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Scherger SJ, Molina KC, Palestine AG, Pecen PE, Bajrovic V. Cytomegalovirus Retinitis in the Modern Era of Solid Organ Transplantation. Transplant Proc 2024; 56:1696-1701. [PMID: 39147617 PMCID: PMC11401753 DOI: 10.1016/j.transproceed.2024.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 07/25/2024] [Accepted: 08/06/2024] [Indexed: 08/17/2024]
Abstract
BACKGROUND Cytomegalovirus retinitis (CMVR) is a well-described complication of CMV disease in immunocompromised hosts. While robust data exists for CMVR in patients with acquired immunodeficiency syndrome (AIDS), the incidence and risk factors for CMVR in solid organ transplant recipients (SOTR) with CMV viremia are less defined. METHODS We performed a retrospective cohort study of SOTR who had CMV viremia and underwent routine ophthalmologic examination between 1/1/2018 and 3/16/2022. Univariate statistics were performed to evaluate risk factors for development of CMVR. RESULTS Overall, 38 patients were included, primarily kidney (78.9%), heart (7.9%), and liver (7.9%) transplant recipients. Five patients (13.2%) developed CMVR during the study period. CMVR was diagnosed an average 281 days after index transplantation, 84 days from the most recent rejection episode, and 69 days from onset of viremia. Only 1 patient (20%) had symptoms at the time of CMVR diagnosis. CMVR was associated with preceding allograft rejection as well as transplanted organ type. CONCLUSION While CMV tissue disease more commonly manifests in other organs, CMVR occurred relatively frequently in this group of high-risk SOTR with CMV viremia. As most of the patients in our study did not have ocular symptoms at the time of diagnosis, routine ophthalmologic screening should be considered in SOTR with CMV viremia.
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Affiliation(s)
- Sias J Scherger
- Department of Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA; Department of Medicine, Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Kyle C Molina
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA; Department of Pharmacy, Scripps Health, La Jolla, CA, USA
| | - Alan G Palestine
- Department of Ophthalmology, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, CO, USA
| | - Paula E Pecen
- Department of Ophthalmology, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, CO, USA
| | - Valida Bajrovic
- Department of Medicine, Icahn School of Medicine at Mt. Sinai, Division of Infectious Diseases, New York, NY, USA
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Razonable RR. Pathogen-specific cell-mediated immunity to guide the management of cytomegalovirus in solid organ transplantation: state of the art clinical review. Expert Rev Clin Immunol 2024:1-14. [PMID: 39039915 DOI: 10.1080/1744666x.2024.2384060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 07/21/2024] [Indexed: 07/24/2024]
Abstract
INTRODUCTION Cytomegalovirus (CMV) is a common opportunistic infection after solid organ transplantation, with significant impact on morbidity and long-term survival. Despite advances in diagnostics and therapeutics, the management of CMV remains very challenging. AREAS COVERED This article reviews emerging data on the clinical utility of laboratory assays that quantify cell-mediated immune responses to CMV. Observational studies have consistently demonstrated that a deficiency in pathogen-specific cell-mediated immunity is correlated with a heightened risk of primary, reactivation or recurrent CMV after transplantation. A limited number of interventional studies have recently investigated cell-mediated immune assays in guiding the prevention and treatment of CMV infection after solid organ transplantation. EXPERT OPINION The pathogenesis and outcome of CMV after solid organ transplantion reflect the interplay between viral replication and CMV-specific immune reconstitution. Research in CMV-specific cell-mediated immunity paved way for the development of several laboratory assays that may assist clinicians in predicting the risk of CMV after transplantation, individualize the approach to CMV disease prevention, guide the need and duration of treatment of CMV infection, and predict the risk of relapse after treatment. More interventional studies are needed to further solidify the role of cell-mediated immune assays in various clinical situations after transplantation.
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Affiliation(s)
- Raymund R Razonable
- Division of Public Health, Infectious Diseases and Occupational Medicine, and the William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA
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Puri P, Kumar V. Proliferative Retinopathy in Non-human Immunodeficiency Virus CMV Retinitis. Ocul Immunol Inflamm 2024; 32:501-504. [PMID: 37290062 DOI: 10.1080/09273948.2023.2219311] [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: 12/12/2022] [Revised: 03/27/2023] [Accepted: 05/24/2023] [Indexed: 06/10/2023]
Abstract
PURPOSE To report a case series of human immunodeficiency virus (HIV)-negative patients with healed cytomegalovirus retinitis presenting with proliferative retinopathy (in the form of neovascularisation elsewhere). METHODS Retrospective case series. Multimodal imaging was performed at each follow-up visit. RESULTS Three patients with non-HIV immune dysfunction were followed up after healing of CMV retinitis. All three developed neovascularisation. Patient 1 after 4 months presented with vitreous haemorrhage for which pars plana vitrectomy was performed. Patient 2 developed neovascularization at disc and neovascularisation elsewhere 4 months after resolution, and patient 3 despite being affected by bilateral CMV retinitis, presented with unilateral neovascularization at 14 month after resolution of retinitis. CONCLUSION Increased incidence of this rare entity could be attributed to partial immune dysfunction in non-HIV patients, limited area of retinitis with a more aggressive occlusive vasculitis. Extensive occlusion with more area of viable retina for angiogenic factor production explains this phenomena. It emphasizes the need for continued follow-up even after healing and to differentiate it from reactivation of retinitis and immune recovery uveitis.Abbreviation: CMV: cytomegalovirus; HIV: human immunodeficiency virus; BCVA: best corrected visual acuity.
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Affiliation(s)
- Prabhav Puri
- Dr. R. P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Delhi, India
| | - Vinod Kumar
- Dr. R. P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Delhi, India
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von Hofsten J, Zetterberg M. Risk Factors for Cytomegalovirus Retinitis in a National Survey in Sweden. Ocul Immunol Inflamm 2024; 32:485-492. [PMID: 36625562 DOI: 10.1080/09273948.2022.2154679] [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: 07/12/2022] [Revised: 10/23/2022] [Accepted: 11/28/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE To investigate predisposing immunosuppressive conditions causing cytomegalovirus retinitis (CMVr) and risk factors for delayed diagnosis in patients diagnosed between 2008 and 2018 in the Swedish population of 10 million. RESULTS Sixty-three consecutive patients (100 eyes) were diagnosed with CMVr. The most common immunosuppressive state predisposing for CMVr was hematopoietic stem cell transplant recipients (27%) and hematological malignancy (24%). Two patients (3.2%) had no other predisposing factor than diabetes mellitus (DM). Patients with delayed diagnosis (≤30 days) were older than those with earlier diagnosis, mean age 68.7 (±9.8) and 48.8 (±17.6), respectively, p = .001. Signs of intraocular inflammation (IOI) were seen in 42 (70%) of cases and more common in delayed than early diagnosis, 16 (89%) and 21 (60%) respectively (p = .03). CONCLUSION Delayed diagnosis was more common in older individuals with signs of IOI. DM may be a risk factor for CMVr, and clinical signs can be mistaken for diabetic retinopathy.
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Affiliation(s)
- Joanna von Hofsten
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Ophthalmology, Halland Hospital Halmstad, Halmstad, Sweden
| | - Madeleine Zetterberg
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Ophthalmology, Sahlgrenska University Hospital, Mölndal, Sweden
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Liang X, An H, He H, Shen B, Ou Z, Li L. Comparison of two different intravitreal treatment regimens combined with systemic antiviral therapy for cytomegalovirus retinitis in patients with AIDS. AIDS Res Ther 2023; 20:46. [PMID: 37452370 PMCID: PMC10347846 DOI: 10.1186/s12981-023-00543-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 07/05/2023] [Indexed: 07/18/2023] Open
Abstract
PURPOSE To compare the efficacy and injection frequency of intravitreal low-dose vs. intermediate-dose ganciclovir therapy in acquired immune deficiency syndrome (AIDS) patients exhibiting cytomegalovirus retinitis (CMVR). METHODS A prospective, single-centre, double-blinded, randomized controlled interventional study was conducted. Fifty patients with a total of 67 included eyes were randomly divided into low-dose (0.4 mg ganciclovir per week) and intermediate-dose (1.0 mg ganciclovir per week) groups. The primary clinical outcomes were the changes in best corrected visual acuity (BCVA) from baseline to the end of treatment and the 12-month follow-up visit as well as the number of intravitreal injections. RESULTS In both groups, the median BCVA, expressed as the logarithm of the minimum angle of resolution (logMAR), improved significantly from baseline to the end of treatment (both p < 0.001), while vision loss from CMVR continued to occur at the 12-month visit. The mean number of injections was 5.8 in the low-dose group and 5.4 in the intermediate-dose group. No significant differences were detected between the two groups (p > 0.05). Regarding the location of CMVR, we found that Zone I lesions led to a worse visual outcome, more injections and a higher occurrence rate of complications than lesions in other zones (p < 0.05). CONCLUSIONS The efficacy and frequency of injections to treat CMVR in AIDS patients were not significantly different between low and intermediate doses. Zone I lesions were associated with a worse visual outcome, more injections and a higher occurrence rate of CMVR-related complications than lesions in other zones.
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Affiliation(s)
- Xuemei Liang
- Department of Fundus Disease, Nanning Aier Eye Hospital, Nanning City, China
| | - Hongmei An
- Department of Fundus Disease, Nanning Aier Eye Hospital, Nanning City, China
| | - Huawei He
- Department of Infectious Diseases, The Fourth Hospital of Nanning, Nanning City, China
| | - Baiyun Shen
- Department of Fundus Disease, Nanning Aier Eye Hospital, Nanning City, China
| | - Zuguo Ou
- Department of Fundus Disease, Nanning Aier Eye Hospital, Nanning City, China
| | - Li Li
- Department of Fundus Disease, Nanning Aier Eye Hospital, Nanning City, China.
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Luo J, Peng J, Zhao PQ, Fei P. CMV Retinitis in Wiskott Aldrich Syndrome. Ocul Immunol Inflamm 2023; 31:134-141. [PMID: 34878956 DOI: 10.1080/09273948.2021.1995762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE Wiskott-Aldrich syndrome (WAS) is an X-linked recessive disease whose optimal curative treatment is hematopoietic stem cell transplantation (HSCT). Patients with WAS may suffer from cytomegalovirus retinitis (CMVR) which can cause vision loss. This study is to report the progression and prognosis of patients with WAS and CMVR. METHODS A retrospective case series of ten patients with WAS and CMVR before and after HSCT who were referred to the Ophthalmology Department of Xinhua Hospital from June 2018 to February 2021. Progression and prognosis were recorded. RESULTS Five patients were diagnosed with CMVR before receiving HSCT at a median age of 10.5 months (range: 4-23 months). Eight patients developed CMVR post-transplantation with a median interval from HSCT of 3.5 months (range: 1-9 months). CONCLUSION Regular fundus examinations and prompt treatments in patients with WAS are therefore crucial before they receiving HSCT or approximately 3.5 months after HSCT until complete reconstitution of immune function.
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Affiliation(s)
- Jia Luo
- Xinhua Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jie Peng
- Xinhua Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Pei-Quan Zhao
- Xinhua Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ping Fei
- Xinhua Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Xu C, Prager AJ, Alonso CD, Pawar AS. Insights From the Eye for Patients With Kidney Transplant. Transplant Proc 2022; 54:2182-2191. [PMID: 36096946 DOI: 10.1016/j.transproceed.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 07/12/2022] [Indexed: 11/29/2022]
Abstract
The eye and the kidney share structural and developmental similarities on a cellular and clinical level, and they are often affected by the same disease processes. Performing an eye exam to look for signs of conditions such as hypertension and diabetes can provide a helpful window into the health of the kidney. Patients with kidney transplants (KT) are a unique population that require close monitoring. These patients are maintained on a number of immunosuppressive medications and may face complications such as medication side effects, infections, and graft rejection. Patients with KT are at higher risk of both infectious and noninfectious eye conditions related to underlying systemic disease or use of immunosuppressive medications. Screening for eye conditions is important because preserving visual function is integral to quality of life, and also because the eye exam can help with early detection and treatment of systemic conditions. Here we describe some of the common eye findings and conditions in patients with KT. We recommend that patients with KT receive annual eye exams, and we hope that the information provided here can help nephrologists become more familiar with eye findings and identify situations where a referral to ophthalmology is warranted.
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Affiliation(s)
| | - Alisa J Prager
- Harvard Medical School, Boston, Massachusetts; Division of Ophthalmology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Carolyn D Alonso
- Harvard Medical School, Boston, Massachusetts; Division of Infectious Disease, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Aditya S Pawar
- Harvard Medical School, Boston, Massachusetts; Division of Nephrology, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
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Human cytomegalovirus: a survey of end-organ diseases and diagnostic challenges in solid organ transplant recipients. Curr Opin Organ Transplant 2022; 27:243-249. [PMID: 36354249 DOI: 10.1097/mot.0000000000000992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE OF REVIEW Human cytomegalovirus (CMV) infection is one of the most important infectious complications in solid organ transplant (SOT) recipients, leading to significant morbidity and mortality. Therefore, early detection and prompt treatment are imperative to improve transplant outcomes. This article highlights the clinical characteristics of the most common CMV end-organ diseases in SOT recipients and their diagnostic modalities and challenges. RECENT FINDINGS CMV can cause a variety of end-organ diseases in SOT recipients. Although CMV nucleic acid amplification by polymerase chain reaction (PCR) is frequently employed to detect CMV reactivation or infection, its predictive value for various CMV end-organ diseases remains uncertain. Given the limitation of PCR or other noninvasive tests, confirmation of CMV end-organ disease may require tissue biopsy, which may not be feasible or available, or may cause untoward complications. SUMMARY The utility of PCR to diagnose CMV end-organ disease is limited. As CMV can infect any organ system(s), clinicians caring for SOT recipients need to maintain vigilance for any signs and symptoms of end-organ disease to allow early recognition and prompt treatment. Invasive procedures might be needed to confirm the diagnosis and minimize the empirical use of antiviral therapy that may have substantial drug toxicities.
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Janicka-Maszke Z, Konopa J, Ślizień M, Glasner P, Chamienia A, Dębska-Ślizień A, Michalska-Małecka K, Glasner L. Cytomegaloviral Retinitis in a Heart Transplant Patient: Case Report and Review of the Literature. Transplant Proc 2022; 54:1158-1166. [PMID: 35760629 DOI: 10.1016/j.transproceed.2022.02.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 02/18/2022] [Indexed: 11/29/2022]
Abstract
Cytomegalovirus (CMV) poses a significant threat to solid organ transplant recipients (SOTR). The incidence of CMV disease in SOTR varies according to immunosuppressive therapy, antiviral prophylaxis, donor and recipient serologic compatibility, and the transplanted organ: 9% to 23%, 22% to 29% and 8% to 32% after heart, liver and kidney transplant, respectively. CMV retinitis (CMVR) is a rare manifestation of CMV with a high risk of blindness. Infection may vary in severity, from initially clinically silent cases to full-blown advanced changes involving the eye. The most characteristic effects are changes in the retina, which usually begin at the retina's periphery and are asymptomatic, then these changes spread toward the center as the disease progresses and impairs vision. We describe CMV vitritis and retinitis in a 74-year-old patient after heart transplantation conducted in 1992. The first symptom of the disease was low vision in the left eye. Initially no blood viremia was observed; then the CMV viral load in the blood and vitreous body of the right eye was 2454 and 26 million IU/mL.Despite the initiation of treatment (intravitreal and then intravenous ganciclovir), the inflammatory process progressed rapidly and vision in the left eye was lost, although functional visual acuity in the right eye was maintained. Systemic antiviral therapy with intravenous ganciclovir lasted 6 weeks until the eradication of CMV viremia. The patient was on prophylactic therapy with oral valganciclovir for 12 months. A clinically silent course of CMVR delays diagnosis and therapy. Therefore, it is recommended that all SOTR undergo periodic ophthalmologic control to avoid delayed diagnosis.
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Affiliation(s)
- Zofia Janicka-Maszke
- Departments of Ophthalmology, Transplantology, and Internal Diseases, Medical University of Gdansk, Gdansk, Poland.
| | - Joanna Konopa
- Departments of Nephrology, Transplantology, and Internal Diseases, Medical University of Gdansk, Gdansk, Poland
| | - Mateusz Ślizień
- Departments of Ophthalmology, Transplantology, and Internal Diseases, Medical University of Gdansk, Gdansk, Poland
| | - Paulina Glasner
- Departments of Ophthalmology, Transplantology, and Internal Diseases, Medical University of Gdansk, Gdansk, Poland
| | - Andrzej Chamienia
- Departments of Nephrology, Transplantology, and Internal Diseases, Medical University of Gdansk, Gdansk, Poland
| | - Alicja Dębska-Ślizień
- Departments of Nephrology, Transplantology, and Internal Diseases, Medical University of Gdansk, Gdansk, Poland
| | - Katarzyna Michalska-Małecka
- Departments of Ophthalmology, Transplantology, and Internal Diseases, Medical University of Gdansk, Gdansk, Poland
| | - Leopold Glasner
- Departments of Ophthalmology, Transplantology, and Internal Diseases, Medical University of Gdansk, Gdansk, Poland
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Multani EK, Bajwa D, Multani PK, Nobakht E, Raj D, Paul RS, Paul RS. EYE DISEASE IN KIDNEY TRANSPLANTATION: CLINICAL CHALLENGES IN A UNIQUE PATIENT POPULATION. Surv Ophthalmol 2021; 67:1252-1269. [PMID: 34954092 DOI: 10.1016/j.survophthal.2021.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 12/14/2021] [Accepted: 12/20/2021] [Indexed: 11/30/2022]
Abstract
Eye disease is common among kidney transplant recipients and their management is challenging. Chronic kidney disease is associated with ocular complications, both independently and in the context of various systemic disorders. In addition, chronic immunosuppression predisposes kidney transplant recipients to an array of long-term ocular issues. This may be broadly categorized into infections, malignancies, and other immunosuppression-specific side effects. The interdependence of kidney disease, transplant pharmacotherapy and ocular health therefore requires a multispecialty approach. Although the kidney transplant population has grown along with the burden of associated oculopathies, systematic guidelines targeting this patient group are lacking. This evidenced-based narrative review summarizes the pertinent issues that may present in the ophthalmic and optometric clinical settings, with emphasis on collaborative management and directions for future research.
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Affiliation(s)
- Eisha K Multani
- MY EYE DR OPTOMETRISTS LLC, 1330 CONNECTICUT AVE NW, WASHINGTON DC, 20037, UNITED STATES
| | - Dalvir Bajwa
- THE NEWCASTLE UPON TYNE HOSPITALS, NHS FOUNDATION TRUST, ROYAL VICTORIA INFIRMARY, QUEEN VICTORIA ROAD, NEWCASTLE UPON TYNE NE1 4LP, UNITED KINGDOM
| | - Priyanika K Multani
- INLAND VISION CENTER OPTOMETRY, 473 E CARNEGIE DR, SUITE 100, SAN BERNADINO, CA 92408
| | - Ehsan Nobakht
- DIVISION OF KIDNEY DISEASE & HYPERTENSION, GEORGE WASHINGTON UNIVERSITY, 2150 PENNSYVANIA AVENUE, SUITE 3-438, WASHINGTON DC, 20037, UNITED STATES
| | - Dominic Raj
- DIVISION OF KIDNEY DISEASE & HYPERTENSION, GEORGE WASHINGTON UNIVERSITY, 2150 PENNSYVANIA AVENUE, SUITE 3-438, WASHINGTON DC, 20037, UNITED STATES
| | - Rohan S Paul
- DIVISION OF KIDNEY DISEASE & HYPERTENSION, GEORGE WASHINGTON UNIVERSITY, 2150 PENNSYVANIA AVENUE, SUITE 3-438, WASHINGTON DC, 20037, UNITED STATES
| | - Rohan S Paul
- DIVISION OF KIDNEY DISEASE & HYPERTENSION, GEORGE WASHINGTON UNIVERSITY, 2150 PENNSYVANIA AVENUE, SUITE 3-438, WASHINGTON DC, 20037, UNITED STATES.
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Silva F, Ficher KN, Viana L, Coelho I, Rezende JT, Wagner D, Vaz ML, Foresto R, Silva Junior HT, Pestana JM. Presumed cytomegalovirus retinitis late after kidney transplant. ACTA ACUST UNITED AC 2021; 44:457-461. [PMID: 33973995 PMCID: PMC9518618 DOI: 10.1590/2175-8239-jbn-2020-0254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 01/19/2021] [Indexed: 01/09/2023]
Abstract
Cytomegalovirus (CMV) retinitis is a rare manifestation of CMV invasive disease and potentially threatening to vision in immunocompromised individuals. Clinical suspicion is fundamental since it is an unusual entity with a progressive and often asymptomatic installation over a long period. The authors report a 70-year-old man with diabetic nephropathy who underwent a kidney transplant (KT) in August 2014 with good clinical evolution. No previous CMV infection or episodes of acute rejection were reported. Five years after transplant, he was admitted due to a reduced visual acuity of the left eye with seven days of evolution with associated hyperemia, without exudate. The ophthalmologic evaluation was compatible with acute necrosis of the retina and presumed associated with CMV infection. He had a progressive improvement after ganciclovir initiation. CMV retinitis is one of the most serious ocular complications in immune-suppressed individuals and can lead to irreversible blindness, and because of that, early diagnosis and treatment remains crucial in obtaining the best visual prognosis in affected patients. Secondary prophylaxis with ganciclovir is not consensual, neither is the safety of reintroducing the antimetabolite in these cases.
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Affiliation(s)
- Filipa Silva
- Centro Hospitalar do Porto, Departamento de Nefrologia e Transplante Renal, Porto, Portugal
| | - Klaus Nunes Ficher
- Universidade Federal de São Paulo, Hospital do Rim, Departamento de Nefrologia, São Paulo, SP, Brasil
| | - Laila Viana
- Universidade Federal de São Paulo, Hospital do Rim, Departamento de Nefrologia, São Paulo, SP, Brasil
| | - Inês Coelho
- Hospital Amato Lusitano, Departamento de Nefrologia, Castelo Branco, Portugal
| | - Juliana Toniato Rezende
- Universidade Federal de São Paulo, Hospital do Rim, Departamento de Nefrologia, São Paulo, SP, Brasil
| | - Daniel Wagner
- Universidade Federal de São Paulo, Hospital do Rim, Departamento Infeccioso, São Paulo, SP, Brasil
| | - Maria Lúcia Vaz
- Universidade Federal de São Paulo, Hospital do Rim, Departamento de Nefrologia, São Paulo, SP, Brasil
| | - Renato Foresto
- Universidade Federal de São Paulo, Hospital do Rim, Departamento de Nefrologia, São Paulo, SP, Brasil
| | | | - José Medina Pestana
- Universidade Federal de São Paulo, Hospital do Rim, Departamento de Nefrologia, São Paulo, SP, Brasil
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Vassallo F, Nuzzi R, Cattani I, Dellacasa C, Giaccone L, De Rosa FG, Cavallo R, Iovino G, Brunello L, Bruno B, Busca A. CMV retinitis in a stem cell transplant recipient treated with foscarnet intravitreal injection and CMV specific immunoglobulins. Ther Adv Hematol 2020; 11:2040620720975651. [PMID: 33354311 PMCID: PMC7734499 DOI: 10.1177/2040620720975651] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 10/23/2020] [Indexed: 01/03/2023] Open
Abstract
Cytomegalovirus (CMV) retinitis (CMVR) has been reported rarely in patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT). In addition, little is known about strategies for ophthalmic surveillance and adequate antiviral treatment of CMVR. A case of CMVR in an allogeneic HSCT recipient is described, including clinical signs and therapy. An adult patient received HSCT from a matched unrelated donor for treatment of a Burkitt lymphoma. Donor and recipients were both CMV positive. Starting on day +40, the patient presented multiple CMV reactivation, treated with valganciclovir, foscarnet and a combination of both. On day +160, the patient started complaining of conjunctival hyperaemia and a decrease in visual acuity. Fundoscopy revealed retinal lesions consistent with CMVR, although whole blood CMV DNAemia was negative. Aqueous humor biopsy showed the presence of CMV infection (CMV DNA 230400 UI/ml). CMVR was treated with foscarnet (180 mg i.v. and 1.2 mg intravitreal injection) combined with anti CMV immunoglobulin at 0.5 ml/kg every 2 weeks. After 4 weeks of systemic therapy, 20 weekly doses of intravitreal foscarnet and six cycles of immunoglobulins, a significant improvement of visual acuity was observed. The treatment was well tolerated with no side effect. In conclusion, our case suggests that systemic and local antiviral treatment combined with CMV-specific-IVIG, may reduce CMV load in the eye of patients with CMVR, leading to a consistent improvement of visual acuity. Systematic ophthalmologic examination should be recommended in HSCT recipients with multiple CMV reactivations and high peak CMV DNA levels.
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Affiliation(s)
- Francesco Vassallo
- Department of Oncology and Hematology, AOU Citta' della Salute e della Scienza, Turin, Italy
| | - Raffaele Nuzzi
- Eye Clinic Section, Department of Surgical Sciences, University of Turin, Italy
| | - Ilaria Cattani
- Eye Clinic Section, Department of Surgical Sciences, University of Turin, Italy
| | - Chiara Dellacasa
- Stem Cell Transplant Center, AOU Citta' della Salute e della Scienza, Turin, Italy
| | - Luisa Giaccone
- Stem Cell Transplant Center, AOU Citta' della Salute e della Scienza, Turin, Italy
| | | | - Rossana Cavallo
- SC Microbiology and Virology, A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy
| | - Giorgia Iovino
- Department of Oncology and Hematology, AOU Citta' della Salute e della Scienza, Turin, Italy
| | - Lucia Brunello
- Stem Cell Transplant Center, AOU Citta' della Salute e della Scienza, Turin, Italy
| | - Benedetto Bruno
- Stem Cell Transplant Center, AOU Citta' della Salute e della Scienza, Turin, Italy
| | - Alessandro Busca
- Stem Cell Transplant Center, AOU Citta' della Salute e della Scienza, Corso Bramante 88, Turin, 10126, Italy
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Qian Z, Fan H, Chen X, Tao Y. The predictive value of interleukin-8 in the development of cytomegalovirus retinitis in HIV-negative patients. Ophthalmic Res 2020; 65:287-292. [PMID: 33326958 DOI: 10.1159/000513791] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 12/15/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION To evaluate the value of interleukin (IL)-8 in the development and management of cytomegalovirus retinitis (CMVR) in HIV-negative patients. INTRODUCTION To evaluate the value of interleukin (IL)-8 in the development and management of cytomegalovirus retinitis (CMVR) in HIV-negative patients. METHODS A retrospective case series from January 2014 to May 2018 was conducted. Forty patients (40 eyes) received intravitreal injection of ganciclovir (IVG). The aqueous levels of the cytomegalovirus (CMV) DNA and IL-8 in each follow-up visit were tested. The initial and final best corrected visual acuity (BCVA), the course of treatment, the recurrence rate, and the occurrence of complications were recorded and analyzed. RESULTS The aqueous value of IL-8 was significantly correlated with the aqueous level of the CMV DNA during treatment but was not associated with the BCVA or the number of IVG. No recurrence occurred in the condition in which a low aqueous IL-8 level was set as the endpoint of the treatment. CONCLUSION In HIV-negative patients with CMVR, IL-8 was closely associated with CMV DNA concentration in the aqueous humor. The real-time aqueous level of IL-8 could be used as one of the evidences of disease recovery.
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Affiliation(s)
| | - Hua Fan
- Shanghai Aier Eye Hospital, Shanghai, China
| | - Xu Chen
- Shanghai Aier Eye Hospital, Shanghai, China
- Aier School of Ophthalmology, Central South University, Changsha, China
| | - Yong Tao
- Department of Ophthalmology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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14
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Deliège PG, Bastien J, Mokri L, Guyot-Colosio C, Arndt C, Rieu P. Belatacept associated - cytomegalovirus retinitis in a kidney transplant recipient: a case report and review of the literature. BMC Ophthalmol 2020; 20:468. [PMID: 33256663 PMCID: PMC7708192 DOI: 10.1186/s12886-020-01741-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 11/23/2020] [Indexed: 11/17/2022] Open
Abstract
Background To report the first case of belatacept-associated multidrug-resistant Cytomegalovirus retinitis in a kidney transplant recipient. Case presentation A 76-year-old African male renal allograft recipient was admitted for acute visual loss of the right eye. Ophthalmological examination of the right eye showed anterior uveitis and vitritis associated with large paravascular haemorrhages and yellow necrotic borders, involving the posterior pole but not the fovea. Both Cytomegalovirus DNA in plasma and aqueous humor were positive. The patient had had several episodes of Cytomegalovirus reactivation subsequent to the introduction of belatacept. His cytomegalovirus was multi-drug resistant, and was treated with maribarir, intravitreal and systemic injections of foscarnet, and anti-Cytomegalovirus human immunoglobulin. In parallel, belatacept was stopped and switched to tacrolimus. Cytomegalovirus DNA became undetectable and there was partial improvement of visual acuity at the last ophthalmologic examination, 18 months after the initial diagnosis of Cytomegalovirus retinitis. Conclusion Cytomegalovirus retinitis is an uncommon opportunistic infection in kidney transplant recipients. Cytomegalovirus retinitis is a serious infection because of the risk of blindness and the occurrence of associated life-threatening opportunistic infections. In view of the recent literature, kidney transplant recipients treated by belatacept immunosuppression may be at increased risk for Cytomegalovirus disease, notably Cytomegalovirus retinitis. The occurrence of Cytomegalovirus retinitis may help improve the selection of patients converted to belatacept.
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Affiliation(s)
| | - Justine Bastien
- Division of Ophtalmology, University Hospital of Reims, Reims, France
| | - Laetitia Mokri
- Division of Nephrology, University Hospital of Reims, Reims, France
| | | | - Carl Arndt
- Division of Ophtalmology, University Hospital of Reims, Reims, France
| | - Philippe Rieu
- Division of Nephrology, University Hospital of Reims, Reims, France.,Laboratory of Nephrology, UMR CNRS URCA 7369 (Matrice Extracellulaire et Dynamique Cellulaire, MEDyC), Reims, France
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15
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Zhang C, Wang YE, Miao H, Hou J. Efficacy and Safety of Aqueous Interleukin-8-Guided Treatment in Cytomegalovirus Retinitis after Bone Marrow Hematopoietic Stem Cell Transplantation. Ocul Immunol Inflamm 2020; 30:758-765. [PMID: 33064057 DOI: 10.1080/09273948.2020.1823422] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE To explore the optimal treatment for cytomegalovirus retinitis (CMVR) in patients status-post Allogeneic bone marrow hematopoietic stem cell transplantation (Allo-HSCT), based on aqueous humor indicators. METHODS A randomized controlled study with 35 eyes. Eyes were randomized with a 1:1 ratio to standard treatment group (Group 1, with treatment endpoint as aqueous CMV-DNA load<103 copy/ml), and interleukin (IL)-8 group (Group 2, with treatment endpoint as aqueous IL-8 level <30 pg/ml or CMV-DNA load<103 copy/ml) to receive antiviral intravitreal injections. Number of injections, CMVR recurrence rate, complication rate, and vision changes were analyzed and compared. RESULTS The mean number of injections in group 2 was less than in group 1 (6 vs 8 respectively, p<0.05). There were no significant differences in CMVR recurrence, complication and vision recovery rate. CONCLUSION Incorporating aqueous humor IL-8 level into the criteria of CMVR treatment decision can safely and effectively reduce the number of intravitreal injections needed and can be used as important indicators to assess treatment endpoint.
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Affiliation(s)
- Chuan Zhang
- Department of Ophthalmology & Clinical Centre of Optometry, Peking University People's Hospital, Eye Diseases and Optometry Institute, Beijing Key Laboratory of Diagnosis and Therapy of Retinal and Choroidal Diseases, College of Optometry, Peking University Health Science Center, Beijing, China
| | - Ye Elaine Wang
- Harvard Eye Associates, Private Practice, Laguna Hills, CA, USA.,Department of Ophthalmology, Stein Eye Institute, UCLA School of Medicine, Los Angeles, CA, USA
| | - Heng Miao
- Department of Ophthalmology & Clinical Centre of Optometry, Peking University People's Hospital, Eye Diseases and Optometry Institute, Beijing Key Laboratory of Diagnosis and Therapy of Retinal and Choroidal Diseases, College of Optometry, Peking University Health Science Center, Beijing, China
| | - Jing Hou
- Department of Ophthalmology & Clinical Centre of Optometry, Peking University People's Hospital, Eye Diseases and Optometry Institute, Beijing Key Laboratory of Diagnosis and Therapy of Retinal and Choroidal Diseases, College of Optometry, Peking University Health Science Center, Beijing, China
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16
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Prognostic factors of cytomegalovirus retinitis after hematopoietic stem cell transplantation. PLoS One 2020; 15:e0238257. [PMID: 32877457 PMCID: PMC7467317 DOI: 10.1371/journal.pone.0238257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 08/12/2020] [Indexed: 11/19/2022] Open
Abstract
PURPOSE To identify the visual prognostic factors in patients with cytomegalovirus (CMV) retinitis after hematopoietic stem cell transplantation (HSCT). METHODS This retrospective cohort study included 4241 patients who underwent HSCT from April 1, 2010 to March 31, 2019 at Seoul St. Mary's Hospital. Of them, 1063 patients presented CMV viremia, and 67 patients (93 eyes) were diagnosed with CMV retinitis. We enrolled 66 patients (91 eyes). The main outcomes included the initial best-corrected visual acuity (BCVA), BCVA at the diagnosis of retinitis and last visit, involved retinal zone, peak CMV DNA levels in the peripheral blood and aqueous humor, time between HSCT and the diagnosis of retinitis, time between the diagnosis of viremia and retinitis, complications, recurrence, survival, and so on. RESULTS The mean BCVA (logarithm of the minimum angle of resolution) values before HSCT, at the time of retinitis diagnosis, and at the last visit were 0.041 ± 0.076, 0.262 ± 0.529, and 0.309 ± 0.547, respectively. Multiple regression analysis revealed that the involved zone (P = 0.001), time between HSCT and retinitis diagnosis (P = 0.019), and survival status (P = 0.001) were associated with the final visual acuity. CONCLUSIONS The final visual prognosis was worse in patients with greater invasion of the central retinal zone, those with a longer interval between HSCT and the diagnosis of retinitis, and those who died. Prompt diagnosis of CMV retinitis through periodic fundus examinations of patients with CMV viremia can prevent severe vision loss. Once CMV viremia is confirmed, we recommend fundus examinations to be immediately performed and repeated every 2 weeks for at least 2 months, even if the CMV DNA titer in the peripheral blood becomes negative.
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17
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Clinical features of cytomegalovirus retinitis after solid organ transplantation versus hematopoietic stem cell transplantation. Graefes Arch Clin Exp Ophthalmol 2020; 259:585-591. [PMID: 32761472 DOI: 10.1007/s00417-020-04871-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/08/2020] [Accepted: 07/27/2020] [Indexed: 01/07/2023] Open
Abstract
PURPOSE To investigate and compare the clinical features of cytomegalovirus (CMV) retinitis after solid organ transplantation (SOT) and hematopoietic stem cell transplantation (HSCT) and to determine the poor prognostic factors. METHODS Patients consulted to the ophthalmology department for CMV viremia after transplantation between March 2008 and February 2018 and followed for more than 6 months were analyzed. Medical records regarding demographic, serologic, and ocular characteristics were compared between the SOT and HSCT groups. Factors associated with poor visual outcomes were determined with logistic regression. RESULTS CMV retinitis developed in 11.3% of patients with CMV viremia following transplantation. In the SOT group (25 eyes/18 patients) and the HSCT group (33 eyes/21 patients), CMV retinitis occurred at 5.8 months and 3.7 months post-transplantation, respectively. Mortality was significantly higher in the HSCT group (52.4% vs. 5.6%, P < 0.001). During the mean 11.7 months of follow-up, visual acuity tended to be aggravated (P = 0.087) despite antiviral treatment, which was especially notable in the SOT group (P = 0.028). Six eyes (10.3%) underwent vitrectomy due to retinal detachment, most of which (5 eyes) were in the SOT group. Multivariate logistic regression analysis showed that the presence of concurrent CMV disease (OR = 14.11, P = 0.009) and foveal involvement (OR = 114.85, P = 0.001) were poor prognostic factors. CONCLUSION Clinical manifestations of CMV retinitis differed between the HSCT and SOT group. Concurrent CMV diseases and foveal involvement were associated with poor visual outcomes in CMV retinitis following transplantation.
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18
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Yan CH, Wang Y, Mo XD, Sun YQ, Wang FR, Fu HX, Chen Y, Han TT, Kong J, Cheng YF, Zhang XH, Xu LP, Liu KY, Huang XJ. Incidence, risk factors, and outcomes of cytomegalovirus retinitis after haploidentical hematopoietic stem cell transplantation. Bone Marrow Transplant 2020; 55:1147-1160. [PMID: 31992849 DOI: 10.1038/s41409-020-0790-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 12/24/2019] [Accepted: 01/13/2020] [Indexed: 12/15/2022]
Abstract
This study investigated the epidemiological characteristics of cytomegalovirus retinitis (CMVR) after haploidentical hematopoietic stem cell transplantation (HSCT). We studied a cohort of 1466 consecutive patients who had undergone haploidentical HSCT between 2013 and 2017. We documented 34 episodes of CMVR in 31 patients, with a median onset of 167 days after the transplant. The cumulative incidence of CMVR was 2.3% 1 year after the transplant. Multivariate analysis suggested that platelet engraft failure at 100 days, EBV DNAemia, refractory or recurrent CMV DNAemia, and acute graft-versus-host disease were related to the development of CMVR in patients with CMV DNAemia. Patients with ≥3 risk factors (high risk) had a higher 1-year incidence of CMVR than patients with ≤2 risk factors (low risk) (26.2% vs. 0.6%, P < 0.001). In patients with CMVR, visual acuity (VA) improved in 16 episodes, remained stable in 10 episodes, and worsened in 8 episodes. The variable related to the improvement of VA was VA ≥ 0.1 at time of CMVR diagnosis. Our study showed that CMVR was a rare complication after haploidentical HSCT but that the risk was greater in patients with multiple risk factors.
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Affiliation(s)
- Chen-Hua Yan
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Xi Zhimen South Street No. 11, Beijing, 100044, China.,Collaborative Innovation Center of Hematology, Suzhou, China
| | - Yu Wang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Xi Zhimen South Street No. 11, Beijing, 100044, China.,Collaborative Innovation Center of Hematology, Suzhou, China
| | - Xiao-Dong Mo
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Xi Zhimen South Street No. 11, Beijing, 100044, China
| | - Yu-Qian Sun
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Xi Zhimen South Street No. 11, Beijing, 100044, China
| | - Feng-Rong Wang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Xi Zhimen South Street No. 11, Beijing, 100044, China
| | - Hai-Xia Fu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Xi Zhimen South Street No. 11, Beijing, 100044, China
| | - Yao Chen
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Xi Zhimen South Street No. 11, Beijing, 100044, China
| | - Ting-Ting Han
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Xi Zhimen South Street No. 11, Beijing, 100044, China
| | - Jun Kong
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Xi Zhimen South Street No. 11, Beijing, 100044, China
| | - Yi-Fei Cheng
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Xi Zhimen South Street No. 11, Beijing, 100044, China
| | - Xiao-Hui Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Xi Zhimen South Street No. 11, Beijing, 100044, China.,Collaborative Innovation Center of Hematology, Suzhou, China
| | - Lan-Ping Xu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Xi Zhimen South Street No. 11, Beijing, 100044, China
| | - Kai-Yan Liu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Xi Zhimen South Street No. 11, Beijing, 100044, China
| | - Xiao-Jun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Xi Zhimen South Street No. 11, Beijing, 100044, China.
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19
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Qian Z, Chen X, Tao Y, Li W, Gu W. Prognostic Factors of Cytomegalovirus Infection Associated Retinitis in HIV-Negative Patients: A Retrospective Cohort Study. Ocul Immunol Inflamm 2019; 29:154-159. [PMID: 31580185 DOI: 10.1080/09273948.2019.1659978] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Purpose: To summarize the prognostic factors of cytomegalovirus (CMV) retinitis (CMVR) in HIV-negative patients treated with multiple intravitreal injections (IVs) of ganciclovir.Methods: A retrospective cohort study (70 eyes) was conducted. Clinical signs, initial and final best corrected visual acuity (BCVA), initial aqueous load of CMV DNA, course of treatment, and occurrence of complications were recorded and analyzed.Results: A positive correlation was found between the baseline and the final best corrected visual acuity (P < .001) and between the initial aqueous CMV DNA load and the number of IVs (P = .01). A lesion close to the posterior pole (P < .001) and a larger retinal lesion (P = .002) remarkably led to worse visual prognosis.Conclusions: Poor visual prognosis was significantly associated with poor initial visual acuity, proximity of lesion to the posterior pole, and an extensive CMV lesion. The treatment duration was positively correlated with the initial aqueous CMV DNA load.
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Affiliation(s)
- Zhuyun Qian
- Department of Opthalmology, Shanghai Aier Eye Hospital, Shanghai, China
| | - Xu Chen
- Department of Opthalmology, Shanghai Aier Eye Hospital, Shanghai, China.,Aier School of Ophthalmology, Central South University, Changsha, Hunan Province, China
| | - Yong Tao
- Department of Ophthalmology, Beijing Yingzhi Aier Eye Hospital, Beijing, China
| | - Wensheng Li
- Department of Opthalmology, Shanghai Aier Eye Hospital, Shanghai, China.,Aier School of Ophthalmology, Central South University, Changsha, Hunan Province, China
| | - Wei Gu
- Beijing Yingzhi Aier Eye Hospital, Beijing, China
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20
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Infectious uveitis in immunodeficient HIV-negative patients: A retrospective study. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2019; 164:410-416. [PMID: 31435074 DOI: 10.5507/bp.2019.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 07/22/2019] [Indexed: 11/23/2022] Open
Abstract
AIMS Cases of infectious uveitis in immunodeficient patients may present with atypical clinical features because the clinical course of disease is usually affected by the compromised immune system. Therefore, it is sometimes difficult to determine the correct diagnosis. The aim of this study was to evaluate a prevalence of immunodeficient HIV-negative individuals among patients with infectious uveitis and to assess diagnostic and therapeutic approaches. METHODS A retrospective study. RESULTS In years 2003-2017, we diagnosed 594 patients with infectious uveitis. In 35 of them, infectious uveitis occurred on the basis of immunodeficiency (malignancy, immunosuppressive therapy etc.). The most common infectious uveitis was cytomegalovirus retinitis, followed by acute retinal necrosis, herpetic anterior uveitis, endogenous fungal endophthalmitis, toxoplasmic retinochoroiditis, progressive outer retinal necrosis and syphilis. In indicated cases, intraocular fluid examination was a valuable diagnostic tool. After initiation of treatment, improvement of BCVA was observed in 13 eyes, stabilization in 13 eyes and deterioration in 11 eyes. In some patients who experienced adverse effects of medication, the recommended doses were decreased. CONCLUSION Our experience shows that patients with diagnoses of acute retinal necrosis or progressive outer retinal necrosis have a poor visual prognosis. The occurrence of cytomegalovirus retinitis signifies a very unfavorable survival prognosis in patients who underwent hematopoietic stem cell transplantation; the patients in our study died within 1 year from cytomegalovirus retinitis diagnosis.
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21
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Basílio-Queirós D, Venturini L, Laib Sampaio K, Sinzger C, Weissinger EM. Fast and Efficient Titration of Human Cytomegalovirus Stocks with a Self-Excisable Bacterial Artificial Chromosomes Cassette by Flow Cytometry. Hum Gene Ther Methods 2019; 30:122-126. [PMID: 31280610 DOI: 10.1089/hgtb.2019.084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The study of human cytomegalovirus (HCMV) has for long been challenging due to the inability of clinical strains to efficiently proliferate in vitro until adaptive mutations occur. These mutations lead to strains that differ considerably from clinical isolates, many of them showing altered cell tropism, a decrease in cell association and higher susceptibility to an innate immune response. These problems were recently solved by the use of bacterial artificial chromosome (BAC) vectors that allow for the conservation of an intact HCMV genome. Other characteristics that render HCMV difficult for in vitro study are related to its slow replication rate that leads to some constraints in its titration. During the cloning of HCMV into BAC vectors, many groups additionally inserted a fluorescent tag to facilitate the virus characterization. However, the methods used for titration of HCMV-BAC stocks are still relaying on the standard methods that are expensive and/or time consuming. In this study, we assessed the possibility of viral titration by fluorescence-activated cell sorting (FACS), making use of the fluorescent tags that many of the HCMV-BACs hold. We compared viral titers obtained by immunohistochemistry with FACS, a faster and inexpensive technique. We showed that viral titers are comparable using the techniques already mentioned, and that titration by FACS is an efficient, fast, and cost-effective method. The establishment of viral titration of BAC vectors by FACS can further simplify the study of HCMV.
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Affiliation(s)
- Débora Basílio-Queirós
- 1Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Letizia Venturini
- 1Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | | | | | - Eva M Weissinger
- 1Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
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22
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Ho M, Invernizzi A, Zagora S, Tsui J, Oldani M, Lui G, McCluskey P, Young AL. Presenting Features, Treatment and Clinical Outcomes of Cytomegalovirus Retinitis: Non-HIV Patients Vs HIV Patients. Ocul Immunol Inflamm 2019; 28:651-658. [PMID: 31166809 DOI: 10.1080/09273948.2019.1604003] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE To compare clinical features, complications, and outcomes of CMV retinitis in non-HIV immunocompromised patients with HIV infected patients. METHODS A retrospective study of patients diagnosed with CMV retinitis with or without HIV infection was performed. Results: Thirty-five eyes from 27 patients (median follow up 26 months) were included. Six patients had HIV infection, the others were immunocompromised from a range of causes. The baseline visual acuity (VA) was similar in the two groups. Prevalence of different types of retinitis (fulminant/indolent) was similar in the two groups. Presence of vitreous haze ≥1+ (p = .041), presence of arteritis, (p = .016) and widespread vascular occlusion (p = .003) were more common in the non-HIV group. CONCLUSION CMV retinitis can present with different features depending on the cause of immunocompromise. Evidence of intraocular inflammation such as vitritis, retinal arteritis, and vascular occlusions was more common in HIV-negative subjects.
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Affiliation(s)
- Mary Ho
- Department of Ophthalmology & Visual Sciences, Chinese University of Hong Kong, Prince of Wales Hospital , Shatin, Hong Kong SAR
| | - Alessandro Invernizzi
- Department of Biomedical and Clinical Science "Luigi Sacco", Luigi Sacco Hospital, University of Milan , Milan, Italy.,Faculty of Medicine and Health, University of Sydney, Save Sight Institute , Sydney, NSW, Australia
| | - Sophia Zagora
- Faculty of Medicine and Health, University of Sydney, Save Sight Institute , Sydney, NSW, Australia
| | - Jolly Tsui
- Department of Ophthalmology & Visual Sciences, Chinese University of Hong Kong, Prince of Wales Hospital , Shatin, Hong Kong SAR
| | - Marta Oldani
- Department of Biomedical and Clinical Science "Luigi Sacco", Luigi Sacco Hospital, University of Milan , Milan, Italy
| | - Grace Lui
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital , Shatin, Hong Kong SAR
| | - Peter McCluskey
- Faculty of Medicine and Health, University of Sydney, Save Sight Institute , Sydney, NSW, Australia
| | - Alvin L Young
- Department of Ophthalmology & Visual Sciences, Chinese University of Hong Kong, Prince of Wales Hospital , Shatin, Hong Kong SAR
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23
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Zöllner SK, Herbrüggen H, Kolve H, Mihailovic N, Schubert F, Reicherts C, Rössig C, Groll AH. Cytomegalovirus retinitis in children and adolescents with acute leukemia following allogeneic hematopoietic stem cell transplantation. Transpl Infect Dis 2019; 21:e13089. [PMID: 30972869 DOI: 10.1111/tid.13089] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/19/2019] [Accepted: 03/23/2019] [Indexed: 11/28/2022]
Abstract
Cytomegalovirus retinitis (CMVR) may occur after allogeneic hematopoietic stem cell transplantation (HSCT). However, little is known about its incidence, strategies for ophthalmic surveillance, and timely implementation of adequate antiviral treatment in pediatric allogeneic HSCT recipients. We provide a retrospective analysis of the epidemiology and clinical features of CMVR in pediatric allogeneic HSCT patients transplanted at our center over a 16-year period. Two patients of this cohort with leukemia are presented. Our analysis is supplemented by a systematic review on pediatric patients with leukemia and CMVR in the setting of allogeneic HSCT. The overall incidence of CMVR in our cohort was 1% (4/338) and 14.2% (3/21) in leukemic patients. In published cases, CMVR occurred at a median of 143 days after transplantation, and, in the majority of patients, was preceded by CMV detection in blood by a median of 93 days. Continued immune suppression following engraftment likely triggers CMVR. Preemptive treatment with ganciclovir as standard is usually successful. Foscarnet is used in case of resistance to ganciclovir or drug-induced granulocytopenia. Overall, CMVR after HSCT in pediatric leukemic patients is rare, but a potentially higher vulnerability of this population for involvement of the eye warrants a standardized ophthalmological examination plan.
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Affiliation(s)
- Stefan K Zöllner
- Department of Pediatric Hematology and Oncology, University Children's Hospital Muenster, Muenster, Germany
| | - Heidrun Herbrüggen
- Department of Pediatric Hematology and Oncology, University Children's Hospital Muenster, Muenster, Germany
| | - Hedwig Kolve
- Department of Pediatric Hematology and Oncology, University Children's Hospital Muenster, Muenster, Germany.,Pharmacy Department, University Hospital Muenster, Muenster, Germany
| | - Natasa Mihailovic
- Department of Ophthalmology, University Hospital Muenster, Muenster, Germany
| | - Friederike Schubert
- Department of Ophthalmology, University Hospital Muenster, Muenster, Germany
| | | | - Claudia Rössig
- Department of Pediatric Hematology and Oncology, University Children's Hospital Muenster, Muenster, Germany
| | - Andreas H Groll
- Department of Pediatric Hematology and Oncology, University Children's Hospital Muenster, Muenster, Germany
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24
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Non-GVHD ocular complications after hematopoietic cell transplantation: expert review from the Late Effects and Quality of Life Working Committee of the CIBMTR and Transplant Complications Working Party of the EBMT. Bone Marrow Transplant 2019; 54:648-661. [PMID: 30531955 PMCID: PMC6497536 DOI: 10.1038/s41409-018-0339-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 08/22/2018] [Indexed: 02/02/2023]
Abstract
Non-graft-versus-host disease (non-GVHD) ocular complications are generally uncommon after hematopoietic cell transplantation (HCT), but can cause prolonged morbidity affecting activities of daily living and quality of life. Here we provide an expert review of non-GVHD ocular complications in a collaboration between transplant physicians and ophthalmologists through the Late Effects and Quality of Life Working Committee of the Center for International Blood and Marrow Transplant Research and the Transplant Complications Working Party of the European Society of Blood and Marrow Transplantation. Complications discussed in this review include cataracts, glaucoma, ocular infections, ocular involvement with malignancy, ischemic microvascular retinopathy, central retinal vein occlusion, retinal hemorrhage, retinal detachment and ocular toxicities associated with medications. We have summarized incidence, risk factors, screening, prevention and treatment of individual complications and generated evidence-based recommendations. Baseline ocular evaluation before HCT should be considered in all patients who undergo HCT. Follow-up evaluations should be considered according to clinical symptoms, signs and risk factors. Better preventive strategies and treatments remain to be investigated for individual ocular complications after HCT. Both transplant physicians and ophthalmologists should be knowledgeable of non-GVHD ocular complications and provide comprehensive collaborative team care.
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25
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Qian Z, Li H, Tao Y, Li W. Initial intravitreal injection of high-dose ganciclovir for cytomegalovirus retinitis in HIV-negative patients. BMC Ophthalmol 2018; 18:314. [PMID: 30526535 PMCID: PMC6288921 DOI: 10.1186/s12886-018-0983-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 11/29/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this study is to examine the clinical outcomes achieved by using initial high-dose intravitreal ganciclovir injections to treat cytomegalovirus retinitis in patients without human immunodeficiency virus (HIV) infection. METHODS Twenty-four eyes (24 patients) with cytomegalovirus retinitis received multiple intravitreal injections of ganciclovir in weekly intervals. A higher dose (6 mg) of ganciclovir was applied at the first intravitreal injection, and a lower dose was used for maintenance. Anterior aqueous humour was obtained before each injection. The best-corrected visual acuity and cytomegalovirus loads in the anterior aqueous humour were measured. RESULTS The mean cytomegalovirus DNA load in aqueous humour decreased significantly from (2.59 ± 2.28) × 105 copies/mL at baseline to (1 ± 1.76) × 104 copies/mL one month later. The aqueous cytomegalovirus DNA load was negative in 17 eyes (70.8%) one month later. No obvious improvement of best-corrected visual acuity was found during the treatment. A positive correlation was proven between initial cytomegalovirus DNA titers in aqueous humour and the total number of intravitreal injections of ganciclovir, as well as between the baseline and final best-corrected visual acuities. No severe complications developed. CONCLUSIONS An initial high dose of ganciclovir (6 mg) and continuous intravitreal injections of ganciclovir could significantly decrease the cytomegalovirus load in HIV-negative patients with cytomegalovirus retinitis. TRIAL REGISTRATION http://clinicaltrials.gov, NCT03598452, retrospectively registered on 24 July 2018.
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Affiliation(s)
- Zhuyun Qian
- Shanghai Aier Eye Hospital, Shanghai, China, No. 1286, Hongqiao Road, Changning District, Shanghai, 200050, China
| | - Haili Li
- Department of Ophthalmology, the First Hospital of Peking University, Beijing, China
| | - Yong Tao
- Department of Ophthalmology, Beijing Chaoyang Hospital, Capital Medical University, No. 8, South Road of Worker's Stadium, Chaoyang District, Beijing, 100020, China.
| | - Wensheng Li
- Shanghai Aier Eye Hospital, Shanghai, China, No. 1286, Hongqiao Road, Changning District, Shanghai, 200050, China. .,Aier School of Ophthalmology, Central South University, Changsha, Hunan Province, China.
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Inamoto Y, Petriček I, Burns L, Chhabra S, DeFilipp Z, Hematti P, Rovó A, Schears R, Shah A, Agrawal V, Ahmed A, Ahmed I, Ali A, Aljurf M, Alkhateeb H, Beitinjaneh A, Bhatt N, Buchbinder D, Byrne M, Callander N, Fahnehjelm K, Farhadfar N, Gale RP, Ganguly S, Hashmi S, Hildebrandt GC, Horn E, Jakubowski A, Kamble RT, Law J, Lee C, Nathan S, Penack O, Pingali R, Prasad P, Pulanic D, Rotz S, Shreenivas A, Steinberg A, Tabbara K, Tichelli A, Wirk B, Yared J, Basak GW, Battiwalla M, Duarte R, Savani BN, Flowers MED, Shaw BE, Valdés-Sanz N. Non-Graft-versus-Host Disease Ocular Complications after Hematopoietic Cell Transplantation: Expert Review from the Late Effects and Quality of Life Working Committee of the Center for International Blood and Marrow Transplant Research and the Transplant Complications Working Party of the European Society for Blood and Marrow Transplantation. Biol Blood Marrow Transplant 2018; 25:e145-e154. [PMID: 30521975 DOI: 10.1016/j.bbmt.2018.11.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 11/28/2018] [Indexed: 01/18/2023]
Abstract
Non-graft-versus-host disease (GVHD) ocular complications are generally uncommon after hematopoietic cell transplantation (HCT) but can cause prolonged morbidity affecting activities of daily living and quality of life. Here we provide an expert review of non-GVHD ocular complications in a collaboration between transplantation physicians and ophthalmologists through the Late Effects and Quality of Life Working Committee of the Center for International Blood and Marrow Transplant Research and the Transplant Complications Working Party of the European Society of Blood and Marrow Transplantation. Complications discussed in this review include cataracts, glaucoma, ocular infections, ocular involvement with malignancy, ischemic microvascular retinopathy, central retinal vein occlusion, retinal hemorrhage, retinal detachment and ocular toxicities associated with medications. We summarize the incidence, risk factors, screening, prevention, and treatment of individual complications and generate evidence-based recommendations. Baseline ocular evaluation before HCT should be considered in all patients who undergo HCT. Follow-up evaluations should be considered according to clinical signs and symptoms and risk factors. Better preventive strategies and treatments remain to be investigated for individual ocular complications after HCT. Both transplantation physicians and ophthalmologists should be knowledgeable about non-GVHD ocular complications and provide comprehensive collaborative team care.
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Affiliation(s)
- Yoshihiro Inamoto
- Division of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan.
| | - Igor Petriček
- Department of Ophthalmology, Zagreb University Clinical Hospital, Zagreb, Croatia
| | - Linda Burns
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program/Be the Match, Minneapolis, Minnesota
| | - Saurabh Chhabra
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Zachariah DeFilipp
- Blood and Marrow Transplant Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Peiman Hematti
- Division of Hematology/Oncology/Bone Marrow Transplantation, Department of Medicine, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Alicia Rovó
- Inselspital, Bern University Hospital, Bern, Switzerland
| | - Raquel Schears
- Division of Hematology, Mayo Clinic Rochester, Rochester, Minnesota
| | - Ami Shah
- Division of Stem Cell Transplantation and Regenerative Medicine, Lucille Packard Children's Hospital, Stanford School of Medicine, Palo Alto, California
| | - Vaibhav Agrawal
- Indiana University Simon Cancer Center, Indianapolis, Indiana
| | - Aisha Ahmed
- University of California, San Francisco, California
| | - Ibrahim Ahmed
- Department of Hematology Oncology and Bone Marrow Transplantation, The Children's Mercy Hospitals and Clinics, Kansas City, Missouri
| | - Asim Ali
- Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Mahmoud Aljurf
- Department of Oncology, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Hassan Alkhateeb
- Division of Hematology, Mayo Clinic Rochester, Rochester, Minnesota
| | | | - Neel Bhatt
- Center for International Blood and Marrow Transplant Program, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Dave Buchbinder
- Division of Pediatrics Hematology, Children's Hospital of Orange County, Orange, California
| | - Michael Byrne
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Kristina Fahnehjelm
- Department of Clinical Neuroscience, Karolinska Institute, St Erik Eye Hospital, Stockholm, Sweden; Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Nosha Farhadfar
- University of Florida Health Shands Hospital, Gainesville, Florida
| | - Robert Peter Gale
- Hematology Research Centre, Division of Experimental Medicine, Department of Medicine, Imperial College London, London, United Kingdom
| | - Siddhartha Ganguly
- Division of Hematological Malignancy and Cellular Therapeutics, University of Kansas Health System, Kansas City, Kansas
| | - Shahrukh Hashmi
- Department of Oncology, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | | | - Erich Horn
- University of Florida Health Shands Hospital, Gainesville, Florida
| | - Ann Jakubowski
- Division of Hematologic Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Rammurti T Kamble
- Division of Hematology and Oncology, Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, Texas
| | - Jason Law
- Tufts Medical Center, Boston, Massachusetts
| | - Catherine Lee
- Utah Blood and Marrow Transplant Program, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | | | - Olaf Penack
- Divison of Hematology and Oncology, Department of Internal Medicine, Charité University Medicine, Campus Rudolf Virchow, Berlin, Germany
| | | | - Pinki Prasad
- Lousiana State University Children's Hospital, New Orleans, Louisiana
| | - Drazen Pulanic
- Division of Hematology, Department of Internal Medicine, University Hospital Center Zagreb, Zagreb, Croatia; School of Medicine, University of Zagreb, Zagreb, Croatia; Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
| | - Seth Rotz
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Aditya Shreenivas
- Division of Hematology and Oncology, Mount Sinai Hospital, New York, New York
| | - Amir Steinberg
- Division of Hematology and Oncology, Mount Sinai Hospital, New York, New York
| | - Khalid Tabbara
- Wilmer Eye Institute, Johns Hopkins Medicine, Baltimore, Maryland
| | - André Tichelli
- Hematology, University Hospital Basel, Basel, Switzerland
| | - Baldeep Wirk
- Division of Bone Marrow Transplant, Seattle Cancer Care Alliance, Seattle, Washington
| | - Jean Yared
- Blood and Marrow Transplantation Program, Division of Hematology/Oncology, Department of Medicine, Greenebaum Comprehensive Cancer Center, University of Maryland, Baltimore, Maryland
| | - Grzegorz W Basak
- Department of Hematology, Oncology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Minoo Battiwalla
- Hematology Branch, Sarah Cannon Center for Blood Cancer, Nashville, Tennessee
| | - Rafael Duarte
- Hematopoietic Transplantation and Hemato-oncology Section, Puerta de Hierro Majadahonda University Hospital, Madrid, Spain
| | - Bipin N Savani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mary E D Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Bronwen E Shaw
- Center for International Blood and Marrow Transplant Program, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nuria Valdés-Sanz
- Department of Ophthalmology, Puerta de Hierro Majadahonda University Hospital, Madrid, Spain
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Abstract
Cytomegalovirus (CMV), human herpes virus (HHV)-6, and HHV-7 are ubiquitous β-herpesviruses that can cause opportunistic infection and disease in kidney transplant recipients. Active CMV infection and disease are associated with acute allograft failure and death, and HHV-6 and HHV-7 replication are associated with CMV disease. CMV prevention strategies are used commonly after kidney transplantation, and include prophylaxis with antiviral medications and preemptive treatment upon the detection of asymptomatic viral replication in blood. Both approaches decrease CMV disease and allograft rejection, but CMV prophylaxis is preferred for high-risk patients because it is easy to administer and may be more effective in real-world settings. CMV disease commonly occurs even with current preventive strategies, whereas HHV-6 and HHV-7 diseases are rare. The clinical manifestations of CMV, HHV-6, and HHV-7 are nonspecific, and laboratory confirmation is essential to establishing diagnoses. Although nucleic acid testing has supplanted other diagnostic modalities given its high sensitivity and specificity, histopathologic examination sometimes is necessary to identify disease definitively. Ganciclovir and valganciclovir are the treatments of choice for CMV and HHV-6, and foscarnet can be used to treat HHV-7. Treatment duration should be informed by the initial severity of disease, and subsequent clinical and virologic responses.
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Yoshikawa T. Betaherpesvirus Complications and Management During Hematopoietic Stem Cell Transplantation. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1045:251-270. [PMID: 29896671 DOI: 10.1007/978-981-10-7230-7_12] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Two of the four betaherpesviruses, Cytomegalovirus (CMV) and human herpesvirus 6B (HHV-6B), play an important role in opportunistic infections in hematopoietic stem cell transplant (HSCT) recipients. These viruses are ubiquitous in humans and can latently infect mononuclear lymphocytes, complicating the diagnosis of the diseases they cause. Although the detection of viral DNA in a patient's peripheral blood by real-time PCR is widely used for monitoring viral infection, it is insufficient for the diagnosis of virus-associated disease. Theoretically, end-organ disease should be confirmed by detecting either viral antigen or significant amounts of viral DNA in a tissue sample obtained from the involved organ; however, this is often difficult to perform in clinical practice. The frequency of CMV-associated diseases has decreased gradually as a result of the introduction of preemptive or prophylactic treatments; however, CMV and HHV-6B infections remain a major problem in HSCT recipients. Measurement of viral DNA load in peripheral blood or plasma using real-time PCR is commonly used for monitoring these infections. Additionally, recent data suggest that an assessment of host immune response, particularly cytotoxic T-cell response, may be a reliable tool for predicting these viral infections. The antiviral drugs ganciclovir and foscarnet are used as first-line treatments; however, it is well known that these drugs have side effects, such as bone marrow suppression and nephrotoxicity. Further research is required to develop less-toxic antiviral drugs.
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Affiliation(s)
- Tetsushi Yoshikawa
- Department of Pediatrics, Fujita Health University School of Medicine, Toyoake, Japan.
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30
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Abstract
Cytomegalovirus (CMV), the largest of the herpesviruses, causes a wide range of clinical syndromes, from asymptomatic infection to severe disease in immunocompromised hosts. Laboratory methods for diagnosis include molecular testing, antigenemia, culture, serology, and histopathology. Treatment of CMV infection and disease is indicated in selected immunocompromised hosts, and preventive approaches are indicated in high-risk groups. This chapter reviews the epidemiology, clinical aspects, and the laboratory diagnosis and management of CMV in immunocompromised hosts.
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Ogonek J, Verma K, Schultze-Florey C, Varanasi P, Luther S, Schweier P, Kühnau W, Göhring G, Dammann E, Stadler M, Ganser A, Koehl U, Koenecke C, Weissinger EM, Hambach L. Characterization of High-Avidity Cytomegalovirus-Specific T Cells with Differential Tetramer Binding Coappearing after Allogeneic Stem Cell Transplantation. THE JOURNAL OF IMMUNOLOGY 2017. [DOI: 10.4049/jimmunol.1601992] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Chan ST, Logan AC. The clinical impact of cytomegalovirus infection following allogeneic hematopoietic cell transplantation: Why the quest for meaningful prophylaxis still matters. Blood Rev 2017; 31:173-183. [DOI: 10.1016/j.blre.2017.01.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 12/16/2016] [Accepted: 01/31/2017] [Indexed: 11/28/2022]
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POSTERIOR EYE SEGMENT COMPLICATIONS RELATED TO ALLOGENEIC HEMATOPOIETIC STEM CELL TRANSPLANTATION. Retina 2017; 37:135-143. [DOI: 10.1097/iae.0000000000001122] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Downes KM, Tarasewicz D, Weisberg LJ, Cunningham ET. Good syndrome and other causes of cytomegalovirus retinitis in HIV-negative patients-case report and comprehensive review of the literature. J Ophthalmic Inflamm Infect 2016; 6:3. [PMID: 26809342 PMCID: PMC4726639 DOI: 10.1186/s12348-016-0070-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 01/04/2016] [Indexed: 12/21/2022] Open
Abstract
We describe a 65-year-old Thai woman who developed cytomegalovirus retinitis (CMVR) in the setting of Good syndrome-a rare, acquired partial immune deficiency caused by thymoma. The patient subsequently developed vitritis with cystoid macular edema (CME) similar to immune recovery uveitis (IRU) despite control of the retinitis with antiviral agents. A comprehensive review of the literature through December, 2014, identified an additional 279 eyes of 208 patients with CMVR in the absence of human immunodeficiency virus (HIV) infection. Including our newly reported case, 9 of the 208 patients (4.3 %) had Good syndrome. Twenty-one of the 208 patients (10.1 %) had CMVR related to intraocular or periocular corticosteroid administration. The remaining 178 patients (85.6 %) acquired CMVR from other causes. Within the subset of patients who did not have Good syndrome or did not acquire CMVR followed by intraocular or periocular corticosteroid administration, there were many other factors contributing to a decline in immune function. The most common included age over 60 years (33.1 %), an underlying malignancy (28.7 %), a systemic autoimmune disorder requiring systemic immunosuppression (19.1 %), organ (15.2 %) or bone marrow (16.3 %) transplantation requiring systemic immunosuppression, and diabetes mellitus (6.1 %). Only 4.5 % of the patients had no identifiable contributor to a decline in immune function. While the clinical features of CMVR are generally similar in HIV-negative and HIV-positive patients, the rates of moderate to severe intraocular inflammation and of occlusive retinal vasculitis appear to be higher in HIV-negative patients.
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Affiliation(s)
- Kenneth M Downes
- The Department of Ophthalmology, California Pacific Medical Center, 2340 Clay Street 5th, San Francisco, CA, 94115, USA.
| | - Dariusz Tarasewicz
- The Department of Ophthalmology, Kaiser Permanente Medical Center, South San Francisco, CA, USA
| | - Laurie J Weisberg
- The Department of Hematology/Oncology, Kaiser Permanente South San Francisco Medical Center, South San Francisco, CA, USA
| | - Emmett T Cunningham
- The Department of Ophthalmology, California Pacific Medical Center, 2340 Clay Street 5th, San Francisco, CA, 94115, USA
- The Department of Ophthalmology, Stanford University School of Medicine, Stanford, CA, USA
- The Francis I. Proctor Foundation, UCSF School of Medicine, San Francisco, CA, USA
- West Coast Retina Medical Group, San Francisco, CA, USA
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Hong SI, Kim T, Park SY, Jung J, Lee JY, Chong YP, Sung H, Lee SO, Choi SH, Kim YS, Woo JH, Kim SH. Sensitivity of the Cytomegalovirus Antigenemia Assay to Diagnose Cytomegalovirus Retinitis. Infect Chemother 2016; 48:302-308. [PMID: 27883376 PMCID: PMC5204009 DOI: 10.3947/ic.2016.48.4.302] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Accepted: 09/02/2016] [Indexed: 12/04/2022] Open
Abstract
Background Cytomegalovirus (CMV) retinitis is one of the most important tissue-invasive CMV diseases in immunocompromised patients. Since 1980, non-invasive diagnostic methods, notably the CMV antigenemia assay, have been widely used as adjunct tests to diagnose tissue-invasive CMV diseases. However, there are limited data on the diagnostic value of the CMV antigenemia assay for diagnosing CMV retinitis. Materials and Methods We performed a retrospective review of all cases of CMV retinitis at Asan Medical Center, Seoul, South Korea over a 9-year period. The diagnosis of CMV retinitis was made by experienced ophthalmologists according to medical history and an ophthalmoscopic appearance of typical retinopathy, together with absence of an alternative diagnosis. Results We analyzed 44 patients with CMV retinitis (affecting 57 eyes) for whom the CMV antigenemia assay was performed. Of the 44 patients, 31 (70%) were HIV-uninfected and 13 (30%) were HIV-infected. The overall sensitivity of the CMV antigenemia assay was 66% (95% confidence interval [CI] 50–80%). The test’s sensitivity showed a non-significant trend towards being higher in HIV-infected patients than in HIV-uninfected patients (sensitivity 85% vs 58%, respectively, P = 0.16). In a subgroup analysis of the 35 patients without other concurrent tissue-invasive CMV disease, the sensitivity of the CMV antigenemia assay was 57% (95% CI 40–74%). Conclusions The CMV antigenemia assay has limited value as a non-invasive diagnostic adjunct test for CMV retinitis. Therefore, the results of the assay need to be interpreted in the context of underlying disease, clinical presentation, and ophthalmoscopic findings.
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Affiliation(s)
- Sun In Hong
- Department of Infectious Diseases, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine, Changwon, Korea.,Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Taeeun Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Se Yoon Park
- Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jiwon Jung
- Division of Infectious Diseases, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Joo Yong Lee
- Department of Ophthalmology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong Phil Chong
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Heungsup Sung
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Oh Lee
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Ho Choi
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yang Soo Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jun Hee Woo
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Han Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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Ogonek J, Kralj Juric M, Ghimire S, Varanasi PR, Holler E, Greinix H, Weissinger E. Immune Reconstitution after Allogeneic Hematopoietic Stem Cell Transplantation. Front Immunol 2016; 7:507. [PMID: 27909435 PMCID: PMC5112259 DOI: 10.3389/fimmu.2016.00507] [Citation(s) in RCA: 269] [Impact Index Per Article: 33.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 11/02/2016] [Indexed: 12/17/2022] Open
Abstract
The timely reconstitution and regain of function of a donor-derived immune system is of utmost importance for the recovery and long-term survival of patients after allogeneic hematopoietic stem cell transplantation (HSCT). Of note, new developments such as umbilical cord blood or haploidentical grafts were associated with prolonged immunodeficiency due to delayed immune reconstitution, raising the need for better understanding and enhancing the process of immune reconstitution and finding strategies to further optimize these transplant procedures. Immune reconstitution post-HSCT occurs in several phases, innate immunity being the first to regain function. The slow T cell reconstitution is regarded as primarily responsible for deleterious infections with latent viruses or fungi, occurrence of graft-versus-host disease, and relapse. Here we aim to summarize the major steps of the adaptive immune reconstitution and will discuss the importance of immune balance in patients after HSCT.
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Affiliation(s)
- Justyna Ogonek
- Transplantation Biology, Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Mateja Kralj Juric
- BMT, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Sakhila Ghimire
- Department of Hematology and Oncology, University of Regensburg, Regensburg, Germany
| | - Pavankumar Reddy Varanasi
- Transplantation Biology, Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Ernst Holler
- Department of Hematology and Oncology, University of Regensburg, Regensburg, Germany
| | | | - Eva Weissinger
- Transplantation Biology, Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
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Jeon S, Lee WK. Cytomegalovirus Retinitis in a Human Immunodeficiency Virus-negative Cohort: Long-term Management and Complications. Ocul Immunol Inflamm 2016; 23:392-9. [PMID: 25760914 DOI: 10.3109/09273948.2014.985385] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To examine the clinical outcomes achieved by using intravitreal ganciclovir injections combined with systemic anti-viral therapy in treating cytomegalovirus (CMV) retinitis in patients without human immunodeficiency virus (HIV) infection. METHODS Twenty-three eyes of 15 HIV-negative patients diagnosed with CMV retinitis were included in this retrospective study. RESULTS The median follow-up was 68 weeks (range, 12-156), and median number of injections was 10 (range, 2-22). The retinal lesions stopped progressing within 1-2 weeks following treatment. All of the eyes showed either unchanged or ≥2 line improvements of BCVA at last visit. There was no development of CMV retinitis in a fellow eye, or recurrence in a studied eye. Systemic complications such as neutropenia were not detected. CONCLUSIONS Intravitreal ganciclovir injections combined with systemic anti-viral treatment is a good therapeutic option for treating CMV retinitis without HIV infection. Such treatment provided favorable visual outcomes, with minimal ocular and systemic complications.
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Affiliation(s)
- Sohee Jeon
- a Department of Ophthalmology , Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine , Seoul , South Korea
| | - Won Ki Lee
- a Department of Ophthalmology , Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine , Seoul , South Korea
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Iu LP, Fan MC, Lau JK, Chan TS, Kwong YL, Wong IY. Long-term Follow-up of Cytomegalovirus Retinitis in Non-HIV Immunocompromised Patients: Clinical Features and Visual Prognosis. Am J Ophthalmol 2016; 165:145-53. [PMID: 27005706 DOI: 10.1016/j.ajo.2016.03.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 03/04/2016] [Accepted: 03/10/2016] [Indexed: 10/22/2022]
Abstract
PURPOSE To evaluate clinical features and long-term visual outcome of cytomegalovirus (CMV) retinitis in patients without human immunodeficiency virus (HIV) infection, and to determine factors that predict visual outcome. DESIGN Retrospective cohort study. METHODS Consecutive patients with CMV retinitis without HIV infection were reviewed. Main outcome measures included clinical features, proportion of eyes with 6-month and final visual acuity (VA) <20/70 and <20/400, and odds ratios of factors associated with poor visual outcome. RESULTS A total of 20 eyes from 13 patients were included with a median follow-up time of 17 months. All had at least 6 months of follow-up except 1 patient who died from sepsis at 1 month. At presentation, 50% of eyes had VA <20/70 and 25% had VA <20/400. Zone 1 involvement occurred in 55% and vitreous haze ≥grade 2+ occurred in 25%. Recurrence occurred in 33.3% at a mean time of 6.4 ± 3.3 weeks after discontinuation of anti-CMV therapy. The retinal detachment rate was 21.7% per eye-year and mortality rate was 11.7% per person-year. At final visit, 60% had VA <20/70 and 35% had VA <20/400. Macular involvement was significantly associated with poor final VA <20/400 (odds ratio = 25.00, P = .016). CONCLUSIONS CMV retinitis without HIV infection was often aggressive at presentation. Significant intraocular inflammation was not uncommon. The long-term visual outcome was poor, especially in those with macular involvement.
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Razonable RR, Blumberg EA. It's not too late: a proposal to standardize the terminology of "late-onset" cytomegalovirus infection and disease in solid organ transplant recipients. Transpl Infect Dis 2015; 17:779-84. [PMID: 26771688 DOI: 10.1111/tid.12447] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- R R Razonable
- Division of Infectious Diseases, Department of Medicine and the William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - E A Blumberg
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Clinical utility of cytomegalovirus viral load in solid organ transplant recipients. Curr Opin Infect Dis 2015; 28:317-22. [DOI: 10.1097/qco.0000000000000173] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Turno-Kręcicka A, Boratyńska M, Tomczyk-Socha M, Mazanowska O. Progressive outer retinal necrosis in immunocompromised kidney allograft recipient. Transpl Infect Dis 2015; 17:400-5. [PMID: 25846017 DOI: 10.1111/tid.12386] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Revised: 01/24/2015] [Accepted: 03/01/2015] [Indexed: 12/16/2022]
Abstract
Ocular complications in patients who underwent renal transplantation are attributed to side effects of the immunosuppressive regimen. Progressive outer retinal necrosis (PORN) syndrome is a clinical variant of necrotizing herpetic retinopathy and it occurs almost exclusively in patients with acquired immunodeficiency syndrome. We present a case of a human immunodeficiency virus-negative patient who underwent renal transplant and, after a few years, developed bilateral PORN associated with viral infections. Varicella zoster virus (VZV) and BK virus were identified by polymerase chain reaction from the vitreous fluid. It is unclear which of the viruses identified had the dominant role in the pathogenesis of PORN and other organ damage, or whether their actions were synergistic. Adequate antiviral immune surveillance, as well as pre-transplant vaccination against VZV, may reduce the incidence of VZV infection and its complications.
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Affiliation(s)
- A Turno-Kręcicka
- Department of Ophthalmology, Wroclaw Medical University, Wroclaw, Poland
| | - M Boratyńska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - M Tomczyk-Socha
- Department of Ophthalmology, Wroclaw Medical University, Wroclaw, Poland
| | - O Mazanowska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
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Delayed-onset cytomegalovirus disease coded during hospital readmission after kidney transplantation. Transplantation 2014; 98:187-94. [PMID: 24621539 DOI: 10.1097/tp.0000000000000030] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Use of prophylactic anti-CMV therapy for 3 to 6 months after kidney transplantation can result in delayed-onset CMV disease. We hypothesized that delayed-onset CMV disease (occurring >100 days posttransplant) occurs more commonly than early-onset CMV disease and that it is associated with death. METHODS We assembled a retrospective cohort of 15,848 adult kidney transplant recipients using 2004 to 2010 administrative data from the California and Florida Healthcare Cost and Utilization Project State Inpatient Databases. We identified demographic data, comorbidities, CMV disease coded during readmission, and inpatient death. We used multivariate Cox proportional hazards modeling to determine risk factors for delayed-onset CMV disease and inpatient death. RESULTS Delayed-onset CMV disease was identified in 4.0%, and early-onset CMV disease was identified in 1.2% of the kidney transplant recipients. Risk factors for delayed-onset CMV disease included previous transplant failure or rejection (HR 1.4) and residence in the lowest-income ZIP codes (HR 1.2). Inpatient death was associated with CMV disease occurring 101 to 365 days posttransplant (HR 1.5), CMV disease occurring greater than 365 days posttransplant (HR 2.1), increasing age (by decade: HR 1.5), nonwhite race (HR 1.2), residence in the lowest-income ZIP codes (HR 1.2), transplant failure or rejection (HR 3.2), previous solid organ transplant (HR 1.7), and several comorbidities. CONCLUSION These data showed that delayed-onset CMV disease occurred more commonly than early-onset CMV disease and that transplant failure or rejection is a risk factor for delayed-onset CMV disease. Further research should be done to determine if delayed-onset CMV disease is independently associated with death.
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Abstract
In treating cytomegalovirus (CMV) infection, it is crucial to decide whether one is treating pre-emptively or if one is treating established disease. Disease may be further divided into viral syndrome and tissue-invasive disease. Generally, mild disease in immunosuppressed patients may be treated with oral valganciclovir. Treatment may also be started with valganciclovir for CMV retinitis in AIDS patients. In other tissue-invasive syndromes, starting with intravenous ganciclovir or foscarnet at full doses (adjusted for renal function) is preferred. Treatment at full doses should be continued until symptom resolution and until blood antigenemia (or DNAemia) is cleared. Patients receiving treatment must be closely monitored for side effects to the drugs, as well as for response. Drug-resistant CMV is a therapeutic challenge; combination therapy with both ganciclovir and foscarnet may be tried. In extreme cases, resorting to unconventional agents like leflunomide or maribavir may be necessary. Immune reconstitution, through reduction in immunosuppression, or the introduction of anti-retroviral therapy, should be attempted. CMX001 is a novel agent active against double-stranded viruses; thus far, resistance to CMX001 does not confer resistance to ganciclovir or foscarnet. Hence, prophylaxis or pre-emptive treatment with CMX001 may allow the use of ganciclovir or foscarnet for treatment.
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Clinical utility of viral load in management of cytomegalovirus infection after solid organ transplantation. Clin Microbiol Rev 2014; 26:703-27. [PMID: 24092851 DOI: 10.1128/cmr.00015-13] [Citation(s) in RCA: 151] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The negative impact of cytomegalovirus (CMV) infection on transplant outcomes warrants efforts toward improving its prevention, diagnosis, and treatment. During the last 2 decades, significant breakthroughs in diagnostic virology have facilitated remarkable improvements in CMV disease management. During this period, CMV nucleic acid amplification testing (NAT) evolved to become one of the most commonly performed tests in clinical virology laboratories. NAT provides a means for rapid and sensitive diagnosis of CMV infection in transplant recipients. Viral quantification also introduced several principles of CMV disease management. Specifically, viral load has been utilized (i) for prognostication of CMV disease, (ii) to guide preemptive therapy, (iii) to assess the efficacy of antiviral treatment, (iv) to guide the duration of treatment, and (v) to indicate the risk of clinical relapse or antiviral drug resistance. However, there remain important limitations that require further optimization, including the interassay variability in viral load reporting, which has limited the generation of standardized viral load thresholds for various clinical indications. The recent introduction of an international reference standard should advance the major goal of uniform viral load reporting and interpretation. However, it has also become apparent that other aspects of NAT should be standardized, including sample selection, nucleic acid extraction, amplification, detection, and calibration, among others. This review article synthesizes the vast amount of information on CMV NAT and provides a timely review of the clinical utility of viral load testing in the management of CMV in solid organ transplant recipients. Current limitations are highlighted, and avenues for further research are suggested to optimize the clinical application of NAT in the management of CMV after transplantation.
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Ariza-Heredia EJ, Nesher L, Chemaly RF. Cytomegalovirus diseases after hematopoietic stem cell transplantation: a mini-review. Cancer Lett 2014; 342:1-8. [PMID: 24041869 DOI: 10.1016/j.canlet.2013.09.004] [Citation(s) in RCA: 121] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Accepted: 09/08/2013] [Indexed: 02/03/2023]
Abstract
Cytomegalovirus (CMV) infection remains a significant complication after hematopoietic stem cell transplantation (HSCT) and may have a deleterious impact on the overall outcome after transplantation. In addition to the direct effects of CMV infection, tissue-invasive CMV diseases may be associated with increased risk of graft versus host disease, myelosuppression, and invasive bacterial and fungal infections. Because of these direct and indirect adverse effects, prevention of CMV infection, mostly through pre-emptive therapy, is one of the essential strategies that may improve outcomes of HSCT recipients. Management of CMV infection relies mainly on intravenous (IV) antiviral therapy with ganciclovir and foscarnet, with or without IV polyclonal immunoglobulins. Although viral resistance remains rare, better tolerated antiviral agents with less serious side effects are needed, and a few will be evaluated in phase III clinical trials in the near future.
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Affiliation(s)
- Ella J Ariza-Heredia
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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Teh B, Khot A, Harrison S, Prince H, Slavin M. A messenger at the door: cytomegalovirus retinitis in myeloma patients with progressive disease. Transpl Infect Dis 2013; 15:E134-8. [DOI: 10.1111/tid.12106] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Revised: 02/14/2013] [Accepted: 03/05/2013] [Indexed: 11/27/2022]
Affiliation(s)
- B.W. Teh
- Department of Infectious Diseases and Infection Control; Peter MacCallum Cancer Centre; East Melbourne; Victoria; Australia
| | - A.S. Khot
- Department of Haematology; Peter MacCallum Cancer Centre; East Melbourne; Victoria; Australia
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Squirrell DM, Bhatta S, Mudhar HS, Rennie IG. Hypertensive iridocyclitis associated with delayed onset biopsy proven Cytomegalovirus retinitis. Indian J Ophthalmol 2013; 62:656-8. [PMID: 23548320 PMCID: PMC4065529 DOI: 10.4103/0301-4738.97086] [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] [Indexed: 11/04/2022] Open
Abstract
We describe a case of primary hypertensive iridocyclitis with biopsy-proven Cytomegaloviral retinitis. It is an observational case report of a 69-year-old diabetic gentleman on azathioprine for Crohn's disease who presented with recurrent episodes of hypertensive iridocyclitis. On the 4 th attendance in 5 months, a granular white lesion was noted in the temporal periphery of the mid-peripheral fundus and a chorioretinal and vitreous biopsy performed. Vitreous PCR was positive for Cytomegalovirus (CMV). Hematoxylin and eosin staining revealed cytomegalic-like inclusions within necrotic neural retina. Transmission electron microscopy revealed herpes family virus particles and immunohistochemistry demonstrated CMV protein. This case provides further evidence implicating CMV infection in the etiology of hypertensive iridocyclitis. With hindsight, the cumulative effect of diabetes and azathioprine on the immune surveillance system proved sufficient to render the patient susceptible to CMV retinitis.
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Affiliation(s)
| | - Sudipto Bhatta
- Department of Ophthalmology, Royal Hallamshire Hospital, Sheffield, United Kingdom
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Management strategies for cytomegalovirus infection and disease in solid organ transplant recipients. Infect Dis Clin North Am 2013; 27:317-42. [PMID: 23714343 DOI: 10.1016/j.idc.2013.02.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Cytomegalovirus is the most common viral pathogen that affects solid organ transplant recipients. It directly causes fever, myelosuppression, and tissue-invasive disease, and indirectly, it negatively impacts allograft and patient survival. Nucleic acid amplification testing is the preferred method to confirm the diagnosis of CMV infection. Prevention of CMV disease using antiviral prophylaxis or preemptive therapy is critical in the management of transplant patients. Intravenous ganciclovir and oral valganciclovir are the first line drugs for antiviral treatment. This article provides a comprehensive review of the current epidemiology, diagnosis, prevention and treatment of CMV infection in solid organ transplant recipients.
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Squires JE, Sisk RA, Balistreri WF, Kohli R. Isolated unilateral cytomegalovirus retinitis: a rare long-term complication after pediatric liver transplantation. Pediatr Transplant 2013; 17:E16-9. [PMID: 22738313 PMCID: PMC3461246 DOI: 10.1111/j.1399-3046.2012.01752.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
To highlight the rare yet devastating complication of CMV retinitis in a minimally immunosuppressed patient eight yr after liver transplantation for biliary atresia. A 22-yr-old female status-post deceased donor liver transplant at age 13 secondary to biliary atresia receiving single agent immunosuppression presented with acute, unilateral, profound decrease in visual acuity. The patient was diagnosed to have acute onset unilateral CMV retinitis. Retinal examination uncovered classical appearance of retinal whitening and retinal hemorrhages with extensive macular involvement. CMV retinitis can occur as a late complication following liver transplantation. Additionally, CMV retinal disease can occur in the absence of laboratory evidence of CMV infection and independent of additional clinical features suggesting CMV disease. Currently, there is no standard of care regarding screening for CMV retinitis, and thus, further research is needed to define the need for potential changes in current clinical practices and post-transplant screening protocols.
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Affiliation(s)
- James E. Squires
- Pediatric Liver Care Center, Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Robert A. Sisk
- Department of Pediatric Ophthalmology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - William F. Balistreri
- Pediatric Liver Care Center, Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Rohit Kohli
- Pediatric Liver Care Center, Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
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Svozílková P, Heissigerová J, Brichová M, Kalvodová B, Dvořák J, Ríhová E. A possible coincidence of cytomegalovirus retinitis and intraocular lymphoma in a patient with systemic non-Hodgkin's lymphoma. Virol J 2013; 10:18. [PMID: 23295015 PMCID: PMC3551720 DOI: 10.1186/1743-422x-10-18] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Accepted: 12/11/2012] [Indexed: 11/25/2022] Open
Abstract
Purpose To present a possible coincidence of cytomegalovirus retinitis and intraocular lymphoma in a patient with systemic non-Hodgkin’s lymphoma. Case presentation A 47-year-old woman presented with decreased visual acuity associated with white retinal lesions in both eyes. A history of pneumonia of unknown aetiology closely preceded the deterioration of vision. Five years previously the patient was diagnosed with follicular non-Hodgkin’s lymphoma. She was treated with a chemotherapy regimen comprised of cyclophosphamide, adriamycin, vincristin, and prednisone with later addition of the anti-CD20 antibody rituximab. She experienced a relapse 19 months later with involvement of the retroperitoneal lymph nodes, and commenced treatment with rituximab and 90Y-ibritumomab tiuxetan. A second relapse occurred 22 months after radioimmunotherapy and was treated with a combination of fludarabine, cyclophosphamide, and mitoxantrone followed by rituximab. The patient experienced no further relapses until the current presentation (April, 2010). Pars plana vitrectomy with vitreous fluid analysis was performed in the right eye. PCR testing confirmed the presence of cytomegalovirus in the vitreous. Atypical lymphoid elements, highly suspicious of malignancy were also found on cytologic examination. Intravenous foscarnet was administered continually for three weeks, followed by oral valganciclovir given in a dose of 900 mg twice per day. In addition, the rituximab therapy continued at three monthly intervals. Nevertheless, cessation of foscarnet therapy was followed by a recurrence of retinitis on three separate occasions during a 3-month period instigating its reinduction to the treatment regime after each recurrence. Conclusions Cytomegalovirus retinitis is an opportunistic infection found in AIDS patients as well as in bone marrow and solid organ transplant recipients being treated with systemic immunosuppressive drugs. This case presents a less common incidence of cytomegalovirus retinitis occurring in a patient with non-Hodgkin’s lymphoma. We demonstrated a possible coexistence of cytomegalovirus retinitis and intraocular lymphoma in this particular patient. The final diagnosis was based on clinical manifestations together with the course of uveitis and its response to treatment alongside the results of vitreous fluid analysis. This report highlights the importance of intraocular fluid examination in cases with nonspecific clinical manifestations. Such an examination allows for the detection of simultaneously ongoing ocular diseases of differing aetiologies and enables the prompt initiation of effective treatment.
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Affiliation(s)
- Petra Svozílková
- Department of Ophthalmology, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, U Nemocnice 2, 128 08, Prague 2, Czech Republic.
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