Human T cell lymphotrophic virus 1/2 in solid organ transplantation

Prevalence of Human T-Lymphotropic Virus Type 1 in Brain-Dead Organ Donors

Background: This study aimed to assess the prevalence of human T-lymphotropic virus type 1 (HTLV-1) among brain-dead organ donors at Masih Daneshvari Hospital in Tehran, Iran. Methods: By enzyme-linked immunosorbent assay (ELISA), 54 organ donors were screened for HTLV-1 virus in this descriptive cross-sectional study. Following that, Western blot confirmation was performed to confirm the HTLV-I infection. Results: Anti-HTLV-1 antibodies were detected in 2 (3.4%) cases out of 54 patients tested by ELISA. A western blot was performed in cases of positive results, but none of the subjects tested positive for HTLV-1 infection. Conclusions: The results of the present study indicated rare cases of HTLV-I infection in brain-dead organ donors. However, it is recommended that organ donors be investigated for the prevalence of this virus.

Clinical and Public Health Implications of Human T-Lymphotropic Virus Type 1 Infection

Human T-lymphotropic virus type 1 (HTLV-1) is estimated to affect 5 to 10 million people globally and can cause severe and potentially fatal disease, including adult T-cell leukemia/lymphoma (ATL) and HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP). The burden of HTLV-1 infection appears to be geographically concentrated, with high prevalence in discrete regions and populations. While most high-income countries have introduced HTLV-1 screening of blood donations, few other public health measures have been implemented to prevent infection or its consequences. Recent advocacy from concerned researchers, clinicians, and community members has emphasized the potential for improved prevention and management of HTLV-1 infection. Despite all that has been learned in the 4 decades following the discovery of HTLV-1, gaps in knowledge across clinical and public health aspects persist, impeding optimal control and prevention, as well as the development of policies and guidelines. Awareness of HTLV-1 among health care providers, communities, and affected individuals remains limited, even in countries of endemicity. This review provides a comprehensive overview on HTLV-1 epidemiology and on clinical and public health and highlights key areas for further research and collaboration to advance the health of people with and at risk of HTLV-1 infection.

Donor-derived Viral Infections in Liver Transplantation

Donor-derived infections are defined as any infection present in the donor that is transmitted to 1 or more recipients. Donor-derived infections can be categorized into 2 groups: "expected" and "unexpected" infections. Expected transmissions occur when the donor is known to have an infection, such as positive serology for cytomegalovirus, Epstein Barr virus, or hepatitis B core antibody, at the time of donation. Unexpected transmissions occur when a donor has no known infection before donation, but 1 or more transplant recipients develop an infection derived from the common donor. Unexpected infections are estimated to occur in far less than 1% of solid organ transplant recipients. We will review the epidemiology, risk factors, and approaches to prevention and management of donor-derived viral infectious disease transmission in liver transplantation.

Isolated Neurogenic Bladder Associated With Human T-Lymphotropic Virus Type 1 Infection in a Renal Transplant Patient From Central Australia: A Case Report

BACKGROUND

Human T-lymphotropic virus type 1 (HTLV-1) is endemic amongst the Aborigines of the Northern Territory of Australia. HTLV-1 associated myelopathy/tropical spastic paraparesis (HAM/TSP) has been associated with this infection. In general population, isolated neurogenic bladder dysfunction in HTLV-1-infected individuals without HAM/TSP has been reported, and the HTLV-1 proviral load has been found to be higher in such patients compared with asymptomatic carriers. In solid organ transplantation, few cases of HAM/TSP have been reported worldwide, but not an isolated neurogenic bladder.

CASE

A 50-year-old indigenous women from Alice Springs with end stage renal disease secondary to diabetic nephropathy with no prior history of bladder dysfunction received a cadaveric renal allograft following which she developed recurrent urinary tract infections. The recipient was seropositive for HTLV-1 infection. HTLV-1 status of donor was not checked. Urodynamic studies revealed stress incontinence and detrusor overactivity without urethral intrinsic sphincter deficiency. She had no features of myelopathy. There was elevation of the serum and cerebrospinal fluid HTLV-1 proviral load. The magnetic resonance imaging myelogram was normal. Pyelonephritis was diagnosed based on clinical features, positive cultures, and renal allograft biopsy. Continuous suprapubic catheter drainage helped preventing further episodes of allograft pyelonephritis in spite of chronic colonization of the urinary tract.

CONCLUSION

Isolated bladder dysfunction is a rare manifestation of HTLV-1 infection and is probably associated with high proviral loads. This may adversely affect renal allograft and patient outcomes.

Human T-lymphotropic virus type 1 infection and solid organ transplantation

HTLV infection appears to be more common among renal transplant candidates than in the related general population. HTLV-1-associated diseases may occur in carriers who are transplanted but there is insufficient evidence to confirm whether these occur more frequently as a result of the associated immunosuppression. Consequently, pre-existing HTLV-1 infection should not be considered a contra-indication to transplantation. The risk of transmission of HTLV-1 through solid organ transplantation from a confirmed infected donor is unknown. There are anecdotes of multiple infections from a single donor. Biologically due to the significant volume of blood and the lack of storage, transmission would be expected to be higher than following blood transfusion. The rate of subsequent disease is unknown, but there are now 11 reports of HAM and 2 of ATL occurring within 4 years of transplantation associated infection. There are insufficient data to know whether the time from infection to onset of disease and the rate of progression differ from transmission through other routes, but early onset and rapid progression is a concern. Responses to enhanced immunosuppression for the treatment of HAM are variable. The risk of HTLV-1 associated disease in exchange for a life-saving major organ transplantation from an infected donor might be considered worth taking by some HTLV-1 uninfected patients. Peri-transplantation antiretroviral prophylaxis with zidovudine and raltegravir is biologically sound but therapeutically unproven. The risks related to HTLV-1 infection appear to preclude the use of any other tissue. All transplant donors should be screened for HTLV-1 infection regardless of perceived risk.

Not the Usual Viral Suspects: Parvovirus B19, West Nile Virus, and Human T-Cell Lymphotrophic Virus Infections After Kidney Transplantation

Kidney transplant recipients are at increased risk of developing clinical disease due to uncommon opportunistic viral pathogens. Refractory anemia is classically associated with parvovirus B19 infection. West Nile virus has the propensity to cause fever and neurologic symptoms, while spastic paresis and lymphoma can be triggered by human T cell lymphotrophic virus. In this review article, the epidemiology, clinical manifestations, diagnosis and treatment of less common viruses are discussed in the setting of kidney transplantation.

HTLV-1-associated myelopathy in a solid organ transplant recipient

Human T-cell lymphotropic virus type-1 (HTLV-1) is endemic in Japan, the Caribbean and in South American countries such as Ecuador. This virus is the cause of HTLV-1-associated myelopathy or tropical spastic paraparesis (HAM/TSP), a myelopathy characterised by chronic progressive paraparesis, spasticity and urinary symptoms. We report the case of a 40-year-old man who received a kidney transplant from a living donor and developed HAM/TSP, 24 months after transplant. The diagnosis was confirmed by detection of HTLV-1 in blood and cerebrospinal fluid by the ELISA and Western Blot tests. For myelopathy, the patient was treated with pulse methylprednisolone, but had poor response to treatment. We recommend that all patients receiving transplants and their donors who come from endemic countries be given a mandatory screening for HTLV-1 through an ELISA test, in an effort to inform candidates for renal transplantation of the potential risk of infection and the development of this disease.

Immunodeficiency-associated viral oncogenesis

Several viruses with different replication mechanisms contribute to oncogenesis by both direct and indirect mechanisms in immunosuppressed subjects after solid organ transplantation, after allogeneic stem cell transplantation, or with human immunodeficiency virus (HIV) infection. Epstein-Barr virus (EBV), human papillomavirus (HPV), Kaposi sarcoma herpesvirus (KSHV), human T-cell lymphotropic virus type 1 (HTLV-1) and Merkel cell polyoma virus (MCV) are the main viruses associated with the development of cancer in immunosuppressed patients. Besides being a main cause of immunodeficiency, HIV1 has a direct pro-oncogenic effect. In this review, we provide an update on the association between the condition of acquired immunodeficiency and cancer risk, specifically addressing the contributions to oncogenesis of HPV, MCV, KSHV, HTLV-1, and EBV.

Postrenal Transplant Human T-Cell Lymphotropic Virus Type I-Associated Myelopathy/Tropical Spastic Paraparesis: A Case Report and Review of the Literature

We report a case of human T-cell lymphotropic virus type I (HTLV-I)-associated myelopathy/tropical spastic paraparesis (HAM/TSP), in a 59 year-old, living-donor, renal transplant recipient from Jamaica. The patient's renal transplant had been performed 11 years ago, and her organ donor was also from Jamaica. Pretransplant HTLV-I serologic status for both the donor and recipient was unknown. The prevalence of HTLV-I seropositivity in the United States and Europe is low, and HAM/TSP is a rare occurrence. The positive predictive value of HTLV-I screening in these regions is therefore, low. This has generated debate among transplant societies regarding universal screening for HTLV-I before solid organ transplantation. Very limited evidence is available for the prevention and treatment of this devastating condition. Our case highlights the importance of selected pretransplant screening for HTLV-I infection among organ donors and candidates from endemic areas. We feel such testing may aid in the early recognition of HAM/TSP and more timely initiation of treatment.

Donor-transmitted HTLV-1-associated myelopathy in a kidney transplant recipient--case report and literature review

Clinical disease due to human T cell lymphotropic virus type 1 (HTLV-1), a retrovirus endemic in certain regions of the world, is rarely reported after solid organ transplantation. In 2009, universal deceased donor organ screening for HTLV-1 was discontinued in the United States. We report the first case of donor-derived HTLV-1-associated myelopathy in a kidney transplant recipient from the United States. The patient, who was HTLV-1-seronegative prior to transplantation, likely acquired HTLV-1 infection from a seropositive organ donor. In this era when screening of donors and recipients for HTLV infection is not mandatory, clinicians should be vigilant in recognizing the risk and potential occurrence of this donor-derived infection in recipients with epidemiologic exposures.