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Guo Y, Zhu Z, Cai W, Tao S, Yin D. Intracerebral opportunistic infections caused by immunosuppressants after orthotopic liver transplantation: Report of two cases and literature review. Front Immunol 2022; 13:1003254. [PMID: 36544772 PMCID: PMC9762491 DOI: 10.3389/fimmu.2022.1003254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 11/11/2022] [Indexed: 12/12/2022] Open
Abstract
Central nervous system (CNS) infections in adults are rare because of normal immunity and the existence of the blood brain barrier, which prevents the invasion of pathogenic microorganisms. Liver transplant recipients are at an increased risk of opportunistic infections (OI) due to immunosuppressive therapy compared to those with normal immunity. Early diagnosis and timely implementation of treatment are critical for the successful treatment of these infections. We present two cases of intracerebral OI after orthotopic liver transplantation (OLT), with different clinical presentations. Patient 1 presented with epileptic seizures, mainly manifested as unresponsiveness, unconsciousness, and coma complicated with involuntary limb twitching. Patient 2 presented with a consciousness disorder, mainly manifested as unclear consciousness content, poor orientation, calculation power, and logical ability. Next-generation sequencing (NGS) examination of the cerebrospinal fluid confirmed human herpesvirus 6 B (HHV-6B) infection in patient 1 and intracranial Aspergillus infection in patient 2. Intracranial OI has insidious onset and atypical clinical manifestations. NGS can allow for the proper diagnosis and monitoring of the effects of treatment.
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An atypical case of viral panuveitis and retinal vasculitis with retrograde extension associated with human herpesvirus-6. Am J Ophthalmol Case Rep 2022; 28:101712. [PMID: 36275189 PMCID: PMC9579305 DOI: 10.1016/j.ajoc.2022.101712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 09/01/2022] [Accepted: 09/17/2022] [Indexed: 11/09/2022] Open
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3
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Central nervous system infections after solid organ transplantation. Curr Opin Infect Dis 2021; 34:207-216. [PMID: 33741794 DOI: 10.1097/qco.0000000000000722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW Significant advances to our understanding of several neuroinfectious complications after a solid organ transplant (SOT) have occurred in the last few years. Here, we review the central nervous system (CNS) infections that are relevant to SOT via a syndromic approach with a particular emphasis on recent updates in the field. RECENT FINDINGS A few key studies have advanced our understanding of the epidemiology and clinical characteristics of several CNS infections in SOT recipients. Risk factors for poor prognosis and protective effects of standard posttransplant prophylactic strategies have been better elucidated. Newer diagnostic modalities which have broad clinical applications like metagenomic next-generation sequencing, as well as those that help us better understand esoteric concepts of disease pathogenesis have been studied. Finally, several studies have provided newer insights into the treatment of these diseases. SUMMARY Recent findings reflect the steady progress in our understanding of CNS infections post SOT. They provide several avenues for improvement in the prevention, early recognition, and therapeutic outcomes of these diseases.
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Handley G, Hasbun R, Okhuysen P. Human herpesvirus 6 and central nervous system disease in oncology patients: A retrospective case series and literature review. J Clin Virol 2021; 136:104740. [PMID: 33548682 DOI: 10.1016/j.jcv.2021.104740] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 01/18/2021] [Accepted: 01/24/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Human herpesvirus 6 (HHV-6) can reactivate with immunosuppression and cause central nervous system (CNS) dysfunction. Much of the literature describes cases after hematopoietic stem cell transplantation (HSCT), ranging from encephalitis to a post-transplant acute limbic encephalitis syndrome (PALE). Outside of HSCT, studies of HHV-6 encephalitis are limited to case reports. OBJECTIVES This study was designed to review HHV-6 CNS infection, and evaluate all patients admitted to MD Anderson Cancer Center between March 2016 and December 2018 with detectable HHV-6 DNA in the cerebrospinal fluid (CSF). STUDY DESIGN Patients with HHV-6 DNA detected in the CSF using the Viracor or Biofire® Meningitis Encephalitis Panel platforms and no other identified etiology were identified and demographic features, known risk factors, imaging findings, CSF analysis, treatments and patient outcomes were extracted from medical records. RESULTS 725 patients underwent HHV-6 testing during the study timeframe, with 19 cases (2.6 %) of HHV-6 mediated CNS disease identified. Most patients, 13/19 (68 %), had undergone HSCT with median time to presentation of 31 days after transplant. Survival at 240 days after transplant was 62 %. CSF had lymphocyte predominance and nearly all patients had peripheral lymphopenia. Other at risk populations identified included patients who received chimeric antigen receptor (CAR) T-cell therapy and biologic immunotherapy. Notable discordance among testing platforms was found in 5/9 (55 %) instances. CONCLUSIONS In addition to HSCT patients, HHV-6 reactivation leading to CNS disease also occurs in settings such as following adoptive T cell therapy or biologic immunotherapy. Significant diagnostic discordance exists between testing platforms.
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Affiliation(s)
- Guy Handley
- Department of Medicine, Division of Infectious Diseases, McGovern Medical School UT Health, 6431 Fannin, MSB 2.112, Houston, TX, 77030, USA.
| | - Rodrigo Hasbun
- Department of Medicine, Division of Infectious Diseases, McGovern Medical School UT Health, 6431 Fannin, MSB 2.112, Houston, TX, 77030, USA
| | - Pablo Okhuysen
- Department of Infectious Diseases, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1460, Houston, TX, 77030, USA
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Todd K, Paulsen G, Danziger-Isakov L, Tarango C. Pure red cell aplasia with isolated human herpes virus 6 infection of bone marrow in postcardiac transplant patient. Pediatr Blood Cancer 2020; 67:e28136. [PMID: 31876110 DOI: 10.1002/pbc.28136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 12/03/2019] [Accepted: 12/04/2019] [Indexed: 11/05/2022]
Affiliation(s)
- Kevin Todd
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Grant Paulsen
- Department of Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Lara Danziger-Isakov
- Department of Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Cristina Tarango
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Pellett Madan R, Hand J. Human herpesvirus 6, 7, and 8 in solid organ transplantation: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13518. [PMID: 30844089 DOI: 10.1111/ctr.13518] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 02/26/2019] [Indexed: 12/17/2022]
Abstract
These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of HHV-6A, HHV-6B, HHV-7, and HHV-8 in the pre- and post-transplant period. The majority of HHV-6 (A and B) and HHV-7 infections in transplant recipients are asymptomatic; symptomatic disease is reported infrequently across organs. Routine screening for HHV-6 and 7 DNAemia is not recommended in asymptomatic patients, nor is prophylaxis or preemptive therapy. Detection of viral nucleic acid by quantitative PCR in blood or CSF is the preferred method for diagnosis of HHV-6 and HHV-7 infection. The possibility of chromosomally integrated HHV-6 DNA should be considered in individuals with persistently high viral loads. Antiviral therapy should be initiated for HHV-6 encephalitis and should be considered for other manifestations of disease. HHV-8 causes Kaposi's sarcoma, primary effusion lymphoma, and multicentric Castleman disease and is also associated with hemophagocytic syndrome and bone marrow failure. HHV-8 screening and monitoring may be indicated to prevent disease. Treatment of HHV-8 related disease centers on reduction of immunosuppression and conversion to sirolimus, while chemotherapy may be needed for unresponsive disease. The role of antiviral therapy for HHV-8 infection has not yet been defined.
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Affiliation(s)
- Rebecca Pellett Madan
- Department of Pediatrics, New York University Langone School of Medicine, New York City, New York
| | - Jonathan Hand
- Department of Infectious Diseases, Ochsner Clinical School, Ochsner Medical Center, The University of Queensland School of Medicine, New Orleans, Louisiana
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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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Abad CL, Razonable RR. Treatment of alpha and beta herpesvirus infections in solid organ transplant recipients. Expert Rev Anti Infect Ther 2016; 15:93-110. [PMID: 27911112 DOI: 10.1080/14787210.2017.1266253] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Human herpesviruses frequently cause infections in solid organ transplant (SOT) recipients. Areas covered: We provide an overview of the clinical impact of alpha and beta herpesviruses and highlight the mechanisms of action, pharmacokinetics, clinical indications, and adverse effects of antiviral drugs for the management of herpes simplex virus, varicella zoster virus and cytomegalovirus. We comprehensively evaluated key clinical trials that led to drug approval, and served as the foundation for management guidelines. We further provide an update on investigational antiviral agents for alpha and beta herpesvirus infections after SOT. Expert commentary: The therapeutic armamentarium for herpes infections is limited by the emergence of drug resistance. There have been major efforts for discovery of new drugs against these viruses, but the results of early-phase clinical trials have been less than encouraging. We believe, however, that more antiviral drug options are needed given the adverse side effects associated with current antiviral agents, and the emergence of drug-resistant virus populations in SOT recipients. Likewise, optimized use and strategies are needed for existing and novel antiviral drugs against alpha and beta-herpesviruses in SOT recipients.
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Affiliation(s)
- C L Abad
- a Division of Infectious Diseases, Department of Medicine , Mayo Clinic , Rochester , MN , USA.,b Department of Medicine, Section of Infectious Diseases , University of the Philippines - Philippine General Hospital , Manila , Philippines
| | - R R Razonable
- a Division of Infectious Diseases, Department of Medicine , Mayo Clinic , Rochester , MN , USA.,c The William J. Von Liebig Center for Transplantation and Clinical Regeneration , Mayo Clinic , Rochester , MN , USA
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Magnetic resonance imaging in viral and prion diseases of the central nervous system. Top Magn Reson Imaging 2015; 23:293-302. [PMID: 25296274 DOI: 10.1097/rmr.0000000000000033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The early detection and specific diagnosis of viral infections of the central nervous system are important because many of these diseases are potentially treatable. However, clinical symptoms and physical examination are often nonspecific, and rapid diagnostic tests are available for some, but not all, viruses. Neuroimaging, in conjunction with clinical history and laboratory tests, plays an important role in narrowing the differential diagnoses. In this article, we review the clinical features, imaging characteristics, diagnosis, and treatment of the more common viral infections and prions that involve the central nervous system.
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Yamamoto T, Watarai Y, Goto N, Horikoshi Y, Yamada S, Yasui K, Tsujita M, Hiramitsu T, Narumi S, Katayama A, Uchida K, Kobayashi T. Encephalitis caused by human herpesvirus-6B in pancreas-after-kidney transplantation. Transpl Infect Dis 2014; 16:853-8. [PMID: 25040797 DOI: 10.1111/tid.12270] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 04/12/2014] [Accepted: 05/05/2014] [Indexed: 11/30/2022]
Abstract
Human herpesvirus-6 (HHV-6) is a common pathogen among children, classically presenting with fever and rash that resolves without specific therapy. HHV-6 can be reactivated in the immunosuppressed patient. After bone marrow and solid organ transplantation, HHV-6 has been linked to various clinical syndromes, including undifferentiated febrile illness, encephalitis, myelitis, hepatitis, pneumonitis, and bone marrow suppression. However, HHV-6 encephalitis after pancreatic transplant has rarely been reported. Early diagnosis and treatment of HHV-6 encephalitis may be important for affected patients. We report the case of a 53-year-old pancreas-after-kidney transplant recipient who initially presented with high fever and confusion 3 weeks after operation. We managed to save the patient's life and preserve the pancreas graft function. We also review previously reported cases of HHV-6B encephalitis in solid organ transplant recipients.
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Affiliation(s)
- T Yamamoto
- Department of Transplant Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan; Department of Transplant Immunology, Nagoya University School of Medicine, Nagoya, Japan
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Abstract
Cardiac transplantation remains the best treatment option for patients with end-stage, NYHA class IV heart failure who have failed conventional therapy. However, transplant rates have remained static largely due to limited organ donor supplies. Therefore, appropriate allocation of this precious resource is critical to maximize benefit, both at a patient level and at a societal level. Neurologic diseases, such as cerebrovascular disease and peripheral neuropathy, are prevalent in this patient population, as the major risk factors for heart disease place patients at risk for neurologic disease as well. Examples include hypertension, smoking, hypercholesterolemia, obesity, and diabetes. Pretransplant neurologic evaluation is very important to identify conditions that may limit survival after cardiac transplantation. In general, systemic diseases exacerbated by immunosuppression, conditions limiting ability to rehabilitate, and dementias are considered contraindications. Post-transplant neurologic complications are divided into central versus peripheral, and early versus late. The most common early complication is ischemic stroke. Other serious complications include hemorrhagic stroke, encephalopathy, and critical illness neuropathy. Over the long term, post-transplant immunosuppressive regimens are considered "a double edged sword." Although immunosuppressive medications are critical to preventing rejection and allograft dysfunction, they do have significant risk of morbidity and mortality associated with them, including neurologic side-effects. These include: (1) drug toxicities, such as lowering of seizure thresholds; (2) encephalopathy, such as posterior reversible encephalopathy syndrome (PRES); (3) infections; (4) malignancies, such as post-transplant lymphoproliferative disorder (PTLD). Many of the same considerations discussed in adult heart transplant recipients apply to pediatric heart transplant recipients as well. In children, seizures are the most common neurologic complication, although other neurologic complication rates are comparable.
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Affiliation(s)
- Alain Heroux
- Heart Failure and Heart Transplant Program, Loyola University Medical Center, Maywood, IL, USA.
| | - Salpy V Pamboukian
- Section of Advanced Heart Failure, Cardiac Transplant, Mechanical Circulatory Support and Pulmonary Vascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
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HHV-6: Clinical and Laboratory Investigations and Correlations With Encephalitis in Liver Transplant Recipients. Transplant Proc 2013; 45:1997-9. [DOI: 10.1016/j.transproceed.2013.01.095] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 01/24/2013] [Indexed: 11/30/2022]
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Monitoring for HHV-6 infection after renal transplantation: evaluation of risk factors for sustained viral replication. Transplantation 2013; 95:842-6. [PMID: 23354300 DOI: 10.1097/tp.0b013e3182807ab7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Human herpesvirus-6 (HHV-6) is known to reactivate after renal transplantation and has been associated with several clinical manifestations. Risk factors for sustained viral replication, however, remain unclear. METHODS Thirty consecutive kidney transplant patients were prospectively followed for HHV-6 replication between February 2007 and February 2008. Plasma samples for DNA detection were collected from the donor and the recipient before transplantation and from the recipient weekly for the first 2 months after transplantation and then every 2 weeks for 2 additional months. HHV-6 active infection was defined as detection of viral DNA in plasma, by polymerase chain reaction, in at least two consecutive samples over an interval of at least 1 week. RESULTS Active viral infection was detected in 25% of the recipients before transplantation and 27% (8 of 30) of the patients after transplantation. The mean time to onset of viral replication was 28.1 days after transplantation and 7 of 8 (87.5%) were asymptomatic. Risk factors associated with active HHV-6 infection were receiving an organ from a living donor (P=0.028), recipients with IgM antibodies detected before transplantation (P=0.005), and pretransplantation recipient HHV-6 viral load more than 10,000 copies/mL plasma (P=0.034). CONCLUSIONS Active HHV-6 infection occurs early after renal transplantation and is mostly asymptomatic. Donor or recipient infection may occur at the time of transplantation and are related to higher rates of posttransplantation infections.
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Le J, Gantt S. Human herpesvirus 6, 7 and 8 in solid organ transplantation. Am J Transplant 2013; 13 Suppl 4:128-37. [PMID: 23465006 DOI: 10.1111/ajt.12106] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- J Le
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
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Razonable RR. Human herpesviruses 6, 7 and 8 in solid organ transplant recipients. Am J Transplant 2013; 13 Suppl 3:67-77; quiz 77-8. [PMID: 23347215 DOI: 10.1111/ajt.12008] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Revised: 07/05/2012] [Accepted: 07/05/2012] [Indexed: 01/25/2023]
Abstract
Human herpesviruses (HHV) 6 and 7 are ubiquitous infections that reactivate commonly in transplant recipients. However, clinical diseases due to these viruses are reported only in 1% of solid organ transplant recipients. Fever, rash and bone marrow suppression are the most common manifestations, but symptoms of tissue invasive disease may be observed. Treatment of HHV-6 and HHV-7 disease includes antiviral therapy and cautious reduction in immunosuppression. HHV-8 is an oncogenic gamma-herpesvirus that causes Kaposi's sarcoma, Castleman's disease and primary effusion lymphomas in transplant recipients. Nonmalignant diseases such as bone marrow suppression and multiorgan failure have also been associated with HHV-8. Reduction in immunosuppression is the first line treatment of HHV-8 infection. Other alternatives for treatment, especially for HHV-8 diseases not responsive to immuno-minimization strategies, are surgery and chemotherapy. Sirolimus has been shown to be a beneficial component for the treatment of Kaposi's sarcoma and the role of antivirals for HHV-8 infection is being investigated.
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Affiliation(s)
- R R Razonable
- Division of Infectious Diseases, Department of Medicine, College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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Abstract
PURPOSE OF REVIEW Human herpesvirus 6 (HHV-6) frequently reactivates after solid-organ and hematopoietic cell transplantation (HCT), and it has been associated with important outcomes in these settings. In 1-2% of recipients or donors, HHV-6 was inherited through chromosomal integration. Although HHV-6 chromosomal integration has not been associated with disease, the resulting very high levels of HHV-6 DNA in human tissue and blood samples can be challenging to interpret in the transplant setting. This review addresses the recent findings regarding the clinical outcomes associated with HHV-6 as well as diagnostic and therapeutic concerns. RECENT FINDINGS The evidence supports a causal association between HHV-6 and central nervous system disease. New studies have further characterized the impact of HHV-6 on the central nervous system. In addition, new studies have explored the associations between HHV-6 and other important outcomes. The implications of integrated HHV-6 in transplant recipients remain undefined, though the possibility of an association with organ rejection has been suggested. New exploratory data exist regarding the safety of antiviral prophylactic and preemptive strategies. SUMMARY Our understanding of the full clinical impact of HHV-6 in the transplant population remains incomplete. A large antiviral trial would not only help to further define causality between HHV-6 associated clinical outcomes but also start to define preventive strategies.
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Infections and organ transplantation: new challenges for prevention and treatment--a colloquium. Transplantation 2012; 93:S4-S39. [PMID: 22374265 DOI: 10.1097/tp.0b013e3182481347] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Comoli P, Ginevri F. Monitoring and managing viral infections in pediatric renal transplant recipients. Pediatr Nephrol 2012; 27:705-17. [PMID: 21359619 DOI: 10.1007/s00467-011-1812-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Revised: 02/01/2011] [Accepted: 02/04/2011] [Indexed: 12/27/2022]
Abstract
Viral infections remain a significant cause of morbidity and mortality following renal transplantation. The pediatric cohort is at high risk of developing virus-related complications due to immunological naiveté and the increased alloreactivity risk that requires maintaining a heavily immunosuppressive environment. Although cytomegalovirus is the most common opportunistic pathogen seen in transplant recipients, numerous other viruses may affect clinical outcome. Recent technological advances and novel antiviral therapy have allowed implementation of viral and immunological monitoring protocols and adoption of prophylactic or preemptive treatment approaches in high-risk groups. These strategies have led to improved viral infection management in the immunocompromised host, with significant impact on outcome. We review the major viral infections seen following kidney transplantation and discuss strategies for preventing and managing these pathogens.
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Affiliation(s)
- Patrizia Comoli
- Pediatric Hematology/Oncology and Research Laboratories, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
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Lautenschlager I, Razonable RR. Human herpesvirus-6 infections in kidney, liver, lung, and heart transplantation: review. Transpl Int 2012; 25:493-502. [PMID: 22356254 DOI: 10.1111/j.1432-2277.2012.01443.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Human herpesvirus-6 (HHV-6), which comprises of HHV-6A and HHV-6B, is a common infection after solid organ transplantation. The rate of HHV-6 reactivation is high, although clinical disease is not common. Only 1% of transplant recipients will develop clinical illness associated with HHV-6 infection, and most are ascribable to HHV-6B. Fever, myelosuppression, and end-organ disease, including hepatitis and encephalitis, have been reported. HHV-6 has also been associated with various indirect effects, including a higher rate of CMV disease, acute and chronic graft rejection, and opportunistic infection such as invasive fungal disease. All-cause mortality is increased in solid organ transplant recipients with HHV-6 infection. HHV-6 is somewhat unique among human viruses because of its ability to integrate into the host chromosome. The clinical significance of chromosomally integrated HHV-6 is not yet defined, although a higher rate of bacterial infection and allograft rejection has been suggested. The diagnosis of HHV-6 is now commonly made using nucleic acid testing for HHV-6 DNA in clinical samples, but this can be difficult to interpret owing to the common nature of asymptomatic viral reactivation. Treatment of HHV-6 is indicated in established end-organ disease such as encephalitis. Foscarnet, ganciclovir, and cidofovir have been used for treatment.
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Affiliation(s)
- Irmeli Lautenschlager
- Department of Virology, Helsinki University Hospital, and Helsinki University, Helsinki, Finland.
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20
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Pustavoitau A, Bhardwaj A, Stevens R. Analytic Review: Neurological Complications of Transplantation. J Intensive Care Med 2011; 26:209-22. [DOI: 10.1177/0885066610389549] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Recipients of solid organ or hematopoietic cell transplants are at risk of life-threatening neurological disorders including encephalopathy, seizures, infections and tumors of the central nervous system, stroke, central pontine myelinolysis, and neuromuscular disorders—often requiring admission to, or occurring in, the intensive care unit (ICU). Many of these complications are linked directly or indirectly to immunosuppressive therapy. However, neurological disorders may also result from graft versus host disease, or be an expression of the underlying disease which prompted transplantation, as well as injury induced during radiation, chemotherapy, surgery, and ICU stay. In rare cases, neuroinfectious pathogens may be transmitted with the transplanted tissue or organ. Diagnosis may be a challenge because clinical symptoms and findings on neuroimaging lack specificity, and a biological specimen or tissue diagnosis is often needed for definitive diagnosis. Management is centered on preventing further neurological injury, etiology-targeted therapy, and balancing the benefits and toxicities of specific immunosuppressive agents.
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Affiliation(s)
- Aliaksei Pustavoitau
- Departments of Anesthesiology Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Anish Bhardwaj
- Departments of Neurology and Neurological Surgery, Tufts University School of Medicine, Boston, MA, USA,
| | - Robert Stevens
- Departments of Anesthesiology Critical Care Medicine, Neurology, Neurosurgery, and Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Razonable RR, Zerr DM. HHV-6, HHV-7 and HHV-8 in solid organ transplant recipients. Am J Transplant 2009; 9 Suppl 4:S97-100. [PMID: 20070702 DOI: 10.1111/j.1600-6143.2009.02899_1.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- R R Razonable
- Division of Infectious Diseases, College of Medicine, Mayo Clinic, Rochester, MN, USA.
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Vinnard C, Barton T, Jerud E, Blumberg E. A report of human herpesvirus 6-associated encephalitis in a solid organ transplant recipient and a review of previously published cases. Liver Transpl 2009; 15:1242-6. [PMID: 19790143 DOI: 10.1002/lt.21816] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Human herpesvirus 6 (HHV-6) is a common pathogen among children, classically presenting as fever and rash that resolve without specific therapy (exanthem subitum or roseola infantum). Also identified as a pathogen in hematopoietic cell transplant and solid organ transplant (SOT) recipients, it has been recognized as a cause of limbic encephalitis, characterized by confusion and amnesia, with magnetic resonance imaging findings of T2 hyperintensity of the amygdala and hippocampus. We report a case of limbic encephalitis associated with HHV-6 infection in a liver transplant recipient, and we review previously reported cases of HHV-6 encephalitis in SOT recipients.
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Affiliation(s)
- Christopher Vinnard
- Division of Infectious Diseases, University of Pennsylvania, Philadelphia, PA 19146, USA.
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Humar A, Asberg A, Kumar D, Hartmann A, Moussa G, Jardine A, Rollag H, Mouas H, Gahlemann CG, Pescovitz MD. An assessment of herpesvirus co-infections in patients with CMV disease: correlation with clinical and virologic outcomes. Am J Transplant 2009; 9:374-81. [PMID: 19120074 DOI: 10.1111/j.1600-6143.2008.02501.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The effect of herpesvirus co-infections (HHV-6, HHV-7) on cytomegalovirus (CMV) disease and its response to therapy is unknown. We prospectively analyzed herpesvirus co-infections in transplant recipients with CMV disease. All patients received 3 weeks of antiviral therapy. Samples were collected at baseline (day 0) and then day 3, 7, 14 and 21 poststart of therapy. Viral load testing for CMV, HHV-6 and HHV-7 was done using quantitative PCR assays in 302 patients of whom 256 had documented symptomatic CMV viremia. In this subset, day 0 HHV-6 co-infection was present in 23/253 (9.1%) and HHV-7 in 17/253 (6.7%). Including those positive at any time point raised the prevalence to 79/256 (30.9%) for HHV-6 and 75/256 (29.3%) for HHV-7. Viral co-infection did not influence the response of CMV disease to antiviral therapy. Baseline CMV viral loads, time to eradication and risk of recurrence were similar in patients with and without HHV-6 or HHV-7 co-infection. Ganciclovir and valganciclovir had no clear effect on HHV-6 and HHV-7 viremia. In conclusion, herpesvirus co-infections are common in patients with CMV disease but with standard antiviral therapy, no clear clinical effects are discernable. Routine monitoring for viral co-infection in patients with CMV disease is not indicated.
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Affiliation(s)
- A Humar
- Department of Medicine, University of Alberta, Edmonton, AB, Canada.
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24
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Emerging Viruses in Transplantation: There Is More to Infection After Transplant Than CMV and EBV. Transplantation 2008; 86:1327-39. [DOI: 10.1097/tp.0b013e31818b6548] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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25
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Bouza E, Loeches B, Muñoz P. Fever of Unknown Origin in Solid Organ Transplant Recipients. Infect Dis Clin North Am 2007; 21:1033-54, ix-x. [DOI: 10.1016/j.idc.2007.09.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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26
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Gurguí M, Muñoz P. Infecciones en el trasplante cardíaco. Enferm Infecc Microbiol Clin 2007; 25:587-97; quiz 598. [DOI: 10.1157/13111187] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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27
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Mohagheghi A, Vallely P. Determination of Frequency of HHV-6 IgG by an In-house ELISA and Detection of Antibody Avidity by Application of Diethylamine. JOURNAL OF MEDICAL SCIENCES 2007. [DOI: 10.3923/jms.2007.952.960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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28
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Ljungman P, Singh N. Human herpesvirus-6 infection in solid organ and stem cell transplant recipients. J Clin Virol 2006; 37 Suppl 1:S87-91. [PMID: 17276376 DOI: 10.1016/s1386-6532(06)70018-x] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
HHV-6 has in recent years become recognized as a potential significant pathogen in both solid organ and stem cell transplant recipients. HHV-6 infections are common after transplantation regardless of the utilized diagnostic technique. Several different clinical manifestations have been described including fever, bone marrow suppression, encephalitis, skin rash, and hepatitis. The most important end-organ disease is encephalitis in stem cell transplant recipients that has been reported to have a mortality of at least 40%. HHV-6 is also considered an immunomodulatory and immunosuppressive virus that may facilitate super-infections with other opportunistic pathogens such as CMV and fungal infections and thereby contribute to overall mortality. No established therapy exists but both ganciclovir and foscarnet have been reported to have in vitro and in vivo efficacy against HHV-6.
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Affiliation(s)
- Per Ljungman
- Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden.
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29
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Abstract
We report the first pediatric case of Mollaret meningitis in an adolescent female with acute lymphoblastic leukemia in remission. This patient had signs and symptoms consistent with meningitis, with three episodes over a 3-month period. Human herpesvirus 6 (HHV-6) was identified during her last episode from polymerase chain reaction assay of a cerebrospinal fluid specimen. She was treated successfully with foscarnet, after which HHV-6 was undetectable in her cerebrospinal fluid.
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Affiliation(s)
- Jared D Capouya
- Department of Pediatrics, College of Medicine, University of South Florida, FL 33731, USA
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30
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Pradeau K, Couty L, Szelag JC, Turlure P, Rolle F, Ferrat P, Bordessoule D, Le Meur Y, Denis F, Ranger-Rogez S. Multiplex real-time PCR assay for simultaneous quantitation of human cytomegalovirus and herpesvirus-6 in polymorphonuclear and mononuclear cells of transplant recipients. J Virol Methods 2006; 132:77-84. [PMID: 16300835 DOI: 10.1016/j.jviromet.2005.09.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2005] [Revised: 08/31/2005] [Accepted: 09/06/2005] [Indexed: 01/01/2023]
Abstract
Human cytomegalovirus (HCMV) and human herpesvirus-6 (HHV-6) are two closely related viruses, which belong to the Herpesviridae family. Following primary infection, they are thought to persist for life as latent forms in mononuclear cells. HCMV and HHV-6 can cause considerable morbidity in immunocompromised individuals, such as transplant patients. A sensitive and specific LightCycler multiplex real-time PCR assay based on fluorescence energy transfer (known as FRET) was developed. This assay, by using two sets of hybridization probes specific for HHV-6 (A and B) and HCMV, can differentiate reliably and quantify simultaneously both viruses in order to diagnose reactivation processes. The assay was optimized and the lower limit of detection for both viruses was determined to be 10 viral genome copies per reaction. Both viruses were quantified in 83 peripheral blood mononuclear cells (PBMCs) and 87 polymorphonuclear leukocytes (PMNLs) collected from 32 transplant recipients. This multiplex real-time quantitative PCR was finally compared with two other quantitation and detection assays used daily in laboratory (PCR DIG detection and antigenemia for HCMV, TaqMan Assay for HHV-6). This technique can be useful for the differentiation and quantitation of HCMV and HHV-6 for monitoring transplant patients.
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Affiliation(s)
- Karine Pradeau
- Laboratoire de Virologie, CHU Dupuytren, Limoges, France
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31
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Abstract
Viruses are among the most common causes of opportunistic infection after transplantation and the most important. The risk for viral infection is a function of the specific virus encountered, the intensity of immune suppression used to prevent graft rejection, and other host factors governing susceptibility. Viral infection, both symptomatic and asymptomatic, causes the "direct effects" of invasive disease and "indirect effects," including immune suppression predisposing to other opportunistic infections and oncogenesis. Rapid and sensitive microbiologic assays for many of the common viruses after transplantation have replaced, for the most part, serologic testing and in vitro cultures for the diagnosis of infection. Furthermore, quantitative molecular tests allow the individualization of antiviral therapies for prevention and treatment of infection. This advance is most prominent in the management of cytomegalovirus, Epstein-Barr, hepatitis B, and hepatitis C viruses. Diagnostic advances have not been accompanied by the development of specific and nontoxic anti-viral agents or effective antiviral vaccines. Vaccines, where available, should be given to patients as early as possible and well in advance of transplantation to optimize the immune response. Studies of viral latency, reactivation, and the cellular effects of viral infection will provide clues for future strategies in prevention and treatment of viral infections.
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Affiliation(s)
- Camille N Kotton
- Transplant Infectious Disease and Compromised Host Service, Infectious Disease Division, Massachusetts General Hospital, 55 Fruit Street; GRJ 504, Boston, MA 02114, USA
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Bonnafous P, Gautheret-Dejean A, Boutolleau D, Caïola D, Agut H. Persistence of DNA in cell cultures may jeopardize the analysis of human herpesvirus 6 dynamics by means of real-time PCR. J Virol Methods 2005; 125:95-8. [PMID: 15737421 DOI: 10.1016/j.jviromet.2004.12.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2004] [Revised: 11/30/2004] [Accepted: 12/01/2004] [Indexed: 11/26/2022]
Abstract
The use of real-time PCR has been described previously for analysing both the replication kinetics and antiviral susceptibility of human herpesvirus 6 in MT4 cells. It is now reported that viral DNA persists in infected cell culture long after the end of lytic virus replication. Consequently, high levels of DNA may correspond to an absence of infectivity and late readout occurring after the exponential phase of virus growth may lead to misinterpretation of the results of susceptibility assays. These limitations must be borne in mind when using real-time PCR.
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Affiliation(s)
- Pascale Bonnafous
- Laboratoire de Virologie, UPRES EA2387, CERVI, Groupe Hospitalier Pitié-Salpêtrière, 75013 Paris, France
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