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Morado-Aramburo O, Hasbun R. Solid organ transplant-related central nervous system infections. Curr Opin Infect Dis 2024; 37:192-200. [PMID: 38602163 DOI: 10.1097/qco.0000000000001016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
PURPOSE OF REVIEW Central nervous system (CNS) infections in solid organ transplant (SOT) recipients may present atypical or nonspecific symptoms. Due to a wider range of infectious agents compared with immunocompetent hosts, diagnosis is challenging. This review categorizes CNS infections in SOT recipients by cause. RECENT FINDINGS New studies have reported new data on the epidemiology and the risk factors associated with each specific pathogen described in this review. Additionally, we included the treatment recommendations. SUMMARY The latest findings give us an insight into the different pathogens causing infectious neurologic complications in SOT recipients.
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Affiliation(s)
- Oscar Morado-Aramburo
- Division of Infectious Diseases, Department of Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, USA
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2
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Hou YB, Chang S, Chen S, Zhang WJ. Intravenous immunoglobulin in kidney transplantation: Mechanisms of action, clinical applications, adverse effects, and hyperimmune globulin. Clin Immunol 2023; 256:109782. [PMID: 37742791 DOI: 10.1016/j.clim.2023.109782] [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: 07/24/2023] [Revised: 09/11/2023] [Accepted: 09/20/2023] [Indexed: 09/26/2023]
Abstract
Intravenous immunoglobulin (IVIG) has been developed for over 40 years. The mechanisms of action of IVIG are complex and diverse, and there may be multiple mechanisms that combine to influence it. IVIG has been used in kidney transplantation for desensitization, treatment of antibody-mediated rejection, and ABO-incompatible transplantation. and treatment or prevention of some infectious diseases. Hyperimmune globulins such as cytomegalovirus hyperimmune globulin (CMV-IG) and hepatitis B hyperimmune globulin (HBIG) have also been used to protect against cytomegalovirus and hepatitis B virus, respectively. However, IVIG is also associated with some rare but serious adverse effects and some application risks, and clinicians need to weigh the pros and cons and develop individualized treatment programs to benefit more patients. This review will provide an overview of the multiple mechanisms of action, clinical applications, adverse effects, and prophylactic measures of IVIG, and hyperimmune globulin will also be introduced in it.
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Affiliation(s)
- Yi-Bo Hou
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology; Key Laboratory of Organ Transplantation, Ministry of Education; NHC Key Laboratory of Organ Transplantation; Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan 430030, China
| | - Sheng Chang
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology; Key Laboratory of Organ Transplantation, Ministry of Education; NHC Key Laboratory of Organ Transplantation; Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan 430030, China
| | - Song Chen
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology; Key Laboratory of Organ Transplantation, Ministry of Education; NHC Key Laboratory of Organ Transplantation; Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan 430030, China
| | - Wei-Jie Zhang
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology; Key Laboratory of Organ Transplantation, Ministry of Education; NHC Key Laboratory of Organ Transplantation; Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan 430030, China.
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3
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Pozzetto B, Grard G, Durand G, Paty MC, Gallian P, Lucas-Samuel S, Diéterlé S, Fromage M, Durand M, Lepelletier D, Chidiac C, Hoen B, Nicolas de Lamballerie X. Arboviral Risk Associated with Solid Organ and Hematopoietic Stem Cell Grafts: The Prophylactic Answers Proposed by the French High Council of Public Health in a National Context. Viruses 2023; 15:1783. [PMID: 37766192 PMCID: PMC10536626 DOI: 10.3390/v15091783] [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: 08/01/2023] [Revised: 08/18/2023] [Accepted: 08/20/2023] [Indexed: 09/29/2023] Open
Abstract
Diseases caused by arboviruses are on the increase worldwide. In addition to arthropod bites, most arboviruses can be transmitted via accessory routes. Products of human origin (labile blood products, solid organs, hematopoietic stem cells, tissues) present a risk of contamination for the recipient if the donation is made when the donor is viremic. Mainland France and its overseas territories are exposed to a complex array of imported and endemic arboviruses, which differ according to their respective location. This narrative review describes the risks of acquiring certain arboviral diseases from human products, mainly solid organs and hematopoietic stem cells, in the French context. The main risks considered in this study are infections by West Nile virus, dengue virus, and tick-borne encephalitis virus. The ancillary risks represented by Usutu virus infection, chikungunya, and Zika are also addressed more briefly. For each disease, the guidelines issued by the French High Council of Public Health, which is responsible for mitigating the risks associated with products of human origin and for supporting public health policy decisions, are briefly outlined. This review highlights the need for a "One Health" approach and to standardize recommendations at the international level in areas with the same viral epidemiology.
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Affiliation(s)
- Bruno Pozzetto
- Haut Conseil de la Santé Publique, Ministère de la Santé et de la Prévention, 75007 Paris, France; (M.D.); (D.L.); (C.C.); (B.H.)
- GIMAP Team, CIRI-Centre International de Recherche en Infectiologie, Université Jean Monnet de Saint-Etienne, Université Claude Bernard Lyon 1, Inserm, U1111, CNRS, 42023 Saint-Etienne, France
- Department of Infectious Agents and Hygiene, University Hospital of Saint-Etienne, 42055 Saint-Etienne, France
| | - Gilda Grard
- National Reference Center for Arboviruses, National Institute of Health and Medical Research (Inserm), 13005 Marseille, France; (G.G.); (G.D.); (X.N.d.L.)
- French Armed Forces Biomedical Research Institute (IRBA), Valérie-André, 91220 Brétigny-sur-Orge, France
| | - Guillaume Durand
- National Reference Center for Arboviruses, National Institute of Health and Medical Research (Inserm), 13005 Marseille, France; (G.G.); (G.D.); (X.N.d.L.)
- French Armed Forces Biomedical Research Institute (IRBA), Valérie-André, 91220 Brétigny-sur-Orge, France
| | - Marie-Claire Paty
- Santé Publique France, The French Public Health Agency, 94410 Saint-Maurice, France;
| | - Pierre Gallian
- Etablissement Français du Sang, 93218 Saint-Denis, France;
- Unité des Virus Émergents (UVE: Aix-Marseille Univ-IRD 190-Inserm 1207), 13385 Marseille, France
| | | | | | - Muriel Fromage
- Agence Nationale de Sécurité du Médicament et des Produits de Santé (ANSM), 93200 Saint-Denis, France;
| | - Marc Durand
- Haut Conseil de la Santé Publique, Ministère de la Santé et de la Prévention, 75007 Paris, France; (M.D.); (D.L.); (C.C.); (B.H.)
| | - Didier Lepelletier
- Haut Conseil de la Santé Publique, Ministère de la Santé et de la Prévention, 75007 Paris, France; (M.D.); (D.L.); (C.C.); (B.H.)
| | - Christian Chidiac
- Haut Conseil de la Santé Publique, Ministère de la Santé et de la Prévention, 75007 Paris, France; (M.D.); (D.L.); (C.C.); (B.H.)
- Department of Infectious and Tropical Diseases, University Hospital of Lyon, 69002 Lyon, France
| | - Bruno Hoen
- Haut Conseil de la Santé Publique, Ministère de la Santé et de la Prévention, 75007 Paris, France; (M.D.); (D.L.); (C.C.); (B.H.)
- Department of Infectious Diseases, University Hospital of Nancy, 54500 Vandoeuvre-lès-Nancy, France
| | - Xavier Nicolas de Lamballerie
- National Reference Center for Arboviruses, National Institute of Health and Medical Research (Inserm), 13005 Marseille, France; (G.G.); (G.D.); (X.N.d.L.)
- French Armed Forces Biomedical Research Institute (IRBA), Valérie-André, 91220 Brétigny-sur-Orge, France
- Unité des Virus Émergents (UVE: Aix-Marseille Univ-IRD 190-Inserm 1207), 13385 Marseille, France
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Lauterio A, De Carlis R, Centonze L, Merli M, Valsecchi M, Monti G, Puoti M, Fumagalli R, De Carlis L. The role of intravenous immunoglobulin in the treatment of community - Acquired West Nile virus encephalitis after liver transplantation. Transpl Infect Dis 2023; 25:e14025. [PMID: 36715644 DOI: 10.1111/tid.14025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 01/09/2023] [Indexed: 01/31/2023]
Affiliation(s)
- Andrea Lauterio
- Department of Transplantation, Division of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Riccardo De Carlis
- Department of Transplantation, Division of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
- Ph.D. Course in Clinical and Experimental Sciences, University of Padua, Padua, Italy
| | - Leonardo Centonze
- Department of Transplantation, Division of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
- Ph.D. Course in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Marco Merli
- Division of Infectious Diseases, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Mila Valsecchi
- Department of Anesthesiology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Gianpaola Monti
- Department of Anesthesiology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Massimo Puoti
- Division of Infectious Diseases, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Roberto Fumagalli
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Department of Anesthesiology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Luciano De Carlis
- Department of Transplantation, Division of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- International Center for Digestive Health, University of Milano-Bicocca, Milan, Italy
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5
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Kumar S, Yadav D, Singh D, Shakya K, Rathi B, Poonam. Recent developments on Junin virus, a causative agent for Argentine haemorrhagic fever. Rev Med Virol 2023; 33:e2419. [PMID: 36635519 DOI: 10.1002/rmv.2419] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 12/21/2022] [Indexed: 01/14/2023]
Abstract
Junin virus consists of ribonucleic acid as the genome and is responsible for a rapidly changing tendency of the virus. The virus is accountable for ailments in the human body and causes Argentine Haemorrhagic Fever (AHF). The infection is may be transmitted through contact between an infected animal/host and a person, and later between person to person. Prevention of outbreaks of AHF in humans can be a tough practice, as their occurrence is infrequent and unpredictable. In this review, recent information from the past 5 years available on the Junin virus including the risk of its emergence, infectious agents, its pathogenesis in humans, available diagnostic and therapeutic approaches, and disease management has been summarised. Altogether, this article would be highly significant in understanding the mechanistic basis behind virus interaction and other processes during the life cycle. Currently, no specific therapeutic options are available to treat the Junin virus infection. The information covered in this review could be important for finding possible treatment options for Junin virus infections.
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Affiliation(s)
- Sumit Kumar
- Department of Chemistry, Miranda House, University of Delhi, Delhi, India
| | - Dharna Yadav
- Department of Chemistry, Miranda House, University of Delhi, Delhi, India
| | - Divya Singh
- Department of Chemistry, Miranda House, University of Delhi, Delhi, India
| | - Kriti Shakya
- Department of Chemistry, Miranda House, University of Delhi, Delhi, India
| | - Brijesh Rathi
- Department of Chemistry, Har Gobind Khorana Centre for Chemical Biology, Hansraj College, University of Delhi, Delhi, India.,Delhi School of Public Health, Institute of Eminence, University of Delhi, Delhi, India
| | - Poonam
- Department of Chemistry, Miranda House, University of Delhi, Delhi, India.,Delhi School of Public Health, Institute of Eminence, University of Delhi, Delhi, India
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6
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Epperson K, Crane C, Ingulli E. Prevention, diagnosis, and management of donor derived infections in pediatric kidney transplant recipients. Front Pediatr 2023; 11:1167069. [PMID: 37152319 PMCID: PMC10162437 DOI: 10.3389/fped.2023.1167069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 03/16/2023] [Indexed: 05/09/2023] Open
Abstract
Donor derived infections (DDIs) in pediatric kidney transplant recipients remain challenging to diagnose and can result in serious morbidity and mortality. This review summarizes the current guidelines and recommendations for prevention, diagnosis, and treatment of unexpected DDIs in pediatric kidney transplant recipients. We provide a contemporary overview of DDI terminology, surveillance, epidemiology, and recommended approaches for assessing these rare events with an emphasis on the pediatric recipient. To address prevention and risk mitigation, important aspects of donor and pediatric candidate evaluations are reviewed, including current Organ Procurement and Transplantation Network (OPTN) and American Society of Transplantation (AST) recommendations. Common unexpected DDI encountered by pediatric transplant teams including multi-drug resistant organisms, tuberculosis, syphilis, West Nile Virus, toxoplasmosis, Chagas disease, strongyloidiasis, candidiasis, histoplasmosis, coccidioidomycosis, and emerging infections such as COVID-19 are discussed in detail. Finally, we consider the general challenges with management of DDIs and share our experience with a novel application of next generation sequencing (NGS) of microbial cell-free DNA that will likely define a future direction in this field.
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Affiliation(s)
- Katrina Epperson
- Department of Pediatrics, Division of Pediatric Nephrology, University of California at San Diego and Rady Children's Hospital, San Diego, CA, United States
| | - Clarkson Crane
- Department of Pediatrics, Division of Pediatric Nephrology, University of California at San Diego and Rady Children's Hospital, San Diego, CA, United States
| | - Elizabeth Ingulli
- Department of Pediatrics, Division of Pediatric Nephrology, University of California at San Diego and Rady Children's Hospital, San Diego, CA, United States
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Abbas A, Qiu F, Sikyta A, Fey PD, Florescu DF. Neuroinvasive West Nile virus infections after solid organ transplantation: Single center experience and systematic review. Transpl Infect Dis 2022; 24:e13929. [PMID: 35980220 PMCID: PMC10078393 DOI: 10.1111/tid.13929] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/11/2022] [Accepted: 07/26/2022] [Indexed: 12/30/2022]
Abstract
West Nile virus (WNv) is a major cause of viral encephalitis in the United States. WNv infection is usually asymptomatic or a limited febrile illness in the immunocompetent hosts, although a small percentage can develop neuroinvasive disease. Neuroinvasive disease due to WNv in solid organ transplant recipients occurs at higher rates than observed in the general population and can have long term neurological sequalae. METHODS We retrospectively reviewed medical records of all solid organ transplant recipients at our institution who tested positive for WNv from 2010 to 2018. Two reviewers performed electronic searches of Medline, Embase, Cochrane Library of literature of WNv infections in SOT. Descriptive statistics were performed on key variables. RESULTS Eight recipients (mean age 54, five males) were diagnosed with neuroinvasive WNv infection at our institution. Distribution of infection was as follows: five kidney transplants, one in each kidney-pancreas, liver, and lung. Diagnoses included meningitis (3), encephalitis (1), meningo-encephalitis (4). Median time from transplant to infection was 49.8 months (2.7-175.4). No infections were considered donor-derived. Five patients received treatment with IVIG. Six patients were alive at median follow-up of 49.5 months (21.7-116.8). We identified 29 studies published from 2002 to 2019. Median time from transplant to infection was 14.2 months, with similar allograft distribution; 53% were donor-derived infections. CONCLUSION WNv infections in solid organ transplant recipients can be a consequence of organ donation or can be acquired via the community. Infections can be more severe in SOT recipients and lead to neuroinvasive disease.
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Affiliation(s)
- Anum Abbas
- Infectious Diseases DivisionUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Fang Qiu
- Department of Biostatistics, College of Public HealthUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Adia Sikyta
- Infectious Diseases DivisionUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Paul D. Fey
- Department of Pathology and MicrobiologyUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Diana F Florescu
- Infectious Diseases DivisionUniversity of Nebraska Medical CenterOmahaNebraskaUSA
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8
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Bacterial and Viral Infection and Sepsis in Kidney Transplanted Patients. Biomedicines 2022; 10:biomedicines10030701. [PMID: 35327510 PMCID: PMC8944970 DOI: 10.3390/biomedicines10030701] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 03/14/2022] [Accepted: 03/15/2022] [Indexed: 02/05/2023] Open
Abstract
Kidney transplanted patients are a unique population with intrinsic susceptibility to viral and bacterial infections, mainly (but not exclusively) due to continuous immunosuppression. In this setting, infectious episodes remain among the most important causes of death, with different risks according to the degree of immunosuppression, time after transplantation, type of infection, and patient conditions. Prevention, early diagnosis, and appropriate therapy are the goals of infective management, taking into account that some specific characteristics of transplanted patients may cause a delay (the absence of fever or inflammatory symptoms, the negativity of serological tests commonly adopted for the general population, or the atypical anatomical presentation depending on the surgical site and graft implantation). This review considers the recent available findings of the most common viral and bacterial infection in kidney transplanted patients and explores risk factors and outcomes in septic evolution.
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Schneider J, Bachmann F, Choi M, Kurvits L, Luisa Schmidt M, Bergfeld L, Meier I, Zuchowski M, Werber D, Hofmann J, Ruprecht K, Eckardt KU, Carleton Jones T, Drosten C, Max Corman V. Autochthonous West Nile virus infection in Germany: Increasing numbers and a rare encephalitis case in a kidney transplant recipient. Transbound Emerg Dis 2022; 69:221-226. [PMID: 34850584 PMCID: PMC8969181 DOI: 10.1111/tbed.14406] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 10/07/2021] [Accepted: 11/17/2021] [Indexed: 12/15/2022]
Abstract
West Nile Virus (WNV) infections are increasingly detected in birds and horses in central Europe, with the first mosquito-borne autochthonous human infection detected in Germany in 2019. Human infections are typically asymptomatic, with occasional severe neurological disease. Because of a low number of cases in central Europe, awareness regarding potential cases is low and WNV diagnostic testing is not routine. We tested cerebrospinal fluid (CSF) samples from unsolved encephalitis and meningitis cases from Berlin from 2019 to 2020, and describe a WNV-encephalitis case in a 33-year-old kidney transplant recipient. The infectious course was resolved by serology, RT-PCR and sequencing of stored samples. Phylogenetic sequence analysis revealed a close relationship of the patient's WNV strain to German sequences from 2019 and 2020. A lack of travel history and patient self-isolation during the SARS-CoV-2 pandemic suggest the infection was acquired in the patient's home or garden. Serological tests of four people sharing the living space were negative. Retrospective RT-PCR and WNV-IgM testing of 671 CSF samples from unsolved encephalitis and meningitis cases from Berlin detected no additional infections. The recent increase of WNV cases illustrates the importance of considering WNV in cases of meningoencephalitis, especially in immunocompromised patients, as described here. Proper education and communication and a revised diagnostic strategy will help to raise awareness and to detect future WNV infections.
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Affiliation(s)
- Julia Schneider
- Institute of Virology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany,German Centre for Infection Research (DZIF), partner site Charité, Berlin, Germany
| | - Friederike Bachmann
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Mira Choi
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Lille Kurvits
- Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Marie Luisa Schmidt
- Institute of Virology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Leon Bergfeld
- Institute of Virology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Iris Meier
- State Office for Health and Social Affairs, Berlin, Germany
| | | | - Dirk Werber
- State Office for Health and Social Affairs, Berlin, Germany
| | - Jörg Hofmann
- Labor Berlin-Charité Vivantes GmbH, Berlin, Germany
| | - Klemens Ruprecht
- Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Terry Carleton Jones
- Institute of Virology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany,German Centre for Infection Research (DZIF), partner site Charité, Berlin, Germany,Centre for Pathogen Evolution, Department of Zoology, University of Cambridge, Cambridge, U.K
| | - Christian Drosten
- Institute of Virology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany,German Centre for Infection Research (DZIF), partner site Charité, Berlin, Germany
| | - Victor Max Corman
- Institute of Virology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany,German Centre for Infection Research (DZIF), partner site Charité, Berlin, Germany
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10
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Collins-Sawaragi YC, Koletsi P, Donlevy EE, Drysdale SB. Initial Seronegative West Nile Virus Encephalitis in an Immunocompromised Child. Pediatr Infect Dis J 2022; 41:60-61. [PMID: 34591804 DOI: 10.1097/inf.0000000000003312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We present a case of initial seronegative West Nile virus encephalitis in an immunocompromised child due to B-cell acute lymphoblastic leukemia. Although diagnostic guidelines for West Nile virus infection exist, we highlight that these may not be met in immunocompromised patients who may have a delayed immune response.
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Affiliation(s)
- Yoshua Colyn Collins-Sawaragi
- From the Department of Paediatric Infectious Diseases, St George's University Hospitals NHS Foundation Trust, London, United Kingdom
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11
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Central nervous system infections after solid organ transplantation. Curr Opin Infect Dis 2021; 34:207-216. [PMID: 33741794 DOI: 10.1097/qco.0000000000000722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW Significant advances to our understanding of several neuroinfectious complications after a solid organ transplant (SOT) have occurred in the last few years. Here, we review the central nervous system (CNS) infections that are relevant to SOT via a syndromic approach with a particular emphasis on recent updates in the field. RECENT FINDINGS A few key studies have advanced our understanding of the epidemiology and clinical characteristics of several CNS infections in SOT recipients. Risk factors for poor prognosis and protective effects of standard posttransplant prophylactic strategies have been better elucidated. Newer diagnostic modalities which have broad clinical applications like metagenomic next-generation sequencing, as well as those that help us better understand esoteric concepts of disease pathogenesis have been studied. Finally, several studies have provided newer insights into the treatment of these diseases. SUMMARY Recent findings reflect the steady progress in our understanding of CNS infections post SOT. They provide several avenues for improvement in the prevention, early recognition, and therapeutic outcomes of these diseases.
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12
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Vilibic-Cavlek T, Savic V, Ferenc T, Mrzljak A, Barbic L, Bogdanic M, Stevanovic V, Tabain I, Ferencak I, Zidovec-Lepej S. Lymphocytic Choriomeningitis-Emerging Trends of a Neglected Virus: A Narrative Review. Trop Med Infect Dis 2021; 6:88. [PMID: 34070581 PMCID: PMC8163193 DOI: 10.3390/tropicalmed6020088] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/18/2021] [Accepted: 05/24/2021] [Indexed: 02/07/2023] Open
Abstract
Lymphocytic choriomeningitis virus (LCMV) is a neglected rodent-borne zoonotic virus distributed worldwide. Since serologic assays are limited to several laboratories, the disease has been underreported, often making it difficult to determine incidence and seroprevalence rates. Although human clinical cases are rarely recorded, LCMV remains an important cause of meningitis in humans. In addition, a fatal donor-derived LCMV infection in several clusters of solid organ transplant recipients further highlighted a pathogenic potential and clinical significance of this virus. In the transplant populations, abnormalities of the central nervous system were also found, but were overshadowed by the systemic illness resembling the Lassa hemorrhagic fever. LCMV is also an emerging fetal teratogen. Hydrocephalus, periventricular calcifications and chorioretinitis are the predominant characteristics of congenital LCMV infection, occurring in 87.5% of cases. Mortality in congenitally infected children is about 35%, while 70% of them show long-term neurologic sequelae. Clinicians should be aware of the risks posed by LCMV and should consider the virus in the differential diagnosis of aseptic meningitis, especially in patients who reported contact with rodents. Furthermore, LCMV should be considered in infants and children with unexplained hydrocephalus, intracerebral calcifications and chorioretinitis. Despite intensive interdisciplinary research efforts, efficient antiviral therapy for LCMV infection is still not available.
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Affiliation(s)
- Tatjana Vilibic-Cavlek
- Department of Virology, Croatian Institute of Public Health, 10000 Zagreb, Croatia; (M.B.); (I.T.); (I.F.)
- School of Medicine, University of Zagreb, 10000 Zagreb, Croatia;
| | - Vladimir Savic
- Laboratory for Virology and Serology, Poultry Center, Croatian Veterinary Institute, 10000 Zagreb, Croatia;
| | - Thomas Ferenc
- Clinical Department of Diagnostic and Interventional Radiology, Merkur University Hospital, 10000 Zagreb, Croatia;
| | - Anna Mrzljak
- School of Medicine, University of Zagreb, 10000 Zagreb, Croatia;
- Department of Gastroenterology and Hepatology, Clinical Hospital Center Zagreb, 10000 Zagreb, Croatia
| | - Ljubo Barbic
- Department of Microbiology and Infectious Diseases with Clinic, Faculty of Veterinary Medicine, University of Zagreb, 10000 Zagreb, Croatia; (L.B.); (V.S.)
| | - Maja Bogdanic
- Department of Virology, Croatian Institute of Public Health, 10000 Zagreb, Croatia; (M.B.); (I.T.); (I.F.)
| | - Vladimir Stevanovic
- Department of Microbiology and Infectious Diseases with Clinic, Faculty of Veterinary Medicine, University of Zagreb, 10000 Zagreb, Croatia; (L.B.); (V.S.)
| | - Irena Tabain
- Department of Virology, Croatian Institute of Public Health, 10000 Zagreb, Croatia; (M.B.); (I.T.); (I.F.)
| | - Ivana Ferencak
- Department of Virology, Croatian Institute of Public Health, 10000 Zagreb, Croatia; (M.B.); (I.T.); (I.F.)
| | - Snjezana Zidovec-Lepej
- Department of Immunological and Molecular Diagnostics, University Hospital for Infectious Diseases “Dr Fran Mihaljevic”, 10000 Zagreb, Croatia;
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13
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Theodoropoulos NM, Greenwald MA, Chin-Hong P, Ison MG. Testing deceased organ donors for infections: An organ procurement organization survey. Am J Transplant 2021; 21:1924-1930. [PMID: 33621430 DOI: 10.1111/ajt.16552] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 01/18/2021] [Accepted: 02/15/2021] [Indexed: 01/25/2023]
Abstract
Organ procurement organizations (OPO) test potential deceased organ donors for infectious diseases required by policy, but many also perform testing for additional infections. The current state of donor testing in the United States is unknown. We sent an IRB approved survey to all 57 U.S. OPOs using REDCap. Descriptive statistics were performed. From the 57 OPOs, we received 46 (80.7%) unique responses with all 11 United Network of Organ Sharing regions represented. Forty of 46 (87%) OPO respondents consulted an Infectious Diseases physician when needed. Eighteen of 46 (39%) tested for West Nile virus (WNV) and 17 of 18 (94%) tested year-round. Eleven of 46 (23.9%) tested for Strongyloides infection while 17 of 46 (37%) tested for Chagas disease. All OPOs performed prospective nucleic acid testing (NAT) for HIV, hepatitis B and hepatitis C on all donors. OPO testing of additional infections has increased since prior surveys but remains variable. Standardization of organ donor infectious diseases evaluation should be considered.
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Affiliation(s)
- Nicole M Theodoropoulos
- Division of Infectious Diseases & Immunology, Department of Medicine, University of Massachusetts, Worcester, Massachusetts, USA
| | | | - Peter Chin-Hong
- Division of Infectious Diseases, University of California San Francisco, San Francisco, California, USA
| | - Michael G Ison
- Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Division of Organ Transplantation, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Division of Infectious Diseases, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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14
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Albert J, Hanisch B, Sgambat K. Approaches to safe living and diet after solid organ transplantation. Pediatr Transplant 2021; 25:e13783. [PMID: 32721079 DOI: 10.1111/petr.13783] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 05/29/2020] [Indexed: 12/24/2022]
Abstract
SOT recipients are at high risk for developing severe infectious complications following discharge from the hospital. Comprehensive anticipatory guidance surrounding everyday lifestyle choices can potentially prevent exposure to infectious agents from the environment. This paper reviews the risks that pediatric and adolescent SOT recipients encounter through exposures such as household contacts, outdoor activities, travel, animal exposures, and dietary choices. Although strong evidence is lacking, this paper makes recommendations aimed at minimizing the risk of infectious complications and hospitalization in pediatric SOT recipients.
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Affiliation(s)
- Jonathan Albert
- Pediatric Infectious Diseases, Children's National Hospital, Washington, District of Columbia, USA
| | - Benjamin Hanisch
- Pediatric Infectious Diseases, Children's National Hospital, Washington, District of Columbia, USA
| | - Kristen Sgambat
- Pediatric Nephrology, Children's National Hospital, Washington, District of Columbia, USA
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15
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Pimenta ES, Cavalcanti MG, Cabral-Castro MJ, Lima MA, Peralta JM, Santoro-Lopes G. Neuroinvasive chikungunya in a liver transplant recipient. Transpl Infect Dis 2021; 23:e13554. [PMID: 33369823 DOI: 10.1111/tid.13554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 11/27/2020] [Accepted: 12/13/2020] [Indexed: 11/28/2022]
Abstract
The influence of chronic immunosuppression on the course of chikungunya virus (CHIKV) infection in recipients of solid organ transplantation (SOT) is still unsettled. Scarce data suggest that the course of CHIKV infection is generally benign in this population. In addition, the occurrence of severe atypical manifestations associated with CHIKV has not been well documented among SOT recipients. In this report, we describe a 64-year-old male liver transplant recipient who was admitted with fever, headache, arthralgia, left palpebral ptosis, mydriasis, and right hemiparesis. Cranial magnetic resonance imaging did not reveal any alteration suggestive of acute infection. Nevertheless, CHIKV was detected in the cerebrospinal fluid (CSF) with a real-time reverse transcriptase assay. Other PCR assays carried out in CSF were negative for HSV-1 and 2, cytomegalovirus, dengue virus (DENV), and Zika virus (ZIKV). CHIKV viremia was also detected while PCR assays for ZIKV and DENV in the blood were negative. ZIKV viruria was simultaneously present in this case. All neurologic manifestations waned within 2 weeks after the onset. This report shows that chikungunya must be considered in the differential diagnosis of acute neurologic disease in SOT recipients who live in or have recently traveled to endemic areas.
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Affiliation(s)
- Eduardo Scarlatelli Pimenta
- Departamento de Doenças Infecciosas e Parasitárias, Faculdade de Medicina, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.,Serviço de Doenças Infecciosas e Parasitárias, Hospital Universitário Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marta Guimarães Cavalcanti
- Serviço de Doenças Infecciosas e Parasitárias, Hospital Universitário Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.,Instituto de Microbiologia Paulo de Góes, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Mauro Jorge Cabral-Castro
- Serviço de Patologia Clínica, Hospital Universitário Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.,Instituto de Microbiologia Paulo de Góes, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marco Antonio Lima
- Departamento de Clinica Médica, Faculdade de Medicina, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.,Laboratório de Pesquisa Clínica em Neuroinfecções, Instituto Nacional de Infectologia, Oswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro, Brazil
| | - José Mauro Peralta
- Instituto de Microbiologia Paulo de Góes, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Guilherme Santoro-Lopes
- Departamento de Doenças Infecciosas e Parasitárias, Faculdade de Medicina, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.,Serviço de Doenças Infecciosas e Parasitárias, Hospital Universitário Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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16
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Mrzljak A, Dinjar-Kujundzic P, Santini M, Barbic L, Kosuta I, Savic V, Tabain I, Vilibic-Cavlek T. West Nile Virus: An Emerging Threat in Transplant Population. Vector Borne Zoonotic Dis 2020; 20:613-618. [PMID: 32228360 DOI: 10.1089/vbz.2019.2608] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
West Nile virus (WNV) has become one of the new challenges for transplant programs. In addition to transmission by mosquito bite, interhuman transmission is possible through blood products or organ transplantation. Majority of WNV infections present as asymptomatic or mild febrile illness, with less than 1% of infected developing neuroinvasive disease. Many studies report naturally acquired or donor-derived WNV infections in solid-organ transplant recipients, mainly kidney, but also liver, heart, lungs and pancreas. Given the much higher risk of neuroinvasive disease (40% and even higher) based on serologic and clinical studies and increased mortality in transplant population, WNV infection should be considered in all patients presented with fever and neurological symptoms after transplantation, especially during the arbovirus transmission season.
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Affiliation(s)
- Anna Mrzljak
- Department of Medicine, Merkur University Hospital, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | | | - Marija Santini
- School of Medicine, University of Zagreb, Zagreb, Croatia
- Department of Neuroinfections and Intensive Care Medicine, University Hospital for Infectious Diseases "Dr Fran Mihaljevic", Zagreb, Croatia
| | - Ljubo Barbic
- Department of Microbiology and Infectious Diseases with Clinic, Faculty of Veterinary Medicine, University of Zagreb, Zagreb, Croatia
| | - Iva Kosuta
- Department of Medicine, Merkur University Hospital, Zagreb, Croatia
| | - Vladimir Savic
- Poultry Center, Croatian Veterinary Institute, Zagreb, Croatia
| | - Irena Tabain
- Department of Virology, Croatian Institute of Public Health, Zagreb, Croatia
| | - Tatjana Vilibic-Cavlek
- School of Medicine, University of Zagreb, Zagreb, Croatia
- Department of Virology, Croatian Institute of Public Health, Zagreb, Croatia
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17
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Michaels MG, La Hoz RM, Danziger-Isakov L, Blumberg EA, Kumar D, Green M, Pruett TL, Wolfe CR. Coronavirus disease 2019: Implications of emerging infections for transplantation. Am J Transplant 2020; 20:1768-1772. [PMID: 32090448 PMCID: PMC9800450 DOI: 10.1111/ajt.15832] [Citation(s) in RCA: 127] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 02/18/2020] [Accepted: 02/20/2020] [Indexed: 01/25/2023]
Abstract
The recent identification of an outbreak of 2019- novel Coronavirus is currently evolving, and the impact on transplantation is unknown. However, it is imperative that we anticipate the potential impact on the transplant community in order to avert severe consequences of this infection on both the transplant community and contacts of transplant patients.
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Affiliation(s)
- Marian G. Michaels
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA,Correspondence Marian G. Michaels
| | - Ricardo M. La Hoz
- Division of Infectious Disease and Geographic Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Lara Danziger-Isakov
- Department of Pediatrics, Division of Infectious Diseases, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Emily A. Blumberg
- Department of Internal Medicine, Division of Infectious Disease, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Deepali Kumar
- Infectious Diseases and Multi-Organ Transplant, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Michael Green
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Timothy L. Pruett
- Department of Surgery, Division of Transplantation, University of Minnesota, Minneapolis, Minnesota, USA
| | - Cameron R. Wolfe
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
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18
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Mrzljak A, Novak R, Pandak N, Tabain I, Franusic L, Barbic L, Bogdanic M, Savic V, Mikulic D, Pavicic-Saric J, Stevanovic V, Vilibic-Cavlek T. Emerging and neglected zoonoses in transplant population. World J Transplant 2020; 10:47-63. [PMID: 32257849 PMCID: PMC7109593 DOI: 10.5500/wjt.v10.i3.47] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 03/15/2020] [Accepted: 03/22/2020] [Indexed: 02/06/2023] Open
Abstract
Zoonoses represent a problem of rising importance in the transplant population. A close relationship and changes between human, animal and environmental health (“One Health” concept) significantly influence the transmission and distribution of zoonotic diseases. The aim of this manuscript is to perform a narrative review of the published literature on emerging and neglected zoonoses in the transplant population. Many reports on donor-derived or naturally acquired (re-)emerging arboviral infections such as dengue, chikungunya, West Nile, tick-borne encephalitis and Zika virus infection have demonstrated atypical or more complicated clinical course in immunocompromised hosts. Hepatitis E virus has emerged as a serious problem after solid organ transplantation (SOT), leading to diverse extrahepatic manifestations and chronic hepatitis with unfavorable outcomes. Some neglected pathogens such as lymphocytic choriomeningitis virus can cause severe infection with multi-organ failure and high mortality. In addition, ehrlichiosis may be more severe with higher case-fatality rates in SOT recipients. Some unusual or severe presentations of borreliosis, anaplasmosis and rickettsioses were also reported among transplant patients. Moreover, toxoplasmosis as infectious complication is a well-recognized zoonosis in this population. Although rabies transmission through SOT transplantation has rarely been reported, it has become a notable problem in some countries. Since the spreading trends of zoonoses are likely to continue, the awareness, recognition and treatment of zoonotic infections among transplant professionals should be imperative.
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Affiliation(s)
- Anna Mrzljak
- Department of Medicine, Merkur University Hospital, Zagreb 10000, Croatia
- School of Medicine, University of Zagreb, Zagreb 10000, Croatia
| | - Rafaela Novak
- School of Medicine, University of Zagreb, Zagreb 10000, Croatia
| | - Nenad Pandak
- Depatment of Medicine, The Royal Hospital Muscat, Muscat 111, Oman
| | - Irena Tabain
- Department of Virology, Croatian Institute of Public Health, Zagreb 10000, Croatia
| | | | - Ljubo Barbic
- Department of Microbiology and Infectious Diseases with Clinic, Faculty of Veterinary Medicine, University of Zagreb, Zagreb 10000, Croatia
| | - Maja Bogdanic
- Department of Virology, Croatian Institute of Public Health, Zagreb 10000, Croatia
| | - Vladimir Savic
- Poultry Center, Croatian Veterinary Institute, Zagreb 10000, Croatia
| | - Danko Mikulic
- Department of Abdominal and Transplant Surgery, Merkur University Hospital, Zagreb 10000, Croatia
| | - Jadranka Pavicic-Saric
- Department of Anesthesiology and Intensive Medicine, Merkur University Hospital, School of Medicine, University of Zagreb, Zagreb 10000, Croatia
| | - Vladimir Stevanovic
- Department of Microbiology and Infectious Diseases with Clinic, Faculty of Veterinary Medicine, University of Zagreb, Zagreb 10000, Croatia
| | - Tatjana Vilibic-Cavlek
- Department of Virology, Croatian Institute of Public Health; School of Medicine, University of Zagreb, Zagreb 10000, Croatia
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19
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Donor-Derived Disease Transmission in Lung Transplantation. CURRENT PULMONOLOGY REPORTS 2020. [DOI: 10.1007/s13665-020-00245-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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20
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Comparative Pathology of West Nile Virus in Humans and Non-Human Animals. Pathogens 2020; 9:pathogens9010048. [PMID: 31935992 PMCID: PMC7168622 DOI: 10.3390/pathogens9010048] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 01/03/2020] [Accepted: 01/03/2020] [Indexed: 12/11/2022] Open
Abstract
West Nile virus (WNV) continues to be a major cause of human arboviral neuroinvasive disease. Susceptible non-human vertebrates are particularly diverse, ranging from commonly affected birds and horses to less commonly affected species such as alligators. This review summarizes the pathology caused by West Nile virus during natural infections of humans and non-human animals. While the most well-known findings in human infection involve the central nervous system, WNV can also cause significant lesions in the heart, kidneys and eyes. Time has also revealed chronic neurologic sequelae related to prior human WNV infection. Similarly, neurologic disease is a prominent manifestation of WNV infection in most non-human non-host animals. However, in some avian species, which serve as the vertebrate host for WNV maintenance in nature, severe systemic disease can occur, with neurologic, cardiac, intestinal and renal injury leading to death. The pathology seen in experimental animal models of West Nile virus infection and knowledge gains on viral pathogenesis derived from these animal models are also briefly discussed. A gap in the current literature exists regarding the relationship between the neurotropic nature of WNV in vertebrates, virus propagation and transmission in nature. This and other knowledge gaps, and future directions for research into WNV pathology, are addressed.
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