1
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Haubrich K, Gantt S, Blydt-Hansen T. Successful treatment of chronic norovirus gastroenteritis with nitazoxanide in a pediatric kidney transplant recipient. Pediatr Transplant 2018; 22:e13186. [PMID: 29635723 DOI: 10.1111/petr.13186] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/08/2018] [Indexed: 12/16/2022]
Abstract
Uncontrolled studies suggest a benefit of nitazoxanide for the treatment of norovirus gastroenteritis in immunocompromised individuals. Here, we report the use of nitazoxanide in a 13-year-old male kidney transplant recipient who developed intractable norovirus gastroenteritis. Reduction of immunosuppression was not possible due to refractory TCMR. Administration of oral immunoglobulin and switching from tacrolimus to sirolimus failed to produce a meaningful clinical response. Treatment with a 14-day course of nitazoxanide resulted in prompt resolution of diarrhea as well as clearance of norovirus from the stool despite intense immunosuppression. Nitazoxanide may be considered as an option for the treatment of intractable norovirus gastroenteritis in pediatric transplant patients when reduced immunosuppression is not feasible or other treatment options have failed. Further studies to evaluate the safety and effectiveness of nitazoxanide in immunocompromised children are needed.
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Affiliation(s)
- Kathryn Haubrich
- Pediatric Nephrology and Multi-Organ Transplant Program and Department of Pharmacy, BC Children's Hospital, Vancouver, BC, Canada
| | - Soren Gantt
- Division of Infectious Diseases, University of British Columbia and BC Children's Hospital, Vancouver, BC, Canada
| | - Tom Blydt-Hansen
- Multi-Organ Transplant Program, University of British Columbia and BC Children's Hospital, Vancouver, BC, Canada
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2
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Dang W, Yin Y, Wang Y, Wang W, Su J, Sprengers D, van der Laan LJW, Felczak K, Pankiewicz KW, Chang KO, Koopmans MPG, Metselaar HJ, Peppelenbosch MP, Pan Q. Inhibition of Calcineurin or IMP Dehydrogenase Exerts Moderate to Potent Antiviral Activity against Norovirus Replication. Antimicrob Agents Chemother 2017; 61:e01095-17. [PMID: 28807916 PMCID: PMC5655111 DOI: 10.1128/aac.01095-17] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 08/05/2017] [Indexed: 12/14/2022] Open
Abstract
Norovirus is a major cause of acute gastroenteritis worldwide and has emerged as an important issue of chronic infection in transplantation patients. Since no approved antiviral is available, we evaluated the effects of different immunosuppressants and ribavirin on norovirus and explored their mechanisms of action by using a human norovirus (HuNV) replicon-harboring model and a surrogate murine norovirus (MNV) infectious model. The roles of the corresponding drug targets were investigated by gain- or loss-of-function approaches. We found that the calcineurin inhibitors cyclosporine (CsA) and tacrolimus (FK506) moderately inhibited HuNV replication. Gene silencing of their cellular targets, cyclophilin A, FKBP12, and calcineurin, significantly inhibited HuNV replication. A low concentration, therapeutically speaking, of mycophenolic acid (MPA), an uncompetitive IMP dehydrogenase (IMPDH) inhibitor, potently and rapidly inhibited norovirus replication and ultimately cleared HuNV replicons without inducible resistance following long-term drug exposure. Knockdown of the MPA cellular targets IMPDH1 and IMPDH2 suppressed HuNV replication. Consistent with the nucleotide-synthesizing function of IMPDH, exogenous guanosine counteracted the antinorovirus effects of MPA. Furthermore, the competitive IMPDH inhibitor ribavirin efficiently inhibited norovirus and resulted in an additive effect when combined with immunosuppressants. The results from this study demonstrate that calcineurin phosphatase activity and IMPDH guanine synthase activity are crucial in sustaining norovirus infection; thus, they can be therapeutically targeted. Our results suggest that MPA shall be preferentially considered immunosuppressive medication for transplantation patients at risk of norovirus infection, whereas ribavirin represents as a potential antiviral for both immunocompromised and immunocompetent patients with norovirus gastroenteritis.
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Affiliation(s)
- Wen Dang
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center, Rotterdam, The Netherlands
| | - Yuebang Yin
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center, Rotterdam, The Netherlands
| | - Yijin Wang
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center, Rotterdam, The Netherlands
| | - Wenshi Wang
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center, Rotterdam, The Netherlands
| | - Junhong Su
- Medical Faculty, Kunming University of Science and Technology, Kunming, People's Republic of China
| | - Dave Sprengers
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center, Rotterdam, The Netherlands
| | - Luc J W van der Laan
- Department of Surgery, Erasmus MC-University Medical Center, Rotterdam, The Netherlands
| | - Krzysztof Felczak
- Center for Drug Design, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Kyeong-Ok Chang
- Department of Diagnostic Medicine and Pathobiology, College of Veterinary Medicine, Kansas State University, Manhattan, Kansas, USA
| | - Marion P G Koopmans
- Department of Viroscience, Erasmus MC-University Medical Center, Rotterdam, The Netherlands
| | - Herold J Metselaar
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center, Rotterdam, The Netherlands
| | - Maikel P Peppelenbosch
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center, Rotterdam, The Netherlands
| | - Qiuwei Pan
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center, Rotterdam, The Netherlands
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3
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Patte M, Canioni D, Fenoel VA, Frange P, Rabant M, Talbotec C, Lacaille F. Severity and outcome of the norovirus infection in children after intestinal transplantation. Pediatr Transplant 2017; 21. [PMID: 28510265 DOI: 10.1111/petr.12930] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/16/2017] [Indexed: 01/17/2023]
Abstract
In immunocompromised patients, the NoV infection is prolonged and severe. We retrospectively studied the severity of the NoV infection in children after an ITx, the treatment, and the long-term evolution. Norovirus PCR in stools was positive for 19 children in 21 separate episodes. The infection was symptomatic in 18 cases. At diagnosis, the median weight loss was 5% (0-11) and the creatinine clearance was 75 mL/min/1.73 m2 (19-142). On 14 digestive biopsies, the pathological findings were non-specific with a constant mononuclear infiltration, showing signs of rejection in one case. Fifteen children in 17 cases were hospitalized for a median duration of 41 days (0-119) with IV infusions for 33 days (0-120). The viral shedding lasted 78 days (20-360). Nine children with severe or prolonged diarrhea received intravenous IGs and four of them additional NTZ. On follow-up, five other children developed a rejection 12 months (1-33) after NoV infection. Four uncontrolled rejections led to graft removal. Children mostly needed hospital admission and IV rehydration, but the symptoms upon presentation were moderate. Symptoms and shedding durations are prolonged as expected. The treatment efficacy cannot be assessed. The rejection induction by the NoV cannot be excluded.
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Affiliation(s)
- Marie Patte
- Gastroenterology-Hepatology-Nutrition Unit, Hôpital Universitaire Necker - Enfants malades, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Danielle Canioni
- Pathology Department, Hôpital Universitaire Necker - Enfants malades, AP-HP, Paris, France
| | - Véronique Avettand Fenoel
- Microbiology Laboratory, Hôpital Universitaire Necker - Enfants malades, AP-HP, Paris Descartes University, Paris, France
| | - Pierre Frange
- Microbiology Laboratory, Hôpital Universitaire Necker - Enfants malades, AP-HP, Paris Descartes University, Paris, France
| | - Marion Rabant
- Pathology Department, Hôpital Universitaire Necker - Enfants malades, AP-HP, Paris, France
| | - Cécile Talbotec
- Gastroenterology-Hepatology-Nutrition Unit, Hôpital Universitaire Necker - Enfants malades, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Florence Lacaille
- Gastroenterology-Hepatology-Nutrition Unit, Hôpital Universitaire Necker - Enfants malades, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
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4
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Eden JS, Chisholm RH, Bull RA, White PA, Holmes EC, Tanaka MM. Persistent infections in immunocompromised hosts are rarely sources of new pathogen variants. Virus Evol 2017; 3:vex018. [PMID: 28775894 PMCID: PMC5534129 DOI: 10.1093/ve/vex018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Many viruses, including human norovirus and influenza, cause self-limiting diseases of short duration. However, infection by the same viruses in an immunocompromised host can result in prolonged illness in the absence of effective treatment. Such persistent infections are often characterized by increased genetic diversity with potentially elevated rates of evolution compared to acute infections, leading to suggestions that immunocompromised hosts represent an important reservoir for the emergence of novel viral variants. Here, we develop a mathematical model that combines epidemiological dynamics with within-host evolution to quantify the relative contribution of immunocompromised hosts to the overall rate of pathogen evolution. Using human norovirus as a case study we show that the majority of evolutionary substitutions are expected to occur in acute infections of immunocompetent hosts. Hence, despite their potential to generate a high level of diversity, infections of immunocompromised hosts likely contribute less to the evolution and emergence of new genetic variants at the epidemiological scale because such hosts are rare and tend to be isolated. This result is robust to variation in key parameters, including the proportion of the population immunocompromised, and provides a means to understand the adaptive significance of mutations that arise during chronic infections in immunocompromised hosts.
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Affiliation(s)
- John-Sebastian Eden
- Marie Bashir Institute for Infectious Diseases and Biosecurity, Charles Perkins Centre, School of Life and Environmental Sciences, and Sydney Medical School, The University of Sydney, Sydney, NSW 2006, Australia.,Centre for Virus Research, The Westmead Institute for Medical Research, Westmead, NSW 2145, Australia
| | - Rebecca H Chisholm
- School of Biotechnology and Biomolecular Sciences, and Evolution & Ecology Research Centre, University of New South Wales, Sydney, NSW 2052, Australia
| | - Rowena A Bull
- Systems Medicine, Inflammation and Infection Research Centre, School of Medical Sciences, Faculty of Medicine, University of New South Wales, Sydney, NSW 2052, Australia
| | - Peter A White
- School of Biotechnology and Biomolecular Sciences, and Evolution & Ecology Research Centre, University of New South Wales, Sydney, NSW 2052, Australia
| | - Edward C Holmes
- Marie Bashir Institute for Infectious Diseases and Biosecurity, Charles Perkins Centre, School of Life and Environmental Sciences, and Sydney Medical School, The University of Sydney, Sydney, NSW 2006, Australia
| | - Mark M Tanaka
- School of Biotechnology and Biomolecular Sciences, and Evolution & Ecology Research Centre, University of New South Wales, Sydney, NSW 2052, Australia
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5
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Abstract
Hospital-associated infection (HAI) in immunocompromised patients can result in high rates of morbidity and mortality. Infections caused by multidrug-resistant organisms (MDROs) are especially worrisome because of the limited choice of remaining antibiotics available when a patient becomes colonized or infected with an MDRO. It is therefore important that immunocompromised patients be cared for in an environment that limits the risk for acquiring infections. However, with healthcare being increasingly delivered in settings other than the traditional inpatient hospital wards, a bigger effort will need to be set forth to prevent or rapidly diagnose HAI. The last few years have seen a significant increase in the number of singleplex and multiplex molecular assays for the detection of many of the organisms responsible for HAI, but more is needed as infections caused by organisms like Legionella pneumophila and Aspergillus species are still diagnosed with methods that have relatively low yield and are slow to provide actionable results. Finally, the use of novel techniques for outbreak investigations will provide new information on transmission of infectious agents in healthcare settings and allow stronger, evidence-based recommendations to be developed for prevention of HAIs in the immunocompromised host.
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6
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Brown LAK, Clark I, Brown JR, Breuer J, Lowe DM. Norovirus infection in primary immune deficiency. Rev Med Virol 2017; 27:e1926. [DOI: 10.1002/rmv.1926] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 01/19/2017] [Accepted: 01/31/2017] [Indexed: 02/06/2023]
Affiliation(s)
| | - Ian Clark
- Department of Cellular Pathology; Royal Free London NHS Foundation Trust; London UK
| | - Julianne R. Brown
- Microbiology, Virology and Infection Control; Great Ormond Street Hospital for Children NHS Foundation Trust; London UK
- NIHR Biomedical Research Centre; Great Ormond Street Hospital for Children NHS Foundation Trust and University College; London UK
| | - Judith Breuer
- Division of Infection and Immunity; University College London; London UK
| | - David M. Lowe
- Institute of Immunity and Transplantation; University College London, Royal Free Campus; London UK
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7
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Chronic Diarrhea. Infect Dis (Lond) 2017. [DOI: 10.1016/b978-0-7020-6285-8.00039-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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8
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Chong PP, van Duin D, Sonderup JL, Grant WJ, Kalil AC, Florescu DF. Predictors of persistent diarrhea in norovirus enteritis after solid organ transplantation. Clin Transplant 2016; 30:1488-1493. [PMID: 27623481 DOI: 10.1111/ctr.12844] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2016] [Indexed: 12/11/2022]
Abstract
Solid organ transplant (SOT) recipients may develop protracted diarrheal illness from norovirus. We performed a retrospective chart review between January 2010 and April 2014 to identify predictors of persistent diarrhea in transplant recipients with norovirus enteritis. A total of 152 SOT recipients with mean age of 31.5 years (SD 23.1) were included: 43.4% male, 34.2% pediatric patients. Allograft types were abdominal 136 (89.5%) (kidney [39.5%], liver-small bowel [23%], other [27%]) and thoracic 16 (10.5%). The median time to diagnosis of first norovirus enteritis episode from date of transplantation was 1.7 (0.3-5.3) years. At time of presentation, diarrhea was present in 141 (93%). Thirty percent had persistent diarrhea at 2 weeks. Hospitalization was required for treatment in 121 (80%) of episodes with the mean length of stay of 10±15.2 days. Most (91%) infections were due to norovirus genogroup II, and gastrointestinal coinfections were seen in 23 (19%) norovirus enteritis episodes. Nausea at time of diagnosis (P=.002) and cytomegalovirus (CMV) infection in the preceding 90 days (P=.036) were identified as independent risk factors for persistent diarrhea using univariate and multivariable logistic regression. Our study shows that nausea on presentation and prior CMV infection were associated with persistent diarrhea in patients with norovirus enteritis.
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Affiliation(s)
- Pearlie P Chong
- Division of Infectious Diseases, University of North Carolina, Chapel Hill, NC, USA.
| | - David van Duin
- Division of Infectious Diseases, University of North Carolina, Chapel Hill, NC, USA
| | | | - Wendy J Grant
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Andre C Kalil
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - Diana F Florescu
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA.,Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA
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9
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Abstract
Noroviruses are among the most common cause of diarrhea in transplant recipients. The clinical spectrum of norovirus infection after transplant is increasingly being recognized. As substantial morbidity is now associated with norovirus infections in this population; the quest for rapid diagnostic modalities and newer therapies has expanded. Transplant recipients with norovirus infection are at risk for several complications, including protracted illness with malnutrition, organ failure, and chronic viral shedding. This review summarizes the current knowledge on the epidemiology, complications, diagnosis, and treatment of norovirus infection in the transplant setting.
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Affiliation(s)
- Michael P Angarone
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, 645 N Michigan Avenue, Suite 900, Chicago, IL, 60611, USA.
| | - Anna Sheahan
- Infection Control and Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mini Kamboj
- Infection Control and Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, USA
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10
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Echenique IA, Stosor V, Gallon L, Kaufman D, Qi C, Zembower TR. Prolonged norovirus infection after pancreas transplantation: a case report and review of chronic norovirus. Transpl Infect Dis 2015; 18:98-104. [PMID: 26460906 DOI: 10.1111/tid.12472] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Revised: 08/27/2015] [Accepted: 09/12/2015] [Indexed: 02/04/2023]
Abstract
Norovirus is a major cause of self-limited gastroenteritis worldwide. Prevention and treatment are thwarted by rapid viral evolution, and thus supportive care remains the mainstay of therapy. Chronic infection in immunocompromised hosts is increasingly described. We report a case of norovirus infection lasting 2543 days in a pancreas transplant recipient. Serial fecal specimens were obtained, from which a map of genetic relatedness was derived. The clinical course was complicated by renal failure that progressed to end-stage renal disease. Minimization of immunosuppression was associated with resolution of the infection. Subsequently, the patient experienced a suspected allograft rejection that did not compromise pancreas function. The patient later underwent living-related renal transplantation without recurrence of enteritis.
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Affiliation(s)
- I A Echenique
- Division of Infectious Disease, Cleveland Clinic Florida, Weston, Florida, USA
| | - V Stosor
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - L Gallon
- Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Division of Nephrology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - D Kaufman
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - C Qi
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Clinical Microbiology Laboratory, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - T R Zembower
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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11
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Belliot G, Lopman BA, Ambert-Balay K, Pothier P. The burden of norovirus gastroenteritis: an important foodborne and healthcare-related infection. Clin Microbiol Infect 2015; 20:724-30. [PMID: 24943671 DOI: 10.1111/1469-0691.12722] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Human norovirus (NoV) is now recognized as one of the most important causative agents of gastroenteritis in all age groups worldwide. During the course of NoV infection, symptoms are usually mild and disappear within 48 h after onset. The incidence of NoV infection is high, with hundreds of cases per 10 000 of the population, although the number of infections is still underestimated. Epidemiological surveys conducted in Europe and North America have shown that NoV infections constitute a major disease burden, especially for young children and the elderly, in whom NoV infection leads to high rates of hospitalization and mortality. NoV infections are also of concern in hospitals, where viral infections can be persistent in immunocompromised patients. Although the cost of NoV infection in the hospital community has not yet been clearly established, it appears that NoV infections could cost hundreds of thousands of euros in terms of unit closure, and NoV-related sickness in patients and health workers. Besides their clinical burden, NoVs, as foodborne pathogens, also cause to millions of dollars of losses for the healthcare system and the food industry. Recent estimates in the USA showed that, annually, NoV illness cost $2 billion and led to a loss of approximately 5000 quality-adjusted life-years, making NoV one of the top five pathogens causing enteric illnesses. The highest cost among 14 foodborne pathogens is also attributed to human NoV in The Netherlands. This accumulation of evidence underlines the enormous impact of NoV on populations.
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Affiliation(s)
- G Belliot
- Laboratory of Virology, National Reference Centre for Enteric Viruses, Public Hospital of Dijon, Dijon, France
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12
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Lee L, Ison M. Diarrhea caused by viruses in transplant recipients. Transpl Infect Dis 2014; 16:347-58. [DOI: 10.1111/tid.12212] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Revised: 12/11/2013] [Accepted: 12/21/2013] [Indexed: 01/25/2023]
Affiliation(s)
- L.Y. Lee
- Department of Medicine; Northwestern University Feinberg School of Medicine; Chicago Illinois USA
- Northwestern University Transplant Outcomes Research Collaborative; Northwestern University Feinberg School of Medicine; Chicago Illinois USA
| | - M.G. Ison
- Department of Medicine; Northwestern University Feinberg School of Medicine; Chicago Illinois USA
- Northwestern University Transplant Outcomes Research Collaborative; Northwestern University Feinberg School of Medicine; Chicago Illinois USA
- Division of Infectious Diseases Northwestern University Feinberg School of Medicine; Chicago Illinois USA
- Division of Organ Transplantation; Northwestern University Feinberg School of Medicine; Chicago Illinois USA
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13
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Owen L, Jones G, Despott EJ, Murray C, Atkinson C, Beal I, Webster DP. Fatal enteritis in a renal transplant patient with post-transplant thrombotic microangiopathy undergoing plasma exchange therapy. J Clin Virol 2014; 59:213-7. [PMID: 24495848 DOI: 10.1016/j.jcv.2014.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Revised: 01/04/2014] [Accepted: 01/06/2014] [Indexed: 11/20/2022]
Affiliation(s)
- Leah Owen
- Watford General Hospital, Vicarage Road, Watford, Hertfordshire, WD18 0HB, United Kingdom.
| | - Gareth Jones
- Royal Free Hospital, Pond Street, London NW3 2QG, United Kingdom.
| | - Edward J Despott
- Royal Free Unit for Endoscopy & Centre for Gastroenterology, UCL Institute for Liver & Digestive Health, 8th Floor South Offices, Royal Free Hospital and University College London, Pond Street, London NW3 2QG, United Kingdom.
| | - Claire Murray
- Department of Cellular Pathology, Royal Free Hospital NHS Trust, Pond Street, London, NW3 2QG, United Kingdom.
| | - Claire Atkinson
- Department of Virology, Royal Free Hospital and University College London, Pond Street, London NW3 2QG, United Kingdom.
| | - Isobel Beal
- Royal Free Hospital, Pond Street, London NW3 2QG, United Kingdom.
| | - Daniel P Webster
- Department of Virology, Royal Free Hospital and University College London, Pond Street, London NW3 2QG, United Kingdom.
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14
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Munir N, Liu P, Gastañaduy P, Montes J, Shane A, Moe C. Norovirus infection in immunocompromised children and children with hospital-acquired acute gastroenteritis. J Med Virol 2013; 86:1203-9. [DOI: 10.1002/jmv.23774] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2013] [Indexed: 12/13/2022]
Affiliation(s)
- Naeemah Munir
- Center for Global Safe Water, Rollins School of Public Health; Emory University; Atlanta Georgia
| | - Pengbo Liu
- Center for Global Safe Water, Rollins School of Public Health; Emory University; Atlanta Georgia
| | - Paul Gastañaduy
- Division of Infectious Diseases, Department of Pediatrics; Emory University School of Medicine; Atlanta Georgia
| | - Julia Montes
- Center for Global Safe Water, Rollins School of Public Health; Emory University; Atlanta Georgia
| | - Andi Shane
- Division of Infectious Diseases, Department of Pediatrics; Emory University School of Medicine; Atlanta Georgia
| | - Christine Moe
- Center for Global Safe Water, Rollins School of Public Health; Emory University; Atlanta Georgia
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15
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An outbreak of norovirus infection in a bone marrow transplant unit. Am J Infect Control 2013; 41:820-3. [PMID: 23415769 DOI: 10.1016/j.ajic.2012.10.025] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Revised: 10/31/2012] [Accepted: 10/31/2012] [Indexed: 11/23/2022]
Abstract
BACKGROUND Norovirus is a single-stranded RNA virus belonging to the Caliciviridae family. METHODS Our observational cohort study aimed to describe a nosocomial outbreak of norovirus on a bone marrow transplant (BMT) unit. RESULTS Six of 8 BMT patients with increased liquid stools tested positive for norovirus: 4 had new onset diarrhea; 2 had acute exacerbations of chronic diarrhea caused by graft versus host disease. Eight non-BMT inpatients had norovirus infection, but 7 of these were community acquired; cumulative incidence rates in BMT and non-BMT units were 26% and 0.16%, respectively. In BMT patients, diarrhea (increased or new onset) lasted 6 to 33 days-durations shorter than those reported in sporadic BMT cases. All patients had private rooms and bathrooms. Five of 6 patients were on the BMT unit during their presumed incubation periods. Three were in adjacent rooms. Three nurses and 1 physician had symptoms compatible with norovirus infection, and all 4 worked while ill. The outbreak ended coincident with implementation of stricter infection control practices. CONCLUSION Norovirus appeared to spread in a BMT unit more avidly than it did among general medical patients. Explanations include prolonged diarrhea and viral excretion, long hospital stays of infected patients, rarity of empiric contact isolation for diarrhea, routine handling of liquid stool, and a closed community of health care workers.
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16
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Abstract
Norovirus is a common cause of gastroenteritis in all ages. Typical infections cause viral shedding periods of days to weeks, but some individuals can shed for months or years. Most norovirus risk models do not include these long-shedding individuals, and may therefore underestimate risk. We reviewed the literature for norovirus-shedding duration data and stratified these data into two distributions: regular shedding (mean 14-16 days) and long shedding (mean 105-136 days). These distributions were used to inform a norovirus transmission model that predicts the impact of long shedders. Our transmission model predicts that this subpopulation increases the outbreak potential (measured by the reproductive number) by 50-80%, the probability of an outbreak by 33%, the severity of transmission (measured by the attack rate) by 20%, and transmission duration by 100%. Characterizing and understanding shedding duration heterogeneity can provide insights into community transmission that can be useful in mitigating norovirus risk.
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17
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van de Ven AAJM, Hoytema van Konijnenburg DP, Wensing AMJ, van Montfrans JM. The role of prolonged viral gastrointestinal infections in the development of immunodeficiency-related enteropathy. Clin Rev Allergy Immunol 2012; 42:79-91. [PMID: 22116710 DOI: 10.1007/s12016-011-8292-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Patients with primary immunodeficiencies are prone to develop enteropathy of unknown pathogenesis. We hypothesize that ineffective clearance of gastrointestinal pathogens, particularly viruses, in combination with defective immune regulation may cause inflammatory enteropathy in certain immunodeficient hosts. We reviewed publications related to prolonged enteric viral infection, immunodeficiency, and the subsequent development of inflammatory enteropathy. Prolonged infection with especially enteroviral infections was reported more often in immunocompromised hosts than in healthy individuals. Protracted enteric viral shedding was not always associated with the presence or duration of gastrointestinal symptoms. The development of immunodeficiency-associated enteropathy after prolonged viral infections was described in sporadic cases. Clinical consequences of viral gut infections in immunocompromised hosts comprise isolation issues and supportive care. Prospective studies in cohorts of immunodeficient patients are required to study the impact of prolonged enteric viral replication with respect to the pathogenesis of non-infectious enteropathy.
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Affiliation(s)
- Annick A J M van de Ven
- Department of Pediatric Immunology and Infectious Diseases, University Medical Center Utrecht/Wilhelmina Children's Hospital, Utrecht, the Netherlands
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18
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Impact of norovirus/sapovirus-related diarrhea in renal transplant recipients hospitalized for diarrhea. Transplantation 2011; 92:61-9. [PMID: 21555974 DOI: 10.1097/tp.0b013e31821c9392] [Citation(s) in RCA: 115] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Diarrhea of unspecified cause frequently occurs after renal transplantation and is usually ascribed to mycophenolic acid toxicity. Norovirus (NoV) and sapovirus (SaV) have been sporadically reported to cause chronic diarrhea in immunocompromised patients. METHODS We undertook a retrospective study (2008-2009) to examine the clinical and epidemiologic significance of NoV and SaV infections in adult renal transplant recipients hospitalized for acute or chronic diarrhea. RESULTS Ninety-six renal transplant recipients were hospitalized for diarrhea at our institution during a 16-month period, 87 of whom were included in the study, including 46 patients with chronic diarrhea. Among 41 patients with unexplained diarrhea, 20 patients were screened for NoV/SaV, 16 of whom were positive. Fifteen of them (94%) had chronic diarrhea. When compared with bacterial and parasitic infections, NoV/SaV infections were associated with a greater weight loss at the time of admission, a 8.7-fold longer duration of symptoms and a more frequent need for mycophenolic acid dosage reduction. Eighty-one percent of patients hospitalized for NoV/SaV-associated diarrhea experienced acute renal failure. Five and one patients subsequently had biopsy-diagnosed active graft rejection and oxalate nephropathy, respectively. Ten of the 14 patients who underwent a longitudinal study of NoV/SaV stool's clearance exhibited a prolonged viral shedding period with a median time of 289 days (107-581 days). CONCLUSIONS Our study indicates that NoV/SaV infection causes posttransplant chronic diarrhea potentially complicated by severe kidney graft impairment.
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Capizzi T, Makari-Judson G, Steingart R, Mertens WC. Chronic diarrhea associated with persistent norovirus excretion in patients with chronic lymphocytic leukemia: report of two cases. BMC Infect Dis 2011; 11:131. [PMID: 21586142 PMCID: PMC3118142 DOI: 10.1186/1471-2334-11-131] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2010] [Accepted: 05/17/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic diarrhea in patients treated with immunosuppressive agents or suffering from immunosuppressive disease can represent a diagnostic and therapeutic challenge to the clinician. Norovirus infection, a major cause of acute epidemic diarrhea, has been described as a cause of chronic diarrhea in patients who are immunosuppressed, including transplant recipients and the very young. CASE PRESENTATIONS We describe two patients, a 64 year-old man and a 59 year-old woman, both suffering from chronic lymphocytic leukemia and hypogammaglobulinemia, who developed chronic diarrhea resistant to therapy. In both cases, after months of symptoms, persistent norovirus infection--documented by repeatedly-positive high-sensitivity stool enzyme immunoassay--was found to be the cause. Both patients died with active diarrheal symptoms. CONCLUSIONS We describe the first cases of advanced chronic lymphocytic leukemia to suffer from chronic symptomatic norovirus infection. Clinicians caring for such patients, particularly those with concomitant hypogammaglobulinema, who have chronic unexplained diarrhea, should consider norovirus infection in the differential diagnosis.
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Affiliation(s)
- Todd Capizzi
- Baystate Regional Cancer Program/Tufts University School of Medicine, Springfield, MA 01107, USA
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Boillat Blanco N, Kuonen R, Bellini C, Manuel O, Estrade C, Mazza-Stalder J, Aubert JD, Sahli R, Meylan P. Chronic norovirus gastroenteritis in a double hematopoietic stem cell and lung transplant recipient. Transpl Infect Dis 2010; 13:213-5. [PMID: 20804535 DOI: 10.1111/j.1399-3062.2010.00565.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Fenollar F. Chronic diarrhea. Infect Dis (Lond) 2010. [DOI: 10.1016/b978-0-323-04579-7.00036-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Westhoff TH, Vergoulidou M, Loddenkemper C, Schwartz S, Hofmann J, Schneider T, Zidek W, van der Giet M. Chronic norovirus infection in renal transplant recipients. Nephrol Dial Transplant 2008; 24:1051-3. [PMID: 19073655 DOI: 10.1093/ndt/gfn693] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Norovirus infection is the most common cause of acute gastroenteritis. In immunocompetent subjects, norovirus infection is a self-limiting disease of short duration. The present report provides first evidence that norovirus can cause chronic infection in renal transplant recipients. Two patients showed persisting norovirus excretion for >7 months and 3 months, respectively. The first patient was asymptomatic after an acute episode of gastroenteritis and eliminated the virus spontaneously. The second patient developed severe symptomatic chronic infection with diffuse abdominal discomfort, fever, transient transplant dysfunction, recurrent episodes of diarrhoea, weight loss and histological signs of chronic intestinal inflammation. Norovirus elimination and relief of symptoms occurred only after reduction of immunosuppression. Thus, norovirus can evoke asymptomatic and symptomatic chronic infection in renal transplant recipients. Norovirus should therefore be considered in the differential diagnosis of both acute and chronic diarrhoea after transplantation. Reduction of immunosuppression may be indicated to allow virus elimination in symptomatic cases.
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Affiliation(s)
- Timm H Westhoff
- Department of Nephrology, Charité Campus Benjamin Franklin, Berlin, Germany.
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