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Papanicolaou GA, Avery RK, Cordonnier C, Duarte RF, Haider S, Maertens J, Peggs KS, Solano C, Young JAH, Fournier M, Murray RA, Wu J, Winston DJ. Treatment for First Cytomegalovirus Infection Post-Hematopoietic Cell Transplant in the AURORA Trial: A Multicenter, Double-Blind, Randomized, Phase 3 Trial Comparing Maribavir With Valganciclovir. Clin Infect Dis 2024; 78:562-572. [PMID: 38036487 PMCID: PMC10954327 DOI: 10.1093/cid/ciad709] [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: 08/09/2023] [Revised: 11/01/2023] [Accepted: 11/15/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Neutropenia may limit the use of valganciclovir treatment for cytomegalovirus (CMV) infection following hematopoietic cell transplant (HCT). A phase 2 study indicated efficacy of maribavir with fewer treatment-limiting toxicities than valganciclovir. METHODS In this multicenter, double-blind, phase 3 study, patients with first asymptomatic CMV infection post-HCT were stratified and randomized 1:1 to maribavir 400 mg twice daily or valganciclovir (dose-adjusted for renal clearance) for 8 weeks with 12 weeks of follow-up. The primary endpoint was confirmed CMV viremia clearance at week 8 (primary hypothesis of noninferiority margin of 7.0%). The key secondary endpoint was a composite of the primary endpoint with no findings of CMV tissue-invasive disease at week 8 through week 16. Treatment-emergent adverse events (TEAEs) were assessed. RESULTS Among patients treated (273 maribavir; 274 valganciclovir), the primary endpoint of noninferiority of maribavir was not met (maribavir, 69.6%; valganciclovir, 77.4%; adjusted difference: -7.7%; 95% confidence interval [CI]: -14.98, -.36; lower limit of 95% CI of treatment difference exceeded -7.0%). At week 16, 52.7% and 48.5% of patients treated (maribavir and valganciclovir, respectively) maintained CMV viremia clearance without tissue-invasive disease (adjusted difference: 4.4%; 95% CI: -3.91, 12.76). With maribavir (vs valganciclovir), fewer patients experienced neutropenia (16.1% and 52.9%) or discontinued due to TEAEs (27.8% and 41.2%). Discontinuations were mostly due to neutropenia (maribavir, 4.0%; valganciclovir, 17.5%). CONCLUSIONS Although noninferiority of maribavir to valganciclovir for the primary endpoint was not achieved based on the prespecified noninferiority margin, maribavir demonstrated comparable CMV viremia clearance during post-treatment follow-up, with fewer discontinuations due to neutropenia. Clinical Trials Registration. NCT02927067 [AURORA].
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Affiliation(s)
| | | | - Catherine Cordonnier
- Henri Mondor Hôpital, Assistance Publique-Hopitaux de Paris, and Université Paris-Est-Créteil, Créteil, France
| | - Rafael F Duarte
- Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Shariq Haider
- Hamilton Health Sciences Corporation, Ontario, Canada
| | | | - Karl S Peggs
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Carlos Solano
- Hospital Clínico Universitario, University of Valencia, Valencia, Spain
| | | | - Martha Fournier
- Takeda Development Center Americas, Inc, Lexington, Massachusetts, USA
| | - Rose Ann Murray
- Takeda Development Center Americas, Inc, Lexington, Massachusetts, USA
| | - Jingyang Wu
- Takeda Development Center Americas, Inc, Lexington, Massachusetts, USA
| | - Drew J Winston
- Los Angeles Medical Center, University of California, Los Angeles, California, USA
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Sun K, Fournier M, Sundberg AK, Song IH. Maribavir: Mechanism of action, clinical, and translational science. Clin Transl Sci 2024; 17:e13696. [PMID: 38071422 PMCID: PMC10801391 DOI: 10.1111/cts.13696] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 10/20/2023] [Accepted: 11/21/2023] [Indexed: 01/24/2024] Open
Abstract
Maribavir is an oral benzimidazole riboside for treatment of post-transplant cytomegalovirus (CMV) infection/disease that is refractory to prior antiviral treatment (with or without resistance). Through competitive inhibition of adenosine triphosphate, maribavir prevents the phosphorylation actions of UL97 to inhibit CMV DNA replication, encapsidation, and nuclear egress. Maribavir is active against CMV strains with viral DNA polymerase mutations that confer resistance to other CMV antivirals. After oral administration, maribavir is rapidly and highly absorbed (fraction absorbed >90%). The approved dose of 400 mg twice daily (b.i.d.) achieves a steady-state area under the curve per dosing interval of 128 h*μg/mL and trough concentration of 4.90 μg/mL (13.0 μM). Maribavir is highly bound to human plasma proteins (98%) with a small apparent volume of distribution of 27.3 L. Maribavir is primarily cleared by hepatic CYP3A4 metabolism; its major metabolite, VP44669 (pharmacologically inactive), is excreted in the urine and feces. There is no clinically relevant impact on maribavir pharmacokinetics by age, sex, race/ethnicity, body weight, transplant type, or hepatic/renal impairment status. In phase II dose-ranging studies, maribavir showed similar rates of CMV viral clearance across 400, 800, or 1200 mg b.i.d. groups, ranging from 62.5-70% in study 202 (NCT01611974) and 74-83% in study 203 (EudraCT 2010-024247-32). In the phase III SOLSTICE trial (NCT02931539), maribavir 400 mg b.i.d. demonstrated superior CMV viremia clearance at week 8 versus investigator-assigned treatments, with lower treatment discontinuation rates. Dysgeusia, nausea, vomiting, and diarrhea were commonly experienced adverse events among patients treated with maribavir in clinical trials.
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Affiliation(s)
- Kefeng Sun
- Quantitative Clinical PharmacologyTakeda Development Center Americas, Inc.LexingtonMassachusettsUSA
| | - Martha Fournier
- Clinical Sciences, Rare Genetics & Hematology Therapeutic Area UnitTakeda Development Center Americas, Inc.LexingtonMassachusettsUSA
| | - Aimee K. Sundberg
- Clinical Sciences, Rare Genetics & Hematology Therapeutic Area UnitTakeda Development Center Americas, Inc.LexingtonMassachusettsUSA
| | - Ivy H. Song
- Quantitative Clinical PharmacologyTakeda Development Center Americas, Inc.LexingtonMassachusettsUSA
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Pérez AB, Santos Bravo M, Vidal-Verdú E, Páez-Vega A, Vaquero-Barrios JM, Montero JL, Marcos MÁ, Torre-Cisneros J. Real-life experience in two cases of secondary prophylaxis with letermovir for CMV infection in solid organ transplantation. Microbiol Spectr 2023; 11:e0163023. [PMID: 37902387 PMCID: PMC10714737 DOI: 10.1128/spectrum.01630-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 09/26/2023] [Indexed: 10/31/2023] Open
Abstract
IMPORTANCE This observation provides comprehensive data on the clinical correlates of both cytomegalovirus (CMV) genotypic follow-up and clinical monitoring and outcomes for two different solid organ transplantation recipients that received letermovir as secondary prophylaxis. Our study emphasizes that monitoring of CMV disease in the patient and early genotypic detection of resistance mutations are essential when using new antiviral drugs for off-label indication in patients experiencing CMV relapses or not responding to standard antiviral therapy. These cases and the bibliography reviewed can be helpful for other researchers and clinicians working in the field to optimize the use of new treatments for transplant recipients since drug-resistant CMV infection is an important emerging problem even with new developments in antiviral treatment.
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Affiliation(s)
- Ana-Belén Pérez
- Microbiology Service, Reina Sofia University Hospital, Cordoba, Spain
- Maimónides Institute for Biomedical Research (IMIBIC), Cordoba, Spain
- Centre of Biomedical Research for Infectious Diseases (CIBERINFEC), Institute of Health Carlos III, Madrid, Spain
| | - Marta Santos Bravo
- Centre of Biomedical Research for Infectious Diseases (CIBERINFEC), Institute of Health Carlos III, Madrid, Spain
- Microbiology Service, Hospital Clínic, Barcelona, Spain
| | - Elisa Vidal-Verdú
- Centre of Biomedical Research for Infectious Diseases (CIBERINFEC), Institute of Health Carlos III, Madrid, Spain
- Infectious Diseases Service, Reina Sofia University Hospital, Cordoba, Spain
- Maimónides Institute for Biomedical Research (IMIBIC), Cordoba, Spain
- Departament of Medicine (Medicine, Dermatology and Otorhinolaryngology), University of Cordoba, Spain
| | - Aurora Páez-Vega
- Centre of Biomedical Research for Infectious Diseases (CIBERINFEC), Institute of Health Carlos III, Madrid, Spain
- Maimónides Institute for Biomedical Research (IMIBIC), Cordoba, Spain
| | - José-Manuel Vaquero-Barrios
- Maimónides Institute for Biomedical Research (IMIBIC), Cordoba, Spain
- Lung Transplantation Section, Reina Sofia University Hospital, Cordoba, Spain
| | - José-Luis Montero
- Maimónides Institute for Biomedical Research (IMIBIC), Cordoba, Spain
- Liver Transplantation Section, Reina Sofia University Hospital, Cordoba, Spain
| | - María-Ángeles Marcos
- Centre of Biomedical Research for Infectious Diseases (CIBERINFEC), Institute of Health Carlos III, Madrid, Spain
- Microbiology Service, Hospital Clínic, Barcelona, Spain
| | - Julián Torre-Cisneros
- Maimónides Institute for Biomedical Research (IMIBIC), Cordoba, Spain
- Centre of Biomedical Research for Infectious Diseases (CIBERINFEC), Institute of Health Carlos III, Madrid, Spain
- Infectious Diseases Service, Reina Sofia University Hospital, Cordoba, Spain
- Departament of Medicine (Medicine, Dermatology and Otorhinolaryngology), University of Cordoba, Spain
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4
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Lee HJ, Woo SJ. Efficacy of ganciclovir versus foscarnet in ganciclovir-resistant cytomegalovirus retinitis: A case report. Eur J Ophthalmol 2023; 33:NP105-NP108. [PMID: 36314436 DOI: 10.1177/11206721221136316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
PURPOSE To report a case of cytomegalovirus (CMV) retinitis improved by treatment with ganciclovir in a patient with ganciclovir-resistant CMV infection associated with Good syndrome. STUDY DESIGN Case report. RESULT A 52-year-old gentleman with Good syndrome presented with visual disturbance in his right eye. He had a history of receiving intravitreal ganciclovir treatment with CMV retinitis a year ago. During treatment for CMV colitis three months ago, in systemic blood, UL97 mutation was identified and improved after changing treatment from ganciclovir to foscarnet. CMV retinitis recurred, and intravitreal ganciclovir injection was performed but there was no improvement. Therefore, the treatment was changed to foscarnet, but retinal infiltration progressed. Accordingly, it was changed to ganciclovir again and as a result, the progression of retinitis could be stopped. CONCLUSIONS Even in the case of CMV retinitis, which has been genetically confirmed to be ganciclovir resistance in systemic blood, ganciclovir treatment can be considered if other anti-CMV agents are not effective.
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Affiliation(s)
- Hyuk Jun Lee
- Department of Ophthalmology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Se Joon Woo
- Department of Ophthalmology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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Sharma P, Dwivedi R, Ray P, Shukla J, Pomin VH, Tandon R. Inhibition of Cytomegalovirus by Pentacta pygmaea Fucosylated Chondroitin Sulfate Depends on Its Molecular Weight. Viruses 2023; 15:v15040859. [PMID: 37112839 PMCID: PMC10142442 DOI: 10.3390/v15040859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 03/13/2023] [Accepted: 03/24/2023] [Indexed: 03/30/2023] Open
Abstract
Many viruses attach to host cells by first interacting with cell surface proteoglycans containing heparan sulfate (HS) glycosaminoglycan chains and then by engaging with specific receptor, resulting in virus entry. In this project, HS–virus interactions were targeted by a new fucosylated chondroitin sulfate from the sea cucumber Pentacta pygmaea (PpFucCS) in order to block human cytomegalovirus (HCMV) entry into cells. Human foreskin fibroblasts were infected with HCMV in the presence of PpFucCS and its low molecular weight (LMW) fractions and the virus yield at five days post-infection was assessed. The virus attachment and entry into the cells were visualized by labeling the purified virus particles with a self-quenching fluorophore octadecyl rhodamine B (R18). The native PpFucCS exhibited potent inhibitory activity against HCMV specifically blocking virus entry into the cell and the inhibitory activities of the LMW PpFucCS derivatives were proportional to their chain lengths. PpFucCS and the derived oligosaccharides did not exhibit any significant cytotoxicity; moreover, they protected the infected cells from virus-induced lytic cell death. In conclusion, PpFucCS inhibits the entry of HCMV into cells and the high MW of this carbohydrate is a key structural element to achieve the maximal anti-viral effect. This new marine sulfated glycan can be developed into a potential prophylactic and therapeutic antiviral agent against HCMV infection.
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Acquier M, Taton B, Alain S, Garrigue I, Mary J, Pfirmann P, Visentin J, Hantz S, Merville P, Kaminski H, Couzi L. Cytomegalovirus DNAemia Requiring (Val)Ganciclovir Treatment for More Than 8 Weeks Is a Key Factor in the Development of Antiviral Drug Resistance. Open Forum Infect Dis 2023; 10:ofad018. [PMID: 36817745 PMCID: PMC9933945 DOI: 10.1093/ofid/ofad018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 01/19/2023] [Indexed: 01/25/2023] Open
Abstract
Background Prolonged (val)ganciclovir [(V)GCV] exposure for ≥6 weeks is a known predisposing factor for cytomegalovirus (CMV) drug resistance. However, the selection of this threshold was based on limited data. In this study, we sought to reappraise the risk factors for the development of (V)GCV resistance through a specific focus on kidney transplant recipients (KTRs). Methods This single-center retrospective study included 313 consecutive KTRs treated for a first CMV episode. Adjusted Cox multivariate regression analysis was used for identifying independent risk factors. Results Antiviral drug resistance was identified in 20 (6%) KTRs. A cumulative (V)GCV exposure for more than 6 weeks (regardless of the viral load) was not associated with antiviral drug resistance (hazard ratio [HR] = 2.45, 95% confidence interval [CI] = 0.33-18.30, P = .38). In contrast, persistent CMV DNAemia requiring (V)GCV treatment for more than 8 weeks was the main independent risk factor for antiviral drug resistance (HR = 11.68, 95% CI = 2.62-52.01, P = .001). The (V)GCV treatment for more than 8 weeks was given to 9% and 18% of patients who had persistent or recurrent CMV DNAemia, respectively. These scenarios were associated with the occurrence of drug resistance in 39% and 12% of cases, respectively. Conclusions Cumulative (V)GCV exposure ≥6 weeks regardless of the viral load is not associated with antiviral drug resistance. In contrast, prolonged exposure to (V)GCV during CMV replication (with a cutoff ³8 weeks) seems to be a key factor.
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Affiliation(s)
- M Acquier
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Bordeaux University Hospital, Bordeaux, France
| | - B Taton
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Bordeaux University Hospital, Bordeaux, France
| | - S Alain
- National Reference Center for Herpes Viruses, Virology Department, Limoges University Hospital, LimogesFrance.,UMR INSERM U1092, RESINFIT, Limoges University, LimogesFrance
| | - I Garrigue
- Laboratory of Virology, Bordeaux University Hospital, Bordeaux, France
| | - J Mary
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Bordeaux University Hospital, Bordeaux, France
| | - P Pfirmann
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Bordeaux University Hospital, Bordeaux, France
| | - J Visentin
- CNRS-UMR 5164 ImmunoConcEpT, Bordeaux University, Bordeaux, France.,Laboratory of Immunology and Immunogenetics, Bordeaux University Hospital, Bordeaux, France
| | - S Hantz
- National Reference Center for Herpes Viruses, Virology Department, Limoges University Hospital, LimogesFrance.,UMR INSERM U1092, RESINFIT, Limoges University, LimogesFrance
| | - P Merville
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Bordeaux University Hospital, Bordeaux, France.,CNRS-UMR 5164 ImmunoConcEpT, Bordeaux University, Bordeaux, France
| | - H Kaminski
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Bordeaux University Hospital, Bordeaux, France.,CNRS-UMR 5164 ImmunoConcEpT, Bordeaux University, Bordeaux, France
| | - L Couzi
- Department of Nephrology, Transplantation, Dialysis and Apheresis, Bordeaux University Hospital, Bordeaux, France.,CNRS-UMR 5164 ImmunoConcEpT, Bordeaux University, Bordeaux, France
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7
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Demin MV, Tikhomirov DS, Tupoleva TA, Filatov FP. [Resistance to antiviral drugs in human viruses from the subfamily Betaherpesvirinae]. Vopr Virusol 2022; 67:285-294. [PMID: 36515284 DOI: 10.36233/0507-4088-136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Indexed: 12/07/2022]
Abstract
The review provides information on the mechanisms of the emergence of resistance to antiviral drugs in human viruses from the subfamily Betaherpesvirinae. Data on the principles of action of antiviral drugs and their characteristics are given. The occurrence rates of viral resistance in various groups of patients is described and information about the possible consequences of the emergence of resistance to antiviral drugs is given. Information is provided regarding the virus genes in which mutations occur that lead to viral resistance, and a list of such mutations that have described so far is given. The significance of the study of mutations leading to the resistance of the virus to antiviral drugs for medical practice is discussed.
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Affiliation(s)
- M V Demin
- National Medical Research Center of Hematology of the Ministry of Health of Russia
| | - D S Tikhomirov
- National Medical Research Center of Hematology of the Ministry of Health of Russia
| | - T A Tupoleva
- National Medical Research Center of Hematology of the Ministry of Health of Russia
| | - F P Filatov
- I.I. Mechnikov Research Institute of Vaccines and Serums of the Ministry of Education and Science of Russia.,National Research Center of Epidemiology and Microbiology named after Honorary Academician N.F. Gamaleya of the Ministry of Health of Russia
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8
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Senaweera S, Edwards TC, Kankanala J, Wang Y, Sahani RL, Xie J, Geraghty RJ, Wang Z. Discovery of N-benzyl hydroxypyridone carboxamides as a novel and potent antiviral chemotype against human cytomegalovirus (HCMV). Acta Pharm Sin B 2022; 12:1671-1684. [PMID: 35847513 PMCID: PMC9279720 DOI: 10.1016/j.apsb.2021.08.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/05/2021] [Accepted: 08/17/2021] [Indexed: 12/29/2022] Open
Abstract
Current drugs for treating human cytomegalovirus (HCMV) infections are limited by resistance and treatment-associated toxicities. In developing mechanistically novel HCMV antivirals, we discovered an N-benzyl hydroxypyridone carboxamide antiviral hit (8a) inhibiting HCMV in submicromolar range. We describe herein the structure–activity relationship (SAR) for 8a, and the characterization of potent analogs for cytotoxicity/cytostatic property, the preliminary mechanism of action, and the absorption, distribution, metabolism and excretion (ADME) properties. The SAR revealed a few pharmacophore features conferring optimal antiviral profile, including the 5-OH, the N-1 benzyl, at least one –CH2− in the linker, and a di-halogen substituted phenyl ring in the amide moiety. In the end, we identified numerous analogs with sub-micromolar antiviral potency and good selectivity index. The preliminary mechanism of action characterization used a pUL89-C biochemical endonuclease assay, a virus entry assay, a time-of-addition assay, and a compound withdrawal assay. ADME profiling measuring aqueous solubility, plasma and liver microsomal stability, and parallel artificial membrane permeability assay (PAMPA) permeability demonstrated largely favorable drug-like properties. Together, these studies validate the N-benzyl hydroxypyridone carboxamide as a viable chemotype for potent and mechanistically distinct antivirals against HCMV.
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9
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Neutralizing Antibodies Limit Cell-Associated Spread of Human Cytomegalovirus in Epithelial Cells and Fibroblasts. Viruses 2022; 14:v14020284. [PMID: 35215877 PMCID: PMC8875165 DOI: 10.3390/v14020284] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/24/2022] [Accepted: 01/27/2022] [Indexed: 02/04/2023] Open
Abstract
Human cytomegalovirus (HCMV) can cause severe clinical disease in immunocompromised individuals, such as allograft recipients and infants infected in utero. Neutralizing activity of antibodies, measured as the ability to prevent the entry of cell-free virus, has been correlated with the reduction in HCMV transmission and the severity of HCMV-associated disease. However, in vivo HCMV amplification may occur mainly via cell-to-cell spread. Thus, quantifying the inhibition of cell-to-cell transmission could be important in the evaluation of therapeutic antibodies and/or humoral responses to infection or immunization. Here, we established a quantitative plaque reduction assay, which allowed for the measurement of the capacity of antibodies to limit HCMV spread in vitro. Using an automated fluorescence spot reader, infection progression was assayed by the expansion of viral plaques during the course of infection with various GFP-expressing viruses. We found that in contrast to non-neutralizing monoclonal antibodies (mAbs), neutralizing mAbs against both glycoprotein B and H (gB and gH) could significantly inhibit viral plaque expansion of different HCMV strains and was equally efficient in fibroblasts as in epithelial cells. In contrast, an anti-pentamer mAb was active only in epithelial cells. Taken together, our data demonstrate that specific anti-HCMV mAbs can significantly limit cell-associated virus spread in vitro.
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10
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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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Trompet E, Temblador A, Gillemot S, Topalis D, Snoeck R, Andrei G. An MHV-68 Mutator Phenotype Mutant Virus, Confirmed by CRISPR/Cas9-Mediated Gene Editing of the Viral DNA Polymerase Gene, Shows Reduced Viral Fitness. Viruses 2021; 13:v13060985. [PMID: 34073189 PMCID: PMC8227558 DOI: 10.3390/v13060985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 05/11/2021] [Accepted: 05/24/2021] [Indexed: 12/04/2022] Open
Abstract
Drug resistance studies on human γ-herpesviruses are hampered by the absence of an in vitro system that allows efficient lytic viral replication. Therefore, we employed murine γ-herpesvirus-68 (MHV-68) that efficiently replicates in vitro as a model to study the antiviral resistance of γ-herpesviruses. In this study, we investigated the mechanism of resistance to nucleoside (ganciclovir (GCV)), nucleotide (cidofovir (CDV), HPMP-5azaC, HPMPO-DAPy) and pyrophosphate (foscarnet (PFA)) analogues and the impact of these drug resistance mutations on viral fitness. Viral fitness was determined by dual infection competition assays, where MHV-68 drug-resistant viral clones competed with the wild-type virus in the absence and presence of antivirals. Using next-generation sequencing, the composition of the viral populations was determined at the time of infection and after 5 days of growth. Antiviral drug resistance selection resulted in clones harboring mutations in the viral DNA polymerase (DP), denoted Y383SGCV, Q827RHPMP-5azaC, G302WPFA, K442TPFA, G302W+K442TPFA, C297WHPMPO-DAPy and C981YCDV. Without antiviral pressure, viral clones Q827RHPMP-5azaC, G302WPFA, K442TPFA and G302W+K442TPFA grew equal to the wild-type virus. However, in the presence of antivirals, these mutants had a growth advantage over the wild-type virus that was moderately to very strongly correlated with antiviral resistance. The Y383SGCV mutant was more fit than the wild-type virus with and without antivirals, except in the presence of brivudin. The C297W and C981Y changes were associated with a mutator phenotype and had a severely impaired viral fitness in the absence and presence of antivirals. The mutator phenotype caused by C297W in MHV-68 DP was validated by using a CRISPR/Cas9 genome editing approach.
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12
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Da Cunha T, Wu GY. Cytomegalovirus Hepatitis in Immunocompetent and Immunocompromised Hosts. J Clin Transl Hepatol 2021; 9:106-115. [PMID: 33604261 PMCID: PMC7868697 DOI: 10.14218/jcth.2020.00088] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/22/2020] [Accepted: 12/08/2020] [Indexed: 12/25/2022] Open
Abstract
Human cytomegalovirus (HCMV) infection is common and affects between 40-100% of the worldwide population. However, the majority of cases are asymptomatic and when severe disease occurs, it is usually restricted to immunocompromised patients. Liver involvement by HCMV differs significantly, accordingly to the immune status of the host. In immunocompromised patients, particularly liver transplant patients, it often causes clinically significant hepatitis. On the other hand, in immunocompetent patients, HCMV hepatitis requiring hospitalization is extremely rare. This review aims to appraise studies regarding the pathophysiology of HCMV hepatitis, including mechanisms of latency and reactivation and its contribution to disease development, clinical presentation, diagnostic modalities and treatment, with a focus on comparing different aspects between immunocompromised and immunocompetent hosts.
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Affiliation(s)
- Teresa Da Cunha
- Department of Medicine, Division of Gastroenterology-Hepatology, University of Connecticut Health Center, Farmington, CT, USA
- Correspondence to: Teresa Da Cunha, Department of Medicine, University of Connecticut Health Center, Farmington, CT 06030, USA. Tel: +1-860-706-2133, Fax: +1-860-679-3159, E-mail:
| | - George Y. Wu
- Department of Medicine, Division of Gastroenterology-Hepatology, University of Connecticut Health Center, Farmington, CT, USA
- Current address: Department of Medicine, University of Connecticut Health Center, Farmington, CT, USA
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13
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Mehta Steinke SA, Alfares M, Valsamakis A, Shoham S, Arav-Boger R, Lees L, Ostrander D, Forman MS, Shedeck A, Ambinder RF, Jones RJ, Avery RK. Outcomes of transplant recipients treated with cidofovir for resistant or refractory cytomegalovirus infection. Transpl Infect Dis 2020; 23:e13521. [PMID: 33220125 DOI: 10.1111/tid.13521] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/15/2020] [Accepted: 11/01/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Treatment of ganciclovir-resistant (GCV-R)/refractory cytomegalovirus (CMV) infections in blood/marrow transplant (BMT) and solid organ transplant (SOT) recipients remains suboptimal. Cidofovir (CDV), a nucleotide analogue with anti-CMV activity, is nephrotoxic and oculotoxic. METHODS We retrospectively evaluated the outcomes of SOT and BMT patients with GCV-R/refractory CMV treated with CDV between 1/1/2008 and 12/31/2017. DATA COLLECTED baseline demographics, CMV serostatus, clinical and virologic presentations and outcomes, UL97 and UL54 genotype mutations, drug toxicities, and cause of death. Descriptive statistics were used. RESULTS 16 patients received CDV for treatment of CMV: six BMT and 10 SOT. Seven (47%) of the patients had high-risk donor/recipient serostatus: six (60%) SOT were D+/R-; one (16.7%) BMT was D-/R+. Median time to CMV DNAemia was 131 days post-transplant (IQR, 37.5-230.3). Proven tissue invasive disease was present in three patients (18.8%). Twelve (75%) had genotype testing; 10 (83.3%) of those had antiviral resistance mutations. While on CDV, six (37.5%) developed nephrotoxicity, and four (25%) developed uveitis (two had both uveitis and nephrotoxicity). Eight (50%) had failure to clear CMV DNAemia despite CDV treatment. Eight (50%) of the patients died; median time to death, after initiation of CDV, was 33.5 days [IQR22-988]. CONCLUSIONS In the absence of good therapeutic alternatives, CDV is used in GCV-R/refractory CMV infection. However, it is associated with a substantial risk of toxicity and failure to clear CMV DNAemia, highlighting the need for development of newer and less toxic therapies. The high mortality in this group of patients underscores the severity of illness in this population.
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Affiliation(s)
- Seema A Mehta Steinke
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins, Baltimore, MD, USA.,Pueblo Infectious Diseases, PLLC, Pueblo, CO, USA
| | - Mona Alfares
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins, Baltimore, MD, USA
| | - Alexandra Valsamakis
- Division of Medical Microbiology, Department of Pathology, Johns Hopkins, Baltimore, MD, USA.,Roche Molecular Diagnostics, Pleasanton, CA, USA
| | - Shmuel Shoham
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins, Baltimore, MD, USA
| | - Ravit Arav-Boger
- Department of Pediatrics, Johns Hopkins, Baltimore, MD, USA.,Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Laura Lees
- Department of Pharmacy, Johns Hopkins, Baltimore, MD, USA
| | - Darin Ostrander
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins, Baltimore, MD, USA
| | - Michael S Forman
- Division of Medical Microbiology, Department of Pathology, Johns Hopkins, Baltimore, MD, USA
| | - Audra Shedeck
- Department of Hematology and Oncology, Johns Hopkins, Baltimore, MD, USA
| | - Richard F Ambinder
- Department of Hematology and Oncology, Johns Hopkins, Baltimore, MD, USA
| | - Richard John Jones
- Department of Hematology and Oncology, Johns Hopkins, Baltimore, MD, USA
| | - Robin K Avery
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins, Baltimore, MD, USA
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Cell Fusion Induced by a Fusion-Active Form of Human Cytomegalovirus Glycoprotein B (gB) Is Inhibited by Antibodies Directed at Antigenic Domain 5 in the Ectodomain of gB. J Virol 2020; 94:JVI.01276-20. [PMID: 32641474 DOI: 10.1128/jvi.01276-20] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 06/29/2020] [Indexed: 01/22/2023] Open
Abstract
Human cytomegalovirus (HCMV) is a ubiquitous pathogen that can cause severe clinical disease in allograft recipients and infants infected in utero Virus-neutralizing antibodies defined in vitro have been proposed to confer protection against HCMV infection, and the virion envelope glycoprotein B (gB) serves as a major target of neutralizing antibodies. The viral fusion protein gB is nonfusogenic on its own and requires glycoproteins H (gH) and L (gL) for membrane fusion, which is in contrast to requirements of related class III fusion proteins, including vesicular stomatitis virus glycoprotein G (VSV-G) or baculovirus gp64. To explore requirements for gB's fusion activity, we generated a set of chimeras composed of gB and VSV-G or gp64, respectively. These gB chimeras were intrinsically fusion active and led to the formation of multinucleated cell syncytia when expressed in the absence of other viral proteins. Utilizing a panel of virus-neutralizing gB-specific monoclonal antibodies (MAbs), we could demonstrate that syncytium formation of the fusogenic gB/VSV-G chimera can be significantly inhibited by only a subset of neutralizing MAbs which target antigenic domain 5 (AD-5) of gB. This observation argues for differential modes of action of neutralizing anti-gB MAbs and suggests that blocking the membrane fusion function of gB could be one mechanism of antibody-mediated virus neutralization. In addition, our data have important implications for the further understanding of the conformation of gB that promotes membrane fusion as well as the identification of structures in AD-5 that could be targeted by antibodies to block this early step in HCMV infection.IMPORTANCE HCMV is a major global health concern, and antiviral chemotherapy remains problematic due to toxicity of available compounds and the emergence of drug-resistant viruses. Thus, an HCMV vaccine represents a priority for both governmental and pharmaceutical research programs. A major obstacle for the development of a vaccine is a lack of knowledge of the nature and specificities of protective immune responses that should be induced by such a vaccine. Glycoprotein B of HCMV is an important target for neutralizing antibodies and, hence, is often included as a component of intervention strategies. By generation of fusion-active gB chimeras, we were able to identify target structures of neutralizing antibodies that potently block gB-induced membrane fusion. This experimental system provides an approach to screen for antibodies that interfere with gB's fusogenic activity. In summary, our data will likely contribute to both rational vaccine design and the development of antibody-based therapies against HCMV.
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Translation of the long-term fundamental studies on viral DNA packaging motors into nanotechnology and nanomedicine. SCIENCE CHINA-LIFE SCIENCES 2020; 63:1103-1129. [DOI: 10.1007/s11427-020-1752-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 06/04/2020] [Indexed: 02/07/2023]
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Where do we Stand after Decades of Studying Human Cytomegalovirus? Microorganisms 2020; 8:microorganisms8050685. [PMID: 32397070 PMCID: PMC7284540 DOI: 10.3390/microorganisms8050685] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 04/27/2020] [Accepted: 05/05/2020] [Indexed: 12/26/2022] Open
Abstract
Human cytomegalovirus (HCMV), a linear double-stranded DNA betaherpesvirus belonging to the family of Herpesviridae, is characterized by widespread seroprevalence, ranging between 56% and 94%, strictly dependent on the socioeconomic background of the country being considered. Typically, HCMV causes asymptomatic infection in the immunocompetent population, while in immunocompromised individuals or when transmitted vertically from the mother to the fetus it leads to systemic disease with severe complications and high mortality rate. Following primary infection, HCMV establishes a state of latency primarily in myeloid cells, from which it can be reactivated by various inflammatory stimuli. Several studies have shown that HCMV, despite being a DNA virus, is highly prone to genetic variability that strongly influences its replication and dissemination rates as well as cellular tropism. In this scenario, the few currently available drugs for the treatment of HCMV infections are characterized by high toxicity, poor oral bioavailability, and emerging resistance. Here, we review past and current literature that has greatly advanced our understanding of the biology and genetics of HCMV, stressing the urgent need for innovative and safe anti-HCMV therapies and effective vaccines to treat and prevent HCMV infections, particularly in vulnerable populations.
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Abstract
PURPOSE OF REVIEW Cytomegalovirus (CMV) is the most common infection after organ transplant. In addition to causing a viral syndrome and infection, it also increases the risk for complications in the organ transplant, along with higher overall morbidity and mortality. Prevention and ideal treatment of CMV is paramount for optimal outcomes, both for individuals as well as for transplant programs. New guidelines and novel therapies are changing the way we manage disease. RECENT FINDINGS Several new antiviral agents have emerged in recent times, including letermovir, maribavir, and brincidofovir, enhancing our ability to prevent and treat CMV. Recent data on novel agents will be reviewed, with an emphasis on recent guidelines and best practices. SUMMARY Optimal treatment, influenced by recent advances in the field, including management of resistant virus, results in better outcomes with this significant and virulent virus.
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Cytomegalovirus viremia among pediatric oncology non-stem cell transplant patients with prolonged fever neutropenia. J Infect Public Health 2020; 13:1176-1180. [PMID: 32224110 DOI: 10.1016/j.jiph.2020.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 01/19/2020] [Accepted: 02/05/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) is a rare cause of prolonged febrile neutropenia (PFN) among pediatric oncology patients, especially in non-stem cell transplant setting (Non-SCTS). Infectious Diseases Society of America (IDSA) guidelines stated briefly that neutropenia is not considered as an indication of CMV re-activation, and thus preventive strategies are not needed; however, multiple studies pressed on the need to treat CMV viremia among patients with PFN even when there is no evidence of end-organ involvement. Therefore, this study aimed to prospectively investigate the significance of CMV as a cause of PFN among pediatric oncology patients in a Non-SCTS. PATIENTS AND METHODS This was a prospective cohort study that was done at Princess Norah Oncology Center, King Abdulaziz Medical City in Jeddah, Saudi Arabia. CMV viral load was monitored weekly once the subject was identified as a case of PFN until resolution. Subjects and treating physicians were blinded to CMV viral load results. RESULTS The data of 27 PFN episodes (48% males) were analyzed. The incidence of CMV viremia was reported as 29.6%. Both CMV positive and negative episodes of PFN had similar rate of spontaneous resolution (p=0.669), with overall mortality as 105 and 125 per 1000 PFN episodes, respectively. No subject received anti-CMV in the positive CMV group; however, one subject did in the negative group for reasons other than CMV infection. CONCLUSION This study demonstrated that CMV was not a significant cause of PFN in Non-SCTS. CMV also had no significant role in terms of survival and severity of the PFN episode.
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20
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Amin A, Farmer DG. Current outcomes after pediatric and adult intestinal transplantation. Curr Opin Organ Transplant 2020; 24:193-198. [PMID: 30676400 DOI: 10.1097/mot.0000000000000608] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW In this article, we will review the outcomes of patients with intestinal transplant (ITx) with a focus on factors affecting long-term graft and patient survival. RECENT FINDINGS The most recent International Intestinal Transplant Registry reports a 1-, 5-, and 10-year graft survival of 71%, 50%, and 41% respectively, for ITx grafts transplanted since 2000. Over the past decades, significant improvements have been achieved in short-term graft and patient outcomes for ITx recipients. The improvement in short-term outcomes may be related to the focused treatment of antihuman leukocyte antigen antibodies, the use of induction immunotherapy protocols, refinements in surgical techniques, establishment of dedicated ITx units, and improved postoperative management.However, long-term graft and patient outcomes for ITx recipients remain stagnant. Issues impairing long-term outcomes of ITx include the challenges in the diagnosis and treatment of chronic rejection and antibody-mediated rejection, progressive decline in renal function, and long-term infectious and malignancy risks especially related to cytomegalovirus, Epstein-Barr virus and posttransplant lymphoproliferative disorder after ITx. SUMMARY Addressing and preventing early and late complications is the key to improving short-term and long-term outcomes after ITx.
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Affiliation(s)
- Arpit Amin
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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Svrlanska A, Ruhland A, Marschall M, Reuter N, Stamminger T. Wedelolactone inhibits human cytomegalovirus replication by targeting distinct steps of the viral replication cycle. Antiviral Res 2019; 174:104677. [PMID: 31836420 DOI: 10.1016/j.antiviral.2019.104677] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 12/06/2019] [Accepted: 12/09/2019] [Indexed: 12/19/2022]
Abstract
Wedelolactone (WDL) is a coumestan present in the plants Eclipta prostrata and Wedelia calendulacea which are used for treatment of a multitude of health problems in traditional medicine. It has previously been shown that WDL exerts antiviral activity against human immunodeficiency virus and hepatitis C virus. In this study, we investigated the effect of WDL on lytic human cytomegalovirus (HCMV) infection. We demonstrate a strong interference with HCMV replication as analyzed in multi-round replication settings. A more detailed analysis of the underlying mechanisms revealed that WDL acts at two distinct steps of the viral replication cycle. During immediate early (IE) times, we observe an inhibition of IE1/IE2 expression. Although WDL was reported to interfere with NF-κB signaling our results suggest the existence of additional mechanisms that impede viral IE expression. During later time points of infection, WDL induced a disruption of the interaction between EZH2 and EED, components of the virus-supportive polycomb repressive complex 2 (PRC2). Thereby, the stability of the PRC2 complex as well as the related complex PRC1 was disturbed leading to diminished viral DNA synthesis. Taken together, we identify WDL as a potent agent against HCMV which interferes at two distinct steps of viral replication.
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Affiliation(s)
- Adriana Svrlanska
- Institute for Clinical and Molecular Virology, Friedrich-Alexander University of Erlangen-Nürnberg, Erlangen, Germany
| | - Anna Ruhland
- Institute for Clinical and Molecular Virology, Friedrich-Alexander University of Erlangen-Nürnberg, Erlangen, Germany
| | - Manfred Marschall
- Institute for Clinical and Molecular Virology, Friedrich-Alexander University of Erlangen-Nürnberg, Erlangen, Germany
| | - Nina Reuter
- Institute for Clinical and Molecular Virology, Friedrich-Alexander University of Erlangen-Nürnberg, Erlangen, Germany
| | - Thomas Stamminger
- Institute for Virology, Ulm University Medical Center, Ulm, Germany.
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Abstract
PURPOSE OF REVIEW Transplant recipients are at risk for cytomegalovirus (CMV) infection and associated morbidity and mortality. We summarize recently introduced or currently investigated modalities for prevention and treatment of CMV infection in hematopoietic cell (HCT) and solid organ transplant (SOT) recipients. RECENT FINDINGS Letermovir was recently approved for CMV prevention in HCT recipients. Data from real world studies support its role to improve outcomes in this population. Letermovir is currently under investigation for broader patient populations and indications. Maribavir is in late stages of development for CMV treatment and may provide a safer alternative to currently available anti-CMV drugs. Promising CMV vaccine candidates and adoptive cell therapy approaches are under evaluation. CMV immune monitoring assays are predicted to play a more central role in our clinical decision making. In recent years, major advances have been made in CMV prevention and treatment in transplant recipients. Rigorous research is ongoing and is anticipated to further impact our ability to improve outcomes in this population.
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Affiliation(s)
- Anat Stern
- Infectious Disease Service, Memorial Sloan Kettering Cancer Center, NY1250 1st Avenue, New York, NY, 10065, USA
| | - Genovefa A Papanicolaou
- Infectious Disease Service, Memorial Sloan Kettering Cancer Center, NY1250 1st Avenue, New York, NY, 10065, USA.
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Grossi PA, Baldanti F, Andreoni M, Perno CF. CMV infection management in transplant patients in Italy. J Clin Virol 2019; 123:104211. [PMID: 31879243 DOI: 10.1016/j.jcv.2019.104211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 10/01/2019] [Accepted: 11/04/2019] [Indexed: 12/27/2022]
Abstract
Transplant represents an effective strategy in the management of chronic organ dysfunction. Nonetheless, life threatening risks remain, especially in the post-transplant; among them, human cytomegalovirus (CMV) is a major concern, currently causing active infections in at least one-third of transplant recipients. Microbiologist and transplant scientific societies redefined guidance on CMV disease prevention and the best use for universal prophylaxis and pre-emptive virological monitoring. Developments in molecular diagnostic supported the spread of the pre-emptive strategy, and quantitative Real Time-PCR assays has unravelled the potential of viral load measurement as a predictor of the infection development in CMV post-transplant management. However, despite the WHO 1st CMV International Standard, the standardization of diagnostic and clinical practice has been limited by the absence of algorithms for calculating conversion factor to International Units and the lack of shared monitoring procedure, both at national and international level. At a regional level, the Italian scientific societies, AMCLI (Italian Clinical Microbiologist Association), SITO (Organ Transplant Italian Society), GITMO (Italian Group for Bone Marrow Transplant), recently tried to define a consensus for post-transplant monitoring. The concerted practice encompasses molecular quantitative PCR assays technical aspects and endorses the relevance of immunologic monitoring for improvement in patient risk stratification and prognosis. Here, we provide an overview of the state of the art of CMV management strategies, with a specific focus on the clinical practices and on the scientific societies' initiatives that aim to implement international standardization guidelines at a national level.
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Affiliation(s)
- Paolo Antonio Grossi
- Infectious Diseases Section, Department of Medicine and Surgery, University of Insubria, Varese; National Center for Transplantation, Rome, Italy
| | - Fausto Baldanti
- Molecular Virology Unit, Policlinic IRCCS Foundation San Matteo, Pavia, Italy
| | - Massimo Andreoni
- Infectious Disease Unit, Policlinic Foundation Tor Vergata, Rome, Italy; Department of Oncology and Oncohematology, University of Milan, Italy; Department of Clinical Virology, ASST Niguarda, Milan, Italy
| | - Carlo Federico Perno
- Infectious Disease Unit, Policlinic Foundation Tor Vergata, Rome, Italy; Department of Oncology and Oncohematology, University of Milan, Italy; Department of Clinical Virology, ASST Niguarda, Milan, Italy.
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Guermouche H, Burrel S, Mercier-Darty M, Kofman T, Rogier O, Pawlotsky JM, Boutolleau D, Rodriguez C. Characterization of the dynamics of human cytomegalovirus resistance to antiviral drugs by ultra-deep sequencing. Antiviral Res 2019; 173:104647. [PMID: 31706899 DOI: 10.1016/j.antiviral.2019.104647] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 09/30/2019] [Accepted: 11/04/2019] [Indexed: 12/12/2022]
Abstract
Prophylactic or preemptive treatment strategies are required to prevent human cytomegalovirus (CMV) infections in transplant recipients. However, treatment failure occurs when CMV resistant-associated variants (RAVs) are selected. Although the diversity of CMV is lower than that of RNA viruses, CMV appears to show some genetic instability, with possible minor emerging resistance that may be undetectable by Sanger sequencing. We aimed to examine CMV-resistance mutations over time by ultra-deep sequencing (UDS) and Sanger sequencing in a kidney transplant recipient experiencing CMV infection. This patient showed a transient response to three different antiviral drugs (valganciclovir, foscarnet, and maribavir) and four episodes of CMV resistance over two years. The full-length UL97 (2.3kpb) and partial UL54 (2.4kpb) CMV genes were studied by UDS and Sanger sequencing and linkage mutations calculated to determine RAVs. We detected four major and five minor resistance mutations. Minor resistant variants (2-20%) were detected by UDS, whereas major resistance substitutions (>20%) were identified by both UDS and Sanger method. We detected cross-resistance to three drugs, despite high CMV loads, suggesting that the fitness of the viral mutants was not impaired. In conclusion, CMV showed complex dynamic of resistance under antiviral drug pressure, as described for highly variable viruses. The emergence of successive RAVs constitutes a clinically challenging complication and contributes to the difficulty of therapeutic management of patients.
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Affiliation(s)
- Hélène Guermouche
- Laboratoire de Virologie, CHU Henri Mondor (AP-HP), INSERM U955 Eq18, Plateforme « Génomiques », IMRB, UPEC, Créteil, France
| | - Sonia Burrel
- Centre National de Référence Herpèsvirus (laboratoire associé), Laboratoire de Virologie, Hôpital Universitaire La Pitié-Salpêtrière, GHU AP-PH. Sorbonne Université (AP-HP), INSERM U1136, iPLESP, Sorbonne Université, Paris, France
| | - Mélanie Mercier-Darty
- Laboratoire de Virologie, CHU Henri Mondor (AP-HP), INSERM U955 Eq18, Plateforme « Génomiques », IMRB, UPEC, Créteil, France
| | - Thomas Kofman
- Service de Néphrologie, Hôpital Universitaire Henri Mondor (AP-HP), Créteil, France
| | - Olivier Rogier
- Laboratoire de Virologie, CHU Henri Mondor (AP-HP), INSERM U955 Eq18, Plateforme « Génomiques », IMRB, UPEC, Créteil, France
| | - Jean-Michel Pawlotsky
- Laboratoire de Virologie, CHU Henri Mondor (AP-HP), INSERM U955 Eq18, Plateforme « Génomiques », IMRB, UPEC, Créteil, France
| | - David Boutolleau
- Centre National de Référence Herpèsvirus (laboratoire associé), Laboratoire de Virologie, Hôpital Universitaire La Pitié-Salpêtrière, GHU AP-PH. Sorbonne Université (AP-HP), INSERM U1136, iPLESP, Sorbonne Université, Paris, France
| | - Christophe Rodriguez
- Laboratoire de Virologie, CHU Henri Mondor (AP-HP), INSERM U955 Eq18, Plateforme « Génomiques », IMRB, UPEC, Créteil, France.
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Fu L, Santhanakrishnan K, Al-Aloul M, Jones NP, Steeples LR. Management of Ganciclovir Resistant Cytomegalovirus Retinitis in a Solid Organ Transplant Recipient: A Review of Current Evidence and Treatment Approaches. Ocul Immunol Inflamm 2019; 28:1152-1158. [PMID: 31621449 DOI: 10.1080/09273948.2019.1645188] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Purpose: Cytomegalovirus retinitis (CMVR) is a serious and potentially sight-threatening infection in immunocompromised individuals. Strategies for the management of drug-resistant CMVR are described. Methods: A case of severe bilateral CMVR in a single lung transplant patient, with UL97 mutation conferring ganciclovir-resistance, is presented. Treatment with standard antiviral agent and adjuvant leflunomide, immunosuppression modifications (calcineurin inhibitors and corticosteroid), intravitreal antiviral therapy and novel use of CMV-immunoglobulin is described. A literature review to support drug-resistant CMVR management is presented. Results: Severe and progressive CMV retinitis was refractory to intravitreal foscarnet and systemic leflunomide. Drug-toxicity restricted systemic antiviral therapy options. The use of combined leflunomide and CMV-immunoglobulins, in the absence of viremia, has not been previously reported. Loss of ganciclovir-resistance was eventually observed permitting successful treatment with systemic and intravitreal ganciclovir. Conclusions: Drug-resistant CMVR is a complex clinical challenge. Multiple systemic and local treatment strategies may be necessary but toxicity, resistance, and co-morbidities may severely restrict available options.
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Affiliation(s)
- L Fu
- Manchester Royal Eye Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre , Manchester, UK.,Centre for Ophthalmology and Vision Sciences, Faculty of Medical and Human Sciences, University of Manchester , Manchester, UK
| | - K Santhanakrishnan
- Department of Cardiothoracic Transplant, Wythenshawe Hospital, Manchester University NHS Foundation Trust , Manchester, UK
| | - M Al-Aloul
- Department of Cardiothoracic Transplant, Wythenshawe Hospital, Manchester University NHS Foundation Trust , Manchester, UK
| | - N P Jones
- Manchester Royal Eye Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre , Manchester, UK.,Centre for Ophthalmology and Vision Sciences, Faculty of Medical and Human Sciences, University of Manchester , Manchester, UK
| | - L R Steeples
- Manchester Royal Eye Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre , Manchester, UK.,Centre for Ophthalmology and Vision Sciences, Faculty of Medical and Human Sciences, University of Manchester , Manchester, UK
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Improvement in detecting cytomegalovirus drug resistance mutations in solid organ transplant recipients with suspected resistance using next generation sequencing. PLoS One 2019; 14:e0219701. [PMID: 31318908 PMCID: PMC6638921 DOI: 10.1371/journal.pone.0219701] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 05/07/2019] [Indexed: 12/20/2022] Open
Abstract
OBJETIVES The aim of this study was to identify CMV drug resistance mutations (DRM) in solid organ transplant (SOT) recipients with suspected resistance comparing next-generation sequencing (NGS) with Sanger sequencing and assessing risk factors and the clinical impact of resistance. METHODS Using Sanger sequencing as the reference method, we prospectively assessed the ability of NGS to detect CMV DRM in the UL97 and UL54 genes in a nationwide observational study from September 2013 to August 2016. RESULTS Among 44 patients recruited, 14 DRM were detected by Sanger in 12 patients (27%) and 20 DRM were detected by NGS, in 16 (36%). NGS confirmed all the DRM detected by Sanger. The additional six mutations detected by NGS were present in <20% of the sequenced population, being located in the UL97 gene and conferring high-level resistance to ganciclovir. The presence of DRM by NGS was associated with lung transplantation (p = 0.050), the administration of prophylaxis (p = 0.039), a higher mean time between transplantation and suspicion of resistance (p = 0.038) and longer antiviral treatment duration before suspicion (p = 0.024). However, the latter was the only factor independently associated with the presence of DRM by NGS in the multivariate analysis (OR 2.24, 95% CI 1.03 to 4.87). CONCLUSIONS NGS showed a higher yield than Sanger sequencing for detecting CMV resistance mutations in SOT recipients. The presence of DRM detected by NGS was independently associated with longer antiviral treatment.
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Gerna G, Lilleri D, Baldanti F. An overview of letermovir: a cytomegalovirus prophylactic option. Expert Opin Pharmacother 2019; 20:1429-1438. [PMID: 31282759 DOI: 10.1080/14656566.2019.1637418] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Introduction: Human cytomegalovirus (HCMV) or human herpesvirus 5 (HHV-5) is a β-herpesvirus that causes widespread infection in nearly all members of the human population worldwide. Its persistence in humans after primary infection in a latent phase as well as a partial non-protective immune response is the basis for repeated re-activation/re-infection episodes occurring both in immunocompetent and immunocompromised subjects. In the latter patient populations, which include hematopoietic stem cell transplant (HSCT) recipients, HCMV reactivation episodes may be particularly severe, leading to both systemic and end-organ diseases. Since the 90s, at least four antiviral drugs targeting the DNA polymerase complex have been developed for the prevention and treatment of HCMV infections in transplant recipients, used as first-line (ganciclovir and valganciclovir) and second-line therapy (foscarnet and cidofovir). However, due to their toxicity and drug-resistance induction, new drugs with different targets were needed. Areas covered: In 2017, a new drug named letermovir (LTV), which targets the HCMV DNA terminase complex, was licensed for prophylaxis of HCMV infections in HSCT recipients. This is the focus of this review. Expert opinion: LTV safety and efficacy are promising. However, long-term adverse events and the emergence of drug-resistant HCMV strains must be investigated in extended clinical trials prior to drawing final conclusions.
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Affiliation(s)
- Giuseppe Gerna
- Laboratories of Genetics, Transplantology and Cardiovascular Diseases, and Biotechnology Laboratories, Fondazione IRCCS Policlinico San Matteo , Pavia , Italy
| | - Daniele Lilleri
- Laboratories of Genetics, Transplantology and Cardiovascular Diseases, and Biotechnology Laboratories, Fondazione IRCCS Policlinico San Matteo , Pavia , Italy
| | - Fausto Baldanti
- Molecular Virology Unit, Microbiology and Virology Department, Fondazione IRCCS Policlinico San Matteo , Pavia , Italy.,Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia , Pavia , Italy
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28
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Andrei G, Van Loon E, Lerut E, Victoor J, Meijers B, Bammens B, Sprangers B, Gillemot S, Fiten P, Opdenakker G, Lagrou K, Kuypers D, Snoeck R, Naesens M. Persistent primary cytomegalovirus infection in a kidney transplant recipient: Multi-drug resistant and compartmentalized infection leading to graft loss. Antiviral Res 2019; 168:203-209. [PMID: 31212020 DOI: 10.1016/j.antiviral.2019.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 05/29/2019] [Accepted: 06/06/2019] [Indexed: 10/26/2022]
Abstract
Cytomegalovirus (CMV) is one of the most common opportunistic infections after transplantation. To prevent CMV infections, universal prophylaxis and pre-emptive therapy with ganciclovir or its prodrug valganciclovir is applied. However, prolonged antiviral therapy may result in drug-resistance emergence. We describe a case of a 43-year-old CMV-seronegative patient who underwent kidney transplantation from a CMV-seropositive donor and developed CMV disease despite valganciclovir prophylaxis. CMV viral load increased even though valgangiclovir dose was augmented and immunosuppressive therapy reduced. CMV genotyping revealed mutations in the viral UL97 protein kinase, explaining ganciclovir-resistant CMV infection. The viral load failed to respond to foscavir, cidofovir and CMV-neutralizing immunoglobulins. Kidney allograft dysfunction developed 3 months post-transplantation with a histopathologic diagnosis of CMV nephropathy and potentially concomitant T-cell mediated rejection. A transplantectomy was performed on day 164 post-transplantation since the patient had uncontrollable CMV disease associated with a circulating multidrug-resistant DNA polymerase-mutant virus. Detailed monitoring in this patient demonstrated hallmarks of complicated CMV disease: (i) relatively rapid evolution of drug-resistant CMV mutants in the setting of persistent high blood viral loads, (ii) emergence of viral drug-resistance linked to acute graft rejection, (iii) transient and, thereafter, lack of response to various anti-CMV treatments, (iv) compartmentalization and heterogeneity of CMV viral populations, (v) possible differential ability of viral mutants to cause disease in the graft, and (vi) detection of minor viral variants by next generation sequencing. Translational research platforms that provide rapid molecular genotyping for detection of CMV drug-resistance are essential in guiding CMV disease management in high-risk transplant recipients.
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Affiliation(s)
| | - Elisabet Van Loon
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Belgium
| | - Evelyne Lerut
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Belgium
| | - Jasper Victoor
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Belgium
| | - Björn Meijers
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Belgium
| | - Bert Bammens
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Belgium
| | - Ben Sprangers
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Belgium
| | | | - Pierre Fiten
- Rega Institute for Medical Research, KU Leuven, Belgium
| | | | - Katrien Lagrou
- Laboratory of Clinical Bacteriology and Mycology University Hospitals Leuven, Leuven, Belgium
| | - Dirk Kuypers
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Belgium
| | - Robert Snoeck
- Rega Institute for Medical Research, KU Leuven, Belgium
| | - Maarten Naesens
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Belgium
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29
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Behzadi MA, Stein KR, Bermúdez-González MC, Simon V, Nachbagauer R, Tortorella D. An Influenza Virus Hemagglutinin-Based Vaccine Platform Enables the Generation of Epitope Specific Human Cytomegalovirus Antibodies. Vaccines (Basel) 2019; 7:vaccines7020051. [PMID: 31207917 PMCID: PMC6630953 DOI: 10.3390/vaccines7020051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 06/06/2019] [Accepted: 06/10/2019] [Indexed: 12/03/2022] Open
Abstract
Human cytomegalovirus (CMV) is a highly prevalent pathogen with ~60%–90% seropositivity in adults. CMV can contribute to organ rejection in transplant recipients and is a major cause of birth defects in newborns. Currently, there are no approved vaccines against CMV. The epitope of a CMV neutralizing monoclonal antibody against a conserved region of the envelope protein gH provided the basis for a new CMV vaccine design. We exploited the influenza A virus as a vaccine platform due to the highly immunogenic head domain of its hemagglutinin envelope protein. Influenza A variants were engineered by reverse genetics to express the epitope of an anti-CMV gH neutralizing antibody that recognizes native gH into the hemagglutinin antigenic Sa site. We determined that the recombinant influenza variants expressing 7, 10, or 13 residues of the anti-gH neutralizing antibody epitope were recognized and neutralized by the anti-gH antibody 10C10. Mice vaccinated with the influenza/CMV chimeric viruses induced CMV-specific antibodies that recognized the native gH protein and inhibited virus infection. In fact, the influenza variants expressing 7–13 gH residues neutralized a CMV infection at ~60% following two immunizations with variants expressing the 13 residue gH peptide produced the highest levels of neutralization. Collectively, our study demonstrates that a variant influenza virus inserted with a gH peptide can generate a humoral response that limits a CMV infection.
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Affiliation(s)
- Mohammad Amin Behzadi
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
| | - Kathryn R Stein
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
| | - Maria Carolina Bermúdez-González
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
- The Global Health Emerging Pathogens Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
| | - Viviana Simon
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
- The Global Health Emerging Pathogens Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
- Division of Infectious Disease, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
| | - Raffael Nachbagauer
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
| | - Domenico Tortorella
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
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30
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Meesing A, Razonable RR. New Developments in the Management of Cytomegalovirus Infection After Transplantation. Drugs 2019; 78:1085-1103. [PMID: 29961185 DOI: 10.1007/s40265-018-0943-1] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Cytomegalovirus (CMV) continues to be one of the most important pathogens that universally affect solid organ and allogeneic hematopoietic stem cell transplant recipients. Lack of effective CMV-specific immunity is the common factor that predisposes to the risk of CMV reactivation and clinical disease after transplantation. Antiviral drugs are the cornerstone for prevention and treatment of CMV infection and disease. Over the years, the CMV DNA polymerase inhibitor, ganciclovir (and valganciclovir), have served as the backbone for management, while foscarnet and cidofovir are reserved for the management of CMV infection that is refractory or resistant to ganciclovir treatment. In this review, we highlight the role of the newly approved drug, letermovir, a viral terminase inhibitor, for CMV prevention after allogeneic hematopoietic stem cell transplantation. Advances in immunologic monitoring may allow for an individualized approach to management of CMV after transplantation. Specifically, the potential role of CMV-specific T-cell measurements in guiding the need for the treatment of asymptomatic CMV infection and the duration of treatment of CMV disease is discussed. The role of adoptive immunotherapy, using ex vivo-generated CMV-specific T cells, is highlighted. This article provides a review of novel drugs, tests, and strategies in optimizing our current approaches to prevention and treatment of CMV in transplant recipients.
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Affiliation(s)
- Atibordee Meesing
- Division of Infectious Diseases, Mayo Clinic, Mayo Clinic College of Medicine and Science, Marian Hall 5, 200 First Street SW, Rochester, MN, 55905, USA
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Raymund R Razonable
- Division of Infectious Diseases, Mayo Clinic, Mayo Clinic College of Medicine and Science, Marian Hall 5, 200 First Street SW, Rochester, MN, 55905, USA.
- William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.
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31
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Jung S, Michel M, Stamminger T, Michel D. Fast breakthrough of resistant cytomegalovirus during secondary letermovir prophylaxis in a hematopoietic stem cell transplant recipient. BMC Infect Dis 2019; 19:388. [PMID: 31068147 PMCID: PMC6505103 DOI: 10.1186/s12879-019-4016-1] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 04/24/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The compound letermovir (LMV) has recently been approved for the prophylaxis of cytomegalovirus (CMV) infection and disease in adult CMV seropositive recipients of an allogeneic hematopoietic stem cell transplant. LMV inhibits CMV replication by binding to the viral terminase complex. However, first cases of clinical LMV resistance have been occurred. Here we report a fast breakthrough of resistant cytomegalovirus during secondary LMV prophylaxis in a hematopoietic-cell transplant recipient. CASE PRESENTATION A 44-year-old male patient with acute myeloid leukemia (AML) experienced a CMV-reactivation within the first 4 weeks of allogeneic hematopoietic-cell transplantation. Administration of LMV was initiated at day + 34. Due to increasing viral loads, LMV treatment was discontinued after 8 days. The patient was then administered with valganciclovir (valGCV) until viral DNA was undetectable. Due to neutropenia, valGCV treatment was switched to LMV secondary prophylaxis. For 4 weeks, the patient maintain virologic suppression. Then, CMV viral loads increased with a fast kinetic. Genotypic testing of the viral polymerase UL54, the kinase UL97 as well as the viral terminase UL56 and UL89 revealed the mutation C325Y in UL56, which is associated with the high level LMV resistance. CONCLUSION It is known that Letermovir is approved for prophylactic purposes. However, it may be used for some patients with CMV infection who either have failed prior therapies or are unable to tolerate other anti-CMV compounds. Particularly, the administration of LMV should be avoided in patients with detectable viral loads. When this is not possible, viral load must be routinely monitored along with UL56 genotyping. Furthermore, LMV administration at high virus loads may foster the rapid selection of resistant CMV mutants.
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Affiliation(s)
- Susanne Jung
- Diakonissenkrankenhaus und Paulinenhilfe gGmbH, Diakonie-Klinikum Stuttgart, Rosenbergstraße 38, 70176, Stuttgart, Germany
| | - Manuela Michel
- Institut für Virologie, Universitätsklinikum Ulm, Albert-Einstein-Allee 11, 89081, Ulm, Germany
| | - Thomas Stamminger
- Institut für Virologie, Universitätsklinikum Ulm, Albert-Einstein-Allee 11, 89081, Ulm, Germany
| | - Detlef Michel
- Institut für Virologie, Universitätsklinikum Ulm, Albert-Einstein-Allee 11, 89081, Ulm, Germany.
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32
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Yang L, Yang Q, Wang M, Jia R, Chen S, Zhu D, Liu M, Wu Y, Zhao X, Zhang S, Liu Y, Yu Y, Zhang L, Chen X, Cheng A. Terminase Large Subunit Provides a New Drug Target for Herpesvirus Treatment. Viruses 2019; 11:v11030219. [PMID: 30841485 PMCID: PMC6466031 DOI: 10.3390/v11030219] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 02/23/2019] [Accepted: 02/27/2019] [Indexed: 12/26/2022] Open
Abstract
Herpesvirus infection is an orderly, regulated process. Among these viruses, the encapsidation of viral DNA is a noteworthy link; the entire process requires a powered motor that binds to viral DNA and carries it into the preformed capsid. Studies have shown that this power motor is a complex composed of a large subunit, a small subunit, and a third subunit, which are collectively known as terminase. The terminase large subunit is highly conserved in herpesvirus. It mainly includes two domains: the C-terminal nuclease domain, which cuts the viral concatemeric DNA into a monomeric genome, and the N-terminal ATPase domain, which hydrolyzes ATP to provide energy for the genome cutting and transfer activities. Because this process is not present in eukaryotic cells, it provides a reliable theoretical basis for the development of safe and effective anti-herpesvirus drugs. This article reviews the genetic characteristics, protein structure, and function of the herpesvirus terminase large subunit, as well as the antiviral drugs that target the terminase large subunit. We hope to provide a theoretical basis for the prevention and treatment of herpesvirus.
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Affiliation(s)
- Linlin Yang
- Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, Sichuan, China.
- Research Center of Avian Diseases, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, Sichuan, China.
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, Chengdu 611130, Sichuan, China.
| | - Qiao Yang
- Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, Sichuan, China.
- Research Center of Avian Diseases, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, Sichuan, China.
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, Chengdu 611130, Sichuan, China.
| | - Mingshu Wang
- Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, Sichuan, China.
- Research Center of Avian Diseases, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, Sichuan, China.
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, Chengdu 611130, Sichuan, China.
| | - Renyong Jia
- Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, Sichuan, China.
- Research Center of Avian Diseases, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, Sichuan, China.
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, Chengdu 611130, Sichuan, China.
| | - Shun Chen
- Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, Sichuan, China.
- Research Center of Avian Diseases, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, Sichuan, China.
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, Chengdu 611130, Sichuan, China.
| | - Dekang Zhu
- Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, Sichuan, China.
- Research Center of Avian Diseases, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, Sichuan, China.
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, Chengdu 611130, Sichuan, China.
| | - Mafeng Liu
- Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, Sichuan, China.
- Research Center of Avian Diseases, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, Sichuan, China.
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, Chengdu 611130, Sichuan, China.
| | - Ying Wu
- Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, Sichuan, China.
- Research Center of Avian Diseases, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, Sichuan, China.
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, Chengdu 611130, Sichuan, China.
| | - Xinxin Zhao
- Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, Sichuan, China.
- Research Center of Avian Diseases, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, Sichuan, China.
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, Chengdu 611130, Sichuan, China.
| | - Shaqiu Zhang
- Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, Sichuan, China.
- Research Center of Avian Diseases, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, Sichuan, China.
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, Chengdu 611130, Sichuan, China.
| | - Yunya Liu
- Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, Sichuan, China.
- Research Center of Avian Diseases, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, Sichuan, China.
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, Chengdu 611130, Sichuan, China.
| | - Yanling Yu
- Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, Sichuan, China.
- Research Center of Avian Diseases, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, Sichuan, China.
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, Chengdu 611130, Sichuan, China.
| | - Ling Zhang
- Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, Sichuan, China.
- Research Center of Avian Diseases, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, Sichuan, China.
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, Chengdu 611130, Sichuan, China.
| | - Xiaoyue Chen
- Research Center of Avian Diseases, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, Sichuan, China.
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, Chengdu 611130, Sichuan, China.
| | - Anchun Cheng
- Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, Sichuan, China.
- Research Center of Avian Diseases, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu 611130, Sichuan, China.
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, Chengdu 611130, Sichuan, China.
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33
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Impacts and Challenges of Advanced Diagnostic Assays for Transplant Infectious Diseases. PRINCIPLES AND PRACTICE OF TRANSPLANT INFECTIOUS DISEASES 2019. [PMCID: PMC7121269 DOI: 10.1007/978-1-4939-9034-4_47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The advanced technologies described in this chapter should allow for full inventories to be made of bacterial genes, their time- and place-dependent expression, and the resulting proteins as well as their outcome metabolites. The evolution of these molecular technologies will continue, not only in the microbial pathogens but also in the context of host-pathogen interactions targeting human genomics and transcriptomics. Their performance characteristics and limitations must be clearly understood by both laboratory personnel and clinicians to ensure proper utilization and interpretation.
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34
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Koval CE. Prevention and Treatment of Cytomegalovirus Infections in Solid Organ Transplant Recipients. Infect Dis Clin North Am 2018; 32:581-597. [PMID: 30146024 DOI: 10.1016/j.idc.2018.04.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Despite advances in prevention and treatment, cytomegalovirus (CMV) infection and disease remain an expected problem in solid organ transplant recipients. Because of the effect of immunosuppressing medications, CMV primary, secondary, and reactivated infection requires antiviral medications to prevent serious direct and indirect effects of the virus. Side effects and drug resistance, however, often limit the capacity of traditional antiviral therapies. This article updates the clinician on current and promising approaches to the management and control of CMV in the solid organ transplant recipient.
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Affiliation(s)
- Christine E Koval
- Department of Infectious Diseases, Cleveland Clinic Foundation, 9500 Euclid Avenue, Box G21, Cleveland, OH 44195, USA.
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35
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Hodowanec AC, Pikis A, Komatsu TE, Sampson MR, Younis IR, O'Rear JJ, Singer ME. Treatment and Prevention of CMV Disease in Transplant Recipients: Current Knowledge and Future Perspectives. J Clin Pharmacol 2018; 59:784-798. [PMID: 30586161 DOI: 10.1002/jcph.1363] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 11/26/2018] [Indexed: 12/29/2022]
Abstract
This review summarizes the significant impact of cytomegalovirus (CMV) infection on solid organ and hematopoietic stem cell transplant recipients. A discussion of the various CMV prevention and treatment strategies is provided, including a detailed description of each of the available CMV antiviral drugs.
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Affiliation(s)
- Aimee C Hodowanec
- Center for Drug Evaluation and Research, Office of Antimicrobial Products, Division of Antiviral Products, Food and Drug Administration, Silver Spring, MD, USA
| | - Andreas Pikis
- Center for Drug Evaluation and Research, Office of Antimicrobial Products, Division of Antiviral Products, Food and Drug Administration, Silver Spring, MD, USA
| | - Takashi E Komatsu
- Center for Drug Evaluation and Research, Office of Antimicrobial Products, Division of Antiviral Products, Food and Drug Administration, Silver Spring, MD, USA
| | - Mario R Sampson
- Center for Drug Evaluation and Research, Office of Translational Sciences, Office of Clinical Pharmacology, Division of Clinical Pharmacology IV, Food and Drug Administration, Silver Spring, MD, USA
| | - Islam R Younis
- Center for Drug Evaluation and Research, Office of Translational Sciences, Office of Clinical Pharmacology, Division of Clinical Pharmacology IV, Food and Drug Administration, Silver Spring, MD, USA
| | - Julian J O'Rear
- Center for Drug Evaluation and Research, Office of Antimicrobial Products, Division of Antiviral Products, Food and Drug Administration, Silver Spring, MD, USA
| | - Mary E Singer
- Center for Drug Evaluation and Research, Office of Antimicrobial Products, Division of Antiviral Products, Food and Drug Administration, Silver Spring, MD, USA
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36
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Ligat G, Cazal R, Hantz S, Alain S. The human cytomegalovirus terminase complex as an antiviral target: a close-up view. FEMS Microbiol Rev 2018; 42:137-145. [PMID: 29361041 PMCID: PMC5972660 DOI: 10.1093/femsre/fuy004] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 01/17/2018] [Indexed: 01/13/2023] Open
Abstract
Human cytomegalovirus (HCMV) is responsible for life-threatening infections in immunocompromised individuals and can cause serious congenital malformations. Available antivirals target the viral polymerase but are subject to cross-resistance and toxicity. New antivirals targeting other replication steps and inducing fewer adverse effects are therefore needed. During HCMV replication, DNA maturation and packaging are performed by the terminase complex, which cleaves DNA to package the genome into the capsid. Identified in herpesviruses and bacteriophages, and with no counterpart in mammalian cells, these terminase proteins are ideal targets for highly specific antivirals. A new terminase inhibitor, letermovir, recently proved effective against HCMV in phase III clinical trials, but the mechanism of action is unclear. Letermovir has no significant activity against other herpesvirus or non-human CMV. This review focuses on the highly conserved mechanism of HCMV DNA-packaging and the potential of the terminase complex to serve as an antiviral target. We describe the intrinsic mechanism of DNA-packaging, highlighting the structure-function relationship of HCMV terminase complex components.
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Affiliation(s)
- G Ligat
- Université Limoges, INSERM, CHU Limoges, UMR 1092, 2 rue Dr Marcland, 87000 Limoges, France.,CHU Limoges, Laboratoire de Bactériologie-Virologie-Hygiène, National Reference Center for Herpesviruses (NRHV), 2 avenue Martin Luther King, 87000 Limoges, France
| | - R Cazal
- Université Limoges, INSERM, CHU Limoges, UMR 1092, 2 rue Dr Marcland, 87000 Limoges, France.,CHU Limoges, Laboratoire de Bactériologie-Virologie-Hygiène, National Reference Center for Herpesviruses (NRHV), 2 avenue Martin Luther King, 87000 Limoges, France
| | - S Hantz
- Université Limoges, INSERM, CHU Limoges, UMR 1092, 2 rue Dr Marcland, 87000 Limoges, France.,CHU Limoges, Laboratoire de Bactériologie-Virologie-Hygiène, National Reference Center for Herpesviruses (NRHV), 2 avenue Martin Luther King, 87000 Limoges, France
| | - S Alain
- Université Limoges, INSERM, CHU Limoges, UMR 1092, 2 rue Dr Marcland, 87000 Limoges, France.,CHU Limoges, Laboratoire de Bactériologie-Virologie-Hygiène, National Reference Center for Herpesviruses (NRHV), 2 avenue Martin Luther King, 87000 Limoges, France
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37
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Pardieck IN, Beyrend G, Redeker A, Arens R. Cytomegalovirus infection and progressive differentiation of effector-memory T cells. F1000Res 2018; 7. [PMID: 30345004 PMCID: PMC6173108 DOI: 10.12688/f1000research.15753.1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/20/2018] [Indexed: 12/22/2022] Open
Abstract
Primary cytomegalovirus (CMV) infection leads to strong innate and adaptive immune responses against the virus, which prevents serious disease. However, CMV infection can cause serious morbidity and mortality in individuals who are immunocompromised. The adaptive immune response to CMV is characterized by large populations of effector-memory (EM) T cells that are maintained lifelong, a process termed memory inflation. Recent findings indicate that infection with CMV leads to continuous differentiation of CMV-specific EM-like T cells and that high-dose infection accelerates this progression. Whether measures that counteract CMV infection, such as anti-viral drugs, targeting of latently infected cells, adoptive transfer of CMV-specific T cells, and vaccination strategies, are able to impact the progressive differentiation of CMV-specific EM-like cells is discussed.
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Affiliation(s)
- Iris N Pardieck
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, The Netherlands
| | - Guillaume Beyrend
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, The Netherlands
| | - Anke Redeker
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, The Netherlands
| | - Ramon Arens
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, The Netherlands
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38
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Britt WJ, Prichard MN. New therapies for human cytomegalovirus infections. Antiviral Res 2018; 159:153-174. [PMID: 30227153 DOI: 10.1016/j.antiviral.2018.09.003] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 08/28/2018] [Accepted: 09/07/2018] [Indexed: 02/07/2023]
Abstract
The recent approval of letermovir marks a new era of therapy for human cytomegalovirus (HCMV) infections, particularly for the prevention of HCMV disease in hematopoietic stem cell transplant recipients. For almost 30 years ganciclovir has been the therapy of choice for these infections and by today's standards this drug exhibits only modest antiviral activity that is often insufficient to completely suppress viral replication, and drives the selection of drug-resistant variants that continue to replicate and contribute to disease. While ganciclovir remains the therapy of choice, additional drugs that inhibit novel molecular targets, such as letermovir, will be required as highly effective combination therapies are developed not only for the treatment of immunocompromised hosts, but also for congenitally infected infants. Sustained efforts, largely in the biotech industry and academia, have identified additional highly active lead compounds that have progressed into clinical studies with varying levels of success and at least two have the potential to be approved in the near future. Some of the new drugs in the pipeline inhibit new molecular targets, remain effective against isolates that have developed resistance to existing therapies, and promise to augment existing therapeutic regimens. Here, we will describe some of the unique features of HCMV biology and discuss their effect on therapeutic needs. Existing drugs will also be discussed and some of the more promising candidates will be reviewed with an emphasis on those progressing through clinical studies. The in vitro and in vivo antiviral activity, spectrum of antiviral activity, and mechanism of action of new compounds will be reviewed to provide an update on potential new therapies for HCMV infections that have progressed significantly in recent years.
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Affiliation(s)
- William J Britt
- Department of Pediatrics, University of Alabama School of Medicine, Birmingham AL 35233-1711, USA
| | - Mark N Prichard
- Department of Pediatrics, University of Alabama School of Medicine, Birmingham AL 35233-1711, USA.
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O'Brien MS, Markovich KC, Selleseth D, DeVita AV, Sethna P, Gentry BG. In vitro evaluation of current and novel antivirals in combination against human cytomegalovirus. Antiviral Res 2018; 158:255-263. [PMID: 30153445 DOI: 10.1016/j.antiviral.2018.08.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 08/22/2018] [Accepted: 08/24/2018] [Indexed: 02/07/2023]
Abstract
Human cytomegalovirus (HCMV) can cause severe disease in patients with compromised or immature immune systems. Currently approved pharmacotherapies for the treatment of systemic HCMV infections [ganciclovir (GCV), cidofovir (CDV), foscarnet] are limited by a high incidence of adverse effects and/or the development of drug resistance. Given that many of these drugs have the same viral target (HCMV-encoded DNA polymerase), cross-resistance is relatively common. The primary means to combat drug resistance is combination pharmacotherapy using therapeutics with different molecular mechanisms of action with the expectation that those combinations result in an additive or synergistic enhancement of effect; combinations that result in antagonism can, in many cases, be detrimental to the outcome of the patient. We therefore tested select combinations of approved (GCV, CDV, letermovir (LMV)) and experimental (brincidofovir (BCV), cyclopropavir (CPV), maribavir (MBV), BDCRB) drugs with the hypothesis that combinations of drugs with different and distinct molecular mechanisms of action will produce an additive and/or synergistic enhancement of antiviral effect against HCMV in vitro. Using MacSynergy II (a statistical package that measures enhancement or lessening of effect relative to zero/additive), select drug combination studies demonstrated combination indices ranging from 160 to 372 with 95% confidence intervals greater than zero indicating that these combinations elicit a synergistic enhancement of effect against HCMV in vitro. These data suggest that administration of a viral DNA polymerase inhibitor, MBV, and/or a viral terminase inhibitor in combination has the potential to address the resistance/cross-resistance problems associated with currently available therapeutics.
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Affiliation(s)
- M Shea O'Brien
- Department of Pharmaceutical and Administrative Sciences, Drake University College of Pharmacy and Health Sciences, 2507 University Ave., Des Moines, IA, 50311, USA.
| | - Kylie C Markovich
- Department of Pharmaceutical and Administrative Sciences, Drake University College of Pharmacy and Health Sciences, 2507 University Ave., Des Moines, IA, 50311, USA.
| | - Dean Selleseth
- Chimerix, 2505 Meridian Parkway, Suite 100, Durham, NC, 27713, USA.
| | - Alexa V DeVita
- Department of Pharmaceutical and Administrative Sciences, Drake University College of Pharmacy and Health Sciences, 2507 University Ave., Des Moines, IA, 50311, USA.
| | - Phiroze Sethna
- Chimerix, 2505 Meridian Parkway, Suite 100, Durham, NC, 27713, USA.
| | - Brian G Gentry
- Department of Pharmaceutical and Administrative Sciences, Drake University College of Pharmacy and Health Sciences, 2507 University Ave., Des Moines, IA, 50311, USA.
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Prevention and treatment of cytomegalovirus in immunocompromised patients: beyond DNA polymerase inhibition. Curr Opin Infect Dis 2018; 31:263-266. [PMID: 29894318 DOI: 10.1097/qco.0000000000000460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Fisher CE, Knudsen JL, Lease ED, Jerome KR, Rakita RM, Boeckh M, Limaye AP. Risk Factors and Outcomes of Ganciclovir-Resistant Cytomegalovirus Infection in Solid Organ Transplant Recipients. Clin Infect Dis 2018; 65:57-63. [PMID: 28369203 DOI: 10.1093/cid/cix259] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 03/28/2017] [Indexed: 12/17/2022] Open
Abstract
Background Ganciclovir-resistant (ganR) cytomegalovirus (CMV) is an emerging and important problem in solid organ transplant (SOT) recipients. Only through direct comparison of ganR- and ganciclovir-sensitive (ganS) CMV infection can risk factors and outcomes attributable specifically to ganciclovir resistance appropriately be determined. Methods We performed a retrospective, case-control (1:3) study of SOT recipients with genotypically confirmed ganR-CMV (n = 37) and ganS-CMV infection (n = 109), matched by donor/recipient CMV serostatus, year and organ transplanted, and clinical manifestation. We used χ2 (categorical) and Mann-Whitney (continuous) tests to determine predisposing factors and morbidity attributable to resistance, and Kaplan-Meier plots to analyze survival differences. Results The rate of ganR-CMV was 1% (37/3467) overall and 4.1% (32/777) among CMV donor-positive, recipient-negative patients, and was stable over the study period. GanR-CMV was associated with increased prior exposure to ganciclovir (median, 153 vs 91 days, P < .001). Eighteen percent (3/17) of lung transplant recipients with ganR-CMV had received <6 weeks of prior ganciclovir (current guideline-recommended resistance testing threshold), and all non-lung recipients had received ≥90 days (median, 160 [range, 90-284 days]) prior to diagnosis of ganR-CMV. GanR-CMV was associated with higher mortality (11% vs 1%, P = .004), fewer days alive and nonhospitalized (73 vs 81, P = .039), and decreased renal function (42% vs 19%, P = .008) by 3 months after diagnosis. Conclusions GanR-CMV is associated with longer prior antiviral duration and higher attributable morbidity and mortality than ganS-CMV. Upcoming revised CMV guidelines should incorporate organ transplant-specific thresholds of prior drug exposure to guide rational ganR-CMV testing in SOT recipients. Improved strategies for prevention and treatment of ganR-CMV are warranted.
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Affiliation(s)
- Cynthia E Fisher
- Division of Allergy and Infectious Diseases, University of Washington.,Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center
| | - Janine L Knudsen
- Division of Allergy and Infectious Diseases, University of Washington
| | - Erika D Lease
- Division of Allergy and Infectious Diseases, University of Washington.,Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington, USA
| | - Keith R Jerome
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center.,Virology Division, Department of Laboratory Medicine, University of Washington, Seattle
| | - Robert M Rakita
- Division of Allergy and Infectious Diseases, University of Washington
| | - Michael Boeckh
- Division of Allergy and Infectious Diseases, University of Washington.,Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center
| | - Ajit P Limaye
- Division of Allergy and Infectious Diseases, University of Washington
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Kim SJ, Huang YT, Foldi J, Lee YJ, Maloy M, Giralt SA, Jakubowski AA, Papanicolaou GA. Cytomegalovirus resistance in CD34 + -selected hematopoietic cell transplant recipients. Transpl Infect Dis 2018; 20:e12881. [PMID: 29570237 PMCID: PMC5988949 DOI: 10.1111/tid.12881] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 02/02/2018] [Accepted: 02/18/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) viremia after CD34+ -selected hematopoietic stem cell transplant (HCT) often requires prolonged antiviral therapy. We report rates and outcomes of resistant CMV in a contemporary cohort of CD34+ -selected HCT recipients managed preemptively. METHODS We retrospectively reviewed 220 consecutive, CMV-seropositive recipients (R+), who received CD34+ -selected HCT at Memorial Sloan Kettering Cancer Center between June 2010 and December 2014. Patients were monitored by quantitative CMV PCR and were treated preemptively. CMV resistance was tested by a genotypic assay. RESULTS One hundred and sixty-one (73%) patients developed CMV viremia and 47 (29% of viremic and 21% of total patients) had CMV resistance testing by one-year from HCT. CMV resistance was confirmed in 19 (12% of viremic and 9% of total) patients and was identified >3 months from HCT in 90% of patients. Twelve patients had mutations in UL97 only; the remaining 7 patients had mutations in UL54 only or UL54 and UL97. By 1 year from HCT, 11 of 19 (58%) patients with mutations had CMV end-organ disease. CMV-related mortality in patients with resistance was 42%. CONCLUSIONS Nine percent of CMV R+, CD34+ -selected HCT recipients had resistant CMV by 1 year from HCT. Of 19 patients with resistant CMV, 58% had CMV end-organ disease and 42% died of CMV. Effective strategies for CMV prevention and restoration of CMV immunity are needed for CD34+ -selected HCT.
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Affiliation(s)
- Seong Jin Kim
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yao-Ting Huang
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Julia Foldi
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yeon Joo Lee
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Medical College, Cornell University, New York, NY, USA
| | - Molly Maloy
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sergio A Giralt
- Weill Medical College, Cornell University, New York, NY, USA
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ann A Jakubowski
- Weill Medical College, Cornell University, New York, NY, USA
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Genovefa A Papanicolaou
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Medical College, Cornell University, New York, NY, USA
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Yamada KH, Majima R, Yamaguchi T, Inoue N. Characterization of phenyl pyrimidine derivatives that inhibit cytomegalovirus immediate-early gene expression. Antivir Chem Chemother 2018; 26:2040206618763193. [PMID: 29546767 PMCID: PMC5890547 DOI: 10.1177/2040206618763193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Background Previously, we established a reporter cell line for human cytomegalovirus and screened anti-human cytomegalovirus compounds using the cell line. In this study, we characterized one of the identified compounds, 2,4-diamino-6–(4-methoxyphenyl)pyrimidine (coded as 35C10). Methods 50% Effective concentrations (EC50s) and 50% cytotoxic concentrations (CC50s) of 35C10 and its derivatives in human fibroblasts were determined by X-gal staining of the cells infected with human cytomegalovirus Towne strain expressing β-galactosidase. Results EC50 and CC50 of 35C10 were 4.3 µM and >200 µM, respectively. Among several 35C10 derivatives, only one lacking 4-amino group of pyrimidine showed a similar EC50. 35C10 weakly inhibited murine cytomegalovirus, herpes simplex virus type 1, and varicella-zoster virus. A “time of addition” experiment suggested that 35C10 inhibited an early phase of the infection. Although 35C10 did not inhibit viral attachment to the cells nor the delivery of viral DNA to the nuclei, it decreased the number of infected cells expressing immediate-early 1 and 2 (IE1/IE2) proteins. 35C10 also inhibited the activation of a promoter for TRL4 in the reporter cells upon human cytomegalovirus infection, but not in the same reporter cells transfected with a plasmid expressing IE2. Conclusion Our findings suggest that 35C10 is a novel compound that inhibits IE gene expression in human cytomegalovirus-infected cells.
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Affiliation(s)
- Koh-Hei Yamada
- 1 Department of Microbiology and Immunology, Gifu Pharmaceutical University, Gifu, Japan
| | - Ryuichi Majima
- 1 Department of Microbiology and Immunology, Gifu Pharmaceutical University, Gifu, Japan
| | - Toyofumi Yamaguchi
- 2 Department of Biosciences, Teikyo University of Science and Technology, Tokyo, Japan
| | - Naoki Inoue
- 1 Department of Microbiology and Immunology, Gifu Pharmaceutical University, Gifu, Japan
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Topalis D, Gillemot S, Snoeck R, Andrei G. Thymidine kinase and protein kinase in drug-resistant herpesviruses: Heads of a Lernaean Hydra. Drug Resist Updat 2018; 37:1-16. [PMID: 29548479 DOI: 10.1016/j.drup.2018.01.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Herpesviruses thymidine kinase (TK) and protein kinase (PK) allow the activation of nucleoside analogues used in anti-herpesvirus treatments. Mutations emerging in these two genes often lead to emergence of drug-resistant strains responsible for life-threatening diseases in immunocompromised populations. In this review, we analyze the binding of different nucleoside analogues to the TK active site of the three α-herpesviruses [Herpes Simplex Virus 1 and 2 (HSV-1 and HSV-2) and Varicella-Zoster Virus (VZV)] and present the impact of known mutations on the structure of the viral TKs. Furthermore, models of β-herpesviruses [Human cytomegalovirus (HCMV) and human herpesvirus-6 (HHV-6)] PKs allow to link amino acid changes with resistance to ganciclovir and/or maribavir, an investigational chemotherapeutic used in patients with multidrug-resistant HCMV. Finally, we set the basis for the understanding of drug-resistance in γ-herpesviruses [Epstein-Barr virus (EBV) and Kaposi's sarcoma associated herpesvirus (KSHV)] TK and PK through the use of animal surrogate models.
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Affiliation(s)
- Dimitri Topalis
- Rega Institute for Medical Research, KU Leuven, Herestraat 49-box 1043, 3000 Leuven, Belgium.
| | - Sarah Gillemot
- Rega Institute for Medical Research, KU Leuven, Herestraat 49-box 1043, 3000 Leuven, Belgium.
| | - Robert Snoeck
- Rega Institute for Medical Research, KU Leuven, Herestraat 49-box 1043, 3000 Leuven, Belgium.
| | - Graciela Andrei
- Rega Institute for Medical Research, KU Leuven, Herestraat 49-box 1043, 3000 Leuven, Belgium.
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Hancer VS, Yarimcan FS, Buyukdogan M, Aki SZ, Oksuz B, Acar K, Acar M, Bulut P. A novel ganciclovir resistance mutation in the UL97 gene of the HHV-5 in an adult hematopoietic stem cell transplant recipient. Future Virol 2017. [DOI: 10.2217/fvl-2017-0085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Therapeutic management of cytomegalovirus (CMV) disease in hematopoietic stem cell transplantation patients can become a challenge because of the emergence of anti-CMV drug resistance. This case report presents a patient with clinical ganciclovir resistance due to a new mutation: histidine-to-asparagine change at residue 393 of UL97. This mutation, which is located in the nonfunctional region of the UL97 gene, is very unusual. Having more information about the mutations leading to drug resistance in CMV is important for both improved clinical management and development of new diagnostic tests and drugs.
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Affiliation(s)
- Veysel Sabri Hancer
- Department of Medical Genetics, Faculty of Medicine, Istinye University, Istanbul
| | - Filiz Saglam Yarimcan
- Department of Medical Microbiology, Faculty of Medicine, Istinye University, Istanbul
| | - Murat Buyukdogan
- Department of Medical Genetics, Faculty of Medicine, Istinye University, Istanbul
| | - Sahika Zeynep Aki
- Division of Hematology, Department of Internal Medicine, Bahcesehir University, Istanbul
| | - Burcu Oksuz
- Istinye University Genetic Diagnosis Center, Istanbul
| | - Kadir Acar
- Division of Hematology, Department of Internal Medicine, Altinbas University, Istanbul
| | - Muradiye Acar
- Istinye University Genetic Diagnosis Center, Istanbul
| | - Pelin Bulut
- Istinye University Genetic Diagnosis Center, Istanbul
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Affiliation(s)
- Margaret L Green
- University of Washington, 1959 NE Pacific Street, Box 359930, Seattle, WA 98195, USA; Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, Seattle, WA 98109, USA.
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Navarro D, San-Juan R, Manuel O, Giménez E, Fernández-Ruiz M, Hirsch HH, Grossi PA, Aguado JM. Cytomegalovirus infection management in solid organ transplant recipients across European centers in the time of molecular diagnostics: An ESGICH survey. Transpl Infect Dis 2017; 19. [PMID: 28859257 DOI: 10.1111/tid.12773] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 05/17/2017] [Accepted: 06/11/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Scant information is available about how transplant centers are managing their use of quantitative molecular testing (QNAT) assays for active cytomegalovirus (CMV) infection monitoring in solid organ transplant (SOT) recipients. The current study was aimed at gathering information on current practices in the management of CMV infection across European centers in the era of molecular testing assays. METHODS A questionnaire-based cross-sectional survey study was conducted by the European Study Group of Infections in Immunocompromised Hosts (ESGICH) of the Society of Clinical Microbiology and Infectious Diseases (ESCMID). The invitation and a weekly reminder with a personal link to an Internet service provider (https://es.surveymonkey.com/) was sent to transplant physicians, transplant infectious diseases specialists, and clinical virologists working at 340 European transplant centers. RESULTS Of the 1181 specialists surveyed, a total of 173 responded (14.8%): 73 transplant physicians, 57 transplant infectious diseases specialists, and 43 virologists from 173 institutions located at 23 different countries. The majority of centers used QNAT assays for active CMV infection monitoring. Most centers preferred commercially available real-time polymerase chain reaction (RT-PCR) assays over laboratory-developed procedures for quantifying CMV DNA load in whole blood or plasma. Use of a wide variety of DNA extraction platforms and RT-PCR assays was reported. All programs used antiviral prophylaxis, preemptive therapy, or both, according to current guidelines. However, the centers used different criteria for starting preemptive antiviral treatment, for monitoring systemic CMV DNA load, and for requesting genotypic assays to detect emerging CMV-resistant variants. CONCLUSIONS Significant variation in CMV infection management in SOT recipients still remains across European centers in the era of molecular testing. International multicenter studies are required to achieve commutability of CMV testing and antiviral management procedures.
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Affiliation(s)
- David Navarro
- Microbiology Service, Hospital Clínico Universitario, Institute for Research INCLIVA, Valencia, Spain.,Department of Microbiology, School of Medicine, University of Valencia, Valencia, Spain
| | - Rafael San-Juan
- Unit of Infectious Diseases, Instituto de Investigación Hospital 12 de Octubre (i+12), University Hospital 12 de Octubre, Universidad Complutense, Madrid, Spain
| | - Oriol Manuel
- Transplantation Center and Service of Infectious Diseases, University Hospital of Lausanne, CHUV, Lausanne, Switzerland
| | - Estela Giménez
- Microbiology Service, Hospital Clínico Universitario, Institute for Research INCLIVA, Valencia, Spain
| | - Mario Fernández-Ruiz
- Unit of Infectious Diseases, Instituto de Investigación Hospital 12 de Octubre (i+12), University Hospital 12 de Octubre, Universidad Complutense, Madrid, Spain
| | - Hans H Hirsch
- Transplantation & Clinical Virology, Department Biomedicine, University of Basel, Basel, Switzerland.,Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Paolo Antonio Grossi
- National Centre for Transplantation, Department of Medicine and Surgery, Infectious and Tropical Diseases Unit, University of Insubria, Varese, Italy
| | - José María Aguado
- Unit of Infectious Diseases, Instituto de Investigación Hospital 12 de Octubre (i+12), University Hospital 12 de Octubre, Universidad Complutense, Madrid, Spain
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Cytomegalovirus Late Protein pUL31 Alters Pre-rRNA Expression and Nuclear Organization during Infection. J Virol 2017; 91:JVI.00593-17. [PMID: 28659485 DOI: 10.1128/jvi.00593-17] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 06/24/2017] [Indexed: 02/01/2023] Open
Abstract
The replication cycle of human cytomegalovirus (CMV) leads to drastic reorganization of domains in the host cell nucleus. However, the mechanisms involved and how these domains contribute to infection are not well understood. Our recent studies defining the CMV-induced nuclear proteome identified several viral proteins of unknown functions, including a protein encoded by the UL31 gene. We set out to define the role of UL31 in CMV replication. UL31 is predicted to encode a 74-kDa protein, referred to as pUL31, containing a bipartite nuclear localization signal, an intrinsically disordered region overlapping arginine-rich motifs, and a C-terminal dUTPase-like structure. We observed that pUL31 is expressed with true late kinetics and is localized to nucleolin-containing nuclear domains. However, pUL31 is excluded from the viral nuclear replication center. Nucleolin is a marker of nucleoli, which are membrane-less regions involved in regulating ribosome biosynthesis and cellular stress responses. Other CMV proteins associate with nucleoli, and we demonstrate that pUL31 specifically interacts with the viral protein, pUL76. Coexpression of both proteins altered pUL31 localization and nucleolar organization. During infection, pUL31 colocalizes with nucleolin but not the transcriptional activator, UBF. In the absence of pUL31, CMV fails to reorganize nucleolin and UBF and exhibits a replication defect at a low multiplicity of infection. Finally, we observed that pUL31 is necessary and sufficient to reduce pre-rRNA levels, and this was dependent on the dUTPase-like motif in pUL31. Our studies demonstrate that CMV pUL31 functions in regulating nucleolar biology and contributes to the reorganization of nucleoli during infection.IMPORTANCE Nucleolar biology is important during CMV infection with the nucleolar protein, with nucleolin playing a role in maintaining the architecture of the viral nuclear replication center. However, the extent of CMV-mediated regulation of nucleolar biology is not well established. Proteins within nucleoli regulate ribosome biosynthesis and p53-dependent cellular stress responses that are capable of inducing cell cycle arrest and/or apoptosis, and they are proposed targets for cancer therapies. This study establishes that CMV protein pUL31 is necessary and sufficient to regulate nucleolar biology involving the reorganization of nucleolar proteins. Understanding these processes will help define approaches to stimulate cellular intrinsic stress responses that are capable of inhibiting CMV infection.
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The Human Virome: Implications for Clinical Practice in Transplantation Medicine. J Clin Microbiol 2017; 55:2884-2893. [PMID: 28724557 DOI: 10.1128/jcm.00489-17] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Advances in DNA sequencing technology have provided an unprecedented opportunity to study the human virome. Transplant recipients and other immunocompromised hosts are at particular risk for developing virus-related pathology; thus, the impact of the virome on health and disease may be even more relevant in this population. Here, we discuss technical considerations in studying the human virome, the current literature on the virome in transplant recipients, and near-future applications of sequence-based findings that can further our understanding of viruses in transplantation medicine.
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50
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Hage E, Wilkie GS, Linnenweber-Held S, Dhingra A, Suárez NM, Schmidt JJ, Kay-Fedorov PC, Mischak-Weissinger E, Heim A, Schwarz A, Schulz TF, Davison AJ, Ganzenmueller T. Characterization of Human Cytomegalovirus Genome Diversity in Immunocompromised Hosts by Whole-Genome Sequencing Directly From Clinical Specimens. J Infect Dis 2017; 215:1673-1683. [PMID: 28368496 DOI: 10.1093/infdis/jix157] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Accepted: 03/22/2017] [Indexed: 01/19/2023] Open
Abstract
Background Advances in next-generation sequencing (NGS) technologies allow comprehensive studies of genetic diversity over the entire genome of human cytomegalovirus (HCMV), a significant pathogen for immunocompromised individuals. Methods Next-generation sequencing was performed on target enriched sequence libraries prepared directly from a variety of clinical specimens (blood, urine, breast milk, respiratory samples, biopsies, and vitreous humor) obtained longitudinally or from different anatomical compartments from 20 HCMV-infected patients (renal transplant recipients, stem cell transplant recipients, and congenitally infected children). Results De novo-assembled HCMV genome sequences were obtained for 57 of 68 sequenced samples. Analysis of longitudinal or compartmental HCMV diversity revealed various patterns: no major differences were detected among longitudinal, intraindividual blood samples from 9 of 15 patients and in most of the patients with compartmental samples, whereas a switch of the major HCMV population was observed in 6 individuals with sequential blood samples and upon compartmental analysis of 1 patient with HCMV retinitis. Variant analysis revealed additional aspects of minor virus population dynamics and antiviral-resistance mutations. Conclusions In immunosuppressed patients, HCMV can remain relatively stable or undergo drastic genomic changes that are suggestive of the emergence of minor resident strains or de novo infection.
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Affiliation(s)
- Elias Hage
- Institute of Virology
- German Centre for Infection Research, Hannover-Braunschweig, Germany
| | - Gavin S Wilkie
- MRC-University of Glasgow Centre for Virus Research, United Kingdom
| | | | - Akshay Dhingra
- Institute of Virology
- German Centre for Infection Research, Hannover-Braunschweig, Germany
| | - Nicolás M Suárez
- MRC-University of Glasgow Centre for Virus Research, United Kingdom
| | | | - Penelope C Kay-Fedorov
- Institute of Virology
- German Centre for Infection Research, Hannover-Braunschweig, Germany
| | - Eva Mischak-Weissinger
- Department of Haematology, Haemostasis and Oncology, Hannover Medical School
- German Centre for Infection Research, Hannover-Braunschweig, Germany
| | - Albert Heim
- Institute of Virology
- German Centre for Infection Research, Hannover-Braunschweig, Germany
| | | | - Thomas F Schulz
- Institute of Virology
- German Centre for Infection Research, Hannover-Braunschweig, Germany
| | - Andrew J Davison
- MRC-University of Glasgow Centre for Virus Research, United Kingdom
| | - Tina Ganzenmueller
- Institute of Virology
- German Centre for Infection Research, Hannover-Braunschweig, Germany
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