A serologic study of cytomegalovirus infections associated with blood transfusions

Study of the Frequency of Herpesvirus Infections Among Patients Suspected Aseptic Meningitis in the West of Iran

Background:

Aseptic meningitis is the most common type of meningitis and is characterized by meningeal inflammation that is not linked to identifiable bacterial pathogens in cerebrospinal fluid (CSF).

Objectives:

This study aimed to evaluate the frequency of aseptic meningitis caused by herpesviruses, namely herpes simplex types I and II (HSV-1, HSV-2), Epstein-Barr virus (EBV), cytomegalovirus (CMV) and varicella-zoster virus (VZV).

Patients and Methods:

A total of 196 CSF samples were collected from patients with suspected meningitis. All samples were smear- and culture-negative for bacterial pathogens. The biochemical and cytological findings of CSF samples were also recorded. DNA was extracted from samples and PCR with specific primers was carried out to detect viruses.

Results:

The 196 samples derived from 100 (52%) men and 96 (48%) women ranging in age from one day to 86 years with an average age of 32.3 ± 25.3 years. Of them, 8 (4.08%) samples yielded positive results, including 5 (2.55%) cases of VZV infection and 3 (1.53%) cases of HSV-1 infection. No cases of HSV-2, CMV or EBV infection were detected. CSF protein and glucose levels among positive cases were all in the normal range.

Conclusions:

The results indicate a considerable rate of herpesvirus infection in patients with aseptic meningitis, and that VZV is the most common herpesvirus to cause infection followed by HSV-1. Our results also showed that a moderate increase in the WBC count and predominance of lymphocytes can be valuable clues in diagnosing viral meningitis. Given the different approaches of drug therapy in bacterial and viral meningitis, use of molecular methods is necessary in hospitals to rapidly discriminate between them.

Cytomegalovirus hijacks CX3CR1(hi) patrolling monocytes as immune-privileged vehicles for dissemination in mice

Peripheral blood myelomonocytic cells are important for cytomegalovirus dissemination to distal organs such as salivary glands where persistent replication and shedding dictates transmission patterns. We find that this process is markedly enhanced by the murine cytomegalovirus (MCMV)-encoded CC chemokine, MCK2, which promotes recruitment of CX3CR1(hi) patrolling monocytes to initial infection sites in the mouse. There, these cells become infected and traffic via the bloodstream to distal sites. In contrast, inflammatory monocytes, the other major myelomonocytic subset, remain virus negative. CX3CR1 deficiency prevents patrolling monocyte migration on the vascular endothelium and interrupts MCMV dissemination to the salivary glands independent of antiviral NK and T cell immune control. In this manner, CX3CR1(hi) patrolling monocytes serve as immune-privileged vehicles to transport MCMV via the bloodstream to distal organs. MCMV commandeers patrolling monocytes to mediate systemic infection and seed a persistent reservoir essential for horizontal transmission.

Human cytomegalovirus latent infection and associated viral gene expression

Human cytomegalovirus (HCMV) is a clinically important and ubiquitous herpesvirus. Following primary productive infection the virus is not completely eliminated from the host, but instead establishes a lifelong latent infection without detectable virus production, from where it can reactivate at a later stage to generate new infectious virus. Reactivated HCMV often results in life-threatening disease in immunocompromised individuals, particularly allogeneic stem cell and solid organ transplant recipients, where it remains one of the most difficult opportunistic pathogens that complicate the care of these patients. The ability of HCMV to establish and reactivate from latency is central to its success as a human pathogen, yet latency remains very poorly understood. This article will cover several aspects of HCMV latency, with a focus on current understanding of viral gene expression and functions during this phase of infection.

Post-transfusion hepatitis in a London hospital: results of a two-year prospective study

Seven hundred and sixty-eight patients were seen and tested at frequent intervals after transfusion of whole blood. Eight patients were judged to have developed icteric or anicteric post-transfusion viral hepatitis, an incidence of 1%. Five were icteric and four of these were hepatitis B antigen (HB Ag) positive; two of these four died. One of the fatal cases and one non-fatal HB Ag positive case had received HB Ag positive blood. Two other antigen-positive patients had received blood or plasma or both which had not been tested for antigen.

Thirty-five patients showed conspicuous or sustained elevations of alanine transaminase without clinical features of hepatitis.

Four were positive for HB Ag but had not received antigen positive blood.

Two who had received antigen positive blood remained antigen negative, but one developed hepatitis B antibody (HB Ab).

Two other patients were also transfused with plasma.

Five had serological evidence of cytomegalovirus (CMV) infection accompanying the enzyme changes.

One patient who had received HB Ag positive blood remained antigen-negative and showed no abnormalities.

Five patients who became HB Ag positive, although they had been given antigen-negative blood, remained clinically and biochemically well.

Cytomegalovirus primary infection or reactivation occurred in another 32 patients; five had isolated, transient enzyme rises, one other was associated with a drug-induced focal liver necrosis and 26 showed no enzyme changes. Epstein–Barr virus infections, one of which was associated with a transient upset of enzyme activity, were detected in five patients. There were no cases of post-perfusion syndrome.

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.

Treatment of congenital cytomegalovirus infection: implications for future therapeutic strategies

Cytomegalovirus (CMV) infection is the most common cause of congenital infection in the developed world, occurring in approximately 1% of all liveborns. Symptomatic disease occurs in 10% of all congenitally infected infants, resulting in a spectrum of clinical manifestations that include microcephaly, chorioretinitis, hepatosplenomegaly and sensorineural hearing loss, among others. Even those children who are asymptomatic at birth have a risk of hearing loss, with approximately 8% experiencing this sequela. Overall, congenital CMV infection accounts for one-third of all cases of sensorineural hearing loss. The economic burden of disease exceeds $2 billion annually in the USA. Therefore, this infection has been the target for antiviral therapy. Studies performed by the National Institute of Allergy and Infectious Diseases Collaborative Antiviral Study Group (CASG) have evaluated ganciclovir for the treatment of symptomatic congenital CMV infection with central nervous system involvement. In a randomized, controlled clinical trial of ganciclovir treatment (6 mg/kg iv every 12 h for 6 weeks) brainstem-evoked responses were utilized as the primary endpoint and demonstrated stabilization of hearing both at 6 months and >1 year. Treatment was associated with neutropenia in over 60% of treated patients. Since ganciclovir must be given intravenously, studies with its prodrug, valganciclovir, have been performed to assess pharmacokinetics and pharmacodynamics. Currently, a clinical trial of 6 weeks versus 6 months of valganciclovir is being performed by the CASG. Notably, only intravenous ganciclovir and orally administered valganciclovir have been used to treat congenital CMV infection. Hopefully, other drugs such as maribavir will be available for evaluation in this population.

Bench-to-bedside review: rare and common viral infections in the intensive care unit--linking pathophysiology to clinical presentation

Viral infections are common causes of respiratory tract disease in the outpatient setting but much less common in the intensive care unit. However, a finite number of viral agents cause respiratory tract disease in the intensive care unit. Some viruses, such as influenza, respiratory syncytial virus (RSV), cytomegalovirus (CMV), and varicella-zoster virus (VZV), are relatively common. Others, such as adenovirus, severe acute respiratory syndrome (SARS)-coronavirus, Hantavirus, and the viral hemorrhagic fevers (VHFs), are rare but have an immense public health impact. Recognizing these viral etiologies becomes paramount in treatment, infection control, and public health measures. Therefore, a basic understanding of the pathogenesis of viral entry, replication, and host response is important for clinical diagnosis and initiating therapeutic options. This review discusses the basic pathophysiology leading to clinical presentations in a few common and rare, but important, viruses found in the intensive care unit: influenza, RSV, SARS, VZV, adenovirus, CMV, VHF, and Hantavirus.

The Role of Photochemical Treatment With Amotosalen and UV-A Light in the Prevention of Transfusion-Transmitted Cytomegalovirus Infections

Primary cytomegalovirus (CMV) infection is usually asymptomatic in immunocompetent patients but can cause serious life-threatening complications in immunocompromised CMV-seronegative patients, including patients receiving a bone marrow or peripheral blood stem cell transplant, recipients of some solid-organ transplants, and low-birth-weight neonates. Current recommendations for preventing transfusion-transmitted CMV (TT-CMV) infection in these patients include exclusive use of CMV-seronegative and/or leukoreduced cellular blood components (red blood cells and platelets) for transfusion. However, breakthrough cases of TT-CMV still occur. Despite improving the safety of blood components, testing remains a reactive approach to blood safety. In contrast, pathogen inactivation technologies offer a proactive approach with the potential to further improve blood safety. To reduce the risks associated with platelet transfusions, a photochemical treatment (PCT) process using a combination of the psoralen amotosalen HCl and long-wavelength UV light has been developed and introduced into clinical practice in Europe. PCT has been shown to result in greater than 5.9-log reductions in infectivity of human CMV in platelet concentrates and to prevent the transfusion transmission of murine CMV in a mouse transfusion model. Thus, PCT pathogen inactivation may play a role in further reducing the incidence of TT-CMV infection in patients who are at risk for serious CMV disease. Because PCT is a technology that targets nucleic acids, it also offers a proactive process for the inactivation of a broad range of viral, bacterial, and protozoan pathogens in addition to CMV.

Impact of allogenic packed red blood cell transfusion on nosocomial infection rates in the critically ill patient

OBJECTIVE

To determine whether critically ill patients who receive allogenic packed red blood cell transfusions are at increased risk of developing nosocomial infections during hospitalization.

DESIGN

Retrospective database study utilizing Project IMPACT.

SETTING

A 40-bed medical-surgical-trauma intensive care unit in an 825-bed tertiary referral teaching hospital.

PATIENTS

One thousand seven hundred and seventeen patients admitted to the medical-surgical-trauma intensive care unit.

MEASUREMENTS AND MAIN RESULTS

Data were collected by using the Project IMPACT database. Nosocomial infection rates were compared among three groups: the entire cohort, the transfusion group, and the nontransfusion group. We determined the nosocomial infection rates in these groups while adjusting for probability of survival by using Mortality Prediction Model (MPM-0) scores, age, gender, and number of units of packed red blood cells transfused. The average number of units transfused per patient was 4.0. The nosocomial infection rate for the entire cohort was 5.94%. The nosocomial infection rates for the transfusion group (n = 416) and the nontransfusion group (n = 1301) were 15.38% and 2.92%, respectively (p <.005 chi-square). Transfusion of packed red blood cells was related to the occurrence of nosocomial infection, and there was a dose-response pattern (the more units of packed red blood cells transfused, the greater the chance of nosocomial infection; p< 0.0001 chi-square). The transfusion group was six times more likely to develop nosocomial infection compared with the nontransfusion group. In addition, for each unit of packed red blood cells transfused, the odds of developing nosocomial infection were increased by a factor of 1.5. A subgroup analysis of nosocomial infection rates adjusted for probability of survival by using MPM-0 scores showed nosocomial infection to occur at consistently higher rates in transfused patients vs. nontransfused patients. A second subgroup analysis adjusted for patient age showed a statistically significant increase in rates of nosocomial infection for transfused patients regardless of age.

CONCLUSIONS

Transfusion of packed red blood cells is associated with nosocomial infection. This association continues to exist when adjusted for probability of survival and age. In addition, mortality rates and length of intensive care unit and hospital stay are significantly increased in transfused patients.

CMV and blood transfusions

Among the human herpesviruses, cytomegalovirus (CMV) is the only one that has assumed significant importance in blood transfusion. Transfusion transmission of CMV (TT-CMV) to seronegative immunocompromised patients can lead to lethal CMV disease. Studies over the past 30 years have demonstrated that monocytes latently infected with CMV represent the primary vector for TT-CMV, and that TT-CMV can be largely abrogated by transfusing at-risk patients with either seronegative units or blood filtered to remove white blood cells. However, the small number of cases of breakthrough TT-CMV that follow transfusion of either seronegative or filtered blood still produce morbidity and mortality. These circumstances have motivated ongoing efforts to provide improved protection from TT-CMV, including the use of CMV DNA amplification for blood screening, and pathogen inactivation to sterilise all blood components prior to transfusion.

A 15-year experience with varicella infections in a pediatric burn unit

Because of their well described global immunosuppression, varicella infection may be hazardous in burned children. It is therefore important to prevent cross-infections within pediatric burn units. We describe a 15-year experience with varicella in a pediatric burn unit, focusing on the morbidity associated with the infection and measures that have been effective in the prevention of cross-infection. We found that varicella infection in acutely burned children is associated with pneumonitis, but little wound related morbidity. Despite the deceptively long incubation period, prompt identification and isolation of index cases was associated with an extremely low incidence of cross-infection. Until widespread administration of varicella vaccine confers herd immunity, varicella remains a threat to hospitalized young children, highlighting the importance of a well planned and executed index case isolation strategy.

Development of a quadriplex polymerase chain reaction for human cytomegalovirus detection

The development of a quadriplex PCR method with amplification of HCMV in a single-step procedure using primers taken from four different regions of the viral genome is described. Different concentrations of dNTPs and MgCl2 were assayed in order to optimize the constitution of the buffer for the multiplex PCR. The specificity of the PCR was tested with 100 ng, 10 ng, and 1 ng of genomic MRC-5 cell DNA infected with CMV in the presence of 10 microg of uninfected MRC-5 cell DNA. The sensitivity of the PCR was evaluated by the amplification of various amounts (100 ng, 10 ng, 1 ng, and 0.1 ng) of genomic MRC-5 cell DNA infected with CMV. The specificity and sensitivity assays were performed for each pair of primers and for the combined four primer pairs in the multiplex PCR. CMV was consistently detected from 10 ng of genomic MRC-5 cell DNA with each primer pair. When all four sets of primers were combined in a single reaction tube, the sensitivity of the assay was equivalent to 10 ng of genomic MRC-5 cell DNA, whereas amplification from 1 ng genomic MRC-5 cell DNA produced only a subset of the amplimers. By amplifying four target-sequences of HCMV simultaneously with minimum incubation time at each temperature, a quadriplex, highly sensitive PCR assay was performed. The use of four primer sets designed in different genomic regions of HCMV allowed the detection of variants and achieved maximal sensitivity and specificity which are essential for a diagnostic utilization.

Lack of difference in cytomegalovirus transmission via the transfusion of filtered-irradiated and nonfiltered-irradiated blood to newborn infants in an endemic area

BACKGROUND

It is accepted that white cells contained in blood components are the most significant source of cytomegalovirus (CMV) infection in immunocompromised and immunodeficient recipients.

STUDY DESIGN AND METHODS

To determine whether white cell filtration of blood would be effective in preventing infection among newborn transfusion recipients in a hyperendemic area, a randomized study was performed. All donor blood units were irradiated before issue to prevent posttransfusion graft-versus-host disease. Recipients were monitored for CMV infection by seroconversion (development of IgM anti-CMV) and CMV-DNA isolation.

RESULTS

Three (9%) of 33 infants who received filtered blood and 1 (5%) of 19 infants given nonfiltered blood were infected with CMV, as determined by the presence of IgM anti-CMV and/or CMV DNA isolation.There was no significant difference in the rate of CMV infection in the two groups.

CONCLUSION

The CMV infection observed in the study may come from other routes such as breastfeeding, rather than from transfusion. Our findings suggest that the routine use of white cell-reduction filtration to reduce the risk of transmitting CMV is unwarranted for neonates in endemic regions.

Frequency, predictors, and appropriateness of blood transfusion after percutaneous coronary interventions

Increased awareness of the risks of blood-borne infections has recently led to profound changes in the practice of transfusion medicine. These changes include, among others, the development of guidelines by the American College of Physicians (ACP) for transfusion. Although the incidence and predictors of vascular complications of percutaneous interventions have been well defined, there are currently no data on frequency, risk factors, and appropriateness of blood transfusions. We performed a retrospective analysis of 628 consecutive percutaneous coronary revascularization procedures. Predictors of blood transfusion were identified using multivariate logistic regression analysis. Appropriateness of transfusions was determined using modified ACP guidelines. Transfusions were administered after 8.9% of interventions (56 of 628). Multivariate analysis identified age >70 years, female gender, procedure duration, coronary stenting, acute myocardial infarction, postprocedural use of heparin and intra-aortic balloon pump placement as independent predictors of blood transfusions (all p <0.05). According to the ACP guidelines, 36 of 56 patients (64%) received transfusions inappropriately. Transfusion reactions (fever) occurred in 10% of patients who received tranfusions appropriately and in 5% of patients who received tranfusions inappropriately. The estimated additional costs per procedure related to transfusions were $551 and $419, respectively. In conclusion, unnecessary transfusions were performed frequently after percutaneous coronary interventions. Application of available guidelines could reduce the number of unnecessary transfusions, thus avoiding exposure of patients to additional risks and reducing procedural costs.

Transfusion-transmitted cytomegalovirus: the part-time pathogen

Viral infection is a well-known risk of blood product transfusion and much work has been devoted to the detection of such well-known pathogens as human immunodeficiency virus and hepatitis viruses in blood donors. Cytomegalovirus (CMV) is found in a much larger percentage of donor units than these other viruses but will cause disease in only a minority of recipients. Many pediatric patients (especially premature infants) are at risk for transfusion-transmitted CMV. This review describes work delineating the populations of patients most at risk for transfusion-transmitted CMV, describes methods for detecting CMV in blood donors, evaluates current methods for leuko-depletion of blood products, and provides recommendations for patients most likely to benefit from blood products with low risk of CMV transmission.

Human cytomegalovirus infection of the monocyte/macrophage lineage in bone marrow

Peripheral blood monocytes (PBM) are one site of persistence of human cytomegalovirus (HCMV) in healthy carriers. However, because PBM circulate only briefly before entering the tissues and are difficult to infect with HCMV, it has been suggested that they may acquire HCMV during development in the bone marrow. Consistent with this, we show evidence that bone marrow progenitors from healthy HCMV carriers contain endogenous HCMV DNA as detected by PCR. We also show that bone marrow precursors are readily infected by clinical isolates of HCMV in vitro but that no viral gene expression occurs until these cells become differentiated. In contrast, incubation of these cells at any developmental stage with the laboratory strain AD169 resulted in few cells expressing viral immediate-early genes, and this correlated with a lack of entry of AD169 virus. These observations are consistent with bone marrow progenitors acting as a reservoir for HCMV and transmitting the viral genome to PBM, in the absence of lytic-gene expression, until they leave the circulation and undergo tissue-specific differentiation to macrophages.

Cytomegalovirus and latency: an overview

Cytomegalovirus (CMV) is a member of the herpes virus group. Infection results in a variety of disorders which depend largely on the immune status of the host. A well known property of CMV is that after primary infection the virus persists in the body of the host resulting in latency. Severe immunodepression or immunodeficiency can cause reactivation of the virus from its latent state, leading to endogenous reinfection. In contrast to other herpes viruses, such as herpes simplex virus which persists in neurons, and Epstein Barr virus which persists in B lymphocytes, little is known about the localization of latent CMV. In order to obtain more insight in the organ or cell type serving as a reservoir for latent CMV, it is important to know more about the course of natural infection and the cells and organs involved. When more information is available about the localization of latent virus, studies concerning the physical state of viral DNA or the extent of viral transcription and/or translation will follow in the near future. In this review some properties of the epidemiology and transmission of human CMV, as well as data about acute infection will be given. In addition, some characteristics of the localization of latent CMV and the physical state of the virus will be discussed. Where necessary, particularly regarding insight into CMV-host interactions, knowledge of animal, particularly murine, rat and guinea pig CMV infections, will be discussed.

Leukodepleted blood components

The use of leukodepleted blood components may reduce some adverse effects of transfusion in certain clinical situations. This review outlines the recognised effects of contaminating passenger leucocytes, the value of leukodepleted components in preventing some of these complications, methods of leukodepletion and the current recommendations for use of these components.

The incidence and consequences of cytomegalovirus transmission via blood transfusion to low birth weight, premature infants in north east Scotland

In a 2-year study involving 133 premature low birth weight (less than 1,500 g) infants, the impact of CMV infection via blood transfusion was assessed. 8.4% (7 out of 83) of transfused infants and 10% (7 out of 70) of those exposed to seropositive blood acquired CMV. In those less than 1,250 g the infection rate rose to 13.2% (7 out of 46). Seropositive infants were at a higher risk of acquiring CMV infection than seronegative ones. CMV infection did not give rise to specific immediate morbidity, and no deaths were attributed to CMV. The only source of nosocomial CMV infection was the transfused seropositive blood. Based on these findings, it was possible to formulate a CMV transfusion policy to premature infants in our region.

Blood-borne Infections Associated with Transfusion

The epidemic of acquired immunodeficiency syndrome (AIDS) and the realization that transmission of human immunodeficiency virus is caused by homologous blood transfusion have changed the way physicians and their patients view the safety of hemotherapy. Considering that nearly four million patients receive the lifesaving benefits of blood transfusions every year in the United States, we need to recognize and reduce the inherent biological complications of this therapy. Currently, a major concern is the transmission of blood-borne infectious agents and the establishment of persistent infection in transfusion recipients, which is apparently facilitated by suppression of the recipient's hematopoietic and immune systems. Education of blood donors, patients, and attending physicians regarding infectious complications of transfusion is essential and remains the most effective procedure for making rational decisions. Before giving blood transfusions, astute physicians should calculate a risk/benefit ratio and communicate it to the patient or family. Potential recipients of transfusions can be assured that the blood supply is safer now than at any time in the past, although there is still a very small risk for the transmission of infectious agents that cause chronic diseases, such as hepatitis, AIDS, neuropathies, and leukemias. It is essential that everyone understands that the goal of a zero-risk blood supply is not attainable. Recent developments in molecular biology and biotechnology, however, provide opportunities for further reduction of infectious complications of blood transfusions.

UltramicroELISA indirecto para la deteccion de anticuerpos totales a citomegalovirus en suero humano

Se normalizó un ultramicroELISA indirecto para la detección de anticuerpos a Citomegalovirus (CMV) humano (UMELISA CMV). Se determinó la concentración óptima de antígeno en 30 ug/ml, la dilución de los sueros fue de 1:40 y la dilución de trabajo del conjugado fue de 1:1500. El UMELISA CMV fue comparado con las técnicas de aglutinación de latex para anticuerpos anti-CMV (Dupont de Neumors) y la inmunofluorescencia indirecta (EFT). Los resultados mostraron un alto grado de concordancia y elevada copositividad y conegatividad del UMELISA con respecto a estos dos ensayos. El método es válido para el pesquisaje de anticuerpos en banco de sangre asi como para el diagnóstico de la infección mediante sueros pareados.

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.

Biological Agents in Infectious Diseases

This article examines the use of classical as well as novel immunological agents to augment the immune system. Strategies to prevent infectious disease using vaccines to prime the immune system are discussed. A prospective overview of acquired immunodeficiency syndrome (AIDS) vaccine development provides insights into the possible agents that may be developed in the near future. The rationale for the use of intravenous immunoglobulin and colony stimulating factors in selected clinical situations is also discussed.

Snake venom coagulopathy: use and abuse of blood products in the treatment of pit viper envenomation

Coagulopathies are commonly encountered in victims of pit viper envenomation. In the majority of patients these defects improve with administration of antivenin. However, blood products are often transfused based on arbitrary criteria and with significant risk to the patient. This article documents the effectiveness and risks of antivenin administration and the risks of blood product transfusion. We recommend that blood products not be used except for clearly defined clinical indications.

Intestinal perforation due to cytomegalovirus infection in patients with AIDS

Intestinal perforation due to cytomegalovirus (CMV) infection in patients with AIDS is the most common life-threatening condition requiring emergency celiotomy in these patients. The authors describe a patient with AIDS with intestinal perforation due to CMV infection, and review 14 additional cases reported in the English-language surgical literature. The diagnostic triad of pneumoperitoneum on x-ray, evidence or history of CMV infection, and AIDS occurred in 70 percent of patients. The most common site of intestinal perforation was the colon (53 percent), followed in frequency by the distal ileum (40 percent) and appendix (7 percent); perforation usually occurred between the distal ileum and splenic flexure of the colon. Colonoscopy, rather than sigmoidoscopy, is recommended as a screening examination in patients with AIDS suspected of having colonic ulceration due to CMV infection. Multiple biopsies of ulcerated tissue should be obtained. Gross and microscopic analyses of involved intestinal tissue reveal the characteristic findings of ulceration and CMV infection. Despite aggressive therapy, the operative mortality rate in patients with AIDS with intestinal perforation due to CMV infection was 54 percent and the overall mortality rate was 87 percent. Postoperative complications occurred in most patients and consisted mainly of systemic sepsis and pneumonia caused by Pneumocystis carinii infection. An increased awareness of this syndrome by physicians frequently called on to manage patients with AIDS is recommended.

Incidence and morbidity of cytomegaloviral infection in patients with mediastinitis following cardiac surgery

To determine the incidence and morbidity of infections with CMV associated with mediastinitis after conventional cardiac surgery, 115 consecutive adult patients with mediastinitis were evaluated with viral cultures of blood and urine. Shedding of CMV was seen in 29 patients (25 percent) within a mean period of 37 +/- 22 days after cardiopulmonary bypass. Viremia was documented in 79 percent (23) of these 29 patients. Acute renal failure and enzymatic abnormalities (AST and LDH) were significantly more common in patients with virologically proven infection with CMV (p less than 0.05). In patients who survived the initial period of bacterial infection, major differences in their clinical course were observed according to their virologic status. After the 15th day of hospitalization following the débridement, the persistence of local infection was more frequent (p less than 0.05) and the mortality was higher (p less than 0.01) in CMV-infected patients. Moreover, the mean duration of hospitalization in the ICU for survivors was 69 +/- 36 days in viral shedders, compared with 48 +/- 27 days in nonshedders (p less than 0.05). Infection with CMV in mediastinitis occurs frequently and is associated with persistence of local infection, prolonged hospitalization, and increased late mortality.

The importance of cytomegalovirus in heart-lung transplant recipients

The first 33 heart-lung transplant recipients in our series were studied for evidence of CMV infection. CMV infection was diagnosed by a change in the serologic status, viral culture, or histology of lung tissue. Of 18 patients who were preoperatively negative for CMV antibody, eight received organs from CMV antibody-positive donors. Five developed pneumonitis (fatal in three)l; one survived primary CMV of the GI tract. Those who recovered from CMV pneumonitis received IV ganciclovir with CMV hyperimmune globulin given prophylactically from the time of transplantation. Only three of ten antibody-negative patients receiving organs from antibody-negative donors developed primary CMV, characterized by only fever in two but associated with rejection, and repeated infection was fatal in a third. CMV reactivation/reinfection occurred in seven of 15 (47 percent) without clinical disease in all but one case. Following heart-lung transplantation, CMV is the cause of considerable mortality and morbidity. We recommend that CMV antibody-negative recipients should receive organs only from antibody-negative donors. If a donor/recipient mismatch occurs, hyperimmune globulin and ganciclovir may improve survival.

Gastric mucosal nodules due to cytomegalovirus infection

We report a patient who developed cytomegalovirus infection after receiving a heart transplant. Nodular gastric lesions were noted on radiologic and endoscopic examinations. Endoscopic biopsy provided early evidence of cytomegalovirus infection.

Prevention of CMV infection by screening for CMV antibodies in renal allograft recipients and their blood and kidney donors

The influence of the cytomegalovirus (CMV) serostatus of blood and kidney donors on patient and graft survival was studied prospectively in 73 cadaveric renal graft recipients. Six out of 12 (50%) CMV seronegative recipients receiving a kidney from a CMV seropositive donor developed CMV disease, in contrast to none of 7 CMV seronegative donor/recipient combinations. Transmission of CMV with blood products to seronegative recipients was not observed in this study. A poor graft survival of 41% 3 years after transplantation was found in CMV seronegative recipients with CMV seropositive allograft donors, compared with an actuarial 3 year graft survival of 72% in the 7 CMV seronegative donor/recipient combinations. Six patients with graft failure had a CMV infection. This study, in accordance with other studies, suggests that selection of CMV seronegative renal allograft donors for CMV seronegative recipients will improve graft survival.

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.

Cytomegalovirus: epidemiology and infection control

Cytomegalovirus (CMV) causes asymptomatic infection in most individuals but can produce devastating illness in immunocompromised hosts and in a small proportion of congenitally infected babies. New techniques in molecular biology have provided insights into the epidemiology and transmission of CMV. Children in day care, their parents, and sexually active individuals, especially homosexual men, are now known to be at particular risk for acquiring CMV. Recent studies show that the risk of CMV acquisition by health care workers is similar to the risk to the general public. Health care workers should be aware of the wide range of clinical manifestations, methods of laboratory diagnosis, and current limitations of treatment of CMV. Careful handwashing and avoidance of excretions and secretions are recommended to decrease the transmission of CMV in the hospital.

A test for human cytomegalovirus-specific immunoglobulins using a modification of a commercial test kit

A technique (Ig-EIA) for the detection of CMV-specific IgG, IgM and IgA in human blood is described. Ig-EIA utilizes alkaline phosphatase-labeled goat anti-human IgG, IgM and IgA as a detection probe and CMV antigen-coated solid phase from commercial kits. Ig-EIA is compared to indirect fluorescent assay (IFA) and indirect hemagglutination (IHA) for sensitivity and specificity. On sequential samples of blood from a set of patients, Ig-EIA clearly demonstrated seroconversion in CMV-specific IgG and IgM. A test of 332 blood donors by Ig-EIA showed 177 (53%) had CMV-specific IgG and 17 (5%) had CMV IgM. Only two of the 17 donors with CMV IgM were nonreactive for CMV-IgG. The potential of CMV-IgM as an indicator of CMV infectivity is discussed.