and cardiac transplant patients who are also more likely to have symptomatic CMV infections. Leukocyte transfusions have been found to be a significant source of CMV infection and disease in bone marrow transplant patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Neonatal cytomegalovirus infections due to blood

Infants with very low birthweights (less than 1250g) are immunocompromised and have immature hematopoietic systems. They require frequent blood transfusions and have an increased susceptibility to infection. These very low birthweight infants who lack passively acquired antibody against CMV, acquire transfusion-associated CMV infections with a frequency of approximately 30%. These infections are associated with significant morbidity and mortality. The source of these postnatally acquired CMV infections are seropositive blood donors. These infections can be prevented by appropriate donor selection and/or blood processing. Recent but limited data suggests that all infants (regardless of birthweight or the presence of antibody against CMV) should receive CMV seronegative blood products if they are likely to receive multiple transfusions from multiple donors.

A new method of autotransfusing blood drained after cardiac surgery

Ideally, autotransfusion after cardiac surgical procedures should offer the protection of underwater-seal drainage and involve additional cost to the patients only if their blood is reinfused. A technique of returning the patient's postoperatively drained blood that employs these features and that we have found to be safe, simple, and cost-effective is presented.

Transfusion-acquired cytomegalovirus infection in cardiac surgery patients

The incidence of transfusion-acquired primary cytomegalovirus (CMV) infection was studied in 483 cardiac surgery patients. Ninety-six patients (20%) were found to lack antibody to CMV [CMV Ab(-)] as measured by radioimmunoassay. Sixty-eight CMV Ab(-) were followed by viral culture and/or serology from eight weeks to one year after transfusion. Transfusion requirements in CMV Ab(-) patients were as follows: whole blood/packed red blood cells, mean 4.7 +/- 2.6 units; platelets (20 patients), 6.9 +/- 3.8 units; fresh frozen plasma (25 patients), mean 3.3 +/- 1.6 units. Forty-nine percent of 235 donor units tested had antibody to CMV. One donor unit (0.4%) had CMV-specific IgM. This was not associated with CMV infection in the recipient. One patient (1.5%) demonstrated evidence of seroconversion to CMV during the follow-up period. This is significantly less than reported in previously published studies (P less than .01). Serological methods used, the age of the transfused blood, the immune status of the transfusion recipient, and the administration of passive antibody in fresh frozen plasma are factors that may be responsible for the low incidence observed.

IgM detection by ELISA in the diagnosis of cytomegalovirus infections in homosexual and heterosexual immunosuppressed patients

A new commercially developed cytomegalovirus (CMV)-IgM ELISA was found to be sensitive and specific when compared with sucrose gradient fractionation of Ig classes in CMV antibody-positive and negative sera. The presence of CMV IgM in patients' sera correlated with positive virus isolation from circulating mononuclear blood cells and urine. Serial examinations of patients with primary or recent CMV infection revealed a typical sequence of IgM and IgG development. The frequency of CMV isolation declined as the concentration of IgM decreased and the IgG levels increased. Since the isolation of CMV from clinical specimens is a cumbersome procedure, we suggest that the IgM ELISA could provide rapid and valuable information on the presence of an active or reactivated CMV infection.

Polyarteritis nodosa associated with acute cytomegalovirus infection

A case of polyarteritis nodosa is described in which the onset of the disease was associated with acute infection by cytomegalovirus. Peripheral neuropathy was the predominant clinical feature, and death occurred 4 years after the onset. This is the first recorded case of polyarteritis in which cytomegalovirus is of possible aetiological significance.

Cytomegalovirus myocarditis

A male patient, aged 31 years, with a cytomegalovirus (CMV) myocarditis is described, who showed a high IgM antibody titer for cytomegalovirus infection of 1:1,024 and a rise of the titer for complement-fixing antibody from 1:< 16 to 1:256. CMV could be isolated from the urine. Investigations for other etiological factors were negative, and we assumed a connection between the cytomegalovirus infection and the myocardial involvement.

Cytomegaloviruria in older infants in intensive care nurseries

Over a four-month period, urine specimens for viral isolation were obtained weekly from all infants older than three weeks in two intensive care nurseries. These babies comprised 43% of the patients in the nurseries surveyed. Cytomegalovirus was cultured from 13 of 93 (14%) of these infants. Eleven of 13 infants who developed cytomegaloviruria were born prematurely, and nine of these 11 were found to be excreting CMV before they reached 40 weeks postconception. Infants excreting CMV received blood transfusions from a mean of 10.45 (+/- 1.80 SE) different donors versus 5.10 (+/- 0.55 SE) for infants without viruria (P less than 0.002) and five of 14 infants undergoing one or more exchange transfusions developed cytomegaloviruria (P less than 0.05). The possible role of other CMV reservoirs and the importance of these findings are discussed.

Cytomegalovirus granulomatous hepatitis

Three patients with granulomatous hepatitis due to cytomegalovirus are described. They are compared to the three previously described patients with this disease, and their clinical and serologic characteristics are discussed. Similarities and differences between infectious mononucleosis (Epstein-Barr virus) and cytomegalovirus infections are adduced. That cytomegalovirus may be a cause of granulomatous hepatitis in the adult is stressed.

Blood as a potential vehicle for the cytomegaloviruses

This study analyzed transfused blood as a potential vehicle for infectious cytomegalovirus (CMV) particles. A total of 207 patients who received a total number of 897 units of blood were monitored. A complement-fixing antibody titer of 1:8, as determined by micro-titer technique, was observed in 14.8 per cent of the blood units. A total of 140 individuals in this study were serosusceptible. Eighty-six serosusceptible individuals did not receive blood containing complement-fixing CMV antibodies. In this patient population three instances of seroconversion were identified. Among the 54 serosusceptible individuals who received at least one unit of blood whose complement-fixing titer to the AD-169 strain of CMV was 1:8 or greater, 13 seroconversions were observed.

Cytomegaloviremia in children with acute lymphocytic leukemia

Leukocyte and urine cultures were done at monthly intervals in 36 children with acute lymphocytic leukemia known to be excreting cytomegalovirus in their or saliva in order to determine the relationship of viremia to clinical cytomegalic inclusion disease. Eleven of 36 (30.5%) patients had viremia. Viremia was related to clinical disease in only three patients; two with chorioretinitis and one with a CMV monomucleosis syndrom. However, the presence of viremia did not serve as a useful means to determine active CID. Viremic patients with CID all had elevated serum levels of IgM and multiple episodes of viremia. Viremia was not related to the duration, type or number of drugs used in immunosuppression, nor to the hematologic status of leukemia. Viremic patients received more blood transfusions than noviremic patients, but the administration of blood products could not be related to the acquisition of infection. Leukopenia, neutropenia, total lymphocyte count, fourfold rise or fall in complement-fixing titer, and viruria had no consistent relationship to viremia or clinical CID.

Diagnosis and management of complications of prosthetic heart valves

Complications after heart valve replacement remain a substantial source of morbidity and mortality despite continuing advances in surgical care and prosthetic design. Infectious endocarditis occurs in about 4 percent of patients and may appear early (within 60 days) or late after operation. Endocarditis of early onset is commonly due to staphylococcal, fungal or gram-negative organisms and is fatal in 70 percent or more of cases. Infection of late onset is more often of streptococcal origin and the mortality rate is lower, about 35 percent. With either type, prompt recognition, vigorous and appropriate antimicrobial therapy and early consideration of surgical intervention are crucial. The postperfusion and postpericardiotomy syndromes are relatively common and relatively benign syndromes associated with postoperative fever. Their recognition is important to prevent confusion with endocarditis or sepsis and thus to reassure the patient and physician. Treatment is primarily symptomatic. Intravascular hemolysis occurs with most prosthetic heart valves but is more common with certain prostheses and with paraprosthetic valve regurgitation, with significant hemolytic anemia in 5 to 15 percent. Oral iron replacement therapy is effective in the majority of patients, but occasionally blood transfusion or reoperation for leak around the prosthesis is necessary. Prosthesis dysfunction due to thrombus may be recognized clinically by recurrence of heart failure, syncope, cardiomegaly and altered prosthetic valve sounds or new murmurs. Hemodynamic studies verify the diagnosis, and prompt reoperation is indicated for this potentially lethal problem. Systemic embolization has decreased markedly with the introduction of cloth-covered prostheses and is frequently related to erratic or ineffective anticoagulant therapy. We continue to recommend anticoagulant therapy for all patients with prosthetic heart valves unless there is a major contraindication.