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Yang D, Yao Y, Sun Y, Jiang E. Refractory cytomegalovirus infections in Chinese patients receiving allogeneic hematopoietic cell transplantation: a review of the literature. Front Immunol 2023; 14:1287456. [PMID: 38187387 PMCID: PMC10770847 DOI: 10.3389/fimmu.2023.1287456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 12/08/2023] [Indexed: 01/09/2024] Open
Abstract
In the absence of prophylactic therapy, cytomegalovirus (CMV) viremia is a common complication following allogeneic hematopoietic cell transplantation (allo-HCT) and represents a significant cause of morbidity and mortality. Approximately 25% of allo-HCT happen in China, where the development and refinement of the 'Beijing protocol' has enabled frequent and increasing use of haploidentical donors. However, refractory CMV infection (an increase by >1 log10 in blood or serum CMV DNA levels after at least 2 weeks of an appropriately dosed anti-CMV medication) is more common among patients with haploidentical donors than with other donor types and has no established standard of care. Here, we review the literature regarding refractory CMV infection following allo-HCT in China.
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Affiliation(s)
- Donglin Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | | | - Yi Sun
- MRL Global Medical Affairs, Shanghai, China
| | - Erlie Jiang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
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2
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Sun YQ, Ma R, Huang XJ. Optimizing the treatment of cytomegalovirus infection in allo-HSCT recipients. Expert Rev Clin Immunol 2023; 19:227-235. [PMID: 36541485 DOI: 10.1080/1744666x.2023.2161510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Cytomegalovirus (CMV) infection continues to negatively impact the prognosis after allogeneic hematopoietic stem cell transplantation (allo-HSCT), even with active monitoring and preemptive strategies. Recent progress in pharmacology, immunotherapy, and vaccines has improved the strategy of CMV management. AREAS COVERED We summarized recent advances in managing CMV infection post allo-HSCT, including diagnosis, prophylaxis, and treatment. In this review, we mainly focused on approaches that have optimized or might optimize the management of CMV infection after allo-HSCT. EXPERT OPINION In our opinion, optimized management covers aspects including the serial monitoring of CMV-DNA and CMI, an accurate diagnosis, effective prophylaxis, and a rational preemptive therapy integrating antiviral drugs and cell therapies. Strategies based on the understanding of CMV pathogenesis and CMV-related immune reconstitution after allo-HSCT will be a direction in future studies.
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Affiliation(s)
- Yu-Qian Sun
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Rui Ma
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Xiao-Jun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
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3
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Yong MK, Shigle TL, Kim YJ, Carpenter PA, Chemaly RF, Papanicolaou GA. American Society for Transplantation and Cellular Therapy Series: #4 - Cytomegalovirus treatment and management of resistant or refractory infections after hematopoietic cell transplantation. Transplant Cell Ther 2021; 27:957-967. [PMID: 34560310 DOI: 10.1016/j.jtct.2021.09.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 09/15/2021] [Indexed: 11/29/2022]
Abstract
The Practice Guidelines Committee of the American Society of Transplantation and Cellular Therapy (ASTCT) partnered with its Transpl. Infect. Dis. Special Interest Group (TID-SIG) to update its 2009 compendium-style infectious disease guidelines for hematopoietic cell transplantation (HCT). A new approach was employed with the goal of better serving clinical providers by publishing each standalone topic in the infectious diseases series as a concise format of frequently asked questions (FAQ), tables, and figures. Adult and pediatric infectious diseases and HCT content experts developed and answered FAQs. Topics were finalized with harmonized recommendations that were made by assigning an A through E strength of recommendation paired with a level of supporting evidence graded I through III. The fourth topic in the series focuses on the management and treatment of cytomegalovirus (CMV) resistant and refractory infections. The diagnosis, definitions of resistant and refractory CMV, risk factors, virological genotypes and treatment algorithms are reviewed.
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Affiliation(s)
- Michelle K Yong
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, 3000, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria, 3000, Australia; Department of Infectious Diseases, Royal Melbourne Hospital, Melbourne Victoria, 3050, Australia.
| | - Terri Lynn Shigle
- Division of Pharmacy, The University of Texas MD Anderson Cancer Centre, Houston, TX, USA
| | - Yae-Jean Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Paul A Carpenter
- Clinical Research Division, Fred Hutchinson Cancer Research Centre, Seattle, WA, USA
| | - Roy F Chemaly
- Department of Infectious Diseases, Infection Control, & Employee Health, The University of Texas MD Anderson Cancer Centre, Houston, TX, USA
| | - Genovefa A Papanicolaou
- Infectious Diseases Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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4
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Jerry Teng CL, Wang PN, Chen YC, Ko BS. Cytomegalovirus management after allogeneic hematopoietic stem cell transplantation: A mini-review. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2021; 54:341-348. [PMID: 33514495 DOI: 10.1016/j.jmii.2021.01.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 01/06/2021] [Accepted: 01/08/2021] [Indexed: 02/05/2023]
Abstract
Because of the high incidence of cytomegalovirus (CMV) seropositivity in the population, CMV infection is a common and severe complication of allogeneic hematopoietic stem cell transplantation (allo-HSCT) in Taiwan. Here we propose a CMV management strategy for patients undergoing allo-HSCT from the Taiwanese perspective, which focuses on the epidemiology, diagnosis, monitoring, prophylaxis, and treatment of CMV infection after allo-HSCT. In terms of CMV monitoring, weekly CMV monitoring with the COBAS® AmpliPrep system is the standard approach because the pp65 CMV antigenemia assay has a lower sensitivity than CMV monitoring with the COBAS® AmpliPrep system. However, pp65 CMV antigenemia assay has a better correlation with clinical symptoms in immunocompromised patients. A 14-week prophylactic course of letermovir is recommended for allo-HSCT recipients in Taiwan, especially for recipients of hematopoietic stem cells from mismatched unrelated and haploidentical donors. Preemptive ganciclovir therapy should be initiated when the CMV viral load exceeds 1000 copies/mL, and should not be discontinued until CMV DNA is no longer detected in the blood. For allo-HSCT recipients who have CMV-related diseases, ganciclovir with or without CMV-specific intravenous immunoglobulin is the standard of care. The limited availability of foscarnet, an alternative for patients who are not responsive to or cannot tolerate ganciclovir, is a crucial issue in Taiwan. For pediatric allo-HSCT recipients, more data are needed to propose a CMV management recommendation.
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Affiliation(s)
- Chieh-Lin Jerry Teng
- Division of Hematology/Medical Oncology, Department of Medicine, Taichung Veterans General Hospital, Taiwan; Department of Life Science, Tunghai University, Taichung, Taiwan; School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Po-Nan Wang
- Division of Hematology, Department of Internal Medicine, Chang Gung Medical Foundation Linkou Branch, Taoyuan, Taiwan
| | - Yee-Chun Chen
- Division of Infectious Diseases, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Medicine, National Taiwan University, College of Medicine, Taiwan
| | - Bor-Sheng Ko
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Hematological Oncology, National Taiwan University Cancer Center, Taipei, Taiwan.
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5
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El Helou G, Razonable RR. Safety considerations with current and emerging antiviral therapies for cytomegalovirus infection in transplantation. Expert Opin Drug Saf 2019; 18:1017-1030. [PMID: 31478398 DOI: 10.1080/14740338.2019.1662787] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction: Human cytomegalovirus (HCMV) is a major contributor of morbidity and mortality, and its management is essential for the successful outcome of solid organ and hematopoietic stem cell transplantation. Areas covered: This review discusses the safety profiles of currently available and emerging antiviral drugs and the other strategies for HCMV prevention and treatment after transplantation. Expert opinion: Strategies for management of HCMV rely largely on the use of antiviral agents that inhibit viral DNA polymerase (ganciclovir/valganciclovir, foscarnet, and cidofovir/brincidofovir) and viral terminase complex (letermovir), with different types and degrees of adverse effects. An investigational agent, maribavir, exerts its anti-CMV effect through UL97 inhibition, and its safety profile is under clinical evaluation. In choosing the antiviral medication to use, it is important to consider these safety profiles in addition to overall efficacy. In addition to antiviral drugs, reduction of immunosuppression is often generally needed in the management of HCMV infection, but with a potential risk of allograft rejection or graft-versus-host disease. The use of HCMV-specific or non-specific intravenous immunoglobulins remains debated, while adoptive HCMV-specific T cell therapy remains investigational, and associated with unique set of adverse effects.
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Affiliation(s)
- Guy El Helou
- Division of Infectious Diseases, Department of Medicine, and William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic College of Medicine and Science , Rochester , MN , USA
| | - Raymund R Razonable
- Division of Infectious Diseases, Department of Medicine, and William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic College of Medicine and Science , Rochester , MN , USA
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6
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Ljungman P, de la Camara R, Robin C, Crocchiolo R, Einsele H, Hill JA, Hubacek P, Navarro D, Cordonnier C, Ward KN. Guidelines for the management of cytomegalovirus infection in patients with haematological malignancies and after stem cell transplantation from the 2017 European Conference on Infections in Leukaemia (ECIL 7). THE LANCET. INFECTIOUS DISEASES 2019; 19:e260-e272. [PMID: 31153807 DOI: 10.1016/s1473-3099(19)30107-0] [Citation(s) in RCA: 244] [Impact Index Per Article: 48.8] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 01/05/2019] [Accepted: 03/05/2019] [Indexed: 12/11/2022]
Abstract
Cytomegalovirus is one of the most important infections to occur after allogeneic haematopoietic stem cell transplantation (HSCT), and an increasing number of reports indicate that cytomegalovirus is also a potentially important pathogen in patients treated with recently introduced drugs for hematological malignancies. Expert recommendations have been produced by the 2017 European Conference on Infections in Leukaemia (ECIL 7) after a review of the literature on the diagnosis and management of cytomegalovirus in patients after HSCT and in patients receiving other types of therapy for haematological malignancies. These recommendations cover diagnosis, preventive strategies such as prophylaxis and pre-emptive therapy, and management of cytomegalovirus disease. Antiviral drugs including maribavir and letermovir are in development and prospective clinical trials have recently been completed. However, management of patients with resistant or refractory cytomegalovirus infection or cytomegalovirus disease is a challenge. In this Review we summarise the reviewed literature and the recommendations of the ECIL 7 for management of cytomegalovirus in patients with haematological malignancies.
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Affiliation(s)
- Per Ljungman
- Department of Cellular Therapy and Allogeneic Stem Cell Transplantation, Karolinska University Hospital, and Division of Hematology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.
| | | | - Christine Robin
- Assistance Publique-Hopitaux de Paris, Department of Hematology, Henri Mondor Hospital and Université Paris-Est Créteil, Créteil, France
| | - Roberto Crocchiolo
- Servizio Immunoematologia e Medicina Trasfusionale, Azienda Socio Sanitaria Territoriale di Bergamo Ovest, Treviglio, Italy
| | - Hermann Einsele
- Medizinische Klinik und Poliklinik II, Julius Maximilians Universitaet, Würzburg, Germany
| | - Joshua A Hill
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Petr Hubacek
- Department of Medical Microbiology and Department of Paediatric Haematology and Oncology, Second Faculty of Medicine of Motol University Hospital and Charles University, Prague, Czech Republic
| | - David Navarro
- Microbiology Service, Hospital Clínico Universitario, Instituto de Investigación INCLIVA, Valencia, Spain; Department of Microbiology, School of Medicine, University of Valencia, Valencia, Spain
| | - Catherine Cordonnier
- Assistance Publique-Hopitaux de Paris, Department of Hematology, Henri Mondor Hospital and Université Paris-Est Créteil, Créteil, France
| | - Katherine N Ward
- Division of Infection and Immunity, University College London, London, UK
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7
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Theobald SJ, Khailaie S, Meyer-Hermann M, Volk V, Olbrich H, Danisch S, Gerasch L, Schneider A, Sinzger C, Schaudien D, Lienenklaus S, Riese P, Guzman CA, Figueiredo C, von Kaisenberg C, Spineli LM, Glaesener S, Meyer-Bahlburg A, Ganser A, Schmitt M, Mach M, Messerle M, Stripecke R. Signatures of T and B Cell Development, Functional Responses and PD-1 Upregulation After HCMV Latent Infections and Reactivations in Nod.Rag.Gamma Mice Humanized With Cord Blood CD34 + Cells. Front Immunol 2018; 9:2734. [PMID: 30524448 PMCID: PMC6262073 DOI: 10.3389/fimmu.2018.02734] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 11/06/2018] [Indexed: 12/27/2022] Open
Abstract
Human cytomegalovirus (HCMV) latency is typically harmless but reactivation can be largely detrimental to immune compromised hosts. We modeled latency and reactivation using a traceable HCMV laboratory strain expressing the Gaussia luciferase reporter gene (HCMV/GLuc) in order to interrogate the viral modulatory effects on the human adaptive immunity. Humanized mice with long-term (more than 17 weeks) steady human T and B cell immune reconstitutions were infected with HCMV/GLuc and 7 weeks later were further treated with granulocyte-colony stimulating factor (G-CSF) to induce viral reactivations. Whole body bio-luminescence imaging analyses clearly differentiated mice with latent viral infections vs. reactivations. Foci of vigorous viral reactivations were detectable in liver, lymph nodes and salivary glands. The number of viral genome copies in various tissues increased upon reactivations and were detectable in sorted human CD14+, CD169+, and CD34+ cells. Compared with non-infected controls, mice after infections and reactivations showed higher thymopoiesis, systemic expansion of Th, CTL, Treg, and Tfh cells and functional antiviral T cell responses. Latent infections promoted vast development of memory CD4+ T cells while reactivations triggered a shift toward effector T cells expressing PD-1. Further, reactivations prompted a marked development of B cells, maturation of IgG+ plasma cells, and HCMV-specific antibody responses. Multivariate statistical methods were employed using T and B cell immune phenotypic profiles obtained with cells from several tissues of individual mice. The data was used to identify combinations of markers that could predict an HCMV infection vs. reactivation status. In spleen, but not in lymph nodes, higher frequencies of effector CD4+ T cells expressing PD-1 were among the factors most suited to distinguish HCMV reactivations from infections. These results suggest a shift from a T cell dominated immune response during latent infections toward an exhausted T cell phenotype and active humoral immune response upon reactivations. In sum, this novel in vivo humanized model combined with advanced analyses highlights a dynamic system clearly specifying the immunological spatial signatures of HCMV latency and reactivations. These signatures can be merged as predictive biomarker clusters that can be applied in the clinical translation of new therapies for the control of HCMV reactivation.
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Affiliation(s)
- Sebastian J Theobald
- Clinic of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany.,Excellence Cluster REBIRTH, Laboratory of Regenerative Immune Therapies Applied, Hannover Medical School, Hannover, Germany.,Partner Site Hannover-Braunschweig, German Center for Infection Research (DZIF), Braunschweig, Germany
| | - Sahamoddin Khailaie
- Department of Systems Immunology and Braunschweig Integrated Centre of Systems Biology (BRICS), Helmholtz Centre for Infection Research, Braunschweig, Germany
| | - Michael Meyer-Hermann
- Department of Systems Immunology and Braunschweig Integrated Centre of Systems Biology (BRICS), Helmholtz Centre for Infection Research, Braunschweig, Germany.,Institute for Biochemistry, Biotechnology and Bioinformatics, Technical University Braunschweig, Braunschweig, Germany
| | - Valery Volk
- Clinic of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany.,Excellence Cluster REBIRTH, Laboratory of Regenerative Immune Therapies Applied, Hannover Medical School, Hannover, Germany
| | - Henning Olbrich
- Clinic of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany.,Excellence Cluster REBIRTH, Laboratory of Regenerative Immune Therapies Applied, Hannover Medical School, Hannover, Germany.,Partner Site Hannover-Braunschweig, German Center for Infection Research (DZIF), Braunschweig, Germany
| | - Simon Danisch
- Clinic of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany.,Excellence Cluster REBIRTH, Laboratory of Regenerative Immune Therapies Applied, Hannover Medical School, Hannover, Germany.,Partner Site Hannover-Braunschweig, German Center for Infection Research (DZIF), Braunschweig, Germany
| | - Laura Gerasch
- Clinic of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany.,Excellence Cluster REBIRTH, Laboratory of Regenerative Immune Therapies Applied, Hannover Medical School, Hannover, Germany
| | - Andreas Schneider
- Clinic of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany.,Excellence Cluster REBIRTH, Laboratory of Regenerative Immune Therapies Applied, Hannover Medical School, Hannover, Germany
| | | | - Dirk Schaudien
- Fraunhofer Institute for Toxicology and Experimental Medicine (ITEM), Hannover, Germany
| | - Stefan Lienenklaus
- Institute for Laboratory Animal Science, Hannover Medical School, Hannover, Germany
| | - Peggy Riese
- Department of Vaccinology and Applied Microbiology, Helmholtz Centre for Infection Research Braunschweig, Braunschweig, Germany
| | - Carlos A Guzman
- Department of Vaccinology and Applied Microbiology, Helmholtz Centre for Infection Research Braunschweig, Braunschweig, Germany
| | | | | | - Loukia M Spineli
- Institute for Biostatistics, Hannover Medical School, Hannover, Germany
| | - Stephanie Glaesener
- Clinic of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | | | - Arnold Ganser
- Clinic of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Michael Schmitt
- Department of Hematology, Oncology and Rheumatology, GMP Core Facility, Heidelberg University Hospital, Heidelberg, Germany
| | - Michael Mach
- Institute of Virology, University Erlangen-Nürnberg, Erlangen, Germany
| | - Martin Messerle
- Partner Site Hannover-Braunschweig, German Center for Infection Research (DZIF), Braunschweig, Germany.,Institute of Virology, Hannover Medical School, Hannover, Germany
| | - Renata Stripecke
- Clinic of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany.,Excellence Cluster REBIRTH, Laboratory of Regenerative Immune Therapies Applied, Hannover Medical School, Hannover, Germany.,Partner Site Hannover-Braunschweig, German Center for Infection Research (DZIF), Braunschweig, Germany
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8
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Schmitt M, Schmitt A, Wiesneth M, Hückelhoven A, Wu Z, Kuball J, Wang L, Schauwecker P, Hofmann S, Götz M, Michels B, Maccari B, Wuchter P, Eckstein V, Mertens T, Schnitzler P, Döhner H, Ho AD, Bunjes DW, Dreger P, Schrezenmeier H, Greiner J. Peptide vaccination in the presence of adjuvants in patients after hematopoietic stem cell transplantation with CD4+ T cell reconstitution elicits consistent CD8+ T cell responses. Theranostics 2017; 7:1705-1718. [PMID: 28529646 PMCID: PMC5436522 DOI: 10.7150/thno.18301] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 03/06/2017] [Indexed: 12/22/2022] Open
Abstract
Rationale: Patients receiving an allogeneic stem cell graft from cytomegalovirus (CMV) seronegative donors are particularly prone to CMV reactivation with a high risk of disease and mortality. Therefore we developed and manufactured a novel vaccine and initiated a clinical phase I trial with a CMV phosphoprotein 65 (CMVpp65)-derived peptide. Methods: Ten patients after allogeneic stem cell transplantation received four vaccinations at a biweekly interval. All patients were monitored for CMVpp65 antigenemia. Flow cytometry for CMV-specific CD8+ and γδ T cells as well as neutralizing anti-CMV antibodies were correlated to clinical parameters. Results: The vaccination was well tolerated. Seven of nine patients cleared CMVpp65 antigenemia after four vaccinations and are still free from antigenemia to this day. Two patients with CMV reactivation showed persisting CMV antigenemia. One patient received prophylactic vaccination and did not develop antigenemia. An increase of up to six-fold in frequency of both CMV-specific CD8+ T cells and/or Vδ2negative γδ T cells was detected. Titers of neutralizing antibodies increased up to the tenfold. Humoral and cellular immune responses correlated with clearance of CMV. Conclusion: In summary, CMVpp65 peptide vaccination for patients after allogeneic stem cell transplantation at high risk for CMV reactivation was safe, well tolerated and clinically encouraging. A study in solid-organ transplant patients is ongoing.
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Affiliation(s)
- Michael Schmitt
- Dept. of Internal Medicine V, Heidelberg University Hospital, 69120 Heidelberg, Germany
- German Cancer Consortium/Deutsches Konsortium für Translationale Krebsforschung (DKTK), 69120 Heidelberg, Germany
| | - Anita Schmitt
- Dept. of Internal Medicine V, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Markus Wiesneth
- Institute of Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service Baden-Württemberg-Hessen and Institute of Transfusion Medicine, University of Ulm, 89081 Ulm, Germany
| | - Angela Hückelhoven
- Dept. of Internal Medicine V, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Zeguang Wu
- Institute of Virology, Ulm University Medical Center, 89081 Ulm, Germany
| | - Jürgen Kuball
- Dept. of Hematology & Laboratory of Translational Immunology, University Medical Center, 3584 CX Utrecht, Netherlands
| | - Lei Wang
- Dept. of Internal Medicine V, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Peter Schauwecker
- Institute of Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service Baden-Württemberg-Hessen and Institute of Transfusion Medicine, University of Ulm, 89081 Ulm, Germany
| | - Susanne Hofmann
- Dept. of Internal Medicine V, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Dept. of Internal Medicine III, University of Ulm, 89081 Ulm, Germany
| | - Marlies Götz
- Dept. of Internal Medicine III, University of Ulm, 89081 Ulm, Germany
| | - Birgit Michels
- Dept. of Internal Medicine V, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Birgit Maccari
- Institute of Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service Baden-Württemberg-Hessen and Institute of Transfusion Medicine, University of Ulm, 89081 Ulm, Germany
| | - Patrick Wuchter
- Dept. of Internal Medicine V, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Volker Eckstein
- Dept. of Internal Medicine V, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Thomas Mertens
- Institute of Virology, Ulm University Medical Center, 89081 Ulm, Germany
| | - Paul Schnitzler
- Dept. of Virology, University of Heidelberg, 69120 Heidelberg, Germany
| | - Hartmut Döhner
- Dept. of Internal Medicine III, University of Ulm, 89081 Ulm, Germany
| | - Anthony D. Ho
- Dept. of Internal Medicine V, Heidelberg University Hospital, 69120 Heidelberg, Germany
- German Cancer Consortium/Deutsches Konsortium für Translationale Krebsforschung (DKTK), 69120 Heidelberg, Germany
| | - Donald W. Bunjes
- Dept. of Internal Medicine III, University of Ulm, 89081 Ulm, Germany
| | - Peter Dreger
- Dept. of Internal Medicine V, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Hubert Schrezenmeier
- Institute of Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service Baden-Württemberg-Hessen and Institute of Transfusion Medicine, University of Ulm, 89081 Ulm, Germany
| | - Jochen Greiner
- Dept. of Internal Medicine III, University of Ulm, 89081 Ulm, Germany
- Dept. of Internal Medicine, Diakonie-Hospital Stuttgart, 70176 Stuttgart, Germany
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9
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Peggs KS. Cytomegalovirus following stem cell transplantation: from pharmacologic to immunologic therapy. Expert Rev Anti Infect Ther 2014; 2:559-73. [PMID: 15482220 DOI: 10.1586/14787210.2.4.559] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Human cytomegalovirus is a large DNA virus that is well-equipped to evade both innate and adaptive host immune responses and to establish lifelong latency. It is a major opportunistic pathogen in immunocompromised hosts. Following allogeneic transplantation, immune responses are often inadequate to inhibit viral reactivation, resulting in progressive tissue damage, manifesting as overt human cytomegalovirus disease that usually presents as pneumonitis, colitis or hepatitis. Currently available antiviral pharmacotherapies are limited by toxicities if used prophylactically, and by a lack of efficacy in established human cytomegalovirus disease. Efforts have therefore focused on molecular diagnostic surveillance protocols that allow earlier intervention and the development of adoptive immunotherapeutic strategies to hasten host immune reconstitution.
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Affiliation(s)
- Karl S Peggs
- Department of Hematology, Royal Free and University College London Medical School, 98 Chenies Mews, London, WC1E 6HX, UK.
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10
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Emery V, Zuckerman M, Jackson G, Aitken C, Osman H, Pagliuca A, Potter M, Peggs K, Clark A. Management of cytomegalovirus infection in haemopoietic stem cell transplantation. Br J Haematol 2013; 162:25-39. [PMID: 23647436 DOI: 10.1111/bjh.12363] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Vincent Emery
- Department of Virology; University College London School of Life and Medical Sciences; London; UK
| | - Mark Zuckerman
- Department of Virology; King's College Hospital; London; UK
| | - Graham Jackson
- Department of Haematology; Freeman Road Hospital; Newcastle; UK
| | - Celia Aitken
- West of Scotland specialist virology centre; Gartnavel General Hospital; Glasgow; UK
| | - Husam Osman
- Birmingham HPA Laboratory; Birmingham Heartlands Hospital; Birmingham; UK
| | | | - Mike Potter
- Section of Haemato-oncology; The Royal Marsden NHS Foundation Trust; London; UK
| | - Karl Peggs
- Department of Haematology; University College London Hospitals; London; UK
| | - Andrew Clark
- Blood and Marrow Transplant Unit; Beatson Oncology Centre; Glasgow; UK
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11
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Dignan FL, Scarisbrick JJ, Cornish J, Clark A, Amrolia P, Jackson G, Mahendra P, Taylor PC, Shah P, Lightman S, Fortune F, Kibbler C, Andreyev J, Albanese A, Hadzic N, Potter MN, Shaw BE. Organ-specific management and supportive care in chronic graft-versus-host disease. Br J Haematol 2012; 158:62-78. [DOI: 10.1111/j.1365-2141.2012.09131.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
| | | | | | - Andrew Clark
- Bone Marrow Transplant Unit; Beatson Oncology Centre; Gartnavel Hospital; Glasgow
| | - Persis Amrolia
- Department of Bone Marrow Transplantation; Great Ormond Street Hospital; London
| | - Graham Jackson
- Department of Haematology; Freeman Road Hospital; Newcastle
| | - Prem Mahendra
- Department of Haematology; University Hospital Birmingham; Birmingham
| | - Peter C. Taylor
- Department of Haematology; Rotherham General Hospital; Rotherham
| | - Pallav Shah
- Department of Respiratory Medicine; Royal Brompton Hospital; London
| | - Sue Lightman
- University College London/Institute of Opthalmology; Moorfields Eye Hospital; London
| | - Farida Fortune
- Department of Oral Medicine; Barts and the London NHS Trust; London
| | | | - Jervoise Andreyev
- Department of Medicine; The Royal Marsden NHS Foundation Trust; London
| | | | - Nedim Hadzic
- Paediatric Liver Service & Institute of Liver Studies; King's College Hospital; London
| | - Michael N. Potter
- Section of Haemato-oncology; The Royal Marsden NHS Foundation Trust; London
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12
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CMV infection after transplant from cord blood compared to other alternative donors: the importance of donor-negative CMV serostatus. Biol Blood Marrow Transplant 2011; 18:92-9. [PMID: 21689774 DOI: 10.1016/j.bbmt.2011.05.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Accepted: 05/23/2011] [Indexed: 01/03/2023]
Abstract
Cytomegalovirus (CMV) infection and disease are important complications after hematopoietic stem cell transplant, particularly after transplant from alternative donors. Allogeneic cord blood transplantation (CBT) is being increasingly used, but immune recovery may be delayed. The aim of this study was to compare CMV infection in CBT with transplants from unrelated or mismatched related donors, from now on defined as alternative donors. A total of 165 consecutive transplants were divided in 2 groups: (1) alternative donors transplants (n = 85) and (2) CBT recipients (n = 80). Donor and recipient (D/R) CMV serostatus were recorded. The incidence of CMV infection, its severity, timing, and outcome were compared. Median follow-up was 257 days (1-1328). CMV infection was monitored by CMV antigenemia and expressed as CMV Ag positive cell/2 × 10(5) polymorphonuclear blood cells. There was a trend toward a higher cumulative incidence of CMV infection among CBT than alternative donor transplant recipients (64% vs 51%, P = .12). The median time to CMV reactivation was 35 days, and was comparable in the 2 groups (P = .8). The maximum number of CMV-positive cells was similar in the 2 groups (11 versus 16, P = .2). The time interval between the first and the last positive CMV antigenemia was almost 4 times longer in CBT compared with alternative donor transplants (109 vs 29 days, respectively, P = .008). The incidence of late CMV infection was also higher in CBT (62% vs 24%, P < .001). The incidence of early and late CMV infection in CBT was similar to D-/R+ alternative transplants, and higher than in D+/R+ alternative transplants: early infection, 72% in CBT versus 69% in D-/R+ alternative versus 55% in D+/R+ alternative (P = .21); and late infection, 67% in CBT versus 60% in D-/R+ alternative versus 7% in D+/R+ alternative (P < .001). Transplant-related mortality and overall survival were similar between the groups: 34% versus 36% (P = .6) and 54% versus 46% (P = .3) for alternative transplant and CBT, respectively. Longer duration and higher incidence of late CMV infection was seen in CBT patients, when compared with alternative donor transplants, whereas no difference in mortality was observed. The duration and incidence of late CMV infection were similar when D-/R+ CBT were compared with D-/R+ alternative donor transplants.
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14
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Lazarus HM, Laughlin MJ. Viral Infections in Hematopoietic Stem Cell Transplant Recipients. ALLOGENEIC STEM CELL TRANSPLANTATION 2010. [PMCID: PMC7120500 DOI: 10.1007/978-1-59745-478-0_29] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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15
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Schreiber A, Härter G, Schubert A, Bunjes D, Mertens T, Michel D. Antiviral treatment of cytomegalovirus infection and resistant strains. Expert Opin Pharmacother 2009; 10:191-209. [PMID: 19236193 DOI: 10.1517/14656560802678138] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
This review discusses the management of resistant cytomegalovirus and prevention strategies for fatal therapy failures. Five drugs, ganciclovir/valganciclovir, cidofovir, foscarnet and fomivirsen, have been approved so far for the treatment of human cytomegalovirus (HCMV) diseases. Except for fomivirsen, all of the approved drugs share the same target molecule, the viral DNA polymerase. The emergence of drug-resistant HCMV has also been reported for all of them. For optimal care of patients, the clinical virologist has to provide the most meaningful assays for monitoring of therapy and early detection of emerging drug-resistant HCMV. Additionally, a quantitative drug monitoring would be helpful. New antiviral agents are urgently needed with less adverse effects, good oral bioavailability and possibly novel targets or mechanisms of action to avoid cross-resistance and to improve the ability to suppress the selection of resistant virus strains by combination therapy. Compounds like maribavir, leflunomide and artesunate, which exhibit anti-HCMV activity in vitro and in patients need to be evaluated in clinical studies. Besides these, new therapy approaches like immunotherapy or new diagnostic techniques like pyrosequencing have to be considered in the future.
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Affiliation(s)
- Andreas Schreiber
- Universitätsklinikum Ulm, Institut für Virologie, Albert-Einstein Allee 11, 89081 Ulm, Germany
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16
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Wang H, Zhu L, Xue M, Liu J, Guo Z. Low-Dose Foscarnet Preemptive Therapy for Cytomegalovirus Viremia after Haploidentical Bone Marrow Transplantation. Biol Blood Marrow Transplant 2009; 15:519-20. [DOI: 10.1016/j.bbmt.2008.12.510] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2008] [Accepted: 12/27/2008] [Indexed: 10/21/2022]
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17
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Abstract
Viruses are important pathogens causing respiratory tract infections both in the community and health‐care facility settings. They are extremely common causes of morbidity in the competent hosts and some are associated with significant mortality in the compromised individuals. With wider application of molecular techniques, novel viruses are being described and old viruses are found to have new significance in different epidemiological and clinical settings. Some of these emerging pathogens may have the potential to cause pandemics or global spread of a severe disease, as exemplified by severe acute respiratory syndrome and avian influenza. Antiviral therapy of viral respiratory infections is often unnecessary in the competent hosts because most of them are self‐limiting and effective agents are not always available. In the immunocompromised individuals or for infections caused by highly pathogenic viruses, such as avian influenza viruses (AIV), antiviral treatment is highly desirable, despite the fact that many of the agents may not have undergone stringent clinical trials. In immunocompetent hosts, antiviral therapy can be stopped early because adaptive immune response can usually be mounted within 5–14 days. However, the duration of antiviral therapy in immunosuppressed hosts depends on clinical and radiological resolution, the degree and duration of immunosuppression, and therefore maintenance therapy is sometimes needed after the initial response. Immunotherapy and immunoprophylaxis appear to be promising directions for future research. Appropriate and targeted immunomodulation may play an important adjunctive role in some of these infections by limiting the extent of end‐organ damage and multi‐organ failure in some fulminant infections.
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Affiliation(s)
- Samson S Y Wong
- Department of Microbiology, Research Centre of Infection and Immunology, The University of Hong Kong, Queen Mary Hospital, Hong Kong
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18
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Mikulska M, Raiola AM, Bruno B, Furfaro E, Van Lint MT, Bregante S, Ibatici A, Del Bono V, Bacigalupo A, Viscoli C. Risk factors for invasive aspergillosis and related mortality in recipients of allogeneic SCT from alternative donors: an analysis of 306 patients. Bone Marrow Transplant 2009; 44:361-70. [PMID: 19308042 DOI: 10.1038/bmt.2009.39] [Citation(s) in RCA: 112] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Invasive aspergillosis (IA) is a serious complication in patients undergoing allogeneic haematopoietic stem cell transplantation (HSCT), particularly from donors other than HLA-identical sibling. All 306 patients who underwent alternative donor HSCT between 01 January 1999 and 31 December 2006 were studied. Late IA was defined as occurring >or=40 days after HSCT. The median follow-up was 284 days (range, 1-2709). Donors were matched unrelated (n=185), mismatched related (n=69), mismatched unrelated (n=35) and unrelated cord blood (n=17). According to European Organization for Research and Treatment of Cancer/Mycoses Study Group criteria, 2 patients already had IA at HSCT, 23 had early IA and 20 had late IA (IA incidence 15%). Eight patients had proven and 37 probable IA. Multivariate analyses showed that significant predictors of IA were delayed neutrophil engraftment, extensive chronic GVHD (cGVHD), secondary neutropenia and relapse after transplant. Early IA was associated with active malignancy at HSCT, CMV reactivation and delayed lymphocyte engraftment. Late IA was predicted by cGVHD, steroid therapy, secondary neutropenia and relapse after HSCT. IA-related mortality among IA patients was 67% and was influenced by use of anti-thymocyte globulin, steroids, higher levels of creatinine, and lower levels of IgA and platelets. The outcome of IA depends on the severity of immunodeficiency and the status of the underlying disease.
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Affiliation(s)
- M Mikulska
- Division of Infectious Diseases, San Martino University Hospital and University of Genoa, Genoa, Italy
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19
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Management of CMV, HHV-6, HHV-7 and Kaposi-sarcoma herpesvirus (HHV-8) infections in patients with hematological malignancies and after SCT. Bone Marrow Transplant 2008; 42:227-40. [PMID: 18587440 DOI: 10.1038/bmt.2008.162] [Citation(s) in RCA: 238] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
These recommendations were prepared by the European Conference on Infections in Leukaemia following a predefined methodology. Literature searches were made to identify studies pertinent to management of CMV, HHV-6, -7 and -8 infections. For CMV, 76 studies were reviewed: 72 published and 4 presented as abstracts. Twenty-nine of these studies were prospective randomized trials. For the other herpesviruses, HHV-6, -7 and -8, no randomized controlled trial has been performed, although data from some studies with other primary endpoints have been used to assess the management of HHV-6 infection. Works presented only as abstracts were used to a very limited extent. The quality of evidence and level of recommendation were graded according to the Center for Disease Control (CDC) criteria.
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20
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Affiliation(s)
- Torsten W Wiegand
- Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, USA
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21
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Hebart H, Einsele H. Clinical aspects of CMV infection after stem cell transplantation. Hum Immunol 2005; 65:432-6. [PMID: 15172442 DOI: 10.1016/j.humimm.2004.02.022] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2003] [Revised: 01/15/2004] [Accepted: 02/03/2004] [Indexed: 10/26/2022]
Abstract
Cytomegalovirus (CMV) infection is one of the most important infectious complications after stem cell transplantation (SCT). Major improvements in the management of CMV infection have been achieved during the last decade, including the introduction of safe blood product support for CMV-seronegative patients, the development of early pre-emptive antiviral therapy based on sensitive diagnostic tests, and antiviral prophylaxis. With the better control of CMV infection during the first 100 days after allogeneic SCT an increase in the incidence of CMV infection and disease after day 100 after transplantation was observed. New methods that allow for the reconstitution of CMV-specific immune responses such as adoptive T-cell therapy are promising tools that might help to improve the management of late CMV infection and disease.
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Affiliation(s)
- Holger Hebart
- Department of Hematology and Oncology, University of Tübingen, Tübingen, Germany.
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22
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Kontoyiannis DP, Lewis RE. Toward more effective antifungal therapy: the prospects of combination therapy. Br J Haematol 2004; 126:165-75. [PMID: 15238137 DOI: 10.1111/j.1365-2141.2004.05007.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The availability of new antifungal agents with unique mechanisms of action and improved tolerability has widened the possibilities for the use of combination antifungal therapy for difficult-to-treat opportunistic mycoses. However, the use of this therapy is largely governed by empiricism, especially in patients with invasive mould infections, for whom there is a tremendous need to improve outcomes. Because of the difficulties associated with the design and conduct of clinical trials of combination antifungal therapy for opportunistic mycoses, the majority of the studies evaluating antifungal combinations are still performed in the laboratory or using animal models of infection. However, the methods used to assess combined antifungal effects in vitro and in animals are poorly standardized, and there is little evidence that data generated from these studies can be translated in treating human mycotic infections. Despite the empiricism of combination antifungal therapy, certain principles help guide the use and study of these regimens.
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Affiliation(s)
- Dimitrios P Kontoyiannis
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas M. D. Anderson Cancer Center, and College of Pharmacy, University of Houston, 77030, USA.
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23
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Corvò R, Lamparelli T, Bruno B, Barra S, Van Lint MT, Vitale V, Bacigalupo A. Low-dose fractionated total body irradiation (TBI) adversely affects prognosis of patients with leukemia receiving an HLA-matched allogeneic bone marrow transplant from an unrelated donor (UD-BMT). Bone Marrow Transplant 2002; 30:717-23. [PMID: 12439693 DOI: 10.1038/sj.bmt.1703701] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2002] [Accepted: 05/15/2002] [Indexed: 11/08/2022]
Abstract
The optimal total body irradiation (TBI) regimen for unrelated donor bone marrow transplant (UD-BMT) is unknown. In the present study we analyze the outcomes of two different TBI regimens used in our center for patients with leukemia undergoing an UD-BMT. Between January 1994 and August 2001, 99 consecutive UD-BMT patients entered this comparative study. The conditioning regimen consisted of cyclophosphamide, 120 mg/kg followed by TBI on days -3, -2 and -1. Forty-six patients received TBI 12 Gy (2 Gy, twice a day) in six fractions (HF-TBI) and 53 patients received TBI 9.90 Gy (3.30 Gy per day) fractionated over 3 days (F-TBI). End-points were transplanted-related mortality (TRM), leukemia relapse rate (LRR) and overall survival (OS). At median follow-up of 22 months (58 months for HF-TBI and 17 for F-TBI, respectively), 60 patients were alive (32 in HF-TBI sub-group and 28 in F-TBI one). The actuarial 5-year TRM was 31% for HF-TBI and 41% for F-TBI (P = 0.1), whereas the 5-year LRR was 13% for HF-TBI and 31% for F-TBI (P = 0.04). The actuarial 5-year OS was 68% for patients treated with HF-TBI and 51% for those treated with F-TBI (P = 0.02). At multivariate analysis F-TBI schedule emerged as an adverse predictor for OS (P = 0.04) and LRR (P = 0.03). These data indicate that a lower total dose of TBI appears significantly less effective in leukemia eradication and associated with worse overall survival when compared with a higher dose of radiation.
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Affiliation(s)
- R Corvò
- UO Oncologia Radioterapica, Istituto Nazionale per la Ricerca sul Cancro, Genoa, Italy
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24
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Waugh SML, Pillay D, Carrington D, Carman WF. Antiviral prophylaxis and treatment (excluding HIV therapy). J Clin Virol 2002; 25:241-66. [PMID: 12423690 DOI: 10.1016/s1386-6532(02)00151-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- S M L Waugh
- West of Scotland Specialist Virology Centre, Gartnavel General Hospital, Great Western Road, Glasgow G12 OYN, UK
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25
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Abstract
Cytomegalovirus (CMV) has major consequences after allogeneic stem cell and solid organ transplantation. CMV may cause significant morbidity and mortality, and monitoring to detect reactivation to reduce disease or management of end organ disease is associated with increased resource utilization. Two other members of the beta-herpesvirus family, human herpesvirus (HHV) type 6 and HHV-7, are increasingly recognized as important pathogens in transplant recipients, either by direct infection (e.g., encephalitis, hepatitis, or pneumonitis) or via interaction with CMV. In addition to direct effects of CMV infection, such indirect effects as an increased risk for bacterial and fungal infections or impaired graft acceptance and function are important research topics. Diagnosis and treatment of CMV infection is currently more advanced than for HHV-6 and HHV-7.
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Affiliation(s)
- Per Ljungman
- Karolinska Institutet, SE-14186 Stockholm, Sweden.
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26
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Affiliation(s)
- Per Ljungman
- Department of Haematology, Huddinge University Hospital, Karolinska Institutet, Stockholm, Sweden.
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27
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Mylonakis E, Kallas WM, Fishman JA. Combination antiviral therapy for ganciclovir-resistant cytomegalovirus infection in solid-organ transplant recipients. Clin Infect Dis 2002; 34:1337-41. [PMID: 11981729 DOI: 10.1086/340101] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2001] [Revised: 01/07/2002] [Indexed: 11/03/2022] Open
Abstract
The resistance of cytomegalovirus (CMV) to ganciclovir is a factor in therapeutic failure and disease progression. The clinical significance of such resistance in solid-organ transplantation has not been completely established. Six patients who developed persistent infection due to ganciclovir-resistant CMV were treated with a combination of ganciclovir (50% of the therapeutic dose) and a daily dose of intravenous foscarnet that gradually increased to a maximum of 125 mg/kg. All patients responded clinically within 72-96 hours. Magnesium depletion occurred in all patients. No clinical or laboratory relapses have been observed in 6-30 months of follow-up. Gradually increasing doses of foscarnet combined with half-dose regimens of ganciclovir are safe and can be beneficial in organ transplant recipients with ganciclovir-resistant CMV infection. Larger studies are needed to identify the patients who are most likely to benefit from this regimen.
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28
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Zaia JA. Prevention and management of CMV-related problems after hematopoietic stem cell transplantation. Bone Marrow Transplant 2002; 29:633-8. [PMID: 12180106 DOI: 10.1038/sj.bmt.1703407] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Prevention and management of human cytomegalovirus (CMV) infection after hematopoietic stem cell transplantation has improved substantially in the past decade. However, with this improvement, there is increased complexity in deciding which diagnostic tests, treatment strategies and immunologic assessments are optimal for different patient populations. The purpose of this review is to address certain practical problems that commonly arise and suggest a suitable approach to management that should have wide applicability.
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Affiliation(s)
- J A Zaia
- Division of Virology, Beckman Research Institute of City of Hope, 1500 Duarte Road, Duarte, CA 91010, USA
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29
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Ohta H, Matsuda Y, Tokimasa S, Sawada A, Kim JY, Sashihara J, Amo K, Miyagawa H, Tanaka-Taya K, Yamamoto S, Tano Y, Aono T, Yamanishi K, Okada S, Hara J. Foscarnet therapy for ganciclovir-resistant cytomegalovirus retinitis after stem cell transplantation: effective monitoring of CMV infection by quantitative analysis of CMV mRNA. Bone Marrow Transplant 2001; 27:1141-5. [PMID: 11551024 DOI: 10.1038/sj.bmt.1703055] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We report three pediatric patients with ganciclovir-resistant cytomegalovirus (CMV) retinitis who were successfully treated with foscarnet. The patients were recipients of hematopoietic stem cell transplantation (SCT) from HLA-mismatched donors. Because these patients had developed or experienced progressive CMV retinitis during ganciclovir therapy, they received foscarnet therapy at 60 mg/kg every 8 h. Their retinitis resolved promptly after initiating foscarnet therapy, suggesting foscarnet's effectiveness in treating ganciclovir-resistant CMV infection. The amount of CMV mRNA was quantitatively measured using an NASBA technique, which amplified the beta2.7 transcripts specific for CMV replication. This technique was useful for monitoring disease activity in a more rapid and sensitive manner than the PCR assay for CMV DNA.
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Affiliation(s)
- H Ohta
- Department of Developmental Medicine (Pediatrics), Osaka University Graduate School of Medicine, Suita, Japan
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30
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Lamparelli T, van Lint MT, Gualandi F, Raiola AM, Barbanti M, Sacchi N, Ficai G, Ghinatti C, Bregante S, Berisso G, Dominietto A, Di Grazia C, Bruno B, Sessarego M, Casarino L, Verdiani S, Bacigalupo A. Alternative donor transplants for patients with advanced hematologic malignancies, conditioned with thiotepa, cyclophosphamide and antithymocyte globulin. Bone Marrow Transplant 2000; 26:1305-11. [PMID: 11223970 DOI: 10.1038/sj.bmt.1702719] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Preparative regimens without total body irradiation (TBI) have been reported for alternative donor hemopoietic stem cell transplants (HSCT). Between 7 September 1994 and 7 June 1999 48 patients with advanced hematologic malignancies were conditioned with thiotepa (THIO) 15 mg/kg, cyclophosphamide (CY) 150 mg/kg and antithymocyte globulin (ATG). Donors were HLA mismatched family members (1-2 antigens) (FAM) (n = 24, median age 31 years) or HLA matched unrelated donors (UD) (n = 24, median age 34 years). GVHD prophylaxis was cyclosporine and methotrexate. Stem cell source was peripheral blood (n = 8) or bone marrow (n = 40). Hematologic recovery was seen in 42/46 (91%) evaluable patients and complete chimerism in 31/37 patients (85%). Acute GVHD grades III-IV were seen in 10/46 patients surviving 10 days (21%) and extensive chronic GVHD in 2/36 patients surviving 100 days (5%). Twenty-six patients died (54%), eight of recurrent disease (17%) and 18 of transplant-related complications (37%): main causes of TRM were GVHD (15%), infections (15%) and graft failure (4%). Twenty-two patients (46%) survive with a median follow-up of 877 days (287-1840). The actuarial 3-year survival is 49% for FAM and 42% for UD transplants. Results obtained with this regimen in unrelated grafts for advanced CML (n = 15) were not significantly different when compared to 21 concurrent UD grafts for advanced CML prepared with CY-TBI. In conclusion, the combination of THIO-CY-ATG allows engraftment of alternative donor hemopoietic stem cells. Results are similar when using unrelated matched donors or partially mismatched family donors, and not significantly different when compared to patients conditioned with CY-TBI.
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Affiliation(s)
- T Lamparelli
- Dipartimento di Ematologia, Ospedale San Martino, Genova, Italy
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31
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32
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Sia IG, Patel R. New strategies for prevention and therapy of cytomegalovirus infection and disease in solid-organ transplant recipients. Clin Microbiol Rev 2000; 13:83-121, table of contents. [PMID: 10627493 PMCID: PMC88935 DOI: 10.1128/cmr.13.1.83] [Citation(s) in RCA: 118] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
In the past three decades since the inception of human organ transplantation, cytomegalovirus (CMV) has gained increasing clinical import because it is a common pathogen in the immunocompromised transplant recipient. Patients may suffer from severe manifestations of this infection along with the threat of potential fatality. Additionally, the dynamic evolution of immunosuppressive and antiviral agents has brought forth changes in the natural history of CMV infection and disease. Transplant physicians now face the daunting task of recognizing and managing the changing spectrum of CMV infection and its consequences in the organ recipient. For the microbiology laboratory, the emphasis has been geared toward the development of more sophisticated detection assays, including methods to detect emerging antiviral resistance. The discovery of novel antiviral chemotherapy is an important theme of clinical research. Investigations have also focused on preventative measures for CMV disease in the solid-organ transplant population. In all, while much has been achieved in the overall management of CMV infection, the current understanding of CMV pathogenesis and therapy still leaves much to be learned before success can be claimed.
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Affiliation(s)
- I G Sia
- Division of Infectious Diseases and Department of Internal Medicine, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA
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33
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Boeckh M. Management of cytomegalovirus infections in blood and marrow transplant recipients. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 1999; 458:89-109. [PMID: 10549382 DOI: 10.1007/978-1-4615-4743-3_9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Affiliation(s)
- M Boeckh
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
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34
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Boeckh M. Current antiviral strategies for controlling cytomegalovirus in hematopoietic stem cell transplant recipients: prevention and therapy. Transpl Infect Dis 1999; 1:165-78. [PMID: 11428987 DOI: 10.1034/j.1399-3062.1999.010305.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Cytomegalovirus (CMV) remains a cause of significant morbidity and mortality after hematopoietic stem cell transplantation (HSCT). Ganciclovir prophylaxis, or preemptive treatment based on detection of antigenemia or CMV DNA by PCR, effectively prevents CMV disease during the first 100 days after transplant in allograft recipients. In recipients of T-cell depleted transplant or if severe acute graft-versus-host disease is present, ganciclovir prophylaxis or preemptive treatment should be started with an induction course of ganciclovir (5 mg/kg BID) and given at least 5 days per week and continued until day 100 after transplant. Although prevention of CMV disease before day 100 is highly effective, there is a continued risk of late-onset CMV disease after day 100. In CMV-seropositive recipients, the incidence of late CMV disease may be as high as 17%. Strategies to prevent late CMV infection and disease are needed. In seronegative recipients, seronegative or leukocyte-reduced blood products are effective in preventing acquisition of CMV through blood products. Controversy exists about the optimal strategy of preventing CMV disease in seropositive autologous HSCT recipients. The outcome of CMV pneumonia remains poor despite treatment with ganciclovir in combination with CMV hyperimmune globulin or intravenous immunoglobulin. Owing to continued clinical significance of CMV in the HSCT setting, new and more effective anti-CMV drugs with improved pharmacokinetic properties are urgently needed.
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Affiliation(s)
- M Boeckh
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, Washington 98109-4417, USA.
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Kusne S, Shapiro R, Fung J. Prevention and treatment of cytomegalovirus infection in organ transplant recipients. Transpl Infect Dis 1999; 1:187-203. [PMID: 11428989 DOI: 10.1034/j.1399-3062.1999.010307.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Cytomegalovirus (CMV) is the most common viral pathogen in organ transplant recipients. The patients at highest risk of developing CMV disease are seronegative recipients of seropositive donors, and seropositive recipients who receive antilymphocyte agents such as OKT3 and antithymocyte globulin (ATG) for induction or for rejection. There have been many trials of CMV prevention, but they are difficult to compare with one another because of variability in definitions and end points. Two modalities that have been used to prevent CMV disease are prophylaxis and preemptive therapy. In prophylaxis all patients are given an antiviral agent in order to prevent CMV disease, while in preemptive therapy (also called targeted prophylaxis) only patients who are identified as 'high risk' are selected for treatment. Selected trials of prophylaxis and preemptive therapy in solid-organ recipients are reviewed. The factors to be considered in using one modality or the other are side effects from antivirals, cost of monitoring and antivirals, efficacy of the two modalities, and potential emergence of drug resistance. Sensitive tests that have been used for early diagnosis and monitoring of CMV are antigenemia and the polymerase chain reaction (PCR). Antigen pp65 is a lower matrix protein and can be detected in peripheral blood leukocytes. The sensitivity and specificity are high and vary from 89% to 100% and 92% to 96%, respectively. Currently, many authors believe that the antigenemia test is more useful than the PCR test. The antigenemia test is useful for viral monitoring as a guide for preemptive therapy after organ transplantation. Persistence of high counts of antigenemia may indicate inadequate antiviral therapy or emergence of resistance. Recurrence of positive antigenemia after treatment of CMV disease can be a sign of relapse. Transplant patients who develop resistance to antiviral drugs are usually seronegative recipients who receive an organ from a seropositive donor and have several courses of antivirals for CMV disease. Ganciclovir is the most frequent antiviral agent used in transplant recipients and is usually well tolerated. Resistance to ganciclovir may occur and is usually secondary to virus mutation in the UL97 gene. The availability of sensitive diagnostic tests such as pp65 antigenemia has made the early diagnosis of CMV possible in organ transplant recipients. CMV is being treated much earlier now, and progression to disseminated disease is uncommon. Prudent use of antiviral drugs will hopefully limit the problem of drug resistance.
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Affiliation(s)
- S Kusne
- Thomas E. Starzl Transplantation Institute, Pittsburgh, Pennsylvania, USA
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