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Yu U, Wang X, Zhang X, Wang C, Yang C, Zhou X, Li Y, Huang X, Wen J, Wen F, Liu S. Cytomegalovirus Infection and the Implications of Drug-Resistant Mutations in Pediatric Allogeneic Hematopoietic Stem Cell Transplant Recipients: A Retrospective Study from a Tertiary Hospital in China. Infect Dis Ther 2021; 10:1309-1322. [PMID: 33966176 PMCID: PMC8322184 DOI: 10.1007/s40121-021-00452-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2021] [Indexed: 10/28/2022] Open
Abstract
INTRODUCTION Drug-resistant cytomegalovirus (CMV) infection remains a challenge in the management of pediatric recipients of hematopoietic stem cell transplantation (HSCT). In this study, we retrospectively reviewed the clinical data on pediatric recipients of HSCT and identified known and unknown drug-resistant CMV variants. METHODS A total of 221 children underwent allogeneic HSCT between October 2017 and November 2019 at Shenzhen Children's Hospital; of these, 35 patients were suspected of having drug-resistant CMV infections and were tested for drug-resistant mutations in the UL97 and UL54 genes by Sanger sequencing. RESULTS Mutations in UL97 or UL54, or in both, were detected in 11 patients. Most of these mutations have not been previously reported. The UL97 mutation (A582V) was detected in only one patient who also harbored two UL54 mutations (T760X and R876W). One patient with both the G604S and T691A mutations in the UL54 gene died of CMV pneumonia. We investigated the risk factors associated with the development of drug-resistant CMV infection. Patients in whom both the donor and recipient had positive CMV serostatuses were less likely to have drug-resistant mutations (Fisher's exact test, p < 0.05). CONCLUSION Newly and previously detected CMV mutations in UL97 and UL54 may be associated with the development of drug-resistant CMV infection. The detection of these mutations may provide guidance for the management of post-transplant CMV infections.
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Affiliation(s)
- Uet Yu
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Xiaodong Wang
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Xiaoling Zhang
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Chunjing Wang
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Chunlan Yang
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Xiaohui Zhou
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Yue Li
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Xiaochan Huang
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Jing Wen
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Feiqiu Wen
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Sixi Liu
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China.
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Chemaly RF, Chou S, Einsele H, Griffiths P, Avery R, Razonable RR, Mullane KM, Kotton C, Lundgren J, Komatsu TE, Lischka P, Josephson F, Douglas CM, Umeh O, Miller V, Ljungman P. Definitions of Resistant and Refractory Cytomegalovirus Infection and Disease in Transplant Recipients for Use in Clinical Trials. Clin Infect Dis 2020; 68:1420-1426. [PMID: 30137245 DOI: 10.1093/cid/ciy696] [Citation(s) in RCA: 119] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 08/17/2018] [Indexed: 12/15/2022] Open
Abstract
Despite advances in preventive strategies, cytomegalovirus (CMV) infection remains a major complication in solid organ and hematopoietic cell transplant recipients. CMV infection may fail to respond to commercially available antiviral therapies, with or without demonstrating genotypic mutation(s) known to be associated with resistance to these therapies. This lack of response has been termed "resistant/refractory CMV" and is a key focus of clinical trials of some investigational antiviral agents. To provide consistent criteria for future clinical trials and outcomes research, the CMV Resistance Working Group of the CMV Drug Development Forum (consisting of scientists, clinicians, regulatory officials, and industry representatives from the United States, Canada, and Europe) has undertaken establishing standardized consensus definitions of "resistant" and "refractory" CMV. These definitions have emerged from the Working Group's review of the available virologic and clinical literature and will be subject to reassessment and modification based on results of future studies.
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Affiliation(s)
- Roy F Chemaly
- Department of Infectious Diseases, Infection Control, and Employee Health, University of Texas MD Anderson Cancer Center, Houston
| | - Sunwen Chou
- Division of Infectious Diseases, Oregon Health and Science University, and Research and Development Service, Veterans Affairs Portland Health Care System
| | - Hermann Einsele
- Department of Internal Medicine II, University Hospital Wuerzburg, Germany
| | - Paul Griffiths
- Institute for Immunity and Transplantation, University College London Medical School, United Kingdom
| | - Robin Avery
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Raymund R Razonable
- Division of Infectious Diseases, Department of Medicine, William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota
| | - Kathleen M Mullane
- Section of Infectious Diseases and Global Health, Department of Medicine, University of Chicago, Illinois
| | - Camille Kotton
- Infectious Diseases Division, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jens Lundgren
- Centre for Health and Infectious Disease Research, Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Denmark
| | - Takashi E Komatsu
- Division of Antiviral Products, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Peter Lischka
- AiCuris Anti-infective Cures GmbH, Wuppertal, Germany
| | | | | | - Obi Umeh
- Shire Global Clinical Development (Immunology Therapeutic Area), Lexington, Massachusetts
| | - Veronica Miller
- Forum for Collaborative Research, University of California, Berkeley
| | - Per Ljungman
- Department of Cellular Therapy and Allogeneic Stem Cell Transplantation, Karolinska University Hospital.,Division of Hematology, Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
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Placental Structure in Preterm Birth Among HIV-Positive Versus HIV-Negative Women in Kenya. J Acquir Immune Defic Syndr 2019; 80:94-102. [PMID: 30272633 PMCID: PMC6289800 DOI: 10.1097/qai.0000000000001871] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background: Preterm birth (PTB) is a major cause of infant morbidity and mortality in developing countries. Recent data suggest that in addition to Human Immunodeficiency Virus (HIV) infection, use of antiretroviral therapy (ART) increases the risk of PTB. As the mechanisms remain unexplored, we conducted this study to determine whether HIV and ART were associated with placental changes that could contribute to PTB. Setting: We collected and evaluated placentas from 38 HIV-positive women on ART and 43 HIV-negative women who had preterm deliveries in Nairobi, Kenya. Methods: Anatomical features of the placentas were examined at gross and microscopic levels. Cases were matched for gestational age and compared by the investigators who were blinded to maternal HIV serostatus. Results: Among preterm placentas, HIV infection was significantly associated with thrombosis (P = 0.001), infarction (P = 0.032), anomalies in cord insertion (P = 0.02), gross evidence of membrane infection (P = 0.043), and reduced placental thickness (P = 0.010). Overall, preterm placentas in both groups were associated with immature villi, syncytial knotting, villitis, and deciduitis. Features of HIV-positive versus HIV-negative placentas included significant fibrinoid deposition with villus degeneration, syncytiotrophoblast delamination, red blood cell adhesion, hypervascularity, and reduction in both surface area and perimeter of the terminal villi. Conclusions: These results imply that HIV infection and/or ART are associated with morphological changes in preterm placentas that contribute to delivery before 37 weeks. Hypervascularity suggests that the observed pathologies may be attributable, in part, to hypoxia. Further research to explore potential mechanisms will help elucidate the pathways that are involved perhaps pointing to interventions for decreasing the risk of prematurity among HIV-positive women.
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Boonsathorn S, Pasomsub E, Techasaensiri C, Apiwattanakul N. Analysis of Ganciclovir-Resistant Cytomegalovirus Infection Caused by the UL97 Gene Mutation in Codons 460 and 520 in Pediatric Patients: A Case Series. Open Forum Infect Dis 2019; 6:ofz480. [PMID: 32528998 PMCID: PMC7275293 DOI: 10.1093/ofid/ofz480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 10/31/2019] [Indexed: 11/14/2022] Open
Abstract
Background Drug-resistant cytomegalovirus (CMV) infection has been increasingly recognized. However, there are limited data in pediatric patients. In this study, the prevalence and factors associated with CMV infection with UL97 mutations in pediatric patients treated with ganciclovir but not responding to treatment were evaluated. Methods This retrospective study was conducted from January 2013 to December 2017. All patients who were suspected of having ganciclovir-resistant CMV infection and had never had ganciclovir prophylaxis were included. Genotypic assay for UL97 mutations in codons 460 and 520 conferring ganciclovir resistance was performed. Factors associated with the presence of UL97 mutations were analyzed. Results Of 34 patients included, 10 patients (29.4%) had a genotypically confirmed UL97 mutation. The median age (interquartile range [IQR]) was 3 (0.85–8.68) years. Ganciclovir resistance was tested at a median time (IQR) of 22.5 (14.3–31) days after initiation of ganciclovir. All resistant isolates harbored a UL97 mutation in codon 460. Compared with patients infected with CMV without UL97 mutation, those infected with UL97 mutation strains were younger (median age [IQR], 3.02 [0.85–8.68] vs 10.45 [2.7–16.4] years) and had a higher maximum viral load (median [IQR], 5.06 [4.74–6.05] vs 4.42 [4.03–4.87] copies/mL). Six of 10 (60%) patients were successfully treated with high-dose ganciclovir (7.5 mg/kg twice daily). Conclusions UL97 mutation ganciclovir-resistant CMV infection was not uncommon in the pediatric population. Screening for this mutation should be considered in patients experiencing virological worsening while ganciclovir is given, even if patients have not previously received ganciclovir prophylaxis.
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Affiliation(s)
- Sophida Boonsathorn
- Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Ekawat Pasomsub
- Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chonnamet Techasaensiri
- Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nopporn Apiwattanakul
- Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Use of Letermovir as Salvage Therapy for Drug-Resistant Cytomegalovirus Retinitis. Antimicrob Agents Chemother 2019; 63:AAC.02337-18. [PMID: 30642941 DOI: 10.1128/aac.02337-18] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 01/04/2019] [Indexed: 12/31/2022] Open
Abstract
Treatment options for drug-resistant cytomegalovirus (CMV) are limited. Letermovir is a novel antiviral recently approved for CMV prophylaxis following hematopoietic cell transplantation, but its efficacy in other settings is unknown. We recently used letermovir for salvage treatment in four solid organ transplant recipients with ganciclovir-resistant CMV retinitis. All patients improved clinically without known adverse drug events. However, three patients failed to maintain virologic suppression, including two patients who developed genotypically confirmed resistance to letermovir while on therapy.
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Cytomegalovirus Viral Load in Bronchoalveolar Lavage to Diagnose Lung Transplant Associated CMV Pneumonia. Transplantation 2018; 102:326-332. [PMID: 28846557 DOI: 10.1097/tp.0000000000001927] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The diagnostic yield for cytomegalovirus (CMV) polymerase chain reaction (PCR) viral load in bronchoalveolar lavage (BAL) or in plasma to diagnose CMV pneumonia in lung transplant recipients remains uncertain and was investigated in a large cohort of consecutive lung transplant recipients. METHODS Bronchoscopies within the first year of lung transplantation with CMV detectable in BAL by PCR (ie, viral load, ≥273 IU/mL) were included (66 recipients; 145 bronchoscopies); at each bronchoscopy episode, 2 independent experts reviewed clinical and laboratory information to determine whether the patient at that time fulfilled the criteria for CMV pneumonia per current international recommendations. Corresponding plasma CMV PCR viral load determined at time of the bronchoscopy (n = 126) was also studied. Optimal CMV PCR viral load cutoff for CMV pneumonia diagnosis was determined using receiver operating characteristics. RESULTS CMV was detected in BAL with CMV PCR in 145 episodes, and 34 (23%) of these episodes fulfilled the criteria for CMV pneumonia. The area under the curve-receiver operating characteristics for CMV in BAL was 90% at the optimum cutoff (4545 IU/mL) with a corresponding sensitivity of 91% and specificity of 77% (in plasma the corresponding values were 274 IU/mL, 63% and 76%, respectively). CONCLUSIONS CMV PCR viral load in BAL had a high performance to diagnose CMV pneumonia in lung transplant recipients; plasma CMV viral load did not reliably aid as a diagnostic tool.
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Impact of CMV PCR Blips in Recipients of Solid Organ and Hematopoietic Stem Cell Transplantation. Transplant Direct 2018; 4:e355. [PMID: 30123828 PMCID: PMC6089517 DOI: 10.1097/txd.0000000000000787] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 03/11/2018] [Indexed: 11/26/2022] Open
Abstract
Background Viral blips reflecting polymerase chain reaction (PCR) artefacts or transient low-level replication are well described in the human immunodeficiency virus setting. However, the epidemiology of such blips in transplant recipients screened for cytomegalovirus (CMV) with PCR remains uncertain and was investigated in a cohort of solid organ and hematopoietic stem cell recipients. Methods Eligible recipients had known donor/recipient CMV IgG serostatus, and 3 CMV PCRs ≥. The CMV PCR triplicates (3 consecutive CMV PCRs) were defined; the first CMV PCR was always negative, and the time between the second and third samples was 7 days ≤. A positive second but negative third sample represented a blip. Odds ratio (OR) for factors associated with a triplicate being a blip was estimated by binomial regression adjusted for repeated measurements. Whether blips affected the hazard ratio (HR) for subsequent CMV infection was determined with a Cox model. Results 851 recipients generated 3883 CMV PCR triplicates. The OR of a triplicate representing a blip decreased with increasing viral load of the second sample (vs 273 IU/mL; >273-910 IU/mL: odds ratio [OR], 0.2; 95% confidence interval [CI], 0.1-0.5; >910 IU/mL: OR, 0.08; 95% CI, 0.02-0.2; P ≤ 0.0002) and increased with intermediary-/low-risk serostatus (vs high risk) (OR, 2.8; 95% CI, 1.2-5.5; P = 0.01). Cumulative exposure to DNAemia in the CMV blips greater than 910 IU/mL indicated increased HR of subsequent CMV infection (HR, 4.6; 95% CI, 1.2-17.2; P = 0.02). Conclusions Cytomegalovirus blips are frequent; particularly when the viral load of the first positive PCR is < 910 IU/mL, and serostatus risk is intermediary/low. Accumulating blips suggest intermittent low-level replication. If blips are suspected, confirmation of ongoing replication before initiation of treatment is prudent.
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Humanes Cytomegalievirus (HCMV). Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2018; 61:116-128. [DOI: 10.1007/s00103-017-2661-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Risk of infectious diseases among first-degree relatives of transplant recipients who develop CMV infection: is the infectious phenotype inheritable? Eur J Clin Microbiol Infect Dis 2017; 36:2391-2398. [PMID: 28791493 DOI: 10.1007/s10096-017-3072-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 07/18/2017] [Indexed: 01/03/2023]
Abstract
Transplant recipients are at high risk of cytomegalovirus (CMV) infection. Mechanisms explaining the variation in risk of infections are far from fully elucidated. We hypothesised that host genetics explains part of the variation in risk of infection and examined if relatives of recipients with CMV infection have higher rates of severe infections compared to relatives of recipients without this infectious phenotype. In a register-based study, we included first-degree relatives of transplant recipients and examined the risk of hospitalisation due to overall infection or viral infection and risk of death among relatives of recipients who developed CMV infection within the first year of transplantation compared to relatives of recipients without CMV. Analyses were adjusted for sex, age and calendar year. We included 4470 relatives who were followed for 103,786 person-years, median follow-up 24 years [interquartile range (IQR) 12-36]. There were a total of 1360 infection-related hospitalisations in the follow-up period, incidence rate (IR) 13.1/1000 person-years [95% confidence interval (CI), 12.4; 13.8]. 206 relatives were hospitalised with viral infection, IR 1.8/1000 person-years (95% CI, 1.6; 2.0). There was no increased risk of hospitalisation due to infections, IR ratio (IRR) 0.99 (95% CI, 0.88; 1.12), nor specifically viral infections, IRR 0.87 (95% CI, 0.63; 1.19), in relatives of recipients with CMV compared to relatives of recipients without CMV. Also, no difference was seen in analyses stratified by transplant type, family relation and CMV serostatus. The risk of hospitalisation due to infection is not increased among first-degree relatives of transplant recipients with CMV infection compared to relatives of recipients without CMV.
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Abstract
Cytomegalovirus (CMV) is a frequent complication of hematopoietic stem cell transplant in pediatric patients, with significant morbidity and mortality. Antiviral drugs are used as prophylactic, preemptive or therapeutic medicines; however, no uniform guidelines exist for the best strategy to prevent CMV disease. Resistance to standard antiviral therapies can lead to further difficulty in managing CMV disease. Studies for investigational therapies are underway and could provide options for treatment of resistant CMV, while limiting toxicities associated with currently used antiviral therapies.
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Wareham NE, Lundgren JD, Da Cunha-Bang C, Gustafsson F, Iversen M, Johannesen HH, Kjær A, Rasmussen A, Sengeløv H, Sørensen SS, Fischer BM. The clinical utility of FDG PET/CT among solid organ transplant recipients suspected of malignancy or infection. Eur J Nucl Med Mol Imaging 2017; 44:421-431. [PMID: 27838763 PMCID: PMC5281676 DOI: 10.1007/s00259-016-3564-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 10/28/2016] [Indexed: 12/23/2022]
Abstract
PURPOSE Solid organ transplant (SOT) recipients are at high risk of developing infections and malignancies. 18F-FDG PET/CT may enable timely detection of these diseases and help to ensure early intervention. We aimed to describe the clinical utility of FDG PET/CT in consecutive, diagnostic unresolved SOT recipients transplanted from January 2004 to May 2015. METHODS Recipients with a post-transplant FDG PET/CT performed as part of diagnostic work-up were included. Detailed chart reviews were done to extract relevant clinical information and determine the final diagnosis related to the FDG PET/CT. Based on á priori defined criteria and the final diagnosis, results from each scan were classified as true or false, and diagnostic values determined. RESULTS Among the 1,814 recipients in the cohort, 145 had an FDG PET/CT performed; 122 under the indication of diagnostically unresolved symptoms with a suspicion of malignancy or infection. The remaining (N = 23) had an FDG PET/CT to follow-up on a known disease or to stage a known malignancy. The 122 recipients underwent a total of 133 FDG PET/CT scans performed for a suspected malignancy (66 %) or an infection (34 %). Sensitivity, specificity, and positive and negative predictive values of the FDG PET/CT in diagnosing these conditions were 97, 84, 87, and 96 %, respectively. CONCLUSION FDG PET/CT is an accurate diagnostic tool for the work-up of diagnostic unresolved SOT recipients suspected of malignancy or infection. The high sensitivity and NPV underlines the potential usefulness of PET/CT for excluding malignancy or focal infections in this often complex clinical situation.
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Affiliation(s)
- Neval E Wareham
- Centre for Health and Infectious Disease Research (CHIP), Department of Infectious Diseases, Section 2100, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark.
| | - J D Lundgren
- Centre for Health and Infectious Disease Research (CHIP), Department of Infectious Diseases, Section 2100, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark
| | - C Da Cunha-Bang
- Department of Haematology, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - F Gustafsson
- Department of Cardiology, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - M Iversen
- Department of Cardiology, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - H H Johannesen
- Department of Clinical Physiology, Nuclear Medicine & PET, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - A Kjær
- Department of Clinical Physiology, Nuclear Medicine & PET, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - A Rasmussen
- Department of Surgical Gastroenterology, Rigshospitalet, Blegdamsvek 9, 2100 Copenhagen Ø, Denmark
| | - H Sengeløv
- Department of Haematology, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - S S Sørensen
- Department of Nephrology, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - B M Fischer
- Department of Clinical Physiology, Nuclear Medicine & PET, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
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Avery RK, Arav-Boger R, Marr KA, Kraus E, Shoham S, Lees L, Trollinger B, Shah P, Ambinder R, Neofytos D, Ostrander D, Forman M, Valsamakis A. Outcomes in Transplant Recipients Treated With Foscarnet for Ganciclovir-Resistant or Refractory Cytomegalovirus Infection. Transplantation 2016; 100:e74-80. [PMID: 27495775 PMCID: PMC5030152 DOI: 10.1097/tp.0000000000001418] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Antiviral-resistant or refractory cytomegalovirus (CMV) infection is challenging, and salvage therapies, foscarnet, and cidofovir, have significant toxicities. Several investigational anti-CMV agents are under development, but more information is needed on outcomes of current treatments to facilitate clinical trial design for new drugs. METHODS Records of solid organ transplant (SOT) and hematopoietic cell transplant (HCT) recipients at a single center over a 10-year period were reviewed retrospectively to characterize those who had received foscarnet treatment for ganciclovir-resistant or refractory CMV infection. Data were collected on virologic responses, mortality, and nephrotoxicity. RESULTS Of 39 patients (22 SOT, 17 HCT), 15 had documented ganciclovir resistance mutations and 11 (28%) of 39 had tissue-invasive CMV. Median duration of foscarnet was 32 days. Virologic failure occurred in 13 (33%) of 39 and relapses of viremia occurred in 31%. Mortality was 12 (31%) of 39 and was higher in HCT than SOT (P = 0.001), although ganciclovir resistance was more common in SOT (P = 0.003). Doses of ganciclovir or valganciclovir were low in 10 (26%) of 39 at some time before switching to foscarnet. Renal dysfunction occurred in 20 (51%) of 39 by end of treatment and in 7 (28%) of 25 after 6 months. CONCLUSIONS Outcomes of existing treatment for ganciclovir-resistant or refractory CMV are suboptimal, in terms of virologic clearance, renal dysfunction, and mortality. These data should provide background information for future clinical trials of newer antiviral agents.
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Affiliation(s)
- Robin K. Avery
- Division of Infectious Diseases (RKA, KAM, SS, DN, DO), Pediatric Infectious Diseases (R A-B), Nephrology (EK), Pharmacy (LL, BT), Pulmonary and Critical Care (PS), the Sidney Kimmel Cancer Center (RA), and Division of Medical Microbiology, Department of Pathology, Pathology (MF, AV), Johns Hopkins
| | - Ravit Arav-Boger
- Division of Infectious Diseases (RKA, KAM, SS, DN, DO), Pediatric Infectious Diseases (R A-B), Nephrology (EK), Pharmacy (LL, BT), Pulmonary and Critical Care (PS), the Sidney Kimmel Cancer Center (RA), and Division of Medical Microbiology, Department of Pathology, Pathology (MF, AV), Johns Hopkins
| | - Kieren A. Marr
- Division of Infectious Diseases (RKA, KAM, SS, DN, DO), Pediatric Infectious Diseases (R A-B), Nephrology (EK), Pharmacy (LL, BT), Pulmonary and Critical Care (PS), the Sidney Kimmel Cancer Center (RA), and Division of Medical Microbiology, Department of Pathology, Pathology (MF, AV), Johns Hopkins
| | - Edward Kraus
- Division of Infectious Diseases (RKA, KAM, SS, DN, DO), Pediatric Infectious Diseases (R A-B), Nephrology (EK), Pharmacy (LL, BT), Pulmonary and Critical Care (PS), the Sidney Kimmel Cancer Center (RA), and Division of Medical Microbiology, Department of Pathology, Pathology (MF, AV), Johns Hopkins
| | - Shmuel Shoham
- Division of Infectious Diseases (RKA, KAM, SS, DN, DO), Pediatric Infectious Diseases (R A-B), Nephrology (EK), Pharmacy (LL, BT), Pulmonary and Critical Care (PS), the Sidney Kimmel Cancer Center (RA), and Division of Medical Microbiology, Department of Pathology, Pathology (MF, AV), Johns Hopkins
| | - Laura Lees
- Division of Infectious Diseases (RKA, KAM, SS, DN, DO), Pediatric Infectious Diseases (R A-B), Nephrology (EK), Pharmacy (LL, BT), Pulmonary and Critical Care (PS), the Sidney Kimmel Cancer Center (RA), and Division of Medical Microbiology, Department of Pathology, Pathology (MF, AV), Johns Hopkins
| | - Brandon Trollinger
- Division of Infectious Diseases (RKA, KAM, SS, DN, DO), Pediatric Infectious Diseases (R A-B), Nephrology (EK), Pharmacy (LL, BT), Pulmonary and Critical Care (PS), the Sidney Kimmel Cancer Center (RA), and Division of Medical Microbiology, Department of Pathology, Pathology (MF, AV), Johns Hopkins
| | - Pali Shah
- Division of Infectious Diseases (RKA, KAM, SS, DN, DO), Pediatric Infectious Diseases (R A-B), Nephrology (EK), Pharmacy (LL, BT), Pulmonary and Critical Care (PS), the Sidney Kimmel Cancer Center (RA), and Division of Medical Microbiology, Department of Pathology, Pathology (MF, AV), Johns Hopkins
| | - Rich Ambinder
- Division of Infectious Diseases (RKA, KAM, SS, DN, DO), Pediatric Infectious Diseases (R A-B), Nephrology (EK), Pharmacy (LL, BT), Pulmonary and Critical Care (PS), the Sidney Kimmel Cancer Center (RA), and Division of Medical Microbiology, Department of Pathology, Pathology (MF, AV), Johns Hopkins
| | - Dionysios Neofytos
- Division of Infectious Diseases (RKA, KAM, SS, DN, DO), Pediatric Infectious Diseases (R A-B), Nephrology (EK), Pharmacy (LL, BT), Pulmonary and Critical Care (PS), the Sidney Kimmel Cancer Center (RA), and Division of Medical Microbiology, Department of Pathology, Pathology (MF, AV), Johns Hopkins
| | - Darin Ostrander
- Division of Infectious Diseases (RKA, KAM, SS, DN, DO), Pediatric Infectious Diseases (R A-B), Nephrology (EK), Pharmacy (LL, BT), Pulmonary and Critical Care (PS), the Sidney Kimmel Cancer Center (RA), and Division of Medical Microbiology, Department of Pathology, Pathology (MF, AV), Johns Hopkins
| | - Michael Forman
- Division of Infectious Diseases (RKA, KAM, SS, DN, DO), Pediatric Infectious Diseases (R A-B), Nephrology (EK), Pharmacy (LL, BT), Pulmonary and Critical Care (PS), the Sidney Kimmel Cancer Center (RA), and Division of Medical Microbiology, Department of Pathology, Pathology (MF, AV), Johns Hopkins
| | - Alexandra Valsamakis
- Division of Infectious Diseases (RKA, KAM, SS, DN, DO), Pediatric Infectious Diseases (R A-B), Nephrology (EK), Pharmacy (LL, BT), Pulmonary and Critical Care (PS), the Sidney Kimmel Cancer Center (RA), and Division of Medical Microbiology, Department of Pathology, Pathology (MF, AV), Johns Hopkins
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13
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Slavov SN, Vilar FC, Wagatsuma VMD, Santana RC, Machado AA, Fonseca BALD, Kashima S, Covas DT. Late emergence of A594V and L595W mutations related to ganciclovir resistance in a patient with HCMV retinitis and long-term HIV progression. ACTA ACUST UNITED AC 2015; 48:777-81. [PMID: 26270327 PMCID: PMC4568804 DOI: 10.1590/1414-431x20154507] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 03/13/2015] [Indexed: 11/22/2022]
Abstract
The emergence of ganciclovir (GCV) resistance during the treatment of human cytomegalovirus (HCMV) infection is a serious clinical challenge, and is associated with high morbidity and mortality. In this case report, we describe the emergence of two consecutive mutations (A594V and L595W) related to GCV resistance in a patient with HCMV retinitis and long-term HIV progression after approximately 240 days of GCV use. Following the diagnosis of retinitis, the introduction of GCV did not result in viral load reduction. The detected mutations appeared late in the treatment, and we propose that other factors (high initial HCMV load, previous GCV exposure, low CD4+ cell count), in addition to the presence of resistance mutations, may have contributed to the treatment failure of HCMV infection in this patient.
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Affiliation(s)
- S N Slavov
- Hemocentro de Ribeirão Preto, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, BR
| | - F C Vilar
- Divisão de Moléstias Infecciosas e Tropicais, Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, BR
| | - V M D Wagatsuma
- Laboratório de Hematologia Experimental, Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, BR
| | - R C Santana
- Divisão de Moléstias Infecciosas e Tropicais, Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, BR
| | - A A Machado
- Divisão de Moléstias Infecciosas e Tropicais, Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, BR
| | - B A L da Fonseca
- Divisão de Moléstias Infecciosas e Tropicais, Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, BR
| | - S Kashima
- Hemocentro de Ribeirão Preto, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, BR
| | - D T Covas
- Hemocentro de Ribeirão Preto, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, BR
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14
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Lodding IP, Sengeløv H, da Cunha-Bang C, Iversen M, Rasmussen A, Gustafsson F, Downing JG, Grarup J, Kirkby N, Frederiksen CM, Mocroft A, Sørensen SS, Lundgren JD. Clinical Application of Variation in Replication Kinetics During Episodes of Post-transplant Cytomegalovirus Infections. EBioMedicine 2015; 2:699-705. [PMID: 26288842 PMCID: PMC4534685 DOI: 10.1016/j.ebiom.2015.05.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 05/04/2015] [Accepted: 05/07/2015] [Indexed: 11/15/2022] Open
Abstract
Background Cytomegalovirus (CMV) infection in transplant recipients is reported to replicate with a doubling time of 1.2–2 days, and weekly screening is recommended for early diagnosis. We re-evaluated these features in our cohort of transplant recipients. Methods The CMV doubling time of the first CMV infection in the first year post-transplant could be calculated for 193 recipients of haematopoietic stem cell or solid organ transplantation. Factors determining the proportion of recipients with a high diagnostic CMV viral load (≥ 18,200 IU/mL) were explored using mathematical simulation. Findings The overall median doubling time was 4.3 days (IQR 2.5–7.8) and was not influenced by prior CMV immunity, or type of transplantation (p > 0.4). Assuming a fixed doubling time of 1.3 days and screening intervals of 7 or 10 days, 11.1% and 33.3% were projected to have a high CMV viral load at diagnosis, compared to 1.4% and 4.3% if the doubling time varies as observed in our cohort. Consistently, 1.9% of recipients screened weekly had a high diagnostic virus load. Interpretation Screening intervals can be extended to 10 days in cohorts with comparable CMV doubling time, whereas shorter than 7 days is required in cohorts with shorter doubling times to maintain pre-emptive screening quality. CMV doubling time was longer than previously reported, and not influenced by type of transplantation or prior CMV immunity. In cohorts with comparable CMV doubling time, intervals between screening with CMV PCR may be extended from 7 to 10 days.
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Affiliation(s)
- I P Lodding
- Centre for Health and Infectious Disease Research (CHIP), Department of Infectious Diseases and Rheumatology, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - H Sengeløv
- Department of Hematology, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - C da Cunha-Bang
- Department of Hematology, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark ; Department of Hematology, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - M Iversen
- Department of Cardiology, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - A Rasmussen
- Department of Surgery C, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - F Gustafsson
- Department of Cardiology, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - J G Downing
- Centre for Health and Infectious Disease Research (CHIP), Department of Infectious Diseases and Rheumatology, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - J Grarup
- Centre for Health and Infectious Disease Research (CHIP), Department of Infectious Diseases and Rheumatology, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - N Kirkby
- Department of Clinical Microbiology, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - C M Frederiksen
- Centre for Health and Infectious Disease Research (CHIP), Department of Infectious Diseases and Rheumatology, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - A Mocroft
- Research Department of Infection and Population Health, University College of London (UCL), Royal Free Hospital Rowland Hill Street London NW3 2PF, United Kingdom
| | - S S Sørensen
- Department of Nephrology, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - J D Lundgren
- Centre for Health and Infectious Disease Research (CHIP), Department of Infectious Diseases and Rheumatology, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
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15
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Weller SK, Kuchta RD. The DNA helicase-primase complex as a target for herpes viral infection. Expert Opin Ther Targets 2013; 17:1119-32. [PMID: 23930666 DOI: 10.1517/14728222.2013.827663] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
INTRODUCTION The Herpesviridae are responsible for debilitating acute and chronic infections, and some members of this family are associated with human cancers. Conventional anti-herpesviral therapy targets the viral DNA polymerase and has been extremely successful; however, the emergence of drug-resistant virus strains, especially in neonates and immunocompromised patients, underscores the need for continued development of anti-herpes drugs. In this article, we explore an alternative target for antiviral therapy, the HSV helicase/primase complex. AREAS COVERED This review addresses the current state of knowledge of HSV DNA replication and the important roles played by the herpesvirus helicase- primase complex. In the last 10 years several helicase/primase inhibitors (HPIs) have been described, and in this article, we discuss and contrast these new agents with established inhibitors. EXPERT OPINION The outstanding safety profile of existing nucleoside analogues for α-herpesvirus infection make the development of new therapeutic agents a challenge. Currently used nucleoside analogues exhibit few side effects and have low occurrence of clinically relevant resistance. For HCMV, however, existing drugs have significant toxicity issues and the frequency of drug resistance is high, and no antiviral therapies are available for EBV and KSHV. The development of new anti-herpesvirus drugs is thus well worth pursuing especially for immunocompromised patients and those who develop drug-resistant infections. Although the HPIs are promising, limitations to their development into a successful drug strategy remain.
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Affiliation(s)
- Sandra K Weller
- University of Connecticut Health Center, Department of Molecular Microbial and Structural Biology , Farmington CT 06030 , USA +1 860 679 2310 ;
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16
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Baker JV, Brummel-Ziedins K, Neuhaus J, Duprez D, Cummins N, Dalmau D, DeHovitz J, Lehmann C, Sullivan A, Woolley I, Kuller L, Neaton JD, Tracy RP. HIV replication alters the composition of extrinsic pathway coagulation factors and increases thrombin generation. J Am Heart Assoc 2013; 2:e000264. [PMID: 23896681 PMCID: PMC3828789 DOI: 10.1161/jaha.113.000264] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background HIV infection leads to activation of coagulation, which may increase the risk for atherosclerosis and venous thromboembolic disease. We hypothesized that HIV replication increases coagulation potentially through alterations in extrinsic pathway factors. Methods and Results Extrinsic pathway factors were measured among a subset of HIV participants from the Strategies for Management of Anti‐Retroviral Therapy (SMART) trial. Thrombin generation was estimated using validated computational modeling based on factor composition. We characterized the effect of antiretroviral therapy (ART) treatment versus the untreated state (HIV replication) via 3 separate analyses: (1) a cross‐sectional comparison of those on and off ART (n=717); (2) a randomized comparison of deferring versus starting ART (n=217); and (3) a randomized comparison of stopping versus continuing ART (n=500). Compared with viral suppression, HIV replication consistently showed short‐term increases in some procoagulants (eg, 15% to 23% higher FVIII; P<0.001) and decreases in key anticoagulants (eg, 5% to 9% lower antithrombin [AT] and 6% to 10% lower protein C; P<0.01). The net effect of HIV replication was to increase coagulation potential (eg, 24% to 48% greater thrombin generation from computational models; P<0.01 for all). The pattern of changes from HIV replication was reversed with ART treatment and consistent across all 3 independent comparisons. Conclusions HIV replication leads to complex changes in extrinsic pathway factors, with the net effect of increasing coagulation potential to a degree that may be clinically relevant. The key influence of changes in FVIII and AT suggests that HIV‐related coagulation abnormalities may involve changes in hepatocyte function in the context of systemic inflammation. Clinical Trial Registration URL: ClinicalTrials.gov. Unique identifier: NCT00027352.
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