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Grgic I, Gorenec L. Human Cytomegalovirus (HCMV) Genetic Diversity, Drug Resistance Testing and Prevalence of the Resistance Mutations: A Literature Review. Trop Med Infect Dis 2024; 9:49. [PMID: 38393138 PMCID: PMC10892457 DOI: 10.3390/tropicalmed9020049] [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: 01/12/2024] [Revised: 02/07/2024] [Accepted: 02/13/2024] [Indexed: 02/25/2024] Open
Abstract
Human cytomegalovirus (HCMV) is a pathogen with high prevalence in the general population that is responsible for high morbidity and mortality in immunocompromised individuals and newborns, while remaining mainly asymptomatic in healthy individuals. The HCMV genome is 236,000 nucleotides long and encodes approximately 200 genes in more than 170 open reading frames, with the highest rate of genetic polymorphisms occurring in the envelope glycoproteins. HCMV infection is treated with antiviral drugs such as ganciclovir, valganciclovir, cidofovir, foscarnet, letermovir and maribavir targeting viral enzymes, DNA polymerase, kinase and the terminase complex. One of the obstacles to successful therapy is the emergence of drug resistance, which can be tested phenotypically or by genotyping using Sanger sequencing, which is a widely available but less sensitive method, or next-generation sequencing performed in samples with a lower viral load to detect minority variants, those representing approximately 1% of the population. The prevalence of drug resistance depends on the population tested, as well as the drug, and ranges from no mutations detected to up to almost 50%. A high prevalence of resistance emphasizes the importance of testing the patient whenever resistance is suspected, which requires the development of more sensitive and rapid tests while also highlighting the need for alternative therapeutic targets, strategies and the development of an effective vaccine.
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Affiliation(s)
- Ivana Grgic
- Department of Molecular and Immunological Diagnostic, University Hospital for Infectious Diseases “Dr. Fran Mihaljevic”, 10000 Zagreb, Croatia
| | - Lana Gorenec
- Department of Molecular and Immunological Diagnostic, University Hospital for Infectious Diseases “Dr. Fran Mihaljevic”, 10000 Zagreb, Croatia
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Chan S, Godsell J, Horton M, Farchione A, Howson LJ, Margetts M, Jin C, Chatelier J, Yong M, Sasadeusz J, Douglass JA, Slade CA, Bryant VL. Case Report: Cytomegalovirus Disease Is an Under-Recognized Contributor to Morbidity and Mortality in Common Variable Immunodeficiency. Front Immunol 2022; 13:815193. [PMID: 35242131 PMCID: PMC8885594 DOI: 10.3389/fimmu.2022.815193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 01/10/2022] [Indexed: 11/13/2022] Open
Abstract
Background Common Variable Immunodeficiency (CVID) is classified as a ‘Predominantly Antibody Deficiency’ (PAD), but there is emerging evidence of cellular immunodeficiency in a subset of patients. This evidence includes CVID patients diagnosed with cytomegalovirus (CMV) infection, a hallmark of ‘combined immunodeficiency’. CMV infection also has the potential to drive immune dysregulation contributing to significant morbidity and mortality in CVID. We aim to determine the extent of cellular immune dysfunction in CVID patients, and whether this correlates with CMV infection status. Methods We conducted a single-center retrospective cohort study of individuals with CVID at the Royal Melbourne Hospital, and identified patients with and without CMV disease or viraemia. We then isolated T-cells from patient and healthy donor blood samples and examined T-cell proliferation and function. Results Six patients (7.6%, 6/79) had either CMV disease (pneumonitis or gastrointestinal disease), or symptomatic CMV viraemia. A high mortality rate in the cohort of patients with CVID and CMV disease was observed, with 4 deaths in the period of analysis (66.6%, 4/6). Individuals with CMV infection showed reduced T-cell division in response to T-cell receptor (TCR) stimulation when compared with CMV-negative patients. Discussion This study demonstrates the morbidity and mortality associated with CMV in CVID, and highlights the need for focused interventions for patients with CVID at risk of CMV disease.
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Affiliation(s)
- Samantha Chan
- Immunology Division, Walter & Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia.,Department of Medical Biology, The University of Melbourne, Melbourne, VIC, Australia.,Department of Clinical Immunology & Allergy, Royal Melbourne Hospital, Melbourne, VIC, Australia.,Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - Jack Godsell
- Department of Clinical Immunology & Allergy, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Miles Horton
- Immunology Division, Walter & Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia.,Department of Medical Biology, The University of Melbourne, Melbourne, VIC, Australia
| | - Anthony Farchione
- Immunology Division, Walter & Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
| | - Lauren J Howson
- Immunology Division, Walter & Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia.,Department of Medical Biology, The University of Melbourne, Melbourne, VIC, Australia
| | - Mai Margetts
- Immunology Division, Walter & Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
| | - Celina Jin
- Immunology Division, Walter & Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia.,Department of Medical Biology, The University of Melbourne, Melbourne, VIC, Australia.,Department of Clinical Immunology & Allergy, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Josh Chatelier
- Department of Clinical Immunology & Allergy, Royal Melbourne Hospital, Melbourne, VIC, Australia.,Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - Michelle Yong
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Joseph Sasadeusz
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Jo A Douglass
- Department of Clinical Immunology & Allergy, Royal Melbourne Hospital, Melbourne, VIC, Australia.,Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - Charlotte A Slade
- Immunology Division, Walter & Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia.,Department of Medical Biology, The University of Melbourne, Melbourne, VIC, Australia.,Department of Clinical Immunology & Allergy, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Vanessa L Bryant
- Immunology Division, Walter & Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia.,Department of Medical Biology, The University of Melbourne, Melbourne, VIC, Australia.,Department of Clinical Immunology & Allergy, Royal Melbourne Hospital, Melbourne, VIC, Australia
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del Rosal T, Quintana-Ortega C, Deyá-Martinez A, Soler-Palacín P, Goycochea-Valdivia WA, Salmón N, Pérez-Martínez A, Alsina L, Martín-Nalda A, Alonso L, Neth O, Bravo-Gallego LY, Gonzalez-Granado LI, Mendez-Echevarria A. Impact of cytomegalovirus infection prior to hematopoietic stem cell transplantation in children with inborn errors of immunity. Eur J Pediatr 2022; 181:3889-3898. [PMID: 36102997 PMCID: PMC9470503 DOI: 10.1007/s00431-022-04614-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 08/05/2022] [Accepted: 09/04/2022] [Indexed: 11/24/2022]
Abstract
UNLABELLED The presence of active viral infections has an impact on the prognosis of patients undergoing hematopoietic stem cell transplantation (HSCT). Nevertheless, the number of reports of cytomegalovirus infection in patients with inborn errors of immunity (IEI) who undergo HSCT is relatively low. To analyze the effect of cytomegalovirus infection acquired prior to curative treatment on patient survival in 123 children with IEI. An observational and retrospective study was performed with patients younger than 18 years diagnosed with IEI who were candidates for HSCT, gene therapy, or thymus transplantation at five hospitals in Spain between 2008 and 2019. We included 123 children, 25 infected by cytomegalovirus prior to undergoing curative treatment (20.3%). At IEI diagnosis, 24 of the patients were already infected, 21 of whom had symptomatic cytomegalovirus disease (87%), while the other three patients developed disease before undergoing curative treatment. The patients with cytomegalovirus infection had higher mortality than those without (p = 0.006). Fourteen patients developed refractory cytomegalovirus infection (56%), all of whom died, while no patients with non-refractory infection died (p = 0.001) All deaths that occurred before curative treatment and three of the five after the treatment were attributed to cytomegalovirus. Patients with refractory cytomegalovirus disease had the highest pre-HSCT mortality rate (64.3%), compared with the non-infected children and those with non-refractory cytomegalovirus disease (10.1%) (p < 0.0001). CONCLUSION Prevention and prompt control of cytomegalovirus infection, together with early HSCT/gene therapy, are crucial for improving the prognosis in children with IEI. WHAT IS KNOWN • Cytomegalovirus is the most frequent viral infection in children with inborn errors of immunity who are candidates to hematopoietic stem cell transplantation (HSCT). • Active viral infections at the time of HSCT lead to worse prognosis. WHAT IS NEW • In children with inborn errors of immunity and indication of HSCT, refractory cytomegalovirus disease is associated with a very high mortality rate, compared with non-infected children and those with non-refractory cytomegalovirus disease. • In patients with novel transplantation indications, the presence and treatment response of CMV infection should be considered to decide the best possible moment for HSCT.
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Affiliation(s)
- Teresa del Rosal
- Pediatric Infectious and Tropical Diseases Department, Hospital Universitario La Paz, Institute for Health Research IdiPAZ, Translational Research Network in Pediatric Infectious Diseases (RITIP), Center for Biomedical Network Research On Rare Diseases (CIBERER U767, Instituto de Salud Carlos III), Madrid, Spain
| | - Cristian Quintana-Ortega
- Pediatric Infectious and Tropical Diseases Department, Hospital Universitario La Paz, Madrid, Spain
| | - Angela Deyá-Martinez
- Study Group for Immune Dysfunction Diseases in Children (GEMDIP), Institut de Recerca Sant Joan de Déu, Clinical Immunology and Primary Immunodeficiencies Unit, Pediatric Allergy and Clinical Immunology Department, Clinical Immunology Program, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Pere Soler-Palacín
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d’Hebron, Vall d’Hebron Research Institute, Universitat Autònoma de Barcelona, Jeffrey Modell Foundation Excellence Center, Barcelona, Catalonia Spain
| | - Walter Alfredo Goycochea-Valdivia
- Pediatric Infectious Diseases, Rheumatology and Immunology Unit, Hospital Universitario Virgen del Rocío, Institute of Biomedicine, Seville, Spain
| | - Nerea Salmón
- Research Institute Hospital, 12 Octubre (imas12), Madrid, Spain ,Immunodeficiency Unit, Department of Pediatrics, Hospital Universitario, 12 de Octubre, Madrid, Spain
| | - Antonio Pérez-Martínez
- Pediatric Hemato-Oncology Department, Hospital Universitario La Paz, Madrid, Spain ,Translational Research in Pediatric Oncology, Hematopoietic Transplantation and Cell Therapy, La Paz Institute for Health Research (IdiPAZ), Madrid, Spain
| | - Laia Alsina
- Study Group for Immune Dysfunction Diseases in Children (GEMDIP), Institut de Recerca Sant Joan de Déu, Clinical Immunology and Primary Immunodeficiencies Unit, Pediatric Allergy and Clinical Immunology Department, Clinical Immunology Program, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
| | - Andrea Martín-Nalda
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d’Hebron, Vall d’Hebron Research Institute, Jeffrey Modell Foundation Excellence Center, Barcelona, Catalonia Spain
| | - Laura Alonso
- Hematopoietic Stem Cell Transplantation Unit, Pediatric Hematology and Oncology Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Research Institute, Jeffrey Modell Foundation Excellence Center, Barcelona, Catalonia Spain
| | - Olaf Neth
- Pediatric Infectious Diseases, Rheumatology and Immunology Unit, Hospital Universitario Virgen del Rocío, Institute of Biomedicine, Seville, Spain
| | - Luz Yadira Bravo-Gallego
- Immunology Department, Hospital Universitario La Paz, Madrid, Spain ,IdiPAZ Institute for Health Research, Center for Biomedical Network Research On Rare Diseases (CIBERER U767, Instituto de Salud Carlos III), Madrid, Spain
| | - Luis Ignacio Gonzalez-Granado
- Research Institute Hospital, 12 Octubre (imas12), Madrid, Spain ,Immunodeficiency Unit, Department of Pediatrics, Hospital Universitario, 12 de Octubre, Madrid, Spain ,School of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Ana Mendez-Echevarria
- Pediatric Infectious and Tropical Diseases Department, Hospital Universitario La Paz, Institute for Health Research IdiPAZ, Translational Research Network in Pediatric Infectious Diseases (RITIP), Madrid, Spain ,CIBERINFECT, Instituto de Salud Carlos III, Madrid, Spain
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Hasan MR, Sundaram MS, Sundararaju S, Tsui KM, Karim MY, Roscoe D, Imam O, Janahi MA, Thomas E, Dobson S, Tan R, Tang P, Lopez AP. Unusual accumulation of a wide array of antimicrobial resistance mechanisms in a patient with cytomegalovirus-associated hemophagocytic lymphohistiocytosis: a case report. BMC Infect Dis 2020; 20:237. [PMID: 32192451 PMCID: PMC7083060 DOI: 10.1186/s12879-020-04966-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 03/11/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Infections with multidrug-resistant organisms (MDRO) pose a serious threat to patients with dysregulated immunity such as in hemophagocytic lymphohistiocytosis (HLH), but such infections have rarely been comprehensively characterized. Here, we present a fatal case of HLH secondary to cytomegalovirus (CMV) infection complicated by both anti-viral drug resistance and sepsis from multiple MDROs including pandrug-resistant superbug bacteria. CASE PRESENTATION A previously healthy, six-year-old boy presented with a 45-day history of fever prior to a diagnosis of hemophagocytic lymphohistiocytosis and hemorrhagic colitis, both associated with CMV. On hospital admission, the patient was found to be colonized with multiple, multidrug-resistant (MDR) bacteria including vancomycin-resistant enterococci (VRE) and carbapenamase-producing organisms (CPO). He eventually developed respiratory, urine and bloodstream infections with highly drug-resistant, including pandrug-resistant bacteria, which could not be controlled by antibiotic treatment. Antiviral therapy also failed to contain his CMV infection and the patient succumbed to overwhelming bacterial and viral infection. Whole genome sequencing (WGS) of the MDR bacteria and metagenomic analysis of his blood sample revealed an unusual accumulation of a wide range of antimicrobial resistance mechanisms in a single patient, including antiviral resistance to ganciclovir, and resistance mechanisms to all currently available antibiotics. CONCLUSIONS The case highlights both the risk of acquiring MDR superbugs and the severity of these infections in HLH patients.
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Affiliation(s)
- Mohammad Rubayet Hasan
- Department of Pathology, Sidra Medicine, Level 2M, Office H2M-24093, PO BOX 26999, Doha, Qatar. .,Weill Cornell Medical College in Qatar, Doha, Qatar.
| | | | - Sathyavathi Sundararaju
- Department of Pathology, Sidra Medicine, Level 2M, Office H2M-24093, PO BOX 26999, Doha, Qatar
| | - Kin-Ming Tsui
- Department of Pathology, Sidra Medicine, Level 2M, Office H2M-24093, PO BOX 26999, Doha, Qatar
| | - Mohammed Yousuf Karim
- Department of Pathology, Sidra Medicine, Level 2M, Office H2M-24093, PO BOX 26999, Doha, Qatar.,Weill Cornell Medical College in Qatar, Doha, Qatar
| | - Diane Roscoe
- Department of Pathology, Sidra Medicine, Level 2M, Office H2M-24093, PO BOX 26999, Doha, Qatar
| | - Omar Imam
- Department of Pathology, Sidra Medicine, Level 2M, Office H2M-24093, PO BOX 26999, Doha, Qatar
| | - Mohammad A Janahi
- Department of Pathology, Sidra Medicine, Level 2M, Office H2M-24093, PO BOX 26999, Doha, Qatar.,Weill Cornell Medical College in Qatar, Doha, Qatar
| | - Eva Thomas
- Department of Pathology, Sidra Medicine, Level 2M, Office H2M-24093, PO BOX 26999, Doha, Qatar.,Weill Cornell Medical College in Qatar, Doha, Qatar
| | - Simon Dobson
- Department of Pathology, Sidra Medicine, Level 2M, Office H2M-24093, PO BOX 26999, Doha, Qatar.,Weill Cornell Medical College in Qatar, Doha, Qatar
| | - Rusung Tan
- Department of Pathology, Sidra Medicine, Level 2M, Office H2M-24093, PO BOX 26999, Doha, Qatar.,Weill Cornell Medical College in Qatar, Doha, Qatar
| | - Patrick Tang
- Department of Pathology, Sidra Medicine, Level 2M, Office H2M-24093, PO BOX 26999, Doha, Qatar.,Weill Cornell Medical College in Qatar, Doha, Qatar
| | - Andres Perez Lopez
- Department of Pathology, Sidra Medicine, Level 2M, Office H2M-24093, PO BOX 26999, Doha, Qatar.,Weill Cornell Medical College in Qatar, Doha, Qatar
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